LOUISVILLE, KY- CLIFTON OAKS CARE AND REHAB CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey.

Provide safe and appropriate respiratory care for a resident when needed

The facility failed to maintain the nasal cannula for supplemental oxygen in the correct position on the resident’s face for Resident #310. Resident #310 became hypoxic and confused, smeared feces on his/her body, and walked in the hallways undressed while covered in feces. While in this hypoxic state, the resident stated a staff member was raping him/her; however, when the supplemental oxygen was put back on the resident, he/she recanted his/her statement.

Reasonably accommodate the needs and preferences of each resident.

Based on observation, interview, record review, and review of facility policy review, it was determined the facility failed to ensure that residents’ right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of twenty-four (24) sampled residents (Resident #65).

Observation of Resident #65’s mobility was limited to his/her wheelchair. The resident was unable to get to the bathroom sink for personal hygiene due to his/her wheelchair not fitting through the bathroom door.

Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure a safe, clean, comfortable, and homelike environment. Observations of the linen storage revealed linens were not available to provide resident grooming, hygiene, and a comfortable bed for five (5) of twenty-four (24) sampled residents (Residents #6, #14, #25, #53 and #78).

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview, record review, and facility policy review, it was determined the facility failed to report allegations of abuse within two (2) hours for one of twenty-four (24) sampled residents (Resident #34). On 05/05/2023, Certified Nurse Assistant (CNA) #18 heard an allegation from Resident #82 that Resident #312 groped Resident #34’s genitals. However, CNA #18 stated she reported this to Registered Nurse (RN) #5 on 05/05/2023. However, staff failed to report this allegation to the Executive Director until four (4) days later on 05/09/2023.

Ensure each resident receives an accurate assessment.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure all assessments accurately reflected the resident’s status for one (1) of twenty-four (24) sampled residents (Resident #359).

Review of the Admission Minimum Data Set (MDS) Assessment, dated 02/20/2023, revealed the resident was not assessed accurately for pressure. The MDS coded Resident #359 as having no pressure ulcer upon admission, however, it was documented by the Advanced Practice Nurse Practitioner (APRN) that the resident had a pressure wound present on his/her right buttock.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

1. Resident #160 expressed to staff his/her desire to be discharged home and he/she was anxious about his/her upcoming court hearing. The resident reported his/her concerns to staff on [DATE]; the week of [DATE], and on [DATE]; however, the facility failed to develop the resident’s individualized person-centered care plan to include adequate supervision and monitoring. Therefore, on [DATE], the resident exited his/her window, climbed on a table with a chair stacked on top of the table and climbed across the facility’s six (6) foot fence. The facility was unaware of the resident’s whereabouts for approximately one (1) day, twelve (12) hours, and forty-five (45) minutes.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Based on interview, record review, and facility policy review, it was determined the facility failed to promote the healing of existing pressure ulcers/injuries for one (1) of twenty-four (24) sampled residents (Resident #359).

Resident #359’s pressure wound was identified by the Advanced Practice Registered Nurse (APRN), on admission. However, the Nursing Admission Assessment and the Admission Minimum Data Set (MDS) failed to include this information. As a result, treatment for the wound was not provided for over a week following admission.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

The facility’s failure to have an effective system in place to ensure the residents’ environment remained free of accident hazards and failed to ensure the residents received adequate supervision and assistance to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on observation, interview, record review and review of the facility’s policy it was determined the facility failed to ensure that each resident, who was incontinent of bladder and bowel on admission, received services and assistance to maintain continence for one (1) of twenty-four (24) sampled residents (Resident #65).

Resident #65 had a neurogenic bladder and paraplegia. He/She had an indwelling suprapubic catheter and a colostomy. The resident utilized adult briefs because his/her catheter leaked. Resident #65 was unable to feel when he/she was wet due to his/her medical condition. Observation revealed the resident was found lying in a wet brief that had soaked through to his/her bedding.

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure that residents received colostomy care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences for one (1) of four (4) sampled residents out of a total sample of twenty-four (24) residents (Resident #65).

Resident #65 had a colostomy and was unable to get out of bed without the use of a Hoyer ([NAME] of mechanical lift) lift. Resident #65 waited until noon for staff to assist with emptying his/her colostomy bag. Resident #65 was unable to obtain the supplies required for the care of his/her colostomy without the staff’s assistance.