Inspection Report Summary
The most recent inspection on January 24, 2025, identified deficiencies related to resident rights, care planning, medication management, respiratory care, and infection control. Earlier inspections also noted issues with expired medications, infection prevention, documentation, and quality assurance processes. Inspectors cited problems with dignity and privacy, mail delivery rights, medication labeling and storage, oxygen therapy, and infection control compliance. Complaint investigations were substantiated, confirming deficiencies affecting multiple residents, but enforcement actions such as fines or license suspensions were not listed in the available reports. The pattern of findings suggests ongoing challenges in care and safety practices without clear improvement over time.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
219% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 7
Jan 24, 2025
Visit Reason
A Recertification and Abbreviated Survey was conducted from 01/21/2025 to 01/24/2025 to assess compliance with 42 CFR 483 subpart B, including investigation of complaints related to resident rights and care.
Findings
The facility was found not to be in substantial compliance with resident rights, specifically dignity and privacy related to catheter bag covers, and rights to forms of communication including mail delivery. Deficiencies were identified in baseline care planning, respiratory care, medication labeling and storage, and oxygen flow rate management. Corrective actions and education plans were outlined for staff.
Complaint Details
The investigation was complaint-related, focusing on resident rights violations including dignity/privacy and mail delivery issues. The complaint was substantiated with findings of deficient practices affecting multiple residents.
Severity Breakdown
SS=D: 5
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with dignity and respect related to privacy and providing a privacy/dignity bag to cover an indwelling urinary catheter bag for 1 of 13 sampled residents. | SS=D |
| Failure to ensure all residents had the right to send and receive mail on Saturdays, affecting all 49 current residents. | SS=F |
| Failure to develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care for 1 of 13 sampled residents. | SS=D |
| Failure to develop and implement a comprehensive person-centered care plan that meets regulatory requirements for 2 of 13 sampled residents. | SS=D |
| Failure to provide respiratory care including tracheostomy care and tracheal suctioning according to professional standards for 1 of 13 sampled residents. | SS=D |
| Failure to ensure proper labeling and storage of drugs and biologicals; undated, opened, and expired medications were found. | SS=F |
| Failure to ensure oxygen therapy was provided according to physician orders and proper oxygen flow rates were maintained for sampled residents. | SS=D |
Report Facts
Survey Census: 49
Sample Size: 13
Residents affected by mail delivery deficiency: 49
Residents with dignity bag deficiency: 1
Residents with baseline care plan deficiency: 1
Residents with comprehensive care plan deficiency: 2
Residents with respiratory care deficiency: 1
Medication carts with expired meds: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Myers | Director of Nursing (DON) | Named in corrective action and education plans related to dignity/privacy and mail delivery deficiencies |
| April Massey | LPN, QA Nurse | Named in corrective action and education plans related to dignity/privacy and mail delivery deficiencies |
| Amy Oaks | Unit Nurse Manager | Named in corrective action and education plans related to dignity/privacy and mail delivery deficiencies |
| Ashlee Gaunce | Administrator | Involved in review and monitoring of deficient practices and corrective actions |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 8
Jan 24, 2025
Visit Reason
A relicensure and complaint survey was conducted from 01/21/2025 to 01/24/2025 to investigate compliance with state and federal regulations and to address specific complaints.
Findings
The facility was found not to have an effective Quality Assurance Performance Improvement (QAPI) process and failed to establish and maintain an infection prevention and control program. Deficiencies included expired medications in use, improper medication storage and labeling, failure to follow infection control protocols, and inadequate documentation related to immunizations and water management for Legionella prevention.
Complaint Details
The complaint investigation revealed multiple deficiencies related to expired medications, infection control breaches, and inadequate immunization documentation. The complaint was substantiated based on observations, interviews, and record reviews.
Deficiencies (8)
| Description |
|---|
| Facility failed to have an effective QAPI process focused on outcomes of care and quality of life. |
| Expired insulin lispro was opened, in use, and dated with an expiration date of 01/16/2025. |
| Facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. |
| Licensed Practical Nurse (LPN) 3 failed to don personal protective equipment (PPE) properly in an enhanced-barrier precaution room. |
| Facility failed to provide documentation of a process flow diagram for water system to include areas where Legionella could grow and spread. |
| Expired medications were found in medication carts and treatment carts, including insulin pens and inhalers. |
| Facility failed to ensure medical records included documentation of resident or representative education regarding benefits and potential side effects of influenza and pneumococcal immunizations. |
| Facility failed to ensure all staff were properly educated and compliant with infection prevention and control policies, including cleaning and disinfecting shared equipment. |
Report Facts
Survey Census: 49
Expired medications observed: 4
BIMS scores: 11
BIMS scores: 15
Employee files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Myers | Director of Nursing | Named in multiple findings related to QAPI audits, infection control education, and immunization compliance. |
| April Massey | QA Nurse | Involved in education and audits related to QAPI and infection control. |
| Ashlee Gaunce | Administrator | Responsible for overseeing QAPI and infection control corrective actions and audits. |
| LPN 3 | Licensed Practical Nurse | Observed failing to don PPE properly and not following infection control protocols. |
| RN 1 | Registered Nurse | Observed cleaning stethoscope improperly and not following infection control procedures. |
| Amy Oaks | LPN, Unit Nurse Manager | Named as monitoring compliance regarding medication labeling and storage. |
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