Inspection Reports for
Grand Haven Nursing Home
105 RODGERS PARK, CYNTHIANA, KY, 41031
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
70% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 8
Date: 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.
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.
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.
Deficiencies (8)
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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