Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Date: Aug 29, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to residents' rights, medication storage, food safety, call system accessibility, and other facility operations.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' rights during meal service, improper medication storage, inadequate food labeling and dating, and missing call light cords in resident bathrooms. These issues posed minimal harm or potential for actual harm to residents.
Deficiencies (4)
F 0550: The facility failed to honor residents' rights related to meal service by not serving all residents at one table before moving to another, affecting 2 residents out of 20 sampled.
F 0761: Medication was stored improperly with unlabeled and expired items found in the medication room, potentially affecting all 83 residents.
F 0812: Food was stored without proper labeling and dating in the nutrition refrigerator, risking foodborne illness for 20 of 83 residents.
F 0919: Call lights in resident bathrooms were missing cords, preventing residents who fell from summoning assistance.
Report Facts
Residents affected: 2
Residents affected: 83
Residents affected: 20
Residents affected: 2
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 28, 2024
Visit Reason
The inspection was conducted due to complaints and observations related to poor quality of care, specifically concerning skin impairment and pest infestations affecting Resident #45, including maggot infestations and flies in the facility.
Complaint Details
The investigation was complaint-driven based on reports and observations of maggot infestations on Resident #45 and persistent fly problems throughout the facility. Resident and family interviews, staff interviews, and observations substantiated the complaints. The root cause was identified as ineffective pest control.
Findings
The facility failed to provide appropriate care to Resident #45, who was found with maggots in her skin folds and wound beds, and the facility had an ineffective pest control program resulting in persistent fly infestations affecting many residents. Multiple staff interviews and observations confirmed ongoing pest issues and inadequate response.
Deficiencies (2)
F684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, resulting in actual harm to Resident #45 who had maggots in her wound beds and skin folds. Flies were observed in the resident's room and throughout the facility.
F925: The facility failed to maintain an effective pest control program to prevent and manage pests, including flies and maggots, affecting all 81 residents. Numerous fly sightings and maggot infestations were documented, indicating minimal harm or potential for actual harm.
Report Facts
Residents affected: 1
Residents affected: 81
Flies found and killed: 20
Flies found and killed: 10
Flies found and killed: 12
Flies found and killed: 10
Flies found and killed: 15
Flies found and killed: 10
Flies found and killed: 10
Flies found and killed: 10
Flies found and killed: 8
Flies found and killed: 4
Flies found and killed: 3
Resident weight: 640
Brief Interview for Mental Status (BIMS) Score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Registered Nurse Aide #1 | State Registered Nurse Aide | Reported maggot sightings on Resident #45 and described facility response |
| State Registered Nurse Aide #6 | State Registered Nurse Aide | Provided bed bath to Resident #45 and reported flies in the room |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed maggots on Resident #45 and notified Director of Nursing |
| Registered Nurse #4 | Registered Nurse | Observed maggot sightings and reported pest control issues |
| Director of Nursing | Director of Nursing | Managed care for Resident #45 and communicated about pest control and hospital transfer |
| Medical Director | Medical Director | Ordered hospital transfer for Resident #45 and identified flies as root cause |
| Administrator | Administrator | Communicated with family and described pest control measures |
| Maintenance Director | Maintenance Director | Reported on pest control efforts and fly control measures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 28, 2024
Visit Reason
The inspection was conducted due to complaints and observations related to poor quality of care involving skin impairment and pest infestation, specifically maggots found on Resident #45 and a persistent fly problem throughout the facility.
Complaint Details
The complaint investigation was substantiated. Resident #45 was found with maggots on multiple occasions, and flies were observed throughout the facility. Staff interviews revealed inadequate bathing schedules, refusal to document incidents initially, and ineffective pest control measures. The facility acknowledged the fly problem but had not fully resolved it.
Findings
The facility failed to provide appropriate treatment and care for Resident #45, who was found with maggots in her wound beds and skin folds, and the facility had an ineffective pest control program resulting in numerous flies throughout the building. Multiple staff interviews and observations confirmed ongoing pest issues and inadequate response to resident care needs.
Deficiencies (2)
F684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, resulting in actual harm to Resident #45 who had maggots in her wound beds and skin folds. Flies were observed in the resident's room and throughout the facility.
F925: The facility failed to maintain an effective pest control program to prevent and manage flies and other pests, affecting all 81 residents with potential minimal harm or risk.
Report Facts
Residents affected: 1
Residents affected: 81
Flies found and killed: 20
Flies found and killed: 10
Flies found and killed: 10
Flies found and killed: 15
Flies found and killed: 10
Flies found and killed: 10
Flies found and killed: 10
Flies found and killed: 8
Flies found and killed: 4
Flies found and killed: 3
Resident weight: 640
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Registered Nurse Aide #1 | State Registered Nurse Aide | Reported maggot sightings on Resident #45 and described facility response |
| State Registered Nurse Aide #6 | State Registered Nurse Aide | Provided bed bath to Resident #45 and observed flies in resident's room |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed maggots on Resident #45 and documented findings despite DON's instruction |
| Registered Nurse #4 | Registered Nurse | Observed maggots and flies, reported pest issues, and suggested increased bathing |
| Director of Nursing | Director of Nursing | Managed care plans and pest control responses, instructed staff on documentation |
| Medical Director | Medical Director | Ordered hospital transfer for Resident #45 and identified flies as root cause |
| Administrator | Administrator | Communicated with family and oversaw pest control measures |
| Maintenance Director | Maintenance Director | Responsible for pest control efforts and facility maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 29, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify family of medication changes, failure to complete significant change MDS assessments, failure to develop individualized care plans, failure to monitor dialysis fistulas, and other care deficiencies.
Complaint Details
The complaint investigation revealed multiple deficiencies related to medication notification, MDS assessments, care planning, dialysis care, continence care, medication labeling, and food storage safety.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of medication changes, failure to complete significant change MDS assessments for residents with condition changes, failure to develop individualized and complete care plans, failure to monitor dialysis access sites as ordered, failure to implement bowel and bladder continence programs, failure to label opened medications properly, and failure to maintain food storage safety standards.
Deficiencies (8)
F 0580: The facility failed to notify the representative of one resident of a medication change involving discontinuation of Celexa.
F 0637: The facility failed to complete Significant Change in Status MDS assessments for three residents with documented declines or improvements in condition.
F 0656: The facility failed to develop person-centered care plans for three residents, including care plans for dementia and urinary tract infection.
F 0657: The facility failed to revise the care plan within 7 days of comprehensive assessment for one resident receiving hemodialysis, omitting monitoring of AV fistula for thrill and bruit.
F 0690: The facility failed to provide appropriate care to maintain or restore bowel and bladder continence for two residents with declines in continence.
F 0698: The facility failed to ensure residents receiving dialysis had their fistulas assessed for thrill, bruit, and infection signs as ordered and documented.
F 0761: The facility failed to ensure medications, specifically eye drops, were dated when opened as required by facility policy.
F 0812: The facility failed to ensure food was stored properly, with ice build-up observed in the walk-in freezer posing a potential hazard.
Report Facts
Residents sampled: 23
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 65
Residents total: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple findings including failure to notify family, failure to update care plans, and failure to ensure dialysis fistula monitoring |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Mentioned in relation to dialysis fistula care and medication labeling |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Mentioned in relation to bowel and bladder tracking responsibilities |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Mentioned in relation to dialysis fistula care |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Mentioned in relation to medication labeling |
| Registered Nurse #1 | Registered Nurse | Mentioned in relation to medication labeling |
| MDS Coordinator | MDS Coordinator | Named in findings related to failure to complete significant change assessments and care plan development |
| Dietary Manager | Dietary Manager | Named in relation to food storage safety and freezer ice build-up |
| Maintenance Man | Maintenance Man | Named in relation to freezer ice build-up and repair |
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