Twin Rivers Nursing And Rehabilitation Center

F-F697, that pain management is provided to residents consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences .5. Monitoring for effectiveness and/or adverse consequences .

Review of Resident R19's undated Admission Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet tab, revealed the resident was readmitted to the facility on [DATE REDACTED] with diagnoses which included chronic pain syndrome and polyneuropathy.

Review of Resident R19's Pain care plan, initiated 02/19/2020 and located in the resident's EMR under the Care Plan tab, revealed the resident's Care Plan identified the following problems: Patient has chronic pain in neck and shoulders; Dx [diagnosis] chronic pain syndrome; Dx Polyneuropathy; Resident returned to facility from pain clinic . [Pain Clinic Physician's Name] has now turned over pain management to [Resident's Attending Physician's Name] .[Resident's Attending Physician's Name] sent script at this time. Resident aware and verbalizes understanding; [Resident R19's Name] has chronic pain r/t [related to] impaired mobility, contractures, and dx of OA [Osteoarthritis]. Resident R19 Care Plan goal stated, Will not experience unrelieved pain through next review. Resident R19's Care Plan included interventions of: .Administer medications as ordered and observe for effectiveness and side effects .Notify physician of any unrelieved s/s [signs/ symptoms] of pain .

Review of Resident R19's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/2024 and located in the MDS tab of the electronic medical record (EMR), revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. The facility further assessed Resident R19 as being on a scheduled pain management regimen, receiving PRN (as needed) pain medications, and frequently having pain during the assessment period.

Review of Resident R19's Physician orders located in the resident's EMR under the List tab, revealed an order, dated 05/20/2024, for Hydromorphone [narcotic pain medication] 2 mg [milligram] by mouth every [six] 6 hours as needed .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 0697 Review of Resident R19's Medication Administration Record (MAR), dated July 2024, revealed the resident was being administered the hydromorphone 2 mg tablet medication PRN (as needed). Continued review of Resident R19's MAR Level of Harm - Minimal harm or revealed no documented evidence the resident's pain was being assessed prior to the administration of the potential for actual harm pain medication, nor was the resident's pain being assessed post administration of the pain medication to measure the effectiveness of the pain medication, as of 07/24/2024. Residents Affected - Few

During an interview, on 07/24/2024 at 11:51 AM, Resident R19 stated she felt like the facility could do better about controlling her pain. When asked to elaborate, the resident stated once her pain medications took effect, then her pain was better. The resident stated she just received her pain medication with her noon medications, about 30 minutes ago, and she would now rate her pain as a seven (7) out of 10 with 10 being

the worse pain possible.

During a subsequent interview, on 07/24/2024 at 4:00 PM, Resident R19 stated the nurse came and explained to her

she could have her pain medication every six (6) hours if she needed it. Resident R19 further stated she thought her pain medication was scheduled and she did not know she could ask for it after six (6) hours of receiving a dose of pain medication.

During record review and interview, on 07/24/2024 at 3:35 PM, Licensed Practical Nurse (LPN) 4 reviewed Resident R19's MAR, dated July 2024, and confirmed there was no documented evidence the resident's pain was being assessed prior to the administration of the PRN pain medication of hydromorphone, nor post administration of the PRN pain medication. LPN4 stated the resident's MAR did not contain a pre or post pain level, but should have. The LPN stated normally when a resident was ordered a PRN pain medication,

the MAR would automatically populate a pre and post section to document the assessments. LPN4 further stated it was important to complete a pre and post pain assessment to ensure the resident's pain was being managed appropriately.

During an interview, on 07/26/2024 at 5:16 PM, the Director of Nursing (DON) stated it was her expectation Resident R19's pain would have been assessed before and after the administration of her PRN pain medication. The DON further stated this was important to ensure the medication was effective.

During an interview with the Administrator, on 07/26/2024 at 5:18 PM, he was questioned regarding the need for pain assessments before and after administration of pain medication. He stated he was not clinical and deferred to the DON.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm 36898 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for two (2) of six (6) residents reviewed for unnecessary medications out of a total of 25 sampled residents, Resident (R)79 and Resident R11. This failure placed both residents at risk for side effects such as drowsiness and sedation.

Resident R79 was ordered Lorazepam (fast-acting antianxiety medication) with no stop date to reevaluate the medical necessity of the medication.

Additionally, Resident R11 was ordered and routinely administered Hydroxyzine HCI (an antihistamine medication) for itching; however, the medication was being used to control the resident's behavior.

The findings include:

1. Review of Resident R79's undated Admission Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet tab, revealed the facility admitted the resident on 05/31/2023 and most recently readmitted the resident on 02/12/2024, with diagnoses which included generalized anxiety disorder (GAD) and restless leg syndrome.

Review of Resident R79's Physician's orders located in the resident's EMR under the List tab, revealed an order, dated 03/22/2024, for Lorazepam (fast-acting antianxiety medication) Oral Concentrate two (2) MG/ML (milligram/milliliter), one (1) ml By Mouth Every four (4) hours as needed. The order did not have a stop date.

Review of Resident R79's Medication Regimen Review (MRR), dated 03/26/2024 and provided by the facility, revealed a pharmacy recommendation of Per CMS [Centers for Medicare and Medicaid Services], PRN psychotropic medications are limited to 14 days (no exceptions). If use is beyond 14 days, the rationale and

an estimated duration of use must be documented. Please add an estimated duration of use to prn Lorazepam for CMS compliance. The Medical Director responded to the recommendation by marking Resident is comfort measures-90 day stop date.

Review of Resident R79's Physician's orders located in the resident's EMR under the List tab, revealed a current order dated 05/30/2024 for Lorazepam Oral Concentrate 2 MG/ML, 1.5 ml By Mouth Every four (4) hours as needed. The order did not have a stop date. This order also included for Comfort Measures Only .

Review of Resident R79's Medication Administration Record (MAR), dated July 2024 and located in the resident's EMR under the MAR/TAR [Treatment Administration Record] tab, revealed the resident was ordered and administered the PRN (as needed) Lorazepam for agitation. The MAR revealed the resident was administered the Lorazepam on 07/01/2024, 07/08/2024, and 07/09/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 0758 During an interview and record review, on 07/25/2024 at 3:16 PM, the Medical Director who was also Resident R79's Attending Physician, reviewed the orders and confirmed there was no stop date on the PRN Lorazepam. The Level of Harm - Minimal harm or Medical Director stated Resident R79 was on end-of-life comfort care, and she was not aware a stop date was needed potential for actual harm for the medication since the resident was on comfort care.

Residents Affected - Few During an interview, on 07/26/2024 at 5:22 PM, the Director of Nursing (DON) stated it was her understanding that a stop date for a PRN antianxiety medication was needed for a resident on comfort care.

2. Review of Resident R11's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the facility admitted the resident on 11/03/2016 and most recently readmitted the resident on 11/22/2022, with diagnoses which included bipolar disorder, cerebral palsy, and generalized anxiety disorder.

Review of Resident R11's Physician orders located in the resident's EMR under the List tab, revealed a current order, originally dated 10/04/2023, for Hydroxyzine HCI [an antihistamine medication with anticholinergic side effects] Oral tablet 25 mg, [one] 1 tablet via G-Tube [Gastric Tube] TID [three times a day] .for itching.

Review of Resident R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/2024 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The assessment also revealed the resident had not engaged in any behaviors during the assessment period.

Review of Resident R11's MARs, dated October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and July 2024 and located in the resident's EMR under

the MAR/TAR tab, revealed the hydroxyzine medication was initialed as administered three (3) times a day as ordered except for the following dates: 11/16/2023 (one dose), 12/05/2023 (one dose), 01/12/2024 (two doses), 01/19/2024 (one dose), 02/22/2024 (one dose) and 06/21/2024 (one dose).

An observation and interview with Resident R11 was conducted on 07/23/2024 at 2:52 PM, in the presence of Licensed Practical Nurse (LPN) 4. When Resident R11 was questioned if he had ever had any problems with his body itching, he stated No. Due to the resident having expressive communication deficit, LPN4 confirmed Resident R11's answer was, No. LPN4 stated Resident R11 had never complained to her of any itching; however, the resident did engage in the behavior of scratching his legs. Further observation revealed Resident R11 had dressings on both legs.

During a subsequent interview, on 07/24/2024 at 9:19 AM, Resident R11 was questioned if he had any itching episodes overnight, and the resident stated, No. Resident R11 was observed to be lying in his bed watching tv.

During an interview, on 07/24/2024 at 3:48 PM, Certified Nursing Assistant (CNA) 4 stated she was often assigned to Resident R11 and was familiar with him. CNA4 stated Resident R11 had never complained to her about itching, and

she had never observed him scratching himself from body itching. CNA4 further stated Resident R11 used to scratch his legs a lot; however, this was a behavior when his call light was not answered quick enough. The CNA stated the resident would also engage in behaviors of yelling or putting himself on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 0758 During an interview, on 07/24/2024 at 3:51 PM, CNA5 stated Resident R11 had never complained to her about itching and she had never observed him scratching his body. Level of Harm - Minimal harm or potential for actual harm During an interview, on 07/25/2024 at 3:16 PM, the Medical Director stated hydroxyzine was normally ordered and administered for itching. However, the Medical Director stated she ordered the medication for Residents Affected - Few Resident R11 more for behaviors and less for itching. The Medical Director further stated when she put the electronic order in, the drop down only had two diagnoses for hydroxyzine, anxiety and itching. In continued interview

the Medical Director further stated the resident had wounds to his legs from him scratching himself, which was a behavior, and this was during a bad period of acting out. She stated she should have only ordered the medication for 10 days and stopped it after that.

During an interview, on 07/26/2024 at 5:27 PM, the Director of Nursing (DON) stated it was her expectation

the Medical Director would have followed the regulatory requirement for the use of the hydroxyzine medication.

During an interview, on 07/26/2024 at 5:53 PM, the Administrator stated it was his expectation the Medical Director would have followed the regulatory guidance when prescribing the hydroxyzine medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43050

Residents Affected - Many Based on observation, interview, and review of facility policies, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures had the potential to affect all 95 residents in the facility who consumed food from the kitchen.

The findings include:

Review of the facility's policy titled, Food Storage: Cold Foods, dated 02/2023, revealed All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Review of the facility's policy titled, Environment, dated 09/2017, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces .All food contact surfaces will be cleaned and sanitized

after each use.

On 07/23/2024, the following observations in the kitchen were identified and verified by the Dietary Manager (DM) and the District Manager.

1. Observation at 8:43 AM, revealed the freezer contained one (1) bag of hamburgers, (1) bag of cookie dough and one (1) bag of dinner rolls that were not sealed.

2. Observation at 9:00 AM, revealed the sanitizer was not dispensing sanitizer from the Eco Lab dispenser; therefore, the sanitizing part of the three (3) pan sink, and red sanitizing buckets had no sanitizer in them.

The Surveyor asked the Dietary Manager to test the sink and the red bucket for sanitizer. No sanitizer registered with the test strips. The DM then added the sanitizer to the sink by hand and mixed it with water and the sanitizer registered.

3. Observation at 11:00 AM, revealed 60 plastic drinking cups and coffee mugs to be used for lunch were not allowed to air dry and were wet on the inside. They were stored stacked in a plastic container beside the tray line to be used for lunch. During this observation, the Dietary Manager asked dietary staff to rewash the cups.

4. Observation at 11:00 AM, revealed there were five (5) plastic cups that had a dried milky like substance and what appeared to be dried food particles on the inside of the cups that were to be used for lunch. The plastic cups were stacked in the dish washing room. During this observation, the Dietary Manager asked dietary staff to rewash the cups.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 0812 5. Observation at 11:00 AM, revealed there were six (6) dirty plates with what appeared to be dried food particles in the plate warmer that were ready to be used for lunch. They were stacked in the plate warmer Level of Harm - Minimal harm or beside the tray line. During this observation, the Dietary Manager asked dietary staff to rewash the plates. potential for actual harm 6. Observation at 11:00 AM, revealed the dirty dishes and dishwasher were in the same room with clean Residents Affected - Many dishes. When the dirty dishes and trays came through a window, a dietary staff member sprayed them

before sending the dishes through to the dishwasher. The dirty spray from the dirty dishes was contaminating the clean cups and dishes which were on a rack in the same room.

7. Observation at 11:00 AM, revealed the 32 kitchen trays the residents used to serve the residents their meals had plastic pieces missing from the corners and edges. Interview with the Dietary Manager during the

observation revealed new trays had been ordered.

During an interview on 07/26/2024 at 3:26 PM, the District Manager stated, It is my expectation for the kitchen to be fully functional, sanitary, and timely.

During an interview on 07/26/2024 at 3:21 PM, the Administrator stated, It is my expectation for the kitchen to follow policies and standards.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 28306 potential for actual harm Based on observation, interview, record review, and review of facility policy, the facility failed to establish and Residents Affected - Few maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow infection control guidelines and facility policy during wound care dressing changes for three (3) of three (3) residents reviewed for wound care out of a total sample of 25 residents, Resident (R) 84, Resident R19, and Resident R81.

The findings include:

Review of the facility's policy titled, Skin Care Standard of Practice, dated 07/2020, revealed, .A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing .

Review of the facility's undated Clean Wound Dressing Change competency for the nursing staff, revealed . Remove old dressing .Discard soiled dressing and gloves in plastic bag. Wash hands. [NAME] [put on] gloves .Pour sterile solution over gauze/cotton swabs using a basin or pouring over plastic bag. Cleanse wound using gauze/swabs from center outward in spiral motion with gentle pressure .Note on dressing: date, time dressing changed, and initials .

1. Review of Resident R84's undated Face Sheet located in the resident's electronic medical record (EMR), under the Face Sheet tab, revealed the facility readmitted the resident on 05/07/2024 with diagnoses of stage IV pressure ulcers to the right and left buttocks.

Review of Resident R84's Care Plan located under the Care Plan tab of the EMR, dated 03/21/2024, revealed a Goal stating .open areas will heal without worsening or complications . Interventions put into place included: Foley catheter to assist in wound healing; Mattress - pressure reduction; Provide gentle support when turning/positioning/transferring, and Provide pressure ulcer care as ordered.

Review of Resident R84's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/2024, revealed the facility assessed the resident as having two (2) stage IV pressure ulcers that were facility acquired.

Review of the Physician Orders located in the resident's EMR under the List tab, revealed an order, dated 07/25/2024 to: .Cleanse area to Right Buttocks with wound cleanser and pat dry. Pack wound with Iodoform Packing Strip and cover with border gauze daily .

Review of the Physician Orders located in the resident's EMR under the List tab revealed an order dated, 07/25/2024 to: .Cleanse area to the Left Buttock with wound cleanser and pat dry. Mix collagen powder with Medi honey and apply to wound. Cover with border gauze daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 During a wound care observation, on 07/26/2024 at 9:15 AM, with Licensed Practical Nurse (LPN) 2, the following failures were noted: 1) The scissors were cleaned with an alcohol prep pads prior to cutting the Level of Harm - Minimal harm or Iodoform packing strip gauze; 2) The over bed table was not cleaned prior to laying the barrier down on top potential for actual harm of it; 3) LPN2 removed the resident's right buttock dressing, then while exposed the resident was turned to

the other side. She then removed the left buttock dressing; 4) LPN2 removed her dirty gloves, then without Residents Affected - Few performing hand hygiene, she applied clean gloves; 5) LPN2 cleaned the left buttock wound with a 4 x 4, then folded the 4 x 4 over and cleaned the wound again using the same 4 x 4; and 6) LPN2 sprayed the wound cleanser directly into the left buttock wound prior to cleaning the wound, and then applied Medi honey into the left buttock wound using a gloved finger.

During an interview on 07/26/2024 at 5:55 PM, LPN2 stated, I only know to clean my scissors with the alcohol preps before using them on a dressing change. I realized I did not clean the over bed table with a bleach wipe when I laid the barrier down. When I was performing the wound care, I remembered that I needed to dress one wound then go to the other one, but that was after I started and had already removed

the dressings on both areas. I did not realize that I had used my gloved finger to apply the ointment into the left buttock wound until we started talking about it just now. I should have used a Q-Tip, and I should have sprayed the wound cleanser to the 4 x 4 instead of spraying it directly into the wound.

2. Review of Resident R19's undated Face Sheet located under the Face Sheet tab in the EMR revealed the facility readmitted the resident on 05/17/2024 with diagnoses including an unstageable pressure ulcer to the right calf and a stage II pressure ulcer to the right heel.

Review of Resident R19's Care Plan located under the Care Plan tab of the EMR, dated 05/08/2024, revealed a Goal stating .skin impairments will show signs of healing . Interventions included: Assist with turning/positioning; Provide diet/fluids as ordered; Provide pressure redistribution cushion to chair; Pressure redistributing mattress to bed to promote skin integrity; and Provide treatments as ordered.

Review of Resident R19's significant change MDS with an ARD of 05/20/2024, revealed the facility assessed the resident as having an unstageable pressure ulcer to the right calf and a stage II pressure ulcer to the right heel which were present on admission to the facility.

Review of the Physician Orders located in the EMR under the List tab, revealed an order, dated 07/25/2024, to .Cleanse area to right calf with wound cleanser and pat dry. Moisten collagen sheet with normal saline and cut to size of the wound bed. Apply collagen sheet to wound bed. Moisten calcium alginate sheet with normal saline and cut to size of wound bed. Apply calcium alginate to wound bed over collagen. Apply superabsorbent dressing and cover with ABD [abdominal gauze] pad. Wrap with Kerlix from just below the knee to ankle daily.

Review of the Physician Orders located in the EMR under the List tab, revealed an order, dated 07/25/2024, to .cleanse wound to Right heel with wound cleanser and pat dry. Apply Medi honey and cover with border gauze daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 During a wound care observation, on 07/26/2024 at 9:45 AM, with Registered Nurse (RN) 1, the following failures were noted: 1) The over bed table was not cleaned prior to placing the barrier on the table; 2) The Level of Harm - Minimal harm or privacy curtain was touching the clean barrier on the over bed table where dressing supplies were located; 3) potential for actual harm The bottle of wound cleanser was stored in the bedside table and was placed on the clean barrier without wiping it with a disinfectant wipe prior to wound care; 4) RN1 obtained Medi honey ointment from the original Residents Affected - Few tube by using a Q-Tip and applied the ointment by spreading it to the outer edges of the wound first, then into

the center of the wound on the right heel; 5) RN1 cleaned the wound to the right calf, then with the same soiled gloves, applied clean dressings as ordered with clean dressing supplies; 6) RN1 cleaned the wound to

the right calf by wiping the 4 x 4 the length of the wound and did not use a circular motion; 7) RN1's dirty gloves touched the privacy curtain prior to removing them after the dressing change to the right calf; 8) The clean dressings were applied to the right heel and to the right calf with no dates documented on the dressings; and 9) RN1 took the dirty scissors back to the Medication Storage room in the rehab unit where clean supplies were kept. RN1 washed the scissors with soap and water, dried them, and placed the scissors back into the wound care cart.

During an interview, on 07/26/2024 at 5:45 PM, RN1 stated, I know right off, I should have cleaned the over bed table with a wipe prior to starting. I sat the wound cleanser on the clean barrier, and I should not have. I realized when I was getting the Medi Honey out of the container that I should have placed it in a medicine cup and not brought the container into the resident's room, and I should have changed my gloves between cleaning and redressing the wound. I forgot to date the dressings that I had applied. When asked if RN1 should have taken the dirty scissors into the medication storage room where the clean dressing supplies were kept, RN1 replied, No. When asked if she should have used the disinfectant wipes to clean the scissors instead of using soap and water, RN1 replied, Yes I should have used the wipes.

3. Review of Resident R81's undated Face Sheet located under the Face Sheet tab in the EMR revealed the facility admitted the resident on 01/26/2024 with diagnoses including an unstageable pressure ulcer of the right heel, diabetes, and peripheral vascular disease.

Review of Resident R81's quarterly MDS with an ARD of 05/03/2024, revealed the facility assessed the resident as having a stage IV pressure ulcer to the right heel which was facility acquired.

Review of Resident R81's Care Plan located under the Care Plan tab of the EMR, dated 03/04/2024, revealed a Goal stating .wounds will shoe [sic] improvement/heal . Interventions included: Float heels off mattress as resident will allow; Pressure reduction mattress; Treatment as ordered; and Provide gentle support when turning/positioning/transferring.

During an observation, on 07/26/2024 at 11:15 AM with RN2, the following failures were noted: 1) The over bed table was not cleaned with a disinfectant wipe prior to placing the barrier down; 2) RN2 cleaned the wound, then used a 4 x 4 to wipe the wound twice without using a different area of the 4 x 4 for each time the wound was wiped.

During an interview, on 07/26/2024 at 5:40 PM, RN2 stated, I didn't clean the over bed table with a wipe

before I placed the barrier down and I should have. I should have used a clean 4 x 4 each time I wiped the wound or used a different area of the 4 x 4 each time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 185087 Department of Health & Human Services Printed: 09/17/2025 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 185087 B. Wing 07/26/2024

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

Twin Rivers Nursing and Rehabilitation Center 2420 West Third Street Owensboro, KY 42301

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 During an interview, on 07/26/2024 at 6:10 PM, the Director of Nursing (DON)stated, The over bed tables should have been cleaned with a disinfectant wipe prior to placing the barrier down. The nurses should Level of Harm - Minimal harm or change gloves after a wound is cleaned and before applying the clean dressings. The dressings should be potential for actual harm timed and dated when the clean dressing is applied. Scissors should be cleaned with a disinfectant wipe and not soap and water before and after each dressing change. The nurse's dirty gloves should not touch the Residents Affected - Few privacy curtain because you have contaminated the curtain when you do that. If the nurse is dressing two wounds, they should be treated as two different wounds. Each being dressed before the nurse moves on to

the next wound. The wound cleanser should be sprayed on a 4 x 4 and not directly into the wound. When the nurse cleans a wound, they should start in the center cleaning in a circular motion and working their way out to the edges of the wound. The nurse can discard the 4 x 4 each time the wound is cleaned, or they can use

a different area of the 4 x 4 to clean the wound. The wound cleanser bottle should not be placed on the clean barrier. Any type of ointment should be placed in a medicine cup and the tube or container should not be taken in the resident's room. This should be applied with a clean Q-Tip.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 185087