Inspection Reports for
Dishman Personal Care Center
220 Worsham Ln, Monticello, KY 42633, MONTICELLO, KY, 42633
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 11
Date: Jun 17, 2025
Visit Reason
This is a re-inspection visit conducted on 06/16/2025 - 06/17/2025 to verify correction of previously cited deficiencies from a prior abbreviated and relicensure survey conducted 03/31/2025 - 04/03/2025.
Complaint Details
The original survey was complaint-related, investigating complaints KY00045383 and KY00045471. The complaints were substantiated with deficient practice cited. The census at that time was 47 residents.
Findings
The deficiencies cited during the prior complaint investigation and abbreviated survey were deemed corrected as of 05/29/2025. The facility implemented corrective actions including background checks, in-service training, medical record improvements, food safety measures, and activity programming enhancements.
Deficiencies (11)
902 KAR 20:036 4(10)(a-e) Section 4. Administration and Operation. The facility failed to maintain current employee records including criminal background checks and abuse registries for 3 of 4 employees reviewed.
902 KAR 20:036 4(10)(h) Section 4. Administration and Operation. The facility failed to provide required orientation and annual in-service training documentation for staff.
902 KAR 20:036 4(11)(b) Section 4. Administration and Operation. The facility failed to maintain current resident medical records with physician or health care practitioner notes for one resident.
902 KAR 20:036 4(11)(b)13 Section 4. Administration and Operation. The facility failed to complete Serious Mental Illness (SMI) Screening Forms for 10 of 26 sampled residents.
902 KAR 20:036 5(1)(a) Section 5. Provision of Services. The facility failed to provide supervision to ensure residents' health care needs were met for one resident.
902 KAR 20:036 5(3)(a) Section 5. Provision of Services. The facility failed to provide each resident with required room accommodations including beds, linens, and personal items.
902 KAR 20:036 5(3)(b)1 Section 5. Provision of Services. The facility failed to maintain a clean and safe environment free of unpleasant odors and ensure proper cleaning of commodes and bathrooms.
902 KAR 20:036 5(3)(b)3 Section 5. Provision of Services. The facility failed to maintain medical records with documentation of dietary services and therapeutic diets for residents.
902 KAR 20:036 5(3)(b)4 Section 5. Provision of Services. The facility failed to maintain proper housekeeping and maintenance including pest control, cleaning, and repair of facility grounds and equipment.
902 KAR 20:036 5(3)(b)5 Section 5. Provision of Services. The facility failed to maintain kitchen policies and procedures including food safety, temperature logs, and proper food handling.
902 KAR 20:036 5(5)(b) Section 5. Provision of Services. The facility failed to provide activity services and a planned activity program to meet residents' social needs.
Report Facts
Census: 47
Sampled residents: 26
Employees reviewed: 4
Residents with missing SMI Screening Forms: 10
Rooms reviewed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sethna Brown | Administrator | Named in relation to deficiencies in employee records, training, and facility policy implementation |
| Mike Helm | PA | Provider involved in medical record and lab work deficiencies |
| Keisha Todd | Psych provider visiting facility twice monthly | |
| Rebecca Lyons | Dietician | Dietician contracted by facility, involved in dietary service deficiencies |
| Cook 1 | Named in relation to food service and kitchen policy deficiencies | |
| Cook 2 | Named in relation to food service and kitchen policy deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
An abbreviated survey investigating multiple complaints was initiated on 2025-06-16 and concluded on 2025-06-17 with no deficient practice identified.
Complaint Details
The visit was complaint-related, investigating multiple complaint IDs including KY#00046163, KY00046191, KY00046195, KY00046305, KY00046392, KY00046428, KY00046432, KY00046478, KY00046494, KY00046504, and KY000535. No deficient practice was identified.
Findings
The investigation found no deficient practices related to the complaints during the abbreviated survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
An abbreviated survey was conducted to investigate complaint KY#00045930.
Complaint Details
Complaint KY#00045930 was investigated and found to have no deficient practice.
Findings
The survey was completed with no deficient practice identified.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
The visit was an on-site revisit survey conducted to verify correction of previously identified deficiencies.
Complaint Details
A complaint survey was initiated on 02/12/2025 related to Complaint KY00045019. A Type A Citation was issued for failure to notify Adult Protective Services (APS) and the state survey agency of an alleged resident abuse incident. The complaint was substantiated based on interviews and record reviews.
Findings
The deficiencies identified in the prior complaint investigation were deemed corrected as of 02/25/2025 based on the acceptable plan of correction and follow-up survey conducted from 03/31/2025 to 04/03/2025.
Deficiencies (1)
P 060: The facility failed to ensure that one of four sampled residents was protected from abuse by reporting all allegations to the appropriate state agencies as required by policy and regulation.
Report Facts
Survey Census: 48
Sample Size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Davis | Administrator | Named in relation to the abuse reporting deficiency and plan of correction |
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