Inspection Reports for
Irvine Nursing and Rehabilitation Center
411 BERTHA WALLACE DRIVE, IRVINE, KY, 40336
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
26% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
An abbreviated survey was conducted to investigate complaints KY00045420 and KY00045473.
Complaint Details
The survey was complaint-related, investigating complaints KY00045420 and KY00045473, with no deficiencies found.
Findings
No deficient practice was identified during the investigation.
Inspection Report
Routine
Deficiencies: 4
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, food service, confidentiality of medical records, and call light accessibility at Irvine Nursing and Rehabilitation Center.
Findings
The facility was found deficient in maintaining confidentiality of medical records, providing food at safe and appetizing temperatures, implementing proper infection prevention and control practices, and ensuring call lights were accessible to residents. Multiple residents and staff interviews, observations, and policy reviews confirmed these deficiencies.
Deficiencies (4)
F 0583: The facility failed to ensure the security and confidentiality of medical records for one resident by disclosing medical information to a non-medical family member of the physician.
F 0804: The facility failed to provide food at safe and appetizing temperatures for 5 residents, with hot foods served below 135°F and cold foods above 41°F, risking resident satisfaction and safety.
F 0880: The facility failed to maintain infection prevention and control practices, as a nurse did not wash hands properly and wore soiled gloves while providing care to a resident.
F 0919: The facility failed to ensure call lights were accessible to residents, with call lights found out of reach during night shift observations, increasing risk of resident harm.
Report Facts
Residents sampled: 29
Residents interviewed about food: 5
Residents attending Resident Group Meeting: 17
Minutes reviewed: 5
Tray pass duration: 18
Food temperature - cheese pizza: 112.9
Food temperature - fruit cocktail: 45
Food temperature - salad: 62.5
Residents attending Resident Council meeting: 17
Grievance dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in confidentiality and infection control deficiencies for improper communication and hand hygiene |
| Physician 1 | Physician whose medical information was improperly disclosed to a family member | |
| Director of Nursing | Director of Nursing | Provided statements on proper notification and infection control expectations |
| Administrator | Administrator | Acknowledged issues with call lights and food service and staff education |
| Dietary Manager | Dietary Manager | Provided food temperature measurements and statements on meal service |
| District Dietary Manager | District Dietary Manager | Provided food temperature measurements and statements on meal service |
| SRNA #14 | State Registered Nursing Assistant | Interviewed about call light accessibility and risks |
| SRNA #12 | State Registered Nursing Assistant | Interviewed about call light accessibility and risks |
| Facility Educator | Facility Educator | Provided information on ongoing call light issues and resident complaints |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 10, 2025
Visit Reason
A Standard Recertification and Abbreviated Survey was initiated to investigate multiple complaints identified by their codes KY34651, KY35885, KY36133, KY38473, KY39986, KY40443, KY40780, KY44991, and KY45067. The survey was conducted from 02/10/2025 to 02/13/2025.
Complaint Details
The investigation was complaint-driven, covering multiple complaint IDs. The Division of Healthcare found all complaints unsubstantiated but identified deficient practices at the highest severity level 'E'.
Findings
The Division of Healthcare determined all complaints were unsubstantiated; however, deficient practices were identified and cited at the highest scope and severity level 'E'. Deficiencies included breaches in personal privacy/confidentiality of records, failure to maintain food at safe and appetizing temperatures, and failure to maintain an effective infection prevention and control program. Multiple interviews, observations, and policy reviews supported these findings.
Deficiencies (4)
Failure to ensure security and confidentiality of medical records for one of twenty-nine sampled residents, including unauthorized disclosure of medical information.
Failure to provide food served at safe and appetizing temperatures, with hot foods below 135°F and cold foods above 41°F.
Failure to maintain an infection prevention and control program that provides a safe, sanitary, and comfortable environment, including improper hand hygiene and glove use by staff.
Failure to maintain an adequate resident call system, with call lights not accessible or functioning properly for multiple residents.
Report Facts
Sampled residents: 29
Residents expressing food concerns: 5
Residents attending group meeting: 17
Residents with call light issues: 4
Residents with call light verification: 3
Compliance date: Mar 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician 1 | Named in relation to breach of confidentiality and communication with resident's family | |
| Registered Nurse 1 | RN | Observed breaching confidentiality and improper infection control practices |
| Director of Nursing | DON | Provided statements on notification policies and hand hygiene expectations |
| Dietary Manager | DM | Observed food temperature issues and provided education on food safety |
| District Dietary Manager | DDM | Verified food temperatures and discussed food safety concerns |
| Administrator | Acknowledged food complaints and facility policies | |
| Education Training Director | Provided education on privacy, infection control, and call light system |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding inaccurate resident assessments, failure to develop and implement complete care plans addressing resident behaviors, and concerns about a discolored area under the stairwell potentially indicating mold.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inaccurate resident diagnosis and assessment, inadequate care planning for resident behaviors, and environmental safety concerns related to a discolored area under the stairwell.
Findings
The facility failed to ensure accurate resident assessments, as a diagnosis of paraphilia was incorrectly entered for Resident 6. The care plan for Resident 6 did not adequately address observed behaviors of touching and patting other residents, and interventions lacked documented outcomes. Additionally, a discolored area under the stairwell was observed but was not tested by an outside certified entity; facility staff concluded it was not mold but a discolored wall.
Deficiencies (3)
F641: The facility failed to ensure each resident received an accurate assessment; Resident 6 was incorrectly diagnosed with paraphilia not supported by hospital or admission records.
F656: The facility failed to develop and implement a complete care plan with measurable interventions for Resident 6's behaviors of touching and patting other residents; no documented review or outcomes of interventions were found.
F921: The facility did not ensure the nursing home area was safe and clean; a dark discolored area under the stairwell was observed but was not inspected by an outside certified entity for mold identification.
Report Facts
Assessment Reference Date: Jul 4, 2024
Assessment Reference Date: Nov 1, 2024
Brief Interview for Mental Status (BIMS) score: 6
Brief Interview for Mental Status (BIMS) score: 7
Moisture reading: 4
Date of admission: Jun 29, 2024
Date of survey completion: Dec 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA12 | State Registered Nurse Aide | Made the sexually inappropriate entry in Resident 6's medical record |
| MDS Coordinator | Responsible for entering baseline care plans and revisions; unsure how incorrect diagnosis was entered | |
| Director of Nursing | DON | Interviewed regarding Resident 6's behaviors and care planning |
| Primary Care Provider | PCP | Interviewed about Resident 6's diagnosis and medication concerns |
| Psychiatric Nurse Practitioner | NP | Interviewed regarding Resident 6's behaviors and diagnosis |
| Regional Plant Operations Director | RPOD | Conducted moisture testing and inspection of discolored wall under stairwell |
| Maintenance Director | MD | Performed facility inspections and addressed discolored wall under stairwell |
| Administrator | Oversight of facility operations and maintenance; interviewed about mold concerns |
Inspection Report
Deficiencies: 1
Date: Oct 8, 2020
Visit Reason
The inspection was conducted to assess compliance with safe and appropriate administration of IV fluids and care related to PICC line dressing changes at the nursing home.
Findings
The facility failed to ensure appropriate care for one resident with a PICC line, specifically not changing the stabilization device or needleless endcap during dressing changes due to use of an incomplete dressing change kit. The facility acknowledged concerns about infection risk and PICC line movement due to this issue.
Deficiencies (1)
F 0694: The facility failed to provide safe and appropriate administration of IV fluids by not changing the stabilization device or needleless endcap during PICC line dressing changes as required by policy and physician orders.
Report Facts
Residents sampled: 21
Residents affected: 1
PICC lines in facility: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Named in failure to change stabilization device and needleless endcap during PICC line dressing change | |
| Director of Nursing (DON) | Provided information about supply issues and acknowledged infection risk |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 4, 2019
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration and infection prevention and control practices at Irvine Nursing and Rehabilitation Center.
Findings
The facility failed to meet professional standards by administering expired Humalog Insulin to one resident for 14 days and failed to maintain proper hand hygiene during medication administration for five residents, increasing the risk of infection transmission.
Deficiencies (2)
F 0658: The facility administered expired Humalog Insulin to Resident #77 for fourteen days after the 28-day expiration date, contrary to pharmacy policy and manufacturer recommendations.
F 0880: The facility failed to implement an effective infection prevention and control program, as staff did not perform proper hand hygiene before, during, and after medication administration for five residents.
Report Facts
Expired doses administered: 37
Residents reviewed for medication pass: 7
Residents affected by infection control deficiency: 5
BIMS score: 5
BIMS score: 15
BIMS score: 99
Years employed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Interviewed regarding expired Humalog Insulin administration to Resident #77 | |
| Unit Coordinator | Interviewed about facility policy adherence on medication expiration | |
| Director of Nursing (DON) | Interviewed about expectations for insulin handling and hand hygiene | |
| Administrator | Interviewed about facility policies on medication expiration and staff expectations | |
| Kentucky Medication Aide (KMA) #2 | Observed and interviewed regarding failure to perform proper hand hygiene during medication administration | |
| LPN Wing Unit Manager (WW UM) | Interviewed about staff hand hygiene expectations and policy enforcement | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed about hand hygiene policy and staff expectations |
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