Inspection Reports for
Morganfield Nursing and Rehabilitation Center
509 NORTH CARRIER ST., MORGANFIELD, KY, 42437
Back to Facility Profile5 Reports
Inspection Report — Apr 4, 2025
Annual Inspection
Date: Apr 4, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to medication management and infection prevention and control.
Findings
The facility failed to ensure proper labeling and dating of opened medication vials, specifically a Tuberculin vial that was not dated. Additionally, the facility did not provide an adequate infection prevention and control program, with staff failing to perform hand hygiene during wound care and medication administration, and failing to clean reusable equipment between residents.
Deficiencies (2)
F 0761: The facility failed to ensure drugs and biologicals were labeled and dated according to professional standards, including an opened Tuberculin vial that was not dated, risking potency and safety.
F 0880: The facility failed to provide an infection prevention and control program, with staff not performing hand hygiene during wound care and medication administration, and not cleaning reusable equipment between residents, increasing infection risk.
Report Facts
Residents sampled: 14
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Interviewed regarding medication vial labeling and hand hygiene failures |
| LPN 1 | Licensed Practical Nurse | Observed failing to perform hand hygiene and improper medication handling |
| Interim Director of Nursing | Regional Quality Manager | Interviewed regarding expectations for medication labeling and infection control |
| Administrator | Interviewed regarding facility policy compliance and infection control expectations | |
| Infection Prevention Nurse | Interviewed regarding infection control expectations and staff training |
Inspection Report — Apr 4, 2025
Renewal
Date: Apr 4, 2025
Visit Reason
A Standard Recertification survey was conducted from 04/01/2025 to 04/04/2025 to assess the facility's compliance with federal regulations for long term care facilities.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B, with deficiencies cited including labeling and storage of drugs and biologicals, infection prevention and control, and life safety code violations. The highest scope and severity level cited was 'E'.
Deficiencies (5)
Failure to ensure drugs and biologicals were labeled and stored according to accepted professional principles, including expiration dating.
Failure to establish and maintain an infection prevention and control program to prevent transmission of communicable diseases and infections.
Failure to maintain smoke barriers to restrict transfer of smoke, affecting 28 residents.
Failure to maintain power strips in accordance with NFPA standards, affecting 8 resident rooms, staff, and 16 residents.
Failure to provide proper storage and securing of oxygen cylinders, affecting 28 residents.
Report Facts
Sample Size: 14
Deficiency Count: 5
Residents Affected: 28
Residents Affected: 8
Staff Affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 2 | Licensed Practical Nurse | Interviewed regarding medication labeling and storage deficiencies |
| Interim Director of Nursing/Regional Quality Manager (DON) | Director of Nursing | Interviewed regarding infection prevention and control and medication administration policies |
| Administrator | Administrator | Interviewed regarding facility policies and infection control expectations |
| Regional Clinical Manager | Regional Clinical Manager | Provided education on medication labeling and infection control |
| Director of Nursing | Director of Nursing | Provided education and oversight of infection control and medication administration |
| Licensed Practical Nurse (LPN) 1 | Licensed Practical Nurse | Observed during medication administration and infection control practices |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed and responsible for smoke barrier and power strip deficiencies |
| Regional Maintenance Supervisor | Regional Maintenance Supervisor | Interviewed and responsible for smoke barrier and power strip deficiencies |
Inspection Report — Jan 15, 2024
Complaint Investigation
Date: Jan 15, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding a resident being left soaked with urine and the facility's failure to properly address grievances.
Complaint Details
The complaint was substantiated as the grievance filed by the family of Resident #56 regarding being left soaked with urine was not addressed or resolved by the facility.
Findings
The facility failed to ensure that grievances were thoroughly investigated and resolved for one resident. Interviews and record reviews revealed no documented evidence that the grievance was addressed or resolved, and staff re-education on incontinent care was not completed.
Deficiencies (1)
F 0585: The facility failed to honor the resident's right to voice grievances without discrimination or reprisal and did not make prompt efforts to resolve grievances. There was no documented evidence that a grievance regarding a resident being left soaked with urine was investigated or resolved.
Report Facts
Residents sampled: 13
Residents affected: 1
Inspection Report — Jan 15, 2024
Routine
Date: Jan 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including communication access, care planning, and medication administration at Morganfield Nursing and Rehabilitation Center.
Findings
The facility failed to ensure residents had assistive devices for hearing, develop and implement comprehensive care plans for residents with specific needs, and administer psychotropic medication only with appropriate diagnoses. Deficiencies were noted in care plan development, implementation, and review, as well as in medication management for psychotropic drugs.
Deficiencies (4)
F 0576: The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods, including assistive hearing devices for one resident with bilateral sensorineural hearing loss.
F 0656: The facility failed to develop and implement a complete care plan for two residents, including communication needs for one resident with hearing loss and hemodialysis care for another.
F 0657: The facility failed to review a resident's comprehensive person-centered care plan since 08/10/2022, despite policy requiring regular updates and reviews.
F 0758: The facility failed to ensure one resident was not administered a psychotropic medication without an appropriate diagnosis, and psychiatric services were not consulted as required.
Report Facts
Residents sampled: 13
Physician care visits: 360
BIMS score: 15
BIMS score: 14
BIMS score: 9
Ziprasidone dosage: 20
Ziprasidone dosage increase: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #8 | CNA | Interviewed regarding Resident #34's hearing difficulties and lack of hearing devices |
| Licensed Practical Nurse #2 | LPN | Interviewed about Resident #34's hearing loss and communication methods |
| MDS Coordinator | Interviewed about care plan review and development responsibilities | |
| Social Services Director | SSD | Interviewed about follow-up on physician care visits and audiology notes |
| Administrator | Interviewed about expectations for nursing follow-up and care plan management | |
| Director of Nursing | DON | Interviewed about care plan expectations and medication management |
| Family Nurse Practitioner | FNP | Interviewed about psychotropic medication prescribing for Resident #53 |
| Clinical Consultant Pharmacist | Interviewed about medication regimen reviews and psychotropic medication oversight |
Inspection Report — Feb 13, 2020
Routine
Date: Feb 13, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, restraint use, infection prevention and control, and adherence to care plans at Morganfield Nursing and Rehabilitation Center.
Findings
The facility failed to ensure one resident was free from physical restraints during meals as required by the care plan. The facility also failed to follow the care plan related to restraint use, maintain an effective infection control program including annual tuberculin testing, proper disinfection of blood glucose monitors, and implementation of isolation precautions for residents with communicable diseases.
Deficiencies (3)
F 0604: The facility failed to ensure one resident's alarming seat belt restraint was released during lunch as required by the care plan.
F 0656: The facility failed to follow the plan of care related to restraint use for one resident by not removing the seatbelt restraint during a meal.
F 0880: The facility failed to maintain an effective infection prevention and control program for three residents, including failure to conduct annual tuberculin skin testing, failure to disinfect blood glucose monitors per manufacturer guidelines, and failure to implement isolation precautions properly.
Report Facts
Residents sampled: 15
Residents sampled: 29
Blood glucose monitor reading: 301
BIMS score: 3
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #1 | State Registered Nurse Aide and restorative aide | Failed to remove Resident #7's seatbelt restraint during lunch |
| Director of Nursing | Director of Nursing (DON) | Provided information on rounds and staff training related to restraint and infection control |
| MDS/Restorative Supervisor | MDS/Restorative Supervisor | Provided information on restraint monitoring and staff training |
| LPN #1 | Licensed Practical Nurse | Observed performing blood glucose monitoring and cleaning procedure |
| Infection Control Preventionist | Infection Control Preventionist | Responsible for infection control duties and tuberculin skin testing oversight |
4 CMS Surveys
CMS Survey — Jan 15, 2024
Jan 15, 2024
CMS Survey — Feb 13, 2020
Feb 13, 2020
CMS Survey — Jan 15, 2024
Jan 15, 2024
CMS Survey — Apr 4, 2025
Apr 4, 2025
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