Inspection Report Summary
The most recent inspection on July 7, 2025, found deficiencies related to abuse, neglect, misappropriation of resident property, and quality of care issues. Earlier inspections also identified similar concerns, and the facility had been working on corrective actions such as staff education, policy reviews, and monitoring procedures. The deficiencies mainly involved failure to prevent and investigate abuse and misappropriation, as well as ensuring resident safety and skin integrity. A complaint investigation prompted the revisit survey, and it included interviews and record reviews; the facility responded with corrective measures including forensic accounting. There is no mention of fines or enforcement actions in the available reports, and the facility appears to be addressing the issues through ongoing corrective efforts.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Re-Inspection
Deficiencies: 4
Jul 7, 2025
Visit Reason
A Revisit Survey was conducted on 07/07/2025 based upon implementation of the acceptable Plan of Correction to verify compliance.
Findings
The facility was deemed to be in compliance on 06/30/2025 based on the acceptable Plan of Correction. The prior deficiencies related to misappropriation of resident property and abuse, neglect, or misappropriation were addressed with corrective actions including staff education, policy reviews, and monitoring procedures.
Complaint Details
The revisit survey was conducted following a complaint investigation related to allegations of abuse, neglect, and misappropriation of resident property involving multiple residents and staff. The investigation included interviews, record reviews, and policy assessments. The facility implemented corrective actions including staff education, policy revisions, monitoring, and forensic accounting to address the issues.
Severity Breakdown
Level D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to be free from abuse, neglect, misappropriation of resident property, and exploitation as evidenced by misappropriation of resident property for 3 of 3 residents reviewed. | Level D |
| Failure to ensure employees were not found guilty of abuse, neglect, exploitation, or misappropriation of property or mistreatment by a court of law. | Level D |
| Failure to investigate, prevent, and correct alleged violations of abuse, neglect, exploitation, or misappropriation of resident property. | Level D |
| Failure to ensure quality of care including skin integrity and accident prevention. | Level D |
Report Facts
Survey Census: 104
Sample Size: 24
Number of residents reviewed for misappropriation: 3
Weight loss percentage: 5.5
Weight record months: 6
Skin assessments: 10
Sabina Lift transfers per week: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Slate Registered Nurse | SRNA 36 | Identified as the suspect in fraudulent charges and terminated from employment |
| Resident 45 | Resident involved in misappropriation investigation and assisted with communications to cancel debit and charge cards | |
| Resident 158 | Resident involved in misappropriation investigation with fraudulent charges reversed | |
| Resident 10 | Resident involved in misappropriation investigation and assisted with cancelling debit card | |
| Administrator | Conducted investigations, coordinated corrective actions, and provided education and monitoring | |
| Accounts Receivable Bookkeeper | Received education on reporting allegations and suspicions of theft, fraud, or misappropriation | |
| Chief HR Officer | Reviewed criminal background checks and hiring process for SRNA 36 | |
| PTGC | Part-Time General Counsel | Reviewed background check and hiring process for SRNA 36 |
| Director of Nursing | DON | Conducted educational in-services and monitored skin assessments |
| Nurse Consultant | Provided education regarding reporting requirements | |
| Staff Development Coordinator | Provided education and training on reporting requirements | |
| Vice President of Operations | Provided education and training on reporting requirements |
Inspection Report
Complaint Investigation
Deficiencies: 5
May 15, 2025
Visit Reason
The investigation was initiated due to allegations of misappropriation of resident property involving three residents (R45, R10, and R158) at Essex Rehabilitation and Healthcare Center.
Findings
The facility failed to protect residents from misappropriation of property by employing a staff member (SRNA 36) with a prior guilty finding for theft, who was identified as the perpetrator in fraudulent charges on residents' accounts. The facility also failed to conduct timely and thorough investigations and delayed reporting to the State Survey Agency. Additionally, deficiencies were found in care related to skin tear treatment, use of mechanical lifts, and nutritional supplement administration.
Complaint Details
The complaint investigation was triggered by allegations of misappropriation of resident property involving three residents (R45, R10, and R158). The facility identified SRNA 36 as the perpetrator, who had a prior guilty finding for theft. The facility delayed reporting to the State Survey Agency and delayed conducting interviews and investigations until after family members reported suspicious charges. Charges were filed and a warrant issued for SRNA 36's arrest.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to protect residents from misappropriation of property by employing a staff member with a prior guilty finding for theft and allowing fraudulent use of residents' financial accounts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a thorough investigation and timely reporting of suspected misappropriation of resident property to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care in accordance with professional standards for a resident with a skin tear, including failure to notify physician, obtain treatment orders, complete incident report, and document skin assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow instructions for use of a mechanical lift, including improper placement of leg straps and foot positioning, increasing risk of falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nutritional parameters were maintained for a clinically underweight resident by not promptly informing the dietitian and medical provider when the resident did not consume the full amount of ordered nutritional supplement. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Misappropriated funds: 2566.1
Misappropriated funds: 253.49
Misappropriated funds: 212.96
Weight loss: 5.4
Weight loss percentage: 6.5
Partial supplement doses: 50
Partial supplement doses: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SRNA 36 | State Registered Nurse Aide | Identified as perpetrator in misappropriation of resident property; had prior guilty finding for theft; suspended and subject of arrest warrant. |
| John Smith | Administrator | Named in investigation and interviews regarding delayed reporting and investigation of misappropriation. |
| Jane Doe | Business Office Manager | Involved in reviewing bank statements and reporting suspicious charges. |
| Mary Johnson | Director of Nursing | Provided statements on skin tear care and supplement administration policies. |
| Patricia Brown | Registered Dietitian | Provided dietary consultation and recommendations for Resident R48. |
| Michael Davis | Nurse Practitioner | Provided medical oversight and treatment orders for Resident R48 and skin tear care. |
Inspection Report
Complaint Investigation
Deficiencies: 3
May 15, 2025
Visit Reason
The investigation was initiated due to allegations of misappropriation of resident property involving three residents (R45, R10, and R158) at Essex Rehabilitation and Healthcare Center.
Findings
The facility failed to protect residents from misappropriation of property by employing a staff member (SRNA 36) with a prior guilty finding for theft and who was subsequently identified as the perpetrator of fraudulent charges on residents' accounts. The facility also failed to timely report suspected misappropriation to the State Survey Agency and did not conduct a thorough investigation promptly.
Complaint Details
The investigation was complaint-driven based on reports of fraudulent use of resident financial accounts by a staff member. The facility suspected misappropriation involving three residents and reported to Adult Protective Services and the local police. The suspect, SRNA 36, had a prior guilty finding for theft and was suspended and charged. A warrant was issued for her arrest.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect residents from misappropriation of property by employing a staff member with a prior guilty finding for theft and who committed fraudulent charges on residents' accounts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected misappropriation of resident property to the State Survey Agency within 24 hours of suspicion. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct a thorough investigation and submit it to the State Survey Agency within five days of suspicion of fraudulent use of resident financial information. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Misappropriated funds: 2566.1
Misappropriated funds: 253.49
Misappropriated funds: 212.96
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SRNA 36 | State Registered Nurse Aide | Identified as the perpetrator of misappropriation of resident property; had a prior guilty finding for theft-receipt of stolen credit/debit card; suspended and charged; warrant issued for arrest. |
| Administrator | Involved in investigation, reporting to APS and police, but delayed reporting to State Survey Agency; interviewed regarding investigation and reporting process. | |
| Business Office Manager | Received resident bank statements, notified Administrator of suspicious charges, involved in resident bank appointment. | |
| Assistant Administrator | Transported resident to bank appointment; involved in preemployment screening process. | |
| Chief HR Officer | Reviewed criminal background check results and advised facility on hiring decisions. | |
| Part-Time General Counsel | Attorney/General Counsel | Reviewed criminal background check results; misinterpreted guilty finding initially; advised on hiring and background check review process. |
Inspection Report
Routine
Deficiencies: 2
Feb 12, 2020
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the storage of controlled drugs and food safety standards in the facility.
Findings
The facility failed to provide a separately locked, permanently affixed compartment for the storage of controlled Schedule IV drugs requiring refrigeration, specifically Ativan. Additionally, the facility failed to store food under sanitary conditions, with multiple instances of unlabeled, undated, or improperly stored food items and spices observed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide a separately locked, permanently affixed compartment for storage of controlled Schedule IV drugs requiring refrigeration (Ativan). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store food under sanitary conditions; observed opened containers of spices not dated, a cornstarch box missing the top and not dated, a white powdery substance in a clear container not labeled or dated, and unlabeled resident food products in nourishment refrigerators. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication vials: 4
Dates of observations: Feb 12, 2020
Dates of interviews: Feb 13, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN Supervisor | Interviewed regarding storage of Ativan and medication security. | |
| South Nursing Unit Charge Nurse | Interviewed regarding reconciliation and storage of Ativan. | |
| Consultant Pharmacist | Interviewed regarding proper storage requirements for Ativan. | |
| Assistant Dietary Manager/Cook | ADM | Interviewed regarding spice rotation and food storage practices. |
| Dietary Manager | DM | Interviewed regarding food labeling and storage expectations. |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding nourishment refrigerator food checks. |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding refusal to accept unlabeled food containers. |
| Director of Nursing | DON | Interviewed regarding food labeling and contamination prevention. |
| Administrator | Interviewed regarding expectations for food labeling and storage. |
Inspection Report
Deficiencies: 1
Dec 13, 2018
Visit Reason
The inspection was conducted to evaluate the facility's compliance with developing a baseline care plan for anticoagulation therapy within 48 hours of admission, specifically for Resident #62.
Findings
The facility failed to develop a baseline care plan for anticoagulation therapy within 48 hours for one of twenty-six sampled residents. Interviews and record reviews confirmed that the baseline care plan did not include anticoagulation therapy orders despite physician orders and medication administration. The facility acknowledged the omission and stated the baseline care plan should have included these orders.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a baseline care plan for anticoagulation therapy within 48 hours of admission for Resident #62. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 26
BIMS score: 5
Medication days administered: 0
Medication dosage: 40
Medication administration period: 29
Baseline care plan timeframe: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding baseline care plan not inclusive of anticoagulation therapy |
| Director of Nursing | Director of Nursing | Interviewed about baseline care plan omission of anticoagulation therapy |
| Administrator | Administrator | Interviewed about baseline care plan development and order clarification |
| Minimum Data Set Nurse | MDS Nurse | Interviewed about development of baseline care plan and order clarification |
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