Inspection Reports for
Elliott Nursing and Rehabilitation
RT 32 EAST, HOWARD CREEK RD, SANDY HOOK, KY, 41171
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 29, 2025
Visit Reason
An off-site Followup Survey was initiated and concluded to verify correction of previous deficiencies and compliance status.
Findings
The facility was determined to have achieved substantial compliance on 05/01/2025 based on the implementation of the acceptable Plan of Correction.
Inspection Report
Routine
Deficiencies: 2
Date: Apr 10, 2025
Visit Reason
Routine inspection of Elliott Nursing and Rehabilitation to assess compliance with medication storage, food service, and resident care regulations.
Findings
The facility failed to ensure proper storage of medications, including insulin stored outside recommended temperature ranges, expired medications present, and unsanitary medication carts. Additionally, the facility failed to honor resident food preferences for some residents, serving foods they had requested to avoid.
Deficiencies (2)
F 0761: The facility failed to store medications, including insulin, within the recommended temperature range of 36 to 46 degrees Fahrenheit. Medication carts were unsanitary, medications were not labeled or dated correctly, and expired medications were found in use.
F 0806: The facility failed to accommodate resident food preferences for 2 of 10 sampled residents, serving foods that residents had requested to avoid, such as bread, pasta, desserts, broccoli, and cauliflower.
Report Facts
Medication refrigerator temperature: 50
Expired medications: 2
Insulin pens: 12
Residents sampled for food preference: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Interviewed about medication storage and temperature monitoring. |
| LPN 3 | Licensed Practical Nurse | Interviewed about medication refrigerator temperature checks. |
| RN 2 | Registered Nurse | Interviewed about medication refrigerator temperature logs. |
| Infection Preventionist Nurse | Infection Preventionist | Interviewed about medication cart audits and storage practices. |
| Director of Nursing | Director of Nursing | Interviewed about medication storage and food preference policies. |
| Consultant Pharmacist | Pharmacist Consultant | Interviewed about medication storage temperature standards and audits. |
| Executive Director | Executive Director | Interviewed about facility expectations for medication storage and food preferences. |
| Account Manager | Account Manager | Interviewed about food substitutions and resident food preferences. |
| Registered Dietitian | Registered Dietitian | Interviewed about menu review and resident food preferences. |
| Food Service District Manager | Food Service District Manager | Interviewed about food preference collection and menu planning. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 20, 2024
Visit Reason
The inspection was conducted following a complaint regarding abuse between two residents at Elliott Nursing and Rehabilitation.
Complaint Details
The complaint investigation was substantiated. Resident R48 reported being hit and kicked by resident R64a on 02/17/2024, resulting in a bloody nose and hospital evaluation. Interviews and incident reports confirmed the abuse occurred.
Findings
The facility failed to ensure residents were free from abuse for 2 of 31 sampled residents. Resident R64a hit and kicked resident R48, causing a bloody nose and requiring hospital evaluation. Both residents were sent for psychiatric consultation and placed under supervision.
Deficiencies (1)
F 0600: The facility failed to protect residents from abuse, as resident R64a hit and kicked resident R48 causing physical injury. The incident was documented and psychiatric consultations were initiated for both residents.
Report Facts
Sampled residents: 31
Residents affected: 2
BIMS score: 3
BIMS score: 12
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 20, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, abuse prevention, care planning, pressure ulcer prevention, medication administration, infection control, and other facility operations.
Findings
The facility was found deficient in honoring resident medication administration preferences, preventing resident abuse, developing comprehensive care plans, preventing pressure ulcers through proper repositioning, and ensuring proper infection control practices related to glucometer disinfection. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (5)
F 0561: The facility failed to accommodate a resident's right to set her own medication schedule, resulting in delayed administration of blood pressure medication for Resident 65.
F 0600: The facility failed to protect residents from abuse when Resident 64a hit and punched Resident 48, causing injury and requiring hospital evaluation.
F 0656: The facility failed to develop and implement comprehensive, person-centered care plans for residents, including failure to include medication timing preferences and pressure ulcer prevention interventions.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers by not repositioning a resident every two hours, resulting in a stage 3 pressure ulcer for Resident 9.
F 0880: The facility failed to ensure proper infection prevention by not disinfecting a shared glucometer after use, creating immediate jeopardy to resident health and safety.
Report Facts
Residents sampled: 31
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN3 | Licensed Practical Nurse | Failed to disinfect glucometer after use, contributing to infection control deficiency |
| KMA5 | Kentucky Medication Aide | Administered medications on 300 and 400 Halls; described medication administration process affecting Resident 65 |
| SRNA4 | State Registered Nurse Aide | Observed Resident 65 waiting for medication and communicated resident's preference |
| SRNA6 | State Registered Nurse Aide | Assigned to Resident 9; admitted failure to reposition resident every two hours |
| RN2 | Registered Nurse | Nurse for Resident 9; described roles in pressure ulcer care and repositioning |
| DNS | Director of Nursing Services | Provided statements on medication administration preferences, care planning, and infection control expectations |
| ED | Executive Director | Provided statements on facility policies and expectations for individualized care and infection control |
| IP/ADNS | Infection Preventionist/Assistant Director of Nursing Services | Described glucometer disinfection procedures and lack of auditing process |
| Medical Director | Medical Director | Provided clinical opinion on pressure ulcer avoidability for Resident 9 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 4, 2022
Visit Reason
The inspection was conducted due to allegations of sexual abuse and failure to develop policies and care plans addressing capacity to consent to sexual activity among residents.
Complaint Details
The complaint investigation was substantiated with findings of sexual abuse incidents involving residents #13, #63, and #68. Immediate Jeopardy was identified on 04/22/2022 and removed on 04/26/2022 after the facility implemented corrective actions.
Findings
The facility failed to protect residents from sexual abuse and did not have effective policies or care plans to assess capacity to consent to sexual activity. Multiple incidents involving residents #13, #63, and #68 were investigated, revealing inappropriate sexual behaviors and lack of timely care plan updates. The facility implemented an Immediate Jeopardy Removal Plan including new policies, education, resident assessments, and care plan revisions.
Deficiencies (2)
F-600: The facility failed to protect residents from sexual abuse and did not develop policies or protocols to determine capacity to consent to sexual contact for three residents.
F-657: The facility failed to develop and revise comprehensive care plans timely for residents exhibiting sexually inappropriate behaviors and did not assess capacity to consent after incidents.
Report Facts
Residents affected: 3
BIMS scores: 5
BIMS scores: 13
BIMS scores: 12
Staff educated: 78
Staff not educated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #2 | Observed sexual abuse incident involving Residents #13 and #68. | |
| Licensed Practical Nurse (LPN) #6 | Observed sexual abuse incident involving Residents #63 and #68. | |
| Director of Social Services | Primary person for initiating and updating behavioral care plans and conducted resident interviews. | |
| Executive Director (ED) | Provided leadership, policy development, and staff education on sexual abuse and consent. | |
| Advanced Practice Registered Nurse (APRN) | Conducted capacity to consent assessments for residents. | |
| Director of Nursing Services (DON) | Oversaw nursing staff education and care plan updates. | |
| Regional Clinical Reimbursement Specialist | Assisted in reviewing and updating residents' care plans. |
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