Deficiencies (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
Routine
Deficiencies: 2
Date: Aug 22, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights and food safety practices at the nursing home.
Findings
The facility failed to consistently support and encourage resident participation in Resident Council meetings, with no meetings held from February through June 2025. Additionally, the facility failed to properly date frozen food items in the kitchen, violating food storage policies.
Deficiencies (2)
F 0565: The facility failed to support and encourage residents to organize and participate consistently in Resident Council meetings for 2 of 5 sampled residents. No meetings were held from February through June 2025, despite resident concerns and facility policy.
F 0812: The facility failed to store frozen green beans appropriately by not dating them after removal from original packaging, contrary to facility policy requiring all food items to be dated.
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 3
Date: Dec 15, 2023
Visit Reason
The investigation was conducted due to complaints and concerns regarding resident care, supervision, fall prevention, and elopement risks at the facility.
Complaint Details
The complaint investigation was triggered by allegations of resident mistreatment, inadequate care planning for falls and supervision, and failure to prevent elopement. The facility was found to have immediate jeopardy related to supervision and elopement risk for Resident #57, who left the facility without staff knowledge and was returned by police. The investigation included interviews, record reviews, and observations.
Findings
The facility failed to treat a resident with dignity, failed to develop and implement adequate person-centered care plans for falls and supervision, and failed to prevent elopement for residents at risk. Multiple residents experienced falls with injuries, and one resident eloped from the facility without adequate supervision.
Deficiencies (3)
F 0550: The facility failed to treat Resident #21 with respect and dignity, as a staff member was rough, frustrated, and used inappropriate language in front of the resident.
F 0656: The facility failed to develop and implement complete, person-centered care plans for falls and supervision for Residents #13, #17, #114, #113, and #115, resulting in inadequate interventions and monitoring.
F 0689: The facility failed to ensure adequate supervision and monitoring to prevent elopement and accidents, resulting in immediate jeopardy for Resident #57 who eloped and for Residents #13 and #17 who had multiple falls with injuries.
Report Facts
Sampled residents: 69
Resident #21 cognitive score: 6
Resident #13 fall risk score: 22
Resident #17 fall risk score: 17
Resident #57 cognitive score: 9
Resident #57 elopement date: 2023
Resident #13 documented falls: 5
Resident #17 fall date: 2023
Resident #115 admission date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #20 | Licensed Practical Nurse | Documented multiple fall incidents and assessments for Resident #13 |
| STNA #32 | State Trained Nurse Aide | Involved in mistreatment incident with Resident #21 |
| STNA #11 | State Trained Nurse Aide | Reported inappropriate behavior of STNA #32 |
| Administrator | Provided statements regarding Resident #57 elopement and facility policies | |
| Social Worker #1 | Social Worker | Created baseline care plan and provided statements regarding Resident #57 |
| RN #4 | Registered Nurse | Night shift supervisor who reported on Resident #57's wandering behavior |
| LPN #7 | Licensed Practical Nurse | Completed admission assessments for Resident #57 |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding resident care plans, supervision, fall prevention, medication management, infection control, and safety measures.
Findings
The facility failed to develop and implement person-centered care plans for fall prevention and supervision for several residents, failed to ensure adequate supervision to prevent elopement and accidents, failed to label and manage medications properly, and failed to implement Enhanced Barrier Precautions for residents with wounds or indwelling devices, leading to immediate jeopardy for resident health and safety.
Deficiencies (4)
F 0656: The facility failed to develop and implement complete, person-centered care plans for falls and supervision for multiple residents, resulting in actual harm.
F 0689: The facility failed to ensure adequate supervision to prevent accidents and elopement, resulting in immediate jeopardy to resident health or safety.
F 0761: The facility failed to ensure opened and in-use medications were labeled with the opened date and were not expired in medication carts and medication rooms.
F 0880: The facility failed to maintain an infection prevention and control program by not implementing Enhanced Barrier Precautions for residents with wounds or indwelling devices as required by CDC and CMS guidelines.
Report Facts
Number of sampled residents: 69
Resident #13 fall risk score: 22
Resident #17 fall risk score: 17
Resident #57 BIMS score: 9
Resident #13 fall risk score: 18
Resident #13 fall risk score: 15
Resident #13 fall risk score: 10
Resident #13 fall risk score: 10
Resident #13 fall risk score: 14
Resident #115 admission date: 2023
Resident #115 care plan initiation date: 2023
Resident #115 incident date: 2023
Resident #17 fall date: 2023
Resident #13 fall dates: 5
Resident #57 elopement date: 2023
Resident #57 walk distance: 1.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #20 | Licensed Practical Nurse | Documented multiple fall incidents and post-fall observations for Resident #13 and Resident #17 |
| LPN #7 | Licensed Practical Nurse | Completed admission assessments and interviews related to Resident #57 |
| STNA #35 | State Trained Nurse Aide | Responded to fall incident involving Resident #17 |
| PTA #1 | Physical Therapy Assistant | Intervened during elopement incident involving Resident #115 |
| Administrator | Facility Administrator | Provided interviews regarding Resident #57 elopement and infection control policies |
| DON | Director of Nursing | Provided interviews regarding care plan updates, supervision, and infection control |
| Quality Program Manager | Quality Program Manager | Provided interviews regarding medication audits and infection control education |
| Pharmacy Technician #1 | Pharmacy Technician | Provided information on medication cart audits |
| Social Worker #1 | Social Worker | Provided discharge planning and concerns about Resident #57 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 28, 2021
Visit Reason
The inspection was conducted to investigate complaints regarding improper food preparation, storage, and distribution practices that could lead to cross contamination and foodborne illness.
Complaint Details
The visit was complaint-related, triggered by concerns about food safety and infection control. The complaint was substantiated based on observations and interviews confirming improper glove use and unsafe storage of cleaning equipment.
Findings
The facility failed to maintain safe food handling practices, including improper storage of cleaning equipment near food preparation areas and dietary staff touching their clothing with gloves during meal service, creating potential for cross contamination.
Deficiencies (1)
F 0812: The facility failed to procure food from approved sources and to store, prepare, distribute, and serve food in accordance with professional standards. Observations revealed cleaning equipment hanging uncovered behind a stand mixer and dietary staff touching their clothing with gloves during meal service, risking cross contamination.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #1 | Dietary Aide | Observed repeatedly touching clothing with gloves during meal service, contributing to cross contamination risk. |
| Dietary Manager | Dietary Manager | Interviewed regarding infection control concerns about cleaning equipment storage and glove use. |
| Administrator | Administrator | Interviewed about infection control issues related to uncovered cleaning equipment and glove hygiene. |
| Director of Nursing | Director of Nursing | Interviewed about infection control concerns and proper glove use. |
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