Inspection Reports for Wellington Parc of Owensboro
2885 New Hartford Rd, Owensboro, KY 42303, United States, KY, 42303
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 11, 2024
Visit Reason
The inspection was conducted due to allegations of abuse involving resident-to-resident altercations that were not immediately reported to the State Survey Agency and other officials as required by state law.
Findings
The facility failed to timely report allegations of abuse involving three residents (R35, R17, and R32) who were involved in altercations with other residents. The incidents included hitting and squeezing without proper notification to the Department for Community Based Services and the State Survey Agency, contrary to facility policy and state regulations.
Complaint Details
The complaint investigation revealed that three resident-to-resident abuse incidents involving R35, R17, and R32 were not reported to the State Survey Agency or the Department for Community Based Services as required. The incidents involved physical altercations such as hitting with a closed fist and hitting with a fly swatter. Interviews with staff and residents confirmed the incidents and the failure to report them.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 17
Residents affected: 3
Alert Documentation monitoring period: 72
15-minute checks: 14
BIMS score: 15
BIMS score: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activity Aide 12 | Activity Aide | Witnessed the altercation between R35 and R65 and provided a statement |
| State Registered Nursing Assistant 10 | State Registered Nursing Assistant | Provided details of the incident involving R65 hitting R35 |
| Director of Nursing | Director of Nursing | Acknowledged the incidents were not reported to the State Survey Agency or Department for Community Based Services |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Responded to incident involving R32 and documented the event |
| Administrator | Administrator | Acknowledged awareness of unreported resident-to-resident altercations and recent training on abuse definitions |
| Medical Director | Medical Director | Unaware that resident-to-resident altercation events were not being reported |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 4
Dec 11, 2019
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with healthcare facility standards, including resident rights, laboratory services, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to protect resident rights by not knocking before entering a resident's room, failure to provide timely laboratory services as ordered, improper food storage practices with undated opened food items, and failure to follow infection control procedures during medication administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Staff failed to knock on door prior to entering the spa room where Resident #38 was located, violating resident rights. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide or obtain laboratory services to meet the needs of Resident #33 as ordered, with BMP labs not drawn every three days as required. | Level of Harm - Minimal harm or potential for actual harm |
| Food stored in the freezer was opened and not dated, violating food service safety standards. | Level of Harm - Minimal harm or potential for actual harm |
| Licensed staff handled resident medication with bare hands during medication pass, failing to follow infection prevention and control procedures. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents receiving meals: 42
BMP lab frequency order: 3
BMP lab missed days: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in deficiency for failing to knock before entering Resident #38's spa room |
| RN #1 | Registered Nurse | Interviewed regarding knocking policy before entering bathroom |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding knocking policy, lab order changes, and infection control audits |
| RN #2 | Registered Nurse | Interviewed regarding lab order and BMP lab completion for Resident #33 |
| Dietician and MDS Coordinator | Dietician and MDS Coordinator | Interviewed regarding lab orders and BMP lab completion |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and dating requirements |
| CMA #1 | Certified Medication Aide | Observed and interviewed regarding handling medications with bare hands |
Inspection Report
Complaint Investigation
Deficiencies: 9
Sep 13, 2018
Visit Reason
The inspection was conducted based on complaint investigations and review of facility compliance with regulatory requirements related to resident care, medication administration, hospice services, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to issue required Medicare notices, incomplete care plan implementation, failure to follow physician diet orders, inadequate pressure ulcer care, inappropriate administration of psychotropic medications without proper diagnoses, improper medication labeling and storage, food safety violations, failure to coordinate hospice care properly, and lapses in infection prevention and control practices.
Complaint Details
The visit was complaint-related, focusing on multiple allegations including failure to provide required Medicare notices, inadequate care planning and implementation, medication errors, food safety violations, and infection control lapses. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to issue Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to residents when Medicare covered services were ending. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure interventions of the comprehensive care plan were followed for a resident with pressure ulcers, specifically failure to float heels as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's diet order for a resident, specifically omission of prune juice from breakfast tray. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were not administered psychotropic medications without appropriate diagnoses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure drugs and biologicals were labeled properly and stored according to professional standards, including expired medications and unlabeled insulin. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards, including expired foods and unsanitary kitchen equipment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure each resident's hospice plan of care and physician orders were included in the plan of care and failed to have signed Physician certification and recertification of terminal illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish and maintain an infection prevention and control program, including failure of medication technicians to sanitize hands between residents during medication pass. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medicare Discharges reviewed: 3
Sampled residents: 15
Residents affected: 1
Residents affected: 1
Residents affected: 5
Expired medications observed: 5
Residents receiving meals: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #8 | CNA | Named in care plan deficiency related to failure to float resident's heels |
| Licensed Practical Nurse #1 | LPN | Named in pressure ulcer care and hospice care deficiencies |
| Director of Nursing | DON | Named in multiple findings including care plan, diet order, medication labeling, hospice coordination, and infection control |
| Certified Medication Technician | CMT | Named in medication labeling and infection control deficiencies |
| Dietary Manager | Named in food safety deficiencies | |
| Pharmacist Consultant | Pharmacist | Named in psychotropic medication review process |
| Resident #40's Physician | Physician | Named in psychotropic medication and hospice deficiencies |
| Hospice Supervisor | Named in hospice care coordination deficiencies | |
| Hospice Social Service Director | Named in hospice care coordination deficiencies | |
| Hospice Registered Nurse #2 | Hospice RN | Named in hospice care coordination deficiencies |
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