Wurtland Nursing & Rehabilitation

F-F677 for specific findings.)

2. Based on observation, interview, and record review, Resident R124, Resident R80, and Resident R36 failed to receive care as needed. Staff incorrectly applied medicated treatments, failed to properly clean a resident's prosthetic eye, and failed to change a dressing as ordered. (Refer to

F-F684 for specific findings.)

3. Based on observation, interview, and record review, Resident R27 and Resident R10 developed facility-acquired pressure ulcers after staff failed to provide pressure prevention approaches including incontinence care and turning/repositioning. (Refer to

F-F686 for specific findings.)

4. Based on observation, interview, and record review, Resident R1 and Resident R125, who each had a catheter, failed to receive care in a manner to prevent and/or timely treat urinary tract infections. (Refer to

F-F690 for specific findings.)

5. Based on interview and record review, Resident R62 was hospitalized for dehydration and hypernatremia after failing to receive all ordered nutrition and fluids through a feeding tube, (Refer to

F-F693 for specific findings.)

6. Based on interview and record review, Resident R119 failed to receive pain medication as ordered after nursing staff failed to order it in a timely manner. (Refer to

F-F697 for specific findings.)

Review of the facility policy titled, Staffing, effective 10/01/2024, revealed the purpose was to provide sufficient care team members with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The census, acuity and diagnoses of the resident population would be considered based on the facility assessment. Further review of the facility policy revealed the company would supply services by sufficient numbers of each of the following care team member types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: licensed nurses and other nursing personnel, including but not limited to State Registered Nurse Aides (SRNAs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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 0725 Review of the facility document titled, Facility Assessment Tool (FAT) dated 11/2023-12/2024 revealed the purpose was to determine what resources were necessary to care for residents competently during both Level of Harm - Minimal harm or day-to-day operations and emergencies. The assessment was used to make decisions about direct care staff potential for actual harm needs as well as the facility's capability to provide services to the residents in the facility and was focused on ensuring each resident was provided care that allowed the resident to maintain or attain their highest Residents Affected - Many practicable physical, mental, and psychosocial well-being.

Continued review of the document, dated 11/2023-12/2024, revealed the intent of the facility assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Additional review of the FAT, Page 3, revealed the facility average daily census was 109 and Page 18 revealed the facility had assessed the need for 12-18 nurse SRNAs per day, four to ten on the day shift and four to eight on the night shift, as well as, the need for four to seven nurses per day, two to five on the day shift and two to four on the night shift. Per the FAT, the facility estimated caring for an average of 35 residents who were dependent of staff for toileting needs with an additional 61 residents requiring assistance of one or two staff members for toileting. Additionally, the facility estimated all residents required some form of assistance with eating, eight of which were totally dependent and an additional three who required substantial/maximal assist. The general facility process section of the FAT outlined to ensure the facility had sufficient staff to meet the needs of the residents at any given time was documented as refer to the Centers for Medicare and Medicaid (CMS) Minimum Staffing Rule.

Review of the facility's PBJ [NAME] report for the fourth quarter of the Fiscal Year 2024 (July 1 - September 30) revealed the facility had a One Star Staffing Rating and submitted weekend staffing data was excessively low.

Initial review of the Detailed Hours Report (DHR) which documented actual hours staff were punched in for work for hours worked on weekend shifts for 09/07/2024, 09/08/2024, 09/15/2024, 09/21/2024, 10/05/2024, and 10/06/2024, 10/20/2024 revealed:

7. On 09/07/2024, five SRNAs worked from 6:00 AM-6:00 PM and an additional one SRNA worked from 8:00 AM to 2:00 PM, indicating from 6:00 AM to 8:00 AM and from 2:00 PM to 6:00 PM each SRNA was responsible for the care of 22 residents and from 8:00 AM to 2:00 PM each SRNA was responsible for the care of 18 residents.

On 09/08/2024, six SRNAs worked from 6:00 AM-6:00 PM indicating each SRNA was responsible for the care of 18 residents.

On 09/15/2024 four SRNAs worked from 6:00 AM-6:00 PM indicating each SRNA was responsible for the care of 27 residents.

On 09/21/2024 six SRNAs worked from 6:00 AM-6:00 PM indicating each SRNA was responsible for the care of 18 residents.

On 10/05/2024 six SRNAs worked from 6:00 AM-6:00 indicating each SRNA was responsible for the care of 18 residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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 0725 On 10/06/2024 five SRNAs worked from 6:00 AM-6:00 indicating each SRNA was responsible for the care of 22 residents. Level of Harm - Minimal harm or potential for actual harm On 10/20/2024 four SRNAs worked from 6:00 AM-6:00 PM each SRNA was responsible for the care of 27 residents. Residents Affected - Many

Review of the DHR dated 10/14/2024 revealed one nurse was working from 6:00 PM to 12:00 AM and was responsible for the care of all the facility's residents.

Review of the facility DHR dated 01/21/2025 revealed five SRNAs were working from 6:00 PM-6:00 AM requiring each SRNA to be responsible for the care of 22 residents.

Review of the DHR dated 01/24/2025 revealed four SRNAs worked from 6:00 PM-6:00 AM and one SRNA worked from 6:00 PM to 12:00 AM, requiring each SRNA to be responsible for the care of 21 residents from 6:00 PM to 12:00 AM and 27 residents from 12:00AM to 6:00 AM.

Review of the DHR dated 01/25/2025 revealed three SRNAs worked from 6:00 PM-9:00 PM, requiring each SRNA to be responsible for the care of 37 residents until an additional two SRNAs arrived at 9:00 PM, totaling five SRNAs who worked from 9:00 PM-6:00 AM requiring each SRNA to be responsible for the care of 22 residents.

Review of the facility document titled Daily Staffing (DS) sheet dated 01/26/2025 revealed the facility scheduled a total of four SRNAs from 6:00 PM-6:00 AM, requiring each SRNA to be responsible for the care of 27 residents.

Review of the DS dated 01/28/2025 revealed six SRNAs worked from 6:00 PM-6:00 AM, requiring each SRNA to be responsible for the care of 18 residents.

Review of the DS dated 01/29/2025 revealed three SRNAs worked from 1:00 AM-6:00 AM, requiring each SRNA to be responsible for the care of 36 residents.

Review of the DS dated 02/01/2025 revealed six SRNAs worked from 6:00 AM-6:00 PM, requiring each SRNA to be responsible for the care of 18 residents.

Review of the facility document titled, Engagement Survey Results, dated 11/2024 revealed documented comments from staff citied the chronic frustrations with the need for more SRNAs 17 times. One comment stated, We need more SRNAs, the workload is horrible and to get everyone changed you sometimes have to miss showers.

Review of the facility document Detailed Hours, dated 07/23/2024 revealed a total of seven SRNAs working from 6:00 AM until 2:00 PM and six SRNAs working from 2:00PM until 6:00 PM. Further review revealed a total of five SRNAs working 6:00 PM until 6:00 AM. Review of the staffing sheet for 07/23/2024 revealed a facility census of 115.

8. a. Review of a Report of Concern, dated 07/02/2024, Family Member (F) 52 reported a concern of Resident R52's call light not being answered timely. The Executive Director (ED) marked the grievance as confirmed and wrote that nurses were educated about call light wait times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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 0725 In an interview on 01/27/2025 at 9:47 AM, F52 stated she reported to the facility that there had been multiple times the family had waited with Resident R52 for over 20 minutes after pressing the call light. She further stated when Level of Harm - Minimal harm or they had been waiting, they would go down to the nurse's desk to find nurses sitting there. Per interview, F52 potential for actual harm stated the ED took notes of the concerns and said she would talk to staff. F52 continued to state administration told her they would put it in Resident R52's Care Plan that she needed to be toileted more frequently Residents Affected - Many than every two hours. F52 added that Resident R52 had a doctor's appointment on 07/24/2024 and was supposed to receive a shower on the evening of 07/23/2024 and wear the clean clothes F52 put out on Resident R52's wheelchair. Per interview, when F52 met Resident R52 at the doctor's office, Resident R52 was still wearing the clothes she was wearing

during the day on 07/23/2024, not the clean ones. Resident R52's hair was dirty and unbrushed. She stated she filed a grievance with the ED, who told her the aide had not given the shower but had charted that she had by mistake. In further interview, F52 stated the ED told her if she did not like the care provided to Resident R52, she could take Resident R52 home.

Review of the facility time punch document, Detailed Hours, dated 11/02/2024 revealed a total of six SRNAs working from 6:00 AM until 6:00 PM. Further review revealed a total of four SRNAs working from 6:00 PM until 6:00 AM. Review of the facility staffing sheet for 11/02/2024 revealed the census was 115.

b. Review of a Report of Concern, dated 11/02/2024, revealed F52 filed a grievance when she found Resident R52 sitting in briefs and clothes soiled with urine and noted urine dripping into the floor beneath Resident R52's wheelchair. Further review revealed the ED marked the grievance as confirmed and noted the care team member was terminated on 11/04/2024.

In an interview on 01/27/2025 at 9:47 AM, F52 stated on 11/02/2024, she came in to find Resident R52's briefs, clothing, and wheelchair saturated with urine and urine puddled in the floor beneath Resident R52's wheelchair. F52 asked an aide, whose name she could not recall, to clean Resident R52 up. F52 stated the staff member told her she could not help until she had picked up dinner trays.

In an interview on 02/01/2025 at 6:28 PM, the Executive Director (ED) stated she recalled F1's grievance related to Resident R52 being left wet on 11/02/2024. She further stated that in investigating the grievance, she confirmed Resident R52 had been wet with urine and the SRNA who responded was rude to F52.

c. Review of the facility time punch document, Detailed Hours, dated 11/22/2024 revealed a total of five SRNAs working 6:00 PM until 6:00 AM. Review of the facility staffing sheet dated 11/22/2024 revealed the facility census was 109.

In an interview on 01/27/2025 at 9:47 AM, F52 stated that on 11/22/2024, she waited one hour and three minutes for staff to answer Resident R52's call light when the resident needed assistance with toileting/incontinence care. Per interview, F52 timed the wait on her phone and took a video.

d. Review of the facility time punch document Detailed Hours, dated 12/04/2024 revealed six SRNAs working from 6:00 AM until 6:00 PM, with two additional SRNAs working 10:00 AM until 4:00 PM, and one SRNA working 6:00 AM until 4:00PM. Further review revealed four SRNAs working 6:00 PM until 6:00 AM. Review of the facility staffing sheet dated 12/04/2024 revealed the facility census was 103.

In an interview on 01/27/2025 at 9:47 AM, F52 stated that on the evening of 12/04/2024, she waited a prolonged period of time for staff to answer Resident R52's call light when the resident needed assistance with toileting and incontinence care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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 0725 e. Review of the facility time punch document, Detailed Hours, dated 01/14/2025, revealed six nurse aides working 6:00 AM until 6:00 PM, one SRNA working 12:30 PM until 5:00 PM, one SRNA working 10:00 AM Level of Harm - Minimal harm or until 6:00 PM, and the wound care SRNA working 9:00 AM until 5:00 PM. Review of the facility staffing sheet potential for actual harm dated 01/14/2025 revealed the census was 108.

Residents Affected - Many In an interview on 01/27/2025 at 9:47 AM, F1 stated she came in the afternoon of 01/14/2025 to find Resident R52 in a soaked brief and clothes wet with urine.

f. Review of the facility time punch document Detailed Hours, dated 01/15/2025, there were six SRNA working 6:00 AM until 6:00 PM, with two additional SRNAs working partial shifts. Further review revealed five SRNAs working from 6:00 PM until 1:00 AM, and 4 SRNAs working from 11:00 PM until 7:00 AM. Review of

the facility staffing sheet for 01/15/2025 revealed the facility census was 109.

In an interview on 01/27/2025 at 9:47 AM, F52 stated she came in the afternoon of 01/15/2025 to find Resident R52 in

a soaked brief and clothes wet with urine.

9. a. Observation on 01/29/2025 at 4:42 PM revealed three call lights, both visual and audible, were alerting

on the back hall. A male resident was overheard stating, Can someone help me, I am a mess. Licensed Practical Nurse (LPN) 2 stated, You will need to wait, buddy.

b. Observation, on 01/29/2025 at 4:45 PM, during dining service, revealed the call light for room [ROOM NUMBER], both visual and audible, was alerting on the front hall. LPN6 was observed sitting at the nurse's station with the call light board behind him alarming and illuminated and he did not get up to assist with answering the call light.

c. Observation on 01/29/2025 at 4:46 PM during dining service, revealed a call light for room [ROOM NUMBER], both visual and audible, was alerting on the front hall. The Activities Director (AD) walked past

the room and did not address the call light.

d. Observation on 01/31/2025 at 10:53 AM revealed two call lights illuminated and audible on the South Hall. LPN1 and LPN2 were observed sitting at the nurse's station with the call light board behind nurses' station illuminated and audible. Neither LPN1 nor LPN2 got up to answer the call lights.

e. Observation on 01/31/2025 at 4:45 PM of one SRNA in the dining room sorting meal tickets while six meal trays were waiting in the pass through ready to be given to the residents and four call lights on the North Hall were illuminated and audible.

f. Observation on 01/31/2025 at 7:50 AM revealed the call light for room [ROOM NUMBER] was lit above the resident's door. Further observation revealed the call light board at the nurse's station displayed a light indicating room [ROOM NUMBER]'s call light was on, as well as making an intermittent beep to alert staff to

the call light. Continued observation revealed LPN1 and LPN2 sitting at the nurse's desk, in view of the control board, where the beeping could be heard, Neither LPN looked over at the control board to see which light was on, nor did they get up to look in the hallway. Per observation, the call light for room [ROOM NUMBER] sounded for four minutes without any response from the LPNs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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 0725 In an interview on 01/31/2025 at 8:00 AM, LPN1 and LPN2 stated it was everyone's responsibility to answer call lights. When asked about the call light that had sounded for several minutes prior to the interview, the Level of Harm - Minimal harm or LPNs asked the survey team if the sound went off at the nurse's station. When the survey team confirmed potential for actual harm that the sound went off, the LPNs failed to provide any response to why they had not acknowledged the call lights. Residents Affected - Many g. Observation on 02/01/2025 at 10:08 AM revealed the call light for room [ROOM NUMBER] was on. No SRNAs were seen in the hallway. Qualified Medication Aide (QMA)8 was present, preparing medicine. The Maintenance Director walked past room [ROOM NUMBER] without turning his head. Observations at 10:12 and 10:13 AM revealed the Social Services Director (SSD) also walked by room [ROOM NUMBER] while the call light was on, without turning her head to look in the resident's room. Observation at 10:17 AM revealed

the call light was still going off (nine minutes after first observed) when ED2 entered the room, asked the resident what he needed and stated he would go get the nurse. The call light remained lit until 10:19 AM when LPN4 entered, asked the resident if he wanted a breathing treatment, and began to administer it, then walked away while it was going in.

10. a. During an interview on 01/26/2025 at 4:40 PM with Resident R90, she stated she had been sitting in a wet bed for a couple hours, had put her call light on twice and was told by the SRNAs they had a new admission and were busy. Observation during this interview revealed the resident's brief appeared heavy with urine.

Review of the DHR, dated 01/26/2025, revealed six SRNAs worked from 6:00 AM-6:00 PM and one SRNA worked from 8:00 AM to 5:00 PM. During the time that Resident R90 was left sitting in the wet bed, each SRNA was responsible for the care of 18 residents from 8:00 AM to 5:00 PM and 22 residents from 6:00AM to 8:00 AM and from 5:00 PM to 6:00 PM.

b. During an interview on 01/26/2025 at 1:58PM with Resident R362, she stated on 01/24/2025 at 6:00 PM during shift change, she requested help having her brief changed. She stated it took staff until after 10:00 PM for them to come and change her brief. Resident R362 stated having to lay in her waste made her feel humiliated/nasty. She stated it took staff so long to come in and change her that some of her body fluid had leaked on her right leg splint where she had broken her leg back in December. Resident R362 also indicated on her cell phone where she had tried to call the facility for help, and no one would answer the phone.

c. During an interview on 01/26/2025 at 2:03 PM, Resident R79 stated she also had to wait at least four (4) hours on 01/24/2025 for staff to come in and change her. Resident R79 stated she felt nasty having to lay in bed waiting for help to change her. She stated she had a stroke and needed assistance in cleaning herself. She stated one staff member came in her room and turned off the call light and disappeared without providing assistance.

During an interview on 01/28/2025 at 9:06 AM with SRNA4, she stated when there were four SRNA's on the back (North) hall, they had between 12-15 residents apiece. When there were only three SRNAs, they had approximately 20 residents apiece. She stated the back hall had many residents who were overweight and were a higher level of care and she needed SRNA3, who was in training, to help out.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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 0725 During an interview on 01/29/2025 at 10:27 AM with SRNA7, she stated staffing had been an issue at the facility for a while. SRNA7 stated that although she could not remember the exact date, there was one night Level of Harm - Minimal harm or there were three SRNAs for the entire building. SRNA7 further stated it was hard to get staff to come to work, potential for actual harm as well as, retain new staff due to the heavy workload.

Residents Affected - Many During an interview on 01/30/2025 at 9:41 AM with SRNA3, she stated she had been at the facility about a month, worked day shift and was typically assigned 16-18 residents. However, one Saturday, the facility was short staffed, and she had 22 residents to care for which she felt was not safe. She stated she often felt like

she was drowning and even though residents with behaviors required more care, 22 residents felt like a lot to care for anywhere. SRNA3 stated she tried to answer all the lights and had been told it was the SRNAs job to answer them. SRNA3 stated the Certified Medication Technicians (CMTs) would help when they could, but the nurses did not get up to answer call lights. She further stated residents have complained to her about long waits for their call light to be answered and there had been mealtimes when there was only one SRNA

in the dining room when there should be two. During mealtimes, there were four - five residents that needed total assist with eating, and she has had to sit all those residents at the same table and feed two residents at

a time. After the meal and upon her return to her assigned hall, SRNA3 stated she would often see several call lights on and no staff visible. SRNA3 stated on this day she had 14 residents and felt like she was rushing around.

Further, on 01/30/2025 at 9:41 AM, SRNA3 stated she was supposed to complete check and change rounds every two hours; however, it was easy to fall behind when caring for a resident that urinated more frequently or in larger amounts. SRNA3 stated on her first round before breakfast, she had walked into a resident's room after a night shift SRNA had told her the resident had been changed. However, she found the resident's bed was soaked and it looked like he had been a mess for hours which she could tell because the longer they sit, the darker the yellow ring (urine-soakage) was. SRNA3 stated it was hard to complete every two-hour rounds on every resident and complete four showers. She stated sometimes she did not take a lunch or would have to leave a resident soiled longer while she finished another resident's shower. Ideally, SRNA3 stated she would like to be able to get to every resident before they soiled themselves so she could assist them to the bathroom if possible. She stated she had to prioritize care based on which residents were

the heaviest care need and there were some residents that did not get the attention they deserved, and she felt bad about that. SRNA3 stated sometimes residents ask her to sit and talk with them, adding, she does not have time to do it.

During an interview on 01/30/2025 at 9:41 AM with SRNA12, she stated she had been at the facility since January 2024. SRNA13, who was present, stated she had been at the facility since July 2024 and neither SRNA had been issued a name tag. Both SRNAs agreed that in an average day, they cared for 15-20 residents and were responsible for meals, baths/showers and changing briefs/clothes/beds as needed, assisting with transportation to activities/smoke breaks, and individual resident care requests. SRNA12 and SRNA13 stated they would lose their bonus if they did not take a lunch, so they would punch out for lunch but then worked through to keep their bonus. SRNA12 and SRNA13 stated many SRNAs have left because of the workload and the nurses did not help out. They further stated they worked short last week, there were only three SRNAs on each hall (18 residents per SRNA) and sometimes they were only staffed for two SRNAs on each hall (27 residents per SRNA).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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 0725 Furnter, SRNA12 and SRNA13 stated, on 01/30/2025 at 9:41 AM, there was usually one SRNA in the dining room who was responsible for sorting the meal tickets, passing the trays, and feeding the assisted diners Level of Harm - Minimal harm or and there had been times they would have to sit all the assisted diners at the same table and feed one while potential for actual harm the others watched and had to wait, which was painful for staff to watch. SRNA12 and SRNA13 stated the facility was short staffed five to seven days a week and especially on the weekend. They stated with three Residents Affected - Many SRNAs on each hall, they would have to split showers and get done as much as they could. They added there was never any time to sit with residents and just talk with them, even with four SRNAs on each hall. SRNA13 stated that most of the nurses were not supportive of the SRNAs and their work but would add tasks like applying a medicated cream or shampoo. They stated Nurses did not come into the room to pause

a tube feeding so the SRNA could check and change a resident, they would tell the SRNA to pause the feed and restart it when care was completed.

During an interview on 01/30/2025 at 11:47 AM with SRNA11, she stated it was hard to get all her responsibilities of oral care, hair combing, toileting, and feeding done and a lot of times they were short staffed. She stated she usually had to also complete three showers in a day and with four SRNAs on each hall, it was still a struggle. SRNA11 stated on this day she had 14 residents and felt like maybe she could complete a check and change every two hours on most of them. She stated her charting recorded the task was done for the resident but not how many times in the shift it was done. SRNA11 stated when they had enough staff, they could complete more showers, do nail care, and help out with work for the next shift. When they worked short, SRNA11 stated sometimes residents did not get their shower and she hoped to be able to pick up that shower the next day. SRNA11 stated that when she alerted management she was unable to complete her work, she was told, We are short and can only do what we can.

In continued interview, on 01/30/2025 at 11:47 AM, SRNA11 stated the nurses would get up from the nurses' station to pass a medication or to do wound care but did not do general rounds on the residents. She stated

the nurses have asked the SRNAs to put on a medicated cream or shampoo and asked her to come back and tell them what the skin looked like. SRNA11 stated the SRNAs would help each other but some were too busy with their own work and the nurses did not help. She remembered one time she entered a droplet precaution room without full personal protective equipment (PPE), only a mask, because she was so far behind, she did not take the time to put on the additional PPE. She further stated it was hard to find anyone to help due to the short staffing. She stated call lights seemed to come on one right after the other and she tried to glance in on the residents that cannot use the call light. Additionally, SRNA11 stated she had no time to just visit with the residents and felt like since staff were all the family the residents had, not being able to spend more time with them could make the residents emotionally depressed.

During an interview on 01/30/2025 at 2:32 PM with SRNA2, she stated she had worked at the facility for three years. She stated staff had been hired and it seemed like she had trained many, but no one would stay. SRNA2 stated she had gotten used to working short and sometimes resident showers did not get done, but she tried to at least get them dressed and wiped off. She stated everyone deserved their shower and she tried to make it up the next day. SRNA2 stated the residents did complain about their call lights not being answered and stated residents would say, I've been waiting so long, but the SRNA came in and shut the light off and left, or said, The aide said they were going to get you and then didn't come back.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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 0725 During an interview on 01/30/2025 at 3:25 PM with SRNA10, he stated he had been an SRNA for thirteen years and started at the facility in 10/2024. He stated he did not know who the Director of Nursing Services Level of Harm - Minimal harm or (DNS) was until the state survey team entered the building, as he had never seen her. He added he did not potential for actual harm know who the Assistant Director of Nursing Services (ADNS) was until two months after he started. SRNA10 stated typical staffing on the weekends was two SRNAs on each hall (27 residents to each SRNA) and Residents Affected - Many sometimes there was a float SRNA available. He stated there were a lot of call offs on the weekends and there had been times the SRNAs were responsible for 30-35 residents each, which he felt was unsafe. SRNA10 stated management did not pitch in if short on the weekends, and he had not really seen management at all until State Surveyors showed up, then Everyone came out of the woods or something to help. He stated he believed it was everyone's responsibility to answer a call light, but the nurses did not answer a call light or change a resident. In fact, they would walk farther to try and find an SRNA instead of answering a light or changing a resident themselves. SRNA 10 stated when he was responsible for 30-35 residents, he could not get them changed every two hours, they would have to wait, and some would end up sitting for three to three and a half hours.

State Registered Nurse Aide (SRNA)10 stated, on 01/30/2025 at 3:25 PM, that residents complained and told him it was ridiculous they had been laying in their urine and feces and they were upset. He stated some would end up with skin breakdown and it hurt them. Additionally, SRNA 10 stated he rarely saw nurses just round on and talk to the residents and he rarely saw management walking in the halls, they mostly stayed in their offices and the ADON only came out of her office when there was something wrong. He stated he charted at the end of the shift but knew a lot of SRNAs did all their charting in the morning which he felt was wrong because you should not chart what you had not done. He stated it got so crazy it felt like there was not enough time to get everything done and if charting was not done, staff would lose their bonus for the week. SRNA10 stated it was hard enough to care for 15 residents, let alone 35 residents and he went home feeling bad because he felt like he had given poor care and the residents had not been cared for how they should be. Finally, SRNA 10 stated he has had to use at mechanical lift alone and risk resident injury due to not enough staff to help.

In an interview on 02/01/2025 at 11:07 AM, SRNA5 stated at the time of interview, she was finishing the first round of incontinence care for the residents in her assignment. Per interview, she stated she was responsible for 25 residents. In continued interview, SRNA5 stated management did not help with incontinence care, and she had rarely seen a member of management on the floor during a weekend. SRNA5 stated when she was responsible for that many residents, she did not have time to perform oral care or showers, and those tasks would only be completed if there was a float aide working.

In an additional interview on 02/01/2025 at 8:04 PM, SRNA5 stated that when the facility was short staffed,

the SRNAs did not typically get the support they needed to care for the residents according to their care plans.

During an interview on 01/29/2025 at 7:31 AM with the Nurse Practitioner (NP) he stated he had worked at

the facility for one year. The NP stated the SRNAs were great, but based on resident condition, he felt they needed more education on the importance of hygiene, position changes, and that relationship to skin breakdown. The NP also stated staffing was an uphill battle across the board and although it was improving, there was still a high turnover.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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 0725 During an interview on 01/29/2025 at 4:22 PM with the Scheduler (SCH) she stated she had been at the facility for thirteen years and had been the scheduler since 2020. SCH stated staffing was census based and Level of Harm - Minimal harm or the facility was considered full at 100 residents. SCH stated her staffing goal for each of the two halls was potential for actual harm one to two licensed nurses on each hall, one Certified Medication Technician (CMT) on each hall and four nurse SRNAs on each hall for the day shift. On night shift, her goal was to have one licensed nurse on each Residents Affected - Many hall, one CMT on each hall, and four SRNAs on each hall. SCH stated she was available 24 hours a day, seven days a week to work the schedule to find coverage for call offs. She stated there was never a time where no one was available to help, and all the staff pitched in, and all staff were responsible for answering call lights. She also stated the company had their own staff float pool as a resource and the facility did not use agency staff. SCH stated during the time of the low staffing indication on the PBJ [NAME] report, nothing unusual was going on but it was warm outside and that may have accounted for increased call offs. SCH stated she felt like there was enough staff to provide for resident needs.

During an interview on 02/01/2025 at 1:30 PM with the Infection Preventionist/Staff Developmen [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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

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

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44396 Residents Affected - Some Based on observations, interview, record review, and review of the manufacturer's instructions, the facility failed to store medications at the correct temperature. Insulin was stored below the recommended temperature range of 36 degrees Fahrenheit (F) and 46 degrees F in two of four medication refrigerators.

The findings include:

Review of the manufacturer's instructions, revised 02/2023, for NovoLog, (insulin aspart)100 units per milliliter (u/ml), revealed unused NovoLog Pens were to be stored in the refrigerator at 36 degrees F - 46 degrees F. Further review revealed instructions to not freeze NovoLog nor use NovoLog if it had been frozen.

Review of the manufacturer's instructions for Fiasp, (insulin aspart) 100 u/ml, revealed it should not be frozen, nor used if having been frozen. Further review revealed instruction to store unused insulin in a refrigerator between 36 degrees F and 46 degrees F.

Review of the manufacturer's instructions for Tresiba (insulin degludec injection) 100 u/ml FlexTouch pen, copyrighted and revised 07/2022, revealed guidance to store unused pens in the refrigerator at 36 degrees F to 46 degrees F and to not freeze the pens nor use them if having been frozen.

Review of the package insert for Lantus (insulin glargine) 100 u/ml, dated 2023, revealed unused Lantus should be stored in a refrigerator between 36 degrees F and 46 degrees F. Further review revealed instruction not to freeze Lantus and to discard if frozen.

Review of Basaglar, (insulin glargine) 100 u/ml, instructions for use, revised 08/2022, revealed instruction to not freeze Basaglar and to not use it if it had been frozen. Further review revealed instruction to store the pens in the refrigerator between 2 degrees Celsius (C) and 8 degrees C (35.6 F and 46.4 F.)

Review of the manufacturer's instructions for Admelog insulin, dated 11/2019, revealed instruction to keep new pens in the refrigerator between 36 degrees F and 46 degrees F. Further review revealed Admelog should not be frozen or used if it had been frozen.

1. Observation in the Front Hall Medication Room on 01/29/2025 at 3:10 PM revealed Refrigerator 1's thermometer registered 26 degrees F. Further observation revealed thick frost in the small freezer section in

the top of the refrigerator. Observation of the temperature logbooks revealed instructions that the accepted range was 36 degrees F - 46 degrees F. The inventory in the refrigerator included the following insulin pens:

Lantus 100 u/m - three pens

Insulin Glargine 300 u/ml - two pens

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 57 185261 Department of Health & Human Services Printed: 09/09/2025 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 185261 B. Wing 02/11/2025

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

Wurtland Nursing and Rehabilitation 100 Wurtland Avenue Wurtland, KY 41144

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

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

F 0761 Insulin Deglu[DATE REDACTED] u/ml - two pens

Level of Harm - Minimal harm or Basaglar 100 u/ml - three pens potential for actual harm Novolog 100 u/ml - five pens. Residents Affected - Some 2. Observation in the Back Medication Room on 01/29/2025 at 3:40 PM revealed Refrigerator 3's thermometer registered 30 degrees F. The inventory in Refrigerator 3 included:

Admelog insulin 100 u/ml- four pens

Fiasp insulin 100 u/ml - one vial

Fiasp insulin 100/u/ml three pens

Tresiba insulin 100 u/ml - seven pens

Basaglar insulin 100 u/ml - three pens

Lantus insulin 100 u/ml - eight pens.

During an interview with the Assistant Director of Nursing (ADON) on 01/29/2025 at 3:10 PM, she stated the outcome of medications stored at 26 degrees F was that they would freeze and thus be ineffective.

Additional interview with the ADON, on 01/29/2025 at 5:05 PM, revealed the Maintenance Director needed to adjust or repair the two refrigerators and defrost Refrigerator 1. The ADON added that the medications in both refrigerators needed to be returned back to the pharmacy.

Interview with the Executive Director (ED1) on 02/01/2025 at 6:28 PM revealed the nurses were responsible for monitoring the medication refrigerator temperatures. She indicated the temperatures were to be monitored on both shifts. In further interview, she stated if staff observed temperatures out of range, the nurses were responsible to take action to correct the temperature and to contact the pharmacy about whether medications should be discarded and reordered.

A Medication Storage policy was requested in writing on 01/29/2025 at 6:04 PM and by email on 02/11/2025 at 10:59 AM. However, none was received prior to exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 57 185261