Inspection Reports for
Fountain Circle Care and Rehabilitation Center
200 GLENWAY ROAD, WINCHESTER, KY, 40391
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Census: 125
Deficiencies: 4
Date: Mar 6, 2025
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident rights, transfer/discharge notifications, medication storage, and infection control practices.
Findings
The facility failed to ensure residents received mail on Saturdays, failed to provide timely and complete transfer/discharge notices including appeal rights for several residents, improperly stored medications and vaccines outside recommended temperature ranges, and failed to maintain an effective infection prevention and control program including proper PPE use and hand hygiene.
Deficiencies (4)
F 0576: Facility failed to ensure residents had the right to receive mail delivered on Saturdays, affecting all 125 residents.
F 0623: Facility failed to provide timely notification of transfer or discharge, including appeal rights, to 4 of 5 residents reviewed.
F 0761: Facility failed to store drugs and biologicals according to accepted professional principles, including improper refrigeration and failure to discard expired medications, affecting many residents.
F 0880: Facility failed to establish and maintain an infection prevention and control program, including failure to wear gowns during wound care and inadequate hand hygiene, affecting some residents.
Report Facts
Residents affected: 125
Residents affected: 25
Residents affected: 40
Residents affected: 2
Residents affected: 4
Medication refrigerators: 3
Medication carts: 2
Inspection Report
Routine
Deficiencies: 4
Date: Dec 19, 2019
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident care, medication management, infection control, and Minimum Data Set (MDS) submission at Fountain Circle Care & Rehabilitation Center.
Findings
The facility failed to ensure call lights were accessible to residents, timely submission of MDS assessments, proper labeling and storage of insulin medications, and appropriate infection control practices related to urinary catheter care. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Deficiencies (4)
F 0558: The facility failed to ensure call lights were within reach for two residents, resulting in inaccessible call lights and potential safety risks.
F 0640: The facility failed to submit the Annual Minimum Data Set (MDS) Assessment for one resident within the required timeframe due to missing electronic signature.
F 0761: The facility failed to ensure insulin vials were labeled with open dates and removed after expiration, resulting in expired insulin being stored on the medication cart.
F 0880: The facility failed to maintain infection control by allowing a resident's suprapubic catheter urinary drainage bag to lie on the floor, increasing risk of infection.
Report Facts
Sampled residents: 28
Residents affected: 2
Residents affected: 1
Residents affected: 1
Insulin expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse #1 | Failed to sign MDS Assessment causing late transmission | |
| Licensed Practical Nurse (LPN) #1 | Noticed call light out of reach and requested longer cord | |
| State Registered Nurse Aide (SRNA) #1 | Unaware call light was out of reach for Resident #25 | |
| Licensed Practical Nurse (LPN) #5 | Reported expired insulin should be removed from cart | |
| Licensed Practical Nurse (LPN) #2 | Responsible for checking insulin expiration dates | |
| Registered Nurse (RN) #2 | Explained insulin labeling and expiration requirements | |
| Director of Nursing | Director of Nursing | Oversaw expectations for insulin storage and infection control |
| Administrator | Administrator | Set expectations for call light monitoring and medication audits |
| Licensed Practical Nurse (LPN) #4 | Reported urinary drainage bags should not be on the floor | |
| Staff Development Coordinator | Staff Development Coordinator | Responsible for infection control education and audits |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 14, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, pain management, drug storage, labeling, and quality assurance processes at Fountain Circle Care & Rehabilitation Center.
Findings
The facility failed to ensure proper pain medication administration for one resident, resulting in missed doses and increased pain. Additionally, the facility did not properly label and store medications, including opened and expired vials, and failed to consistently monitor refrigerator temperatures. The facility also had deficiencies in maintaining an effective Quality Assurance Performance Improvement (QAPI) program to address these issues.
Deficiencies (3)
F 0697: The facility failed to provide safe and appropriate pain management for Resident #342 by not administering prescribed Neurontin doses on 11/13/18 and 11/14/18 due to medication unavailability.
F 0761: The facility failed to ensure drugs and biologicals were labeled with appropriate dates and stored properly, including opened medications without labels or expiration dates and missing refrigerator temperature logs.
F 0865: The facility failed to maintain an effective QAPI program to correct quality deficiencies, evidenced by repeat failures in medication storage and labeling despite prior corrective actions.
Report Facts
Missed medication doses: 4
Tuberculin vial expiration date: Sep 30, 2018
Plan of Correction compliance date: Dec 24, 2017
QAPI audit frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Interviewed regarding medication reorder process and responsibility for Resident #342's pain medication |
| Registered Nurse #1 | RN | Interviewed about pain assessment and medication effectiveness monitoring |
| Assistant Director of Nursing | ADON | Interviewed about medication reorder expectations and labeling policies |
| Director of Nursing | DON | Interviewed about medication reorder reports and staff responsibilities |
| Administrator | Interviewed about expectations for medication monitoring and ordering | |
| LPN #1 | LPN | Interviewed about medication labeling and refrigerator temperature monitoring |
| LPN #2 | LPN | Interviewed about medication dating and refrigerator temperature monitoring |
| A Wing Unit Manager | Interviewed about responsibility for dating medication vials and monitoring refrigerator temperatures |
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