Inspection Reports for
Edgemont Healthcare
323 WEBSTER AVENUE, CYNTHIANA, KY, 41031
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement policies and procedures to assess residents' capacity to consent to sexual relationships.
Complaint Details
The complaint investigation found that residents R4 and R13 engaged in sexual behavior without documented capacity to consent assessments. Interviews with staff and guardians revealed no prior evaluations were done before the relationship. The facility was unaware that its abuse policy required procedures for capacity to consent assessments and coordination with QAPI.
Findings
The facility failed to assess two residents (R4 and R13) for their capacity to consent to sexual relationships prior to the survey. The facility's abuse policy did not include required components related to capacity to consent assessments and coordination with the Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (1)
F 0607: The facility failed to develop and implement policies and procedures to prevent abuse, neglect, and theft, specifically lacking a protocol to assess residents' capacity to consent to sexual contact and coordination with the QAPI program.
Report Facts
BIMS score: 11
BIMS score: 12
Residents involved: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Reported observations and involvement in notification of sexual behavior incidents |
| Director of Nursing | Director of Nursing | Interviewed regarding awareness of residents' sexual activity and policy knowledge |
| Administrator | Administrator | Interviewed regarding policy awareness and views on residents' relationship |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Performed capacity to consent evaluation after the survey |
| Social Services Director | Social Services Director | Interviewed about resident reports and policy requests for capacity evaluations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 25, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to reasonably accommodate residents' needs and preferences, specifically related to personal belongings and room environment, and concerns about the facility's air conditioning system and overall maintenance conditions.
Complaint Details
The complaint investigation focused on residents' rights violations related to personal belongings and room accommodations, and on the facility's failure to maintain safe environmental conditions due to HVAC system failures and building disrepair. The complaints were substantiated with evidence of emotional distress to residents and unsafe temperature conditions.
Findings
The facility failed to accommodate residents' preferences regarding TV placement, shelving, and mattress toppers, causing emotional distress to residents. Additionally, the facility experienced prolonged HVAC system failures resulting in unsafe high temperatures, and multiple areas of the building showed significant disrepair and cleanliness issues, affecting residents' comfort and safety.
Deficiencies (2)
F 0558: The facility failed to reasonably accommodate the needs and preferences of residents R54 and R10 by moving or removing personal items and mounting televisions without resident input, causing emotional distress and infringing on resident rights.
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment by not promptly repairing the HVAC system, resulting in temperatures as high as 90 degrees Fahrenheit in resident areas and 110 degrees in the kitchen, and by allowing multiple areas to remain in disrepair and unclean.
Report Facts
Residents sampled: 21
Residents affected: 2
Temperature: 90
Temperature: 110
Duration of HVAC issues: 21
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Made decisions about TV mounting and shelf removal, stated facility knows best for residents | |
| Director of Maintenance | Performed TV mounting and shelf removal per Administrator's instructions, managed HVAC repair | |
| Director of Nursing | DON | Interviewed regarding TV placement, mattress toppers, and facility conditions |
| Registered Nurse 3 | RN | Reported resident distress related to TV placement and HVAC issues |
| State Registered Nursing Aide 2 | SRNA | Reported resident distress and complaints about heat |
| Ombudsman1 | Reported resident complaints and facility conditions | |
| Contract Staff 2 | Reported resident distress about TV placement and shelf removal |
Inspection Report
Routine
Deficiencies: 17
Date: Jul 25, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, staffing, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, inadequate accommodation of resident preferences, failure to provide a safe and comfortable environment including temperature control, misappropriation of resident property, inaccurate resident assessments, incomplete and untimely care plans, inadequate assistance with activities of daily living, insufficient activities programming, failure to prevent and treat pressure ulcers, improper catheter care, inadequate dialysis communication, insufficient staffing levels, improper medication labeling, lack of infection control compliance, and failure to maintain essential equipment.
Deficiencies (17)
F0550: The facility failed to treat residents with dignity and respect, exposing residents to privacy violations and failing to cover catheter bags as required.
F0558: The facility failed to reasonably accommodate resident preferences, causing emotional distress by moving personal items and mounting televisions without resident input.
F0577: The facility failed to post survey results in a location accessible to residents, limiting their right to review inspection findings.
F0584: The facility failed to maintain a safe, clean, and comfortable environment, including prolonged HVAC failure causing high temperatures and multiple areas of disrepair.
F0602: The facility failed to protect residents from misappropriation of personal property and failed to reimburse for missing items.
F0641: The facility failed to ensure accurate resident assessments, resulting in an inaccurate MDS for a resident receiving insulin injections.
F0656: The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and failed to revise care plans after incidents.
F0677: The facility failed to provide adequate assistance with activities of daily living, including timely incontinence care, causing resident distress.
F0679: The facility failed to provide activities to meet residents' needs, leaving a cognitively impaired resident unstimulated and isolated.
F0686: The facility failed to provide appropriate pressure ulcer care and prevention, resulting in a Stage III pressure ulcer that worsened and remained unhealed for over 175 days.
F0690: The facility failed to provide appropriate catheter care, allowing catheter tubing and bags to drag on the floor, increasing infection risk.
F0698: The facility failed to ensure safe, appropriate dialysis care by not maintaining ongoing communication and documentation with the dialysis center.
F0725: The facility failed to maintain sufficient nursing staff with appropriate skills to meet resident needs, resulting in inadequate care and staff shortages.
F0761: The facility failed to properly label multi-use medications with opening dates, risking administration of expired medications.
F0838: The facility failed to conduct and document a comprehensive facility-wide assessment to determine staffing needs and contingency plans for emergencies.
F0880: The facility failed to implement an effective infection prevention and control program, including failure to don gowns during wound care and inadequate hand hygiene.
F0908: The facility failed to maintain essential equipment in safe operating condition; the mechanical lift scale was broken and unusable for weighing residents.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Staffing: 4
Facility census: 64
BIMS score: 0
BIMS score: 15
BIMS score: 14
BIMS score: 15
Wound size: 17.05
Date of survey: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN3 | Registered Nurse | Named in findings related to catheter care, staffing, and wound care |
| SRNA5 | State Registered Nurse Aide | Named in findings related to incontinence care and repositioning |
| SRNA4 | State Registered Nurse Aide | Named in findings related to repositioning and wound care |
| DON | Director of Nursing | Named in multiple findings related to care plan, staffing, and infection control |
| Administrator | Facility Administrator | Named in multiple findings related to staffing, equipment, and policies |
| LPN3 | Licensed Practical Nurse | Named in findings related to MDS assessment |
| RN1 | Registered Nurse | Named in infection control finding related to gown use |
| RN2 | Registered Nurse | Named in infection control and oxygen tubing findings |
| Dietician | Dietician | Named in findings related to weighing residents and nutrition |
| Therapy Director | Therapy Director | Named in pressure ulcer care findings |
| LPN4 | Licensed Practical Nurse | Named in dialysis communication findings |
| SRNA1 | State Registered Nurse Aide | Named in infection control hand hygiene findings |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 25, 2021
Visit Reason
The inspection was conducted following a complaint regarding resident-to-resident abuse and concerns about food storage and labeling practices in the facility.
Complaint Details
The complaint investigation substantiated that Resident #16 was physically abused by Resident #24 on 03/21/2021. The incident was observed by staff and resulted in a minor injury. The facility took corrective actions including moving Resident #16 to another room and increasing monitoring of Resident #24.
Findings
The facility failed to protect a resident from abuse by another resident, resulting in a minor injury. Additionally, the facility failed to store and label food properly according to professional standards, including food brought in from outside sources.
Deficiencies (4)
F 0600: The facility failed to protect residents from abuse, as Resident #16 was struck in the face by Resident #24, causing a small red area that resolved within ten minutes.
F 0812: The facility failed to store food in accordance with professional standards, including unlabeled and undated food items in the kitchen refrigerator.
F 0812: The Director of Nursing stated that food removed from its original container must be labeled and dated at the time of removal to ensure residents receive the correct foods.
F 0813: The facility failed to properly label and store food brought in from outside sources, with some items lacking dates or resident names and being stored in the wrong refrigerator.
Report Facts
Residents sampled: 16
Residents affected by abuse: 1
Blood glucose level: 67
Blood glucose recheck: 145
Food items observed unlabeled: 12
Bowls of unlabeled food: 4
Commercial pizza boxes observed: 2
Cinnamon rolls: 2
Resident #24 glucose monitoring frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed the abuse incident and assisted in resident assessment |
| Director of Nursing | Director of Nursing (DON) | Observed the abuse incident, coordinated response, and provided statements on food labeling and storage policies |
| Dietary Manager | Dietary Manager | Provided information on food labeling and storage procedures and identified deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 7, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, infection control, and facility environment.
Findings
The facility failed to develop and implement a comprehensive care plan addressing a resident's limited range of motion and contractures, failed to provide or document restorative nursing care and range of motion exercises, failed to maintain proper infection prevention practices during medication administration, and failed to ensure a safe, sanitary environment due to sewage contamination in the basement near food storage.
Deficiencies (4)
F 0656: The facility failed to develop and implement a complete care plan with measurable objectives and timeframes for Resident #22's medical and nursing needs related to limited range of motion and contractures.
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion for Resident #22, who had functional limitations and contractures, and failed to document restorative nursing care or range of motion exercises.
F 0880: The facility failed to establish and maintain an infection prevention and control program, as evidenced by a nurse administering medications without performing hand hygiene and handling pills with bare hands.
F 0921: The facility failed to ensure a safe, sanitary, and comfortable environment by allowing sewage contamination in the basement near dry goods and pantry areas, risking cross-contamination of food supplies.
Report Facts
Residents sampled: 19
Residents affected: 1
Residents affected: 2
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in infection control deficiency for failing to perform hand hygiene and handling medication with bare hands |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding restorative care and infection control policies |
| SRNA #3 | State Registered Nurse Aide | Interviewed about restorative care delivery and documentation |
| Director of Nursing | Director of Nursing | Interviewed about restorative care, care plan development, and infection control expectations |
| Administrator | Facility Administrator | Interviewed about restorative care expectations, infection control, and environmental safety |
| Director of Maintenance | Director of Maintenance | Interviewed regarding sewage spill and environmental safety |
| Dietary Manager | Dietary Manager | Interviewed regarding responsibility for cleaning basement and food safety |
Viewing
Loading inspection reports...
