Vanceburg Rehab And Care, Llc

F-F697 )

The findings include:

Review of the facility's policy titled, Facility Responsibilities, revised 03/26/2024, revealed .It is the policy of

this facility to uphold and comply with the facility responsibilities .13. Notification of Change. a. A facility will immediately inform the resident; consult with the resident's physician .when there is: .ii. A significant change

in the residents' physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). iii. A need to alter treatment significantly .

Review of Resident R76's undated Admission Record revealed the the facility admitted the resident on 04/10/2024 with diagnoses which included alcoholic cirrhosis of liver, congestive heart failure, pain, and unilateral inguinal hernia.

Review of Resident R76's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/18/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Continued review of the MDS revealed the facility assessed the resident to have received scheduled and PRN (as needed) pain medications.

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 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0580 During an interview on 08/19/2024 at 11:50 AM, Resident R76 stated the facility ran out of his narcotic pain medication of Dilaudid this past weekend. The resident stated he was in severe pain over the weekend and rated his Level of Harm - Actual harm highest pain level at a 10 on a scale of zero to 10 with 10 being the most severe pain.

Residents Affected - Few Review of Resident R76's physician's Orders, revealed an order, Dilaudid Oral Tablet 4 MG [milligram] .Give 1 tablet every 3 hours as needed for pain, dated 08/05/2024.

Review of Resident R76's Medication Administration Record (MAR) for August 2024 revealed on 08/17/2024 at 4:00 PM, Resident R76 was administered his last dose of Dilaudid medication until 08/19/2024 at 8:00 AM. The MAR also revealed Resident R76's pain level was assessed and documented as 8 upon administration of the Dilaudid medication on 08/17/2024 at 4:00 PM.

Review of Resident R76's nursing Progress Note, dated 08/18/2024 at 5:24 PM, noted, Resident has not had pain medications all day today, as we continue to wait for the refill of his Dilaudid to come in. It has been reordered a few different times over the past week, but never came in. There was no documented evidence that the resident's physician and/or another provider was notified.

During an interview on 08/21/2024 at 10:58 PM, Licensed Practical Nurse (LPN) 1 stated the facility utilized

an emergency pharmacy kit (E-kit). When asked what the facility's practice was if a resident ran out of pain medication, and the pharmacy had not delivered it prior to the next scheduled dose, LPN1 stated she would first notify the physician and see if they wanted to order a medication from the E-kit and/or follow the physician's instructions.

During an interview on 08/21/2024 at 11:09 AM, Nurse Practitioner (NP) 1 stated Resident R76 was receiving hospice services; however, after collaboration with hospice, the facility was responsible for ensuring a hospice resident's medication was available at the facility to be administered as ordered. The NP stated it was her expectation nursing would have notified herself, the on-call physician service, or the Medical Director when

the resident ran out of the medication, and the pharmacy had not delivered the refill of the medication. NP1 stated had she or another provider been notified, something could have been ordered from the facility's E-kit, and the provider could have inquired with the pharmacy what was causing the delay.

During an interview on 08/21/2024 at 11:36 AM, the Unit Manager (UM) stated the nurses should have immediately notified the resident's physician and the hospice provider. The UM stated the physician could have ordered a pain medication stocked in the facility's E-kit for pain such as oxycodone or hydrocodone (both were narcotic pain medication used to treat pain). The UM also stated it was important the physician would have been notified to ensure Resident R76's pain management needs were met.

During an interview on 08/22/2024 at 5:15 PM, LPN2 stated she administered Resident R76's last dose of Dilaudid on 08/17/2024 at approximately 3:00 PM. When asked if she notified the physician or another provider once she administered Resident R76's last dose of Dilaudid, LPN2 stated she did not notify the physician or hospice services, but she should have as this was the facility's practice. When asked if there was a reason that she did not notify the physician, the LPN stated she thought Resident R76's Fentanyl patch would cover his pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0580 During an interview on 08/22/2024 at 5:46 PM, the Regional Nurse Consultant (RNC) stated it was her expectation the nurses would have contacted the physician when Resident R76's Dilaudid was not available to be Level of Harm - Actual harm administered to him. The RNC also stated had the physician been notified, the physician could have ordered

a pain medication from the E-kit. She stated the hospice physician should have been notified as well. The Residents Affected - Few RNC stated it was the facility's responsibility to ensure the resident's medication was ordered and available to be administered to Resident R76. The RNC further stated the facility's Medical Director collaborated with the hospice physician, and then the Medical Director wrote the prescriptions for the hospice pain medications.

During an interview on 08/22/2024 at 6:38 PM, the Medical Director stated it was her expectation the facility's nursing staff would have notified her that Resident R76 was out of his Dilaudid pain medication. The Medical Director stated with the resident's diagnoses, the dose of Dilaudid the resident was ordered and frequently administered, and the significant amount he missed, he would have experienced pain and had she been notified or another provider notified, along with hospice being notified, a one-time order for a pain medication could have been given and administered to the resident.

During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation the physician would have been notified if there was an issue with getting Resident R76's pain medication to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Level of Harm - Minimal harm or potential for actual harm 36898

Residents Affected - Few Based on interview, record review, and review of the facility's policy, the facility failed to ensure a resident who had a negative Preadmission Screening and Resident Review (PASARR) Level I and then later had a significant change in status and a new serious mental illness diagnosis was accurately and timely referred for

a PASARR Level II referral for 1 of 6 residents (Resident (R) 32) reviewed for PASARRs out of 28 sampled residents. This failure placed the resident at risk of qualifying for specialized services but not receiving the services due to the inaccuracy of the PASARR Level II referral.

The findings include:

Review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, revised 12/24/2023 revealed, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities .in accordance with the State's Medicaid rules for screening .b. PASARR Level II-a comprehensive evaluation by the appropriate state-designated authority that determines whether individual has MD [Mental Disorder] .and recommends any specialized services .the individual needs .8. Any resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional review .9. Any resident who exhibits a new evident or possible serious mental disorder .will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review .

Review of Resident R32's undated Admission Record, located in the resident's electronic medical record (EMR) under

the Profile tab revealed the facility admitted the resident on 04/08/2022 with diagnoses which included anxiety disorder. The Admission Record also revealed on 08/22/2022 the resident received a new serious mental disorder diagnosis of Psychotic Disorder With Delusions .

Review of Resident R32's Preadmission Screening and Resident Review program summary, provided by the facility revealed on 07/06/2023 the facility initiated a significant change in status PASARR Level II referral due to a new added diagnosis (psychotic disorder). The summary documented the resident received the diagnosis on 08/22/2022, 11 months prior to the Level II referral.

During an interview on 08/22/2024 at 10:09 AM, the PASARR Specialist (PS) and the PASARR Nurse Coordinator (PNC) with the State's PASARR Agency both stated Resident R32's significant change in status Level II referral was not completed timely. The PS stated the referral for a Level II should have been completed within 14 days of receiving the new mental illness diagnosis. The PNC stated when reviewing the Level II referral, the facility did not describe the diagnosis, who gave the diagnosis, or how it impaired the resident's functioning. The PS agreed and stated the facility did not correctly complete the Level II for a referral to be completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0644 During an interview on 08/22/2024 at 5:55 PM, the Regional Nurse Consultant (RNC) verified Resident R32's PASARR significant change in status referral for a new diagnosis was not completed timely or fully. The RNC Level of Harm - Minimal harm or stated it was her expectation PASARRs be completed accurately and timely. potential for actual harm

During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation residents' Residents Affected - Few PASARRs would have been completed correctly and timely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or 36898 potential for actual harm Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents' Residents Affected - Few Preadmission Screening and Resident Review (PASARR) Level I accurately reflected their current mental illness diagnoses for 3 of 6 residents (Resident (R) 32, Resident R36, and Resident R50) out of 28 sampled residents. This failure inaccurately produced negative PASARRs Level I and placed the residents at risk for unmet psychosocial needs and services had the PASARR triggered for a Level II referral.

The findings include:

Review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, revised 12/24/2023, revealed Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities . i. Negative Level I Screen-permits admission to proceed and ends the PASARR process unless a possible serious mental disorder .arises later .

1. Review of Resident R32's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 04/08/2022 with a diagnosis of anxiety disorder.

Review of Resident R32's Preadmission Screening and Resident Review Level I, dated 04/11/2022 and provided by

the facility, revealed for question, 2a. Diagnosis, Identify whether the individual has a current or suspected mental illness . The diagnoses listed were Anxiety Disorder and Dementia without Behavioral Disturbance [neurocognitive disorder].

2. Review of Resident R36's undated Admission Record, located in the resident's EMR under the Profile tab revealed

the facility admitted the resident on 06/28/2021 with diagnoses which included paranoid personality disorder and anxiety disorder.

Review of Resident R36's Preadmission Screening and Resident Review Level I, dated 06/30/2021 and provided by

the facility, revealed for question, 2a. Diagnosis, Identify whether the individual has a current or suspected mental illness ., the question was left blank which indicated the resident had no mental illnesses.

3. Review of Resident R50's undated Admission Record, located in the resident's EMR under the Profile tab revealed

the facility admitted the resident on 03/09/2021. The Admission Record did not list any mental health diagnoses upon admission.

Review of Resident R50's hospital Discharge Summary, dated 03/09/2021 and located in the resident's EMR under

the Misc [Miscellaneous] tab, revealed the resident was discharged to the facility with diagnoses which included schizoaffective disorder, bipolar type .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0645 Review of Resident R50's Preadmission Screening and Resident Review Level I, dated 03/11/2021 and provided by

the facility, revealed for the PASARR Level I question, 2a. Diagnosis, Identify whether the individual has a Level of Harm - Minimal harm or current or suspected mental illness ., the question was left blank which indicated the resident had no mental potential for actual harm illnesses.

Residents Affected - Few During an interview on 08/22/2024 at 10:09 AM, PASARR Specialist (PS) and PASARR Nurse Coordinator (PNC) with the State's PASARR Agency both stated Resident R32, Resident R36, and Resident R50's Level I PASARRs were not completed accurately. The PS stated Resident R32's diagnoses section was completed inaccurately as dementia was

a neurocognitive disorder, and this section was specifically for mental illness diagnoses only. Continued

interview revealed Resident R36's and Resident R50's PASARRs were incorrect as the diagnoses sections were left blank and should have included both Resident R36 and Resident R50's mental illness diagnoses.

During an interview on 08/22/2024 at 5:55 PM, the Regional Nurse Consultant (RNC) verified the above PASARRs were inaccurate. The RNC stated it was her expectation PASARRs be completed accurately.

During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation the residents' PASARRs would have been completed correctly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 15879 Residents Affected - Few Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement person centered comprehensive care plans for pain, activities, and a significant weight loss for 3 of 28 sampled residents, Resident (R) 76, Resident R34, and Resident R31. This placed the residents at risk for decreased quality of life, quality of care, and further exacerbation of an illness.

The findings include:

Review of the facility's policy titled, Comprehensive Care Plans, revised 12/23/2023, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being f. Resident specific interventions that reflect the resident's needs and preferences and align with

the resident's cultural identity, as indicated.

1. Review of Resident R76's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 04/10/2024 with diagnoses which included alcoholic cirrhosis of liver, congestive heart failure (CHF), pain, and unilateral inguinal hernia.

Review of Resident R76's nursing Admission progress note, dated 04/10/2024 and located in the resident's EMR under the Progress Notes tab, revealed, Resident admitted .on Hospice .

Review of Resident R76's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/18/2024 in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact.

During an interview on 08/19/2024 at 11:50 AM, Resident R76 stated the facility ran out of his Dilaudid narcotic pain medication this past weekend. The resident stated he was in severe pain over the weekend and rated his highest pain level at a 10 on a scale of zero to 10 with 10 being the most severe pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 R76's Comprehensive Care Plan (CCP), located in the resident's EMR under the Care Plan tab, revealed a focus initiated on 04/10/2024 and revised on 05/27/2024 that indicated, The resident needs pain Level of Harm - Actual harm management and monitoring related to generalized pain, enlarged scrotum, cirrhosis of liver, [and] mouth pain. Resident R76's goal indicated, Will maintain adequate level of comfort as evidenced by minimal s/sx Residents Affected - Few [signs/symptoms] of unrelieved pain or distress, or verbalizing satisfaction with level of comfort . The CCP interventions for the resident to obtain his goal included, .Provide pain medication as ordered .Utilize pain monitoring scale as ordered . Continued review of Resident R76's CCP revealed a focus of Resident requires Hospice services elated to cirrhosis of liver, chronic hepatic failure, [and] CHF. Resident R76's goal indicated, Resident's end of life wishes will be honored. The CCP interventions for the resident to obtain this goal included, .Administer medications as ordered .Notify hospice of any changes in resident's condition .Observe for pain and discomfort .

Review of Resident R76's nursing Progress Note, dated 08/18/2024 at 5:24 PM and located in the resident's EMR under the Progress Note tab, revealed, Resident has not had pain medications all day today, as we continue to wait for the refill of his Dilaudid to come in .

During an interview on 08/21/2024 at 12:20 PM, Resident R76 stated he received his last dose of Dilaudid Saturday afternoon. The resident stated Saturday night and all of Sunday he experienced so much pain he could not eat much of his meals and a couple of times he did not eat any of the meals. Resident R76 stated he was nauseated and had anxiety, and the nurse had to administer Ativan (antianxiety medication) and Phenergan (antiemetic medication).

During an interview on 08/21/2024 at 11:50 AM, Certified Nurse Aide (CNA) 5 stated he worked this past weekend and was assigned to Resident R76. CNA5 stated on Saturday evening (08/17/2024) Resident R76 asked him three or four times to let the nurse know he was in pain and was requesting his pain medication. CNA5 stated he could tell Resident R76 was experiencing pain because he was not himself Saturday or Sunday. CNA5 stated the resident would grunt at the end of his sentences, moan, and had facial grimacing.

During an interview on 08/22/2024 at 5:15 PM, Licensed Practical Nurse (LPN) 2 stated Resident R76 was care planned for pain management, and if his pain was not controlled, then his care plan would not have been implemented fully.

During an interview on 08/22/2024 at 5:46 PM, the Regional Nurse Consultant (RNC) reviewed Resident R76's CCP and stated the resident's care plan was not implemented due to the resident experiencing pain because the facility did not have his pain medication on hand.

During an interview on 08/22/2024 at 6:38 PM, the Medical Director, who was also Resident R76's Attending Physician, stated considering the dose he was on, the amount of the Dilaudid pain mediation Resident R76 missed was significant. The Medical Director also stated with the resident's cirrhosis of the liver and his large hernia,

the resident would have been in pain.

2. Review of Resident R34's annual MDS with an ARD date of 05/30/2024, located in the MDS tab of the EMR revealed the facility admitted the resident on 08/17/2022. Resident R34 had a BIMS score of 14 out of 15 indicating Resident R34's cognition was intact. Resident R34 had diagnoses of diabetes mellitus, schizophrenia, and unspecified hallucinations, and marked as having no weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 R34's diet order, dated 04/09/2023, located in the EMR under the Order tab, revealed, Controlled Carb [carbohydrate] diet, Regular texture, Regular/Thin consistency, Large protein portions only @ [at] all Level of Harm - Actual harm meals. May have small serving from dessert cart. May have special occasion meals.

Residents Affected - Few Review of Resident R34's CCP revised 05/29/2024, located in the EMR under the Care Plan tab, revealed, Nutritional Risk r/t [related to]: -dx [diagnoses] DM II [type two diabetes mellitus], schizophrenia, HTN [hypertension], HLD [hyperlipidemia] -need for therapeutic diet -potential side effects of antipsychotic medications: increased wt [weight] and obesity -obesity status with no interest in weight reduction at this time. The goal included, Resident R34 will maintain current level of PO [oral] intake at 76-100% [percent]/meal. An intervention for complications of Resident R34's diabetes mellitus included, Monitor/document/report PRN [as needed] any s/sx [sign/symptom] of hyperglycemia .weight loss .

Review of Resident R34's weight history, located in the EMR under the Weight/Vitals tab, revealed Resident R34 had lost nine percent of his body weight in five months (151 days). This included: 08/05/2024 at 237.8 Lbs. [pounds] standing;

07/05/2024 at 243.0 Lbs. standing; 06/06/2024 at 246.2 Lbs. standing; 06/05/2024 at 247.6 Lbs. standing; 05/03/2024 at 259.2 Lbs. standing; 04/03/2024 at 259.4 Lbs. standing; and 03/07/2024 at 261.6 Lbs. standing.

Review of Resident R34's Nutrition/Dietary Note, dated 06/12/2024, located in the EMR under the Progress Notes, revealed, Reweight was obtained 06/06/2024 of 246.2# [pounds], indicating a true significant weight loss of 13# (5.0%) has occurred x 30 days. Resident remains within obese BMI [body mass index] class (BMI=33.4). Has orders for CCD [controlled carbohydrate diet] diet, regular textures, thin consistencies, and large portion protein q [every] meal. Intake records show he has been eating 51-75%/meal on average over the last [seven] 7 days. Informed resident of weight change. Resident states he has not been intentionally trying to lose weight, but also is not concerned with weight loss. He voices no weight related goals at this time. Weight loss is considered beneficial due to obesity status but should be achieved at a safe/controlled rate of < [less than] 5%/month. Will continue with current plan at this time. RD [Registered Dietitian] will monitor and follow up with resident routinely and remains available PRN via consult.

Review of Resident R34's Nutrition/Dietary Note, dated 08/07/2024, located in the EMR under the Progress Notes, revealed, Resident R34 triggers for a significant weight loss of 21.4# (8.3%) x 90 days. CBW= 237.8#. He remains within obese BMI class (BMI= 32.2). Resident has orders for CCD diet, regular textures, thin consistencies, and large portion protein q meal. Intake records show he has been eating 76-100%/meal on average over

the last [seven] 7 days. Due to obesity status and resident continuing to have excellent PO intake, weight reduction is considered beneficial. No new recs [recommendations] at present time. RD will continue to monitor and follow up routinely and remains available PRN via consult.

Review of Resident R34's meal intake documentation, dated 08/03/2024 to 08/21/2024, located in the EMR under the Task tab, revealed Resident R34 consumed 76-100% of most meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 a telephone interview on 08/21/2024 at 5:50 PM, the RD was asked if she was aware of Resident R34's weight loss. The RD stated she was aware of significant weight loss but it's beneficial due to his obese status. The Level of Harm - Actual harm RD acknowledged although weight loss could be beneficial for his obese status, the reason he was losing might not be beneficial should it continue. The RD was asked if the weight loss for beneficial reasons was Residents Affected - Few care planned with goals, and when was Resident R34's weight loss enough, the RD stated, I missed care planning it, I forgot.

During an interview on 08/22/2024 at 8:25 AM, the Dietary Manager (DM) stated a planned weight loss needed to be care planned.

3. Review of Resident R31's Face Sheet located in the Admission tab of the EMR, revealed Resident R31 was admitted to the facility on [DATE REDACTED] with diagnoses of Huntington's Disease, cognitive communication disorder, anxiety, and contracture of the left hand.

Review of the MDS located under the MDS tab of the EMR, with an ARD of 06/25/2024, revealed Resident R31 had a BIMS score of one out of 15 which indicated his cognition was severely impaired. Review of the MDS revealed Resident R31 liked trivia, discussions, reading, puzzles, television, movies, bingo, cards, video games, tablet, church, nature, and musicals. The preferences further revealed Resident R31 enjoyed church services, gospel music, and he face-timed with his wife multiple times a day. Review of Resident R31's preferences revealed it was very important to him to go to religious services and gospel music.

Review of Resident R31's CCP, dated 03/22/2024 and 07/16/2024 located under the Care Plan tab in the EMR, revealed a problem for activities which indicated Resident R31 preferred independent activities or spending time with his family on the Facebook portal. Review of the interventions included: resident was to be invited to activities, spend time with his family on the Facebook portal, television, country music, reading, cards, and

he was to receive in-room activities three times a week. Review of the CCP further revealed Resident R31 liked to talk to his wife daily on the Facebook portal.

Review of Resident R31's activity calendar documentation for August and July 2024 revealed Resident R31 had used the Facebook portal one time to talk to his wife.

During an interview on 08/22/2024 at 10:38 AM, Resident R31 stated he would like to go to musicals and church if the facility had those activities. Resident R31 stated he was not able to get up himself and depended on staff to get him up for activities.

During an interview with Resident R31's wife on 08/19/2024 at 2:42 PM, she stated they had gone to a July 4th singing activity in the dining room, and that was the only one she knew Resident R31 had been to. She stated that she was not sure what activities the facility did with the resident.

During an interview on 08/21/2024 at 3:50 PM, the Activity Director (AD) stated Resident R31 liked to use Facebook portal to talk to his wife. The AD further revealed staff had to set the computer up for the resident to use the Facebook portal because he was unable to set it up himself.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 an interview on 08/21/2024 at 4:11 PM, the Activity Assistant (AA1) stated staff did one-on-one reading, hand massages, leg massages, and talked to Resident R31. The AA1 stated Resident R31's arms were contracted, Level of Harm - Actual harm and he could not do puzzles, but he liked being read to and massaging his legs, but for the most part she made sure the television or radio was on. The AA1 stated that Resident R31 had a Facebook portal, but it had to be Residents Affected - Few set up for him because he was unable to set it up himself. The AA1 further stated staff did not document that

she asked him if he wanted to set up the Facebook portal.

During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation that residents' care plans were followed.

36190

36898

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or 15879 potential for actual harm Based on interview, record review, and review of the facility's policy, the facility failed to ensure 1 of 28 Residents Affected - Few sampled resident, Resident (R) 31, was provided with activities of his interest. The failure to provide these activities placed Resident R31 at risk for isolation.

The findings include:

Review of the facility's policy titled, Activities, dated 02/01/2024 revealed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independent and interactive within the community .activities refers to any endeavor other than routine . Activities of Daily Living (ADL) in which a resident participates that is intended to enhance his/her sense of wellbeing and promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self esteem, pleasure, comfort, education, creativity, success, and independence. Activities will be designed with the intent to enhance the resident's sense of wellbeing, belonging, and usefulness, reflect residents' interest and reflect cultural and religious interests of the resident and reflect choices of the resident. Space and equipment necessary are provided to ensure the residents care plan is followed. Activities will include individual, small, and large group activities as well as indoor and outdoor activities, religious programs. The facility will consider accommodation in schedules, supplies, and timing in order to optimize a resident's ability to participate in activities of choice.

Review of Resident R31's Face Sheet located in the Admission tab of the electronic medical record (EMR) revealed

the facility admitted Resident R31 on 09/26/2017 with diagnoses of Huntington's Disease, cognitive communication disorder, and contracture of the left hand

Review of Resident R31's Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/25/2024, revealed Resident R31 had a Brief Interview for Mental Status (BIMS) score of one out of 15 which indicated his cognition was severely impaired. Review of the MDS revealed Resident R31 liked trivia, discussions, reading, puzzles, television, movies, bingo, cards, video games, tablet, church, nature, and musicals. The preferences further revealed Resident R31 enjoyed church services, gospel music, and he face-timed with his wife multiple times a day. Review of Resident R31's preferences revealed it was very important to him to go to religious services and to listen to gospel music. Review of the MDS indicated that Resident R31 was usually understood.

Review of Resident R31's comprehensive Care Plan, dated 03/22/2024 with a target date of 07/16/2024 located in the EMR under the Care Plan tab revealed a problem for activities. Review of the care plan further revealed Resident R31 preferred independent activities or spending time with his family on the Facebook portal. Review of the interventions included: resident was to be invited to activities, spend time with his family on the Facebook portal, television, country music, reading, cards, and he was to receive in-room activities three times a week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0679 Review of Resident R31's July 2024 Activity Calendar revealed on 07/02/2024 he was people watching in the hallway;

on 07/03/2024 he was people watching; on 07/05/2024 he had aroma therapy and was read to; on Level of Harm - Minimal harm or 07/08/2024 he had aroma therapy, and his leg was massaged; on 07/10/2024 he had aroma therapy, and his potential for actual harm arm was massaged; on 07/11/2024 he had aroma therapy, and his leg was massaged; on 07/15/2024 his television was turned on, and the Activity Assistant (AA) 1 talked to him; on 07/17/2024 AA1 set up Residents Affected - Few Facebook; on 07/19/2024 AA1 turned the television on and talked to him; on 07/24/2024 AA1 read to him and massaged his legs; on 07/25/2024 and 07/26/2024 AA1 talked with Resident R31 and did aroma therapy; on 07/29/2024 AA1 talked and read to him; on 07/30/2024 he had aroma therapy, and his legs were massaged.

Review of the July 2024 Activity Calendar for all residents revealed on 07/07/2024, 07/14/2024, 07/21/2024, and 07/28/2024 gospel music and church services were offered. However, review of the documentation from

these activities revealed Resident R31 did not attend any of them.

Review of Resident R31's August 2024 Activity Calendar, through 08/21/2024, revealed on 08/02/2024 Resident R31 was up in

the hallway; on 08/07/2024 he was talked to; on 08/08/2024 he was talked to, and the television was turned on; on 08/09/2024 he was talked to, and the television was turned on; on 08/14/2024 he was up in a chair in

the common area; on 08/15/2024 his wife visited, and he was read to; on 08/16/2024 he was up in a chair in

the common area; on 08/19/2024 his wife visited; and on 08/21/2024 the television was turned on.

Review of the August 2024 Activity Calendar, through 08/21/2024, for all residents revealed on 08/04/2024, 08/11/2024, and 08/18/2024 all day gospel music and church services were offered. Further review revealed

on 08/06/2024, outdoor time and snacks were done. Also, on 08/03/2024, 08/10/2024, and 08/17/2024 the

review revealed Saturday morning news was offered. Further review revealed Bible study was offered on 08/21/2024. Review of the documentation from these activities revealed Resident R31 did not attend any of them.

During an interview on 08/22/2024 at 10:38 AM, Resident R31 stated he would like to go to musicals and church if the facility had those activities. Resident R31 stated he was not able to get up himself and depended on staff to get him up for activities.

During an interview with Resident R31's wife on 08/19/2024 at 2:42 PM, she stated she and Resident R31 had gone to a July 4th singing activity in the dining room. She stated she was not sure what activities the facility did with the resident.

During an interview on 08/21/2024 at 4:11 PM with AA1, she stated staff did one-on-one reading, hand massages, leg massages, and talking with Resident R31. AA1 stated she gave him things he might need for independent activities like turning on the television or radio. AA1 stated Resident R31 was contracted and could not do puzzles, but he liked being read to and massaging his legs. She stated she tried to make sure the television or radio was on, and Resident R31 had a Facebook portal, but it had to be set up for him because he was unable to set it up himself. AA1 stated she had not set the Facebook portal up for him in a couple of months because

he had not asked her to set it up. AA1 stated she did not document that she asked him if he wanted to set up

the Facebook portal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0679 During an interview on 08/21/2024 at 3:50 PM, the Activity Director (AD) stated staff usually got Resident R31 up daily, and he went to activities three times a week. The AD stated Resident R31 used the Facebook portal to talk to his wife. Level of Harm - Minimal harm or The AD further stated staff had to set the computer up for the resident to use the Facebook portal because potential for actual harm he was unable to set it up himself.

Residents Affected - Few During an interview on 08/22/2024 at 8:24 PM, the Administrator stated residents should have activities while

in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36190 potential for actual harm Based on observation, interview, record review and review of the facility's policy, the facility failed to maintain Residents Affected - Few acceptable nutritional parameters by not assessing the reason for significant weight loss for 1 of 6 sampled residents, Resident (R) 34, reviewed for nutrition in the sample of 28 residents. This had the potential to cause further weight loss without a root cause analysis and/or additional interventions put in place.

The findings include:

Review of the facility's policy titled Nutrition Management, dated 02/01/2024, revealed, 2. Identification/assessment . c. A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Components of the assessment may include but are not limited to vi. Presence of persistent hunger, poor intake, or continued weight loss.

Review of Resident R34's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/30/2024, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE REDACTED]. Resident R34 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating Resident R34's cognition was intact. Resident R34 had diagnoses of diabetes mellitus, schizophrenia, and unspecified hallucinations, and the MDS was marked as having no weight loss.

Review of Resident R34's diet order, dated 04/09/2023, located in the EMR under the Order tab revealed a Controlled Carb [carbohydrate] diet, Regular texture, Regular/Thin consistency, Large protein portions only @ [at] all meals. May have small serving from dessert cart. May have special occasion meals.

Review of Resident R34's Care Plan, revised 05/29/2024, located in the EMR under the Care Plan tab revealed Nutritional Risk r/t [related to]: -dx [diagnoses] DM II [type two diabetes mellitus], schizophrenia, HTN [hypertension], HLD [hyperlipidemia] -need for therapeutic diet -potential side effects of antipsychotic medications: increased wt [weight] and obesity -obesity status with no interest in weight reduction at this time. The goal included Resident R34 will maintain current level of PO [oral] intake at 76-100%/meal. An intervention for complications of Resident R34's diabetes mellitus included, Monitor/document/report PRN [as needed] any s/sx [sign/symptom] of hyperglycemia .weight loss .

Review of Resident R34's weight history, located in the EMR under the Weight/Vitals tab, revealed Resident R34 had lost nine percent of his body weight in five months (151 days). This included: 08/05/2024 at 237.8 Lbs. [pounds] standing;

07/05/2024 at 243.0 Lbs. standing; 06/06/2024 at 246.2 Lbs. standing; 06/05/2024 at 247.6 Lbs. standing; 05/03/2024 at 259.2 Lbs. standing; 04/03/2024 at 259.4 Lbs. standing; 03/07/2024 at 261.6 Lbs. standing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0692 Review of the Registered Dietician (RD)'s Comprehensive Nutritional Evaluation in the EMR under the Evaluation tab, dated 05/29/2024, revealed Resident R34 had an elevated A1C (blood test that reflected the average Level of Harm - Minimal harm or blood sugar level for the past two to three months). Further review, in the RD's Dietary Quarterly Evaluation, potential for actual harm dated 02/22/2024, revealed the RD noted Resident R34 had an elevated albumin level (blood test that checked your liver and kidney function), Fasting Blood Sugar (FBS), A1C, Blood Urea Nitrogen (BUN), BUN/Creatinine Residents Affected - Few ratio, and Potassium (K+) blood level.

Review of Resident R34's Nutrition/Dietary Note, dated 06/12/2024, located in the EMR under the Progress Notes revealed, Reweight was obtained 06/06/2024 of 246.2# [pounds], indicating a true significant weight loss of 13# (5.0%) has occurred x 30 days. Resident remains within obese BMI [body mass index] class (BMI=33.4). Has orders for CCD [controlled carbohydrate diet] diet, regular textures, thin consistencies, and large portion protein q [every] meal. Intake records show he has been eating 51-75%/meal on average over the last [seven] 7 days. Informed resident of weight change. Resident states he has not been intentionally trying to lose weight, but also is not concerned with weight loss. He voices no weight related goals at this time. Weight loss is considered beneficial due to obesity status but should be achieved at a safe/controlled rate of < [less than] 5% [percent]/month. Will continue with current plan at this time. RD will monitor and follow up with resident routinely and remains available PRN [as needed] via consult.

Review of Resident R34's Nutrition/Dietary Note, dated 08/07/2024, located in the EMR under the Progress Notes revealed, Resident R34 triggers for a significant weight loss of 21.4# (8.3%) x 90 days. CBW= 237.8#. He remains within obese BMI class (BMI= 32.2). Resident has orders for CCD diet, regular textures, thin consistencies, and large portion protein q meal. Intake records show he has been eating 76-100%/meal on average over

the last [seven] 7 days. Due to obesity status and resident continuing to have excellent PO intake, weight reduction is considered beneficial. No new recs [recommendations] at present time. RD will continue to monitor and follow up routinely and remains available PRN [as needed] via consult.

Review of Resident R34's meal intake documentation, dated 08/03/2024 to 08/21/2024, located in the EMR under the Task tab revealed Resident R34 consumed 76-100% of the meals.

Observation on 08/20/2024 at 12:50 PM revealed Resident R34 was served his lunch in his room. Resident R34 ate 100% of his meal that consisted of a large serving of baked fish, rice, vegetables, bread, and a dessert.

Observation on 08/21/2024 at 9:09 AM revealed Resident R34 was served his breakfast in his room. Resident R34 ate 100% of his meal that consisted of cereal, a large serving of scrambled eggs, sausage, toast, milk, and juice. Resident R34 was asked if he got enough to eat at meals. Resident R34 did not answer the question.

During a telephone interview on 08/21/2024 at 5:50 PM, the RD was asked if she was aware of Resident R34's weight loss. The RD stated she was aware of significant weight loss but it's beneficial due to his obese status. The RD was asked why Resident R34 was losing weight, and the RD stated she was not sure because Resident R34 ate well, and

he was not active. The RD was asked if it was acceptable for Resident R34 to continue to have unplanned weight loss, and if no, what was in place to address it. The RD stated, Although weight loss could be beneficial for his obese status, the reason he's losing weight may not be beneficial should it continue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0692 Observation on 08/22/2024 at 7:58 AM revealed Resident R34 was served his breakfast in his room. Resident R34 ate 100% of his meal that consisted of a large portion of scrambled eggs mixed with sausage, toast, cereal, orange juice, Level of Harm - Minimal harm or and milk. potential for actual harm

During an interview on 08/22/2024 at 8:25 AM, the Dietary Manager (DM) was asked why Resident R34 was losing Residents Affected - Few weight. The DM stated she did ask Resident R34 if he wanted more food this morning and he said yes. The DM stated

she was not sure why Resident R34 was losing weight but would talk to the RD about it and see if Resident R34 needed large portions for all food items.

During an interview on 08/22/2024 at 10:53 AM, the Nurse Practitioner (NP)1 was asked about Resident R34's weight loss. NP1 stated she was not aware of any significant weight loss. NP1 reviewed the EMR and stated, Resident R34's BMI is high but I see what you mean about Resident R34's weight is trending down. NP1 stated the RD oversaw Resident R34's nutrition.

During an interview on 08/22/2024 at 6:07 PM, the Unit Manager (UM) was asked if the facility had a weight committee. The UM stated they had a NAR [nutrition at risk] committee. The UM was asked if she was aware of any significant weight loss for Resident R34. The UM stated, No, Resident R34 gets large protein at meals but that's all. The UM stated Resident R34 was not discussed during their NAR for significant weight loss in the 08/22/2024 meeting, 08/15/2024 meeting, or 07/31/2024 meeting. The UM was asked how a resident got on the list on the NAR meetings. The UM stated the RD sent a list of residents with significant weight loss. The UM stated Resident R34 would take more food at times when offered and would also ask for more food. The UM stated the RD documented weight loss as beneficial but no cause for the weight loss was determined. The UM asked if a root cause analysis was completed, and the UM stated she did not think so. The UM stated if there was no reason for Resident R34 to lose weight, it could not be labeled as planned and could be a symptom of something wrong.

During an interview on 08/22/2024 at 8:26 PM, the Administrator was asked about Resident R34's weight loss and his expectations. The Administrator stated to ensure Resident R34 was provided the correct nutrition, a root cause analysis should be done to determine why Resident R34 was losing weight.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm 15879

Residents Affected - Few Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure 2 out of the 3 residents with a gastrostomy tube (G-tube) had the tube placement verified and the residual determined prior to any fluids or medications being administered, Resident (R) 46 and Resident R80. This failure had

the potential for these residents to be at risk for aspiration pneumonia.

The findings include:

Review of the facility's policy titled, Medication Administration via Enteral Tube, dated 02/14/2024, revealed,

It is the policy of the facility to ensure the safe and effective administration of medication via enteral feeding tube by utilizing best practice guidelines .enteral tube placement must be verified prior to administration of fluids or medication .

1. Review of Resident R46's Face Sheet located in the Admission Record of the electronic medical record (EMR) revealed the facility admitted Resident R46 on 04/01/2023 with diagnoses of malignant neoplasm of larynx, dementia, and dysphagia that required enteral feedings.

Review of Resident R46's annual Minimum Data Set (MDS) located in the MDS tab of the EMR, with an assessment reference date (ARD) of 06/13/2024, revealed Resident R46 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident's cognition was moderately impaired.

Review of Resident R46's comprehensive Care Plan located in the Care Plan tab of the EMR revealed a problem was listed for enteral feeding, and staff was to check for tube placement and gastric contents/residual volume according to the facility's protocol.

Observation on 08/20/2024 at 4:45 PM of Licensed Practical Nurse (LPN) 4 revealed Resident R46 was in the bed in his room. Resident R46 was to receive a bolus of water through the G-tube. LPN4 did not check for placement of the G-tube prior to flushing it. LPN4 attempted to flush the G-tube, but the water would not go down the tube, so

she used the plunger to get the water to flush. During this observation, LPN4 started Resident R46's tube feeding of Two Cal formula at 50 milliliters per hour.

2. Review of Resident R80's Face Sheet located in the Admission Record of the EMR revealed the facility admitted Resident R80 on 03/18/2024 with diagnoses of dysphagia, gastrostomy status, dementia with psychotic features, diabetes, and malnutrition.

Review of Resident R80's significant change MDS, with an ARD of 07/25/2024, revealed a BIMS score of zero which indicated the resident was not able to complete the assessment.

Review of Resident R80's Physician Orders, dated 08/22/2024 at 7:03 AM in the EMR revealed a stat (immediate)abdominal x-ray was ordered to check for G-tube placement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 0693 Observation on 08/22/2024 at 4:55 PM of LPN4 revealed Resident R80 was in the bed in his room. LPN4 did not check for placement or residual before flushing the tube. LPN4 flushed Resident R80's G-tube with water, then a Level of Harm - Minimal harm or Glucerna bolus, flushed with water again, gave a Glucerna bolus, and ended the administration with a bolus potential for actual harm of water.

Residents Affected - Few During an interview on 08/21/2024 at 11:24 AM, LPN4 revealed the G-tube placement should have been checked before she administered any fluids or feeding, but she forgot to check placement. LPN4 further revealed if the G-tube was not in the right place there was a possibility the feeding or fluids could go into the lungs which could cause aspiration pneumonia or an infection.

During an interview with LPN3 on 08/21/2024 at 9:45 AM, LPN3 stated staff should check for placement of

the G-tube before administering anything down the tube. LPN3 stated staff should instill about 30 ml of air, listen with your stethoscope for the air, and then check for residual before administering any fluids or medications. LPN3 stated if the G-tube was not in the right place, the fluid or medication instilled could go into the resident's lungs.

During an interview on 08/21/2024 at 11:49 AM, the Director of Nursing (DON) stated that placement and residual of the G-tube should be verified before instilling anything down the tube. The DON stated the nurse should instill air into the tube and listen with the stethoscope for the air and then pull back on the syringe to check for residual. The DON revealed if the nurse did not check for placement it put the resident at risk of aspiration pneumonia.

During an interview on 08/22/2024 at 5:07 PM, the Administrator stated that placement of the G-tube should be verified before any fluids or medication were administered. The Administrator further stated that fluids could go into the wrong place if the tube was misplaced.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Actual harm 36898

Residents Affected - Few Based on interview, record review, and review of the facility's policies, the facility failed to ensure a resident, who was on end of life hospice services, pain was effectively managed per the physician orders for 1 of 2 residents reviewed for pain out of 28 sampled residents, Resident (R) 76. Resident R76 was ordered Dilaudid (a narcotic pain medication used to treat severe pain) every three hours as needed. Resident R76 was administered his last dose of Dilaudid on 08/17/2024 at 4:00 PM. The facility did not procure the resident's Dilaudid until 08/19/2024, and the medication was administered to the resident at 8:00 AM which indicated the resident went without the pain medication for 40 hours. This failure resulted in harm to Resident R76 due to him experiencing severe pain.

The findings include:

Review of the facility's policy titled, Pain Management Program, dated 08/01/2024, revealed, Purpose: Promote recognition and intervention to manage pain at the individual's goal or tolerance level to promote

the highest quality of life practicable .a. Pain can affect the person's ability to function and perform activities of daily living such as bathing, toileting, dressing, and walking. b. Pain has also been shown to increase stress, delay healing, decrease mobility and interfere with sleep and appetite. c. Chronic pain can cause psychological and emotional distress, leading to depression, low self-esteem, social isolation, and feelings of hopelessness . The goal of this program is to manage the resident's pain to optimize their quality of life. By effectively managing pain, the team continues to provide the highest quality of care while helping residents maintain their maximum level of independence.a. The physician's role .is to consider various medications and interventions that may provide pain relief that are not associated with negative impact on the resident's function or level of orientation or wakefulness .

Review of the facility's policy titled, Hospice Services Facility Agreement, revised February 2023, revealed, It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination .e the facility will immediately notify the hospice about the following: i. A significant change in the resident's physical, mental, social, or emotional status .h. A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient .and drugs necessary for palliation of pain and symptoms associated with the terminal illness .

Review of Resident R76's undated Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 04/10/2024 with diagnoses which included alcoholic cirrhosis of liver, congestive heart failure, pain, and unilateral inguinal hernia.

Review of Resident R76's nursing Admission progress note, dated 04/10/2024 and located in the resident's EMR under the Progress Notes tab, revealed, Resident admitted .on Hospice of Hope Maysville.

Review of Resident R76's physician Orders, located in the EMR under the Orders tab, revealed an order dated 04/11/2024 for hospice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 R76's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/18/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the Level of Harm - Actual harm resident was cognitively intact. Continued review of the MDS revealed the facility assessed the resident to have received scheduled and PRN (as needed) pain medications. Residents Affected - Few

During an interview on 08/19/2024 at 11:50 AM, Resident R76 stated the facility ran out of his Dilaudid narcotic pain medication this past weekend. The resident stated he was in severe pain over the weekend and rated his highest pain level at a 10 on a scale of zero to 10 with 10 being the most severe pain.

Review of Resident R76's physician Orders, located in the resident's EMR under the Orders tab, revealed an order dated 08/05/2024 for Dilaudid Oral Tablet 4 MG [milligram] .Give 1 tablet every 3 hours as needed for pain. Continued review of the Orders revealed a physician order dated 07/12/2024 for Fentanyl Transdermal Patch [medication to treat severe chronic pain] 72 Hour 72 MCG/HR [microgram/hour] .Apply 1 patch trans dermally one time a day every 3 day(s) for pain .

Review of Resident R76's Controlled Drug Receipt/Record/Disposition Form, dated 08/12/2024, revealed the facility received 30 tablets of Dilaudid 4 MG tablets for Resident R76.

Review of Resident R76's Medication Administration Record (MAR), dated August 2024 and located in the EMR under

the Orders tab, revealed from 08/12/2024 through 08/15/2024 the resident was administered the Dilaudid PRN pain medication at a minimum of five doses each day. Continued review of the MAR revealed on 08/17/2024 at 4:00 PM, Resident R76 was administered his last dose of Dilaudid medication until 08/19/2024 at 8:00 AM. The MAR also revealed Resident R76's pain level was assessed and documented as 8 upon administration of the Dilaudid medication on 08/17/2024 at 4:00 PM.

Review of Resident R76's nursing Progress Note, dated 08/17/2024 at 4:55 PM and located in the resident's EMR under the Progress Notes tab, revealed the nurse documented Resident R76's follow-up post administration of the Dilaudid as effective with a post administration pain level of 2.

Review of the Controlled Drug Receipt/Record/Disposition Form, dated 08/19/2024, revealed the facility received 30 tablets of Dilaudid. Further review revealed, on 08/19/2024 at 8:00 AM, Resident R76's pain level was nine, and he was administered Dilaudid pain medication.

Review of Resident R76's nursing Progress Note, dated 08/18/2024 at 4:16 AM and located in the resident's EMR under the Progress Notes tab, revealed, Resident is out of Hydromorphone [Dilaudid] 4mg at this time. This nurse called .Pharmacy when residents [sic] refills didn't get shipped to facility .Pharmacy to STAT [rush/without delay] residents Hydromorphone (Dilaudid) 4mg to facility.

Review of Resident R76's nursing Progress Note, dated 08/18/2024 at 5:24 PM and located in the resident's EMR under the Progress Note tab, revealed, Resident has not had pain medications all day today, as we continue to wait for the refill of his Dilaudid to come in. It has been reordered a few different times over the past week, but never came in.

Review of Resident R76's nursing Progress Note, dated 08/18/2024 at 5:27 PM and located in the resident's EMR under the Progress Notes tab, revealed, Pharmacy stated this morning they would Stat it in today.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 During an interview on 08/21/2024 at 12:20 PM, Resident R76 stated he received his last dose of Dilaudid Saturday afternoon. The resident stated Saturday night and all of Sunday he experienced so much pain he could not Level of Harm - Actual harm eat much of his meals and a couple times he did not eat any of the meal. Resident R76 stated he had anxiety and was nauseated. The nurse had to administer him Ativan (antianxiety pain medication) and Phenergan (antiemetic Residents Affected - Few medication).

During an interview on 08/21/2024 at 11:50 AM, Certified Nurse Aide (CNA) 5 stated he worked this past weekend and was assigned to Resident R76. CNA5 stated on Saturday evening (08/17/2024) Resident R76 asked him three or four times to let the nurse know he was in pain and was requesting his pain medication. CNA5 stated he could tell Resident R76 was experiencing pain because he was not himself Saturday or Sunday. CNA5 stated the resident would grunt at the end of his sentences, moan, and had facial grimacing. CNA5 stated on Sunday (08/18/2024) Resident R76 pushed his call light numerous times and every time the resident requested his pain medication, he would be holding his stomach when asking. CNA5 stated he reported the resident's complaints of pain and requests for pain medications to Licensed Practical Nurse (LPN) 2 each time. CNA5 stated the second time CNA5 reported the resident's complaint of pain to LPN2, she stated that she was still waiting for the pharmacy to deliver the medication. CNA5 stated he asked LPN2 to go and explain this to Resident R76.

During an interview on 08/21/2024 at 6:04 PM, CNA4 stated on Saturday evening/night (08/17/2024), he went into the resident's room to bring his dinner to him, and the resident stated he was in too much pain to eat. CNA4 stated he could tell Resident R76 was in pain because he never missed a meal, even if it was eating a peanut butter sandwich. CNA4 stated he reported the resident's complaint of pain to the nurse.

During an interview on 08/21/2024 at 6:48 PM, Kentucky Medication Aide (KMA) 1 stated she was assigned to administer medications to Resident R76 on Sunday (08/18/2024). KMA1 stated she received shift report from LPN2 and was told Resident R76 was out of his Dilaudid, but it had been ordered from the pharmacy. KMA1 stated she could tell Resident R76 was not feeling the best, and the resident requested his PRN Ativan because of his anxiety and Phenergan because he reported his stomach was upset.

During an interview on 08/22/2024 at 5:15 PM, LPN2 stated she administered Resident R76 his last available dose of Dilaudid on Saturday (08/17/2024) around 3:00 PM. LPN2 stated she had ordered it a couple of times herself. LPN2 stated she changed Resident R76's Fentanyl patch Saturday morning, and to her knowledge, the resident was not in any pain prior to leaving after her shift at approximately 7:00 PM. LPN2 stated she called

the pharmacy on Sunday evening to check the status of the delivery of the medication, and the pharmacy told her it was on its way. The LPN stated Resident R76 asked her if she had heard anything about his medication, and she told the resident the pharmacy was sending the medication STAT. When asked what the resident's pain level on Saturday and Sunday was when he did not have the Dilaudid pain medication, LPN2 stated she did not assess the resident's pain. When asked if she notified the resident's physician or another provider regarding the resident being out of the Dilaudid and the pharmacy not delivering the medication, LPN2 stated

she thought the resident's Fentanyl patch would provide pain coverage. LPN2 also stated it was the facility's practice to notify the resident's physician and hospice and follow their orders; however, she did not do this and stated, it's my fault. She stated it was important for hospice residents to have their end-of-life medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 During an interview on 08/21/2024 at 11:36 AM, the Unit Manager (UM) stated on 08/19/2024 she was reviewing the nursing reports from the weekend when she identified Resident R76 was without his Dilaudid pain Level of Harm - Actual harm medication. The UM stated nursing should have notified a provider for an order for a medication out of the facility's E-kit for Resident R76 to be administered something for pain. The UM stated it would have been important for Residents Affected - Few nursing staff to notify a provider to meet the resident's needs of effective pain management.

During an interview on 08/21/2024 at 11:09 AM, Nurse Practitioner (NP) 1 stated Resident R76 was receiving hospice services, and the facility was responsible for ordering residents' pain medications from the pharmacy. NP1 stated the facility collaborated with the hospice care team including the resident's hospice physician. NP1 also stated on 08/05/2024, the resident's attending physician changed the resident's oxycodone he was receiving for breakthrough pain to Dilaudid for better control of the resident's pain. Further interview with NP1 revealed if the facility ran out of Resident R76's Dilaudid and was having trouble receiving it from the pharmacy, the nurse should have notified the on-call physician service, herself, or attending/Medical Director for an order for Resident R76 to be administered a pain medication from the facility's emergency pharmacy (E-kit) until the issue with the pharmacy was resolved. NP1 stated this would have been what she would have expected from the nurses. NP1 further stated Resident R76 had a terminal prognosis with cirrhosis of the liver and an inoperable hernia.

The NP stated with the resident's terminal illnesses and with the resident going all day without any Dilaudid for breakthrough pain, the resident could have experienced excruciating pain.

During an interview on 08/22/2024 at 6:34 PM, the Consultant Pharmacist (CP) stated if Resident R76 was requesting

the Dilaudid pain medication, then he was probably in pain as the Dilaudid was used to cover his breakthrough pain the Fentanyl patch did not cover. The CP stated hospice residents should never go without pain medications during their end-of-life care.

During an interview on 08/22/2024 at 5:46 PM, the Regional Nurse Consultant (RNC) stated it was her expectation that the nurses would have contacted the physician when Resident R76's Dilaudid medication was not available. The RNC stated the physician could have ordered something form the facility's E-kit in the interim while waiting for the medication to arrive from the pharmacy

During an interview on 08/22/2024 at 6:38 PM, the Medical Director, who was also Resident R76's Attending Physician, stated the amount of the Dilaudid pain mediation Resident R76 missed considering the dose he was on was significant, and with the resident's cirrhosis and his large hernia, the resident would have been in pain.

The Medical Director stated the significant amount of pain could have caused the resident to experience nausea. The Medical Director also stated it was important hospice residents' pain was controlled for end-of-life comfort care.

During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation Resident R76's pain would have been managed, and his medications administered as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 15879 potential for actual harm Based on observation, interview, record review, and review of the facility's policy, the facility's nursing staff Residents Affected - Few failed to use appropriate Personal Protective Equipment (PPE) for 1 out of 28 sampled residents who were

on Enhanced Barrier Precautions (EBP), Resident (R) 237. Specifically, nurses did not wear a gown when performing Resident R237's wound treatment. This failure had the potential to cause an infection of the resident's wound.

The findings include:

Review of the facility's policy titled, Enhanced Barrier Precautions, dated 02/01/2024, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi drug resistant organisms [MDRO]. Enhanced Barrier precautions refer to the use of gown and gloves for use

during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) all staff are expected to comply with all designated precautions . high contact resident care activities that require the use of gown and gloves .include wound care, any skin opening requiring a dressing .

Review of Resident R237 Face Sheet located in the Admission Record tab of the electronic medical record (EMR) revealed the facility admitted Resident R237 on 08/12/2024 with diagnoses of Parkinson's, neurofibromatosis, malignant neoplasm skin, and disorder of skin and subcutaneous tissue.

Review of Resident R237 admission Minimum Data Set (MDS) located under the MDS tab of the EMR, with an assessment reference date (ARD) of 08/19/2024, revealed Resident R237 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the assessment was unable to be completed.

Review of Resident R237 Physician Orders, dated 08/12/2024, located under the Orders tab of the EMR revealed an order for wound care to be done to the left neck.

Observation on 08/21/2024 at 3:04 PM of Registered Nurse (RN) 3 and Licensed Practical Nurse (LPN) 1 revealed neither RN3 or LPN1 put on a gown prior to entering Resident R237's room to perform the wound treatment and dressing change. Observation further revealed signage on the door stated Enhanced Barrier Precautions (EBP) was to be utilized. Observation of the signage revealed a gown, mask, and gloves were to be worn if wound care was being done.

During an interview on 08/22/2024 at 3:23 PM, RN3 stated PPE should have been used with Resident R237 because

the resident had an open wound. RN3 stated that anyone with an open wound, catheter, or any opened areas should be on EBP. RN3 stated she should have put on a gown prior to performing Resident R237's wound treatment. RN3 stated not wearing a gown during the wound treatment put other residents at risk for spreading an infection.

During an interview on 08/22/2024 at 3:23 PM, LPN1 confirmed there was an isolation cart on the outside of Resident R237's room and signage that indicated the resident was on EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 185238 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 185238 B. Wing 08/22/2024

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

Vanceburg Hills 58 Eastham Street Vanceburg, KY 41179

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 08/22/2024 at 5:34 PM, the Regional Nurse Consultant (RNC) stated when EBP signage was on the door and a wound treatment was to be done, nurses should have worn a gown, mask, Level of Harm - Minimal harm or and gloves when doing care. The RNC stated if fluids were present then goggles should be worn. The RNC potential for actual harm stated there was a risk for contamination with MDROs and carrying them to other residents.

Residents Affected - Few During an interview on 08/22/2024 at 5:00 PM, the Administrator stated that if a resident was on EBP then a gown, gloves, and mask should be worn from an infection control standpoint. The Administrator further stated failure to wear PPE would pose a risk of bringing an infection into the facility or spreading the infection to others.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 185238