The Indigo at Pikeville

The facility failed to ensure medications were administered according to physician orders, resulting in a 16% medication error rate during the 8:00am medication pass. Specifically, a medication aide crushed enteric-coated Ferrous Sulfate tablets for Resident #4, despite there being no order to crush medications and instructions that the coating should not be disturbed.

The facility failed to ensure medications were administered as ordered for several residents, including errors with medications for heart rate, blood pressure, iron, and constipation. Additionally, record reviews revealed errors regarding antibiotic and laxative administration.

The facility failed to ensure the Special Care Unit (SCU) was free of hazards by allowing items such as disposable razors, antifungal cream, and prescription toothpaste to be accessible to residents. Observations and interviews confirmed that hazardous or ingestible items were not stored or secured according to the facility's dementia-specific program and safety policies.

The facility failed to maintain the Special Care Unit (SCU) in a manner free of hazards and obstructions. Specifically, hazardous items including disposable shaving razors, antifungal cream, and various toiletries were found accessible to residents in 27 resident rooms.

The facility failed to respond immediately to an incident involving a resident who was found unresponsive without a pulse. Despite the resident being documented as a 'Full Code,' staff failed to administer cardiopulmonary resuscitation (CPR) as required by facility policy and state regulations.

The facility failed to ensure medications were administered using proper infection control measures. During a medication pass, a medication aide was observed administering a nasal spray without wearing gloves, increasing the risk of cross-contamination and disease transmission.

A medication aide failed to follow infection control measures by not wearing gloves when administering a nasal medication to a resident. Additionally, the aide used ungloved hands to document the administration in the computer system, increasing the risk of cross-contamination.

The facility failed to process resident refunds within 30 days of a resident's death. Specifically, two out of four residents reviewed had not yet been refunded the remaining balance of their care costs.

The facility failed to provide supervision in accordance with residents' assessed needs and facility policy for 2 of 5 sampled residents. This failure resulted in falls that caused significant injuries, including a nose and facial fracture with a closed head injury for one resident, and facial contusions and chipped teeth for another.