Inspection Reports for Irvine Nursing and Rehabilitation Center

411 BERTHA WALLACE DRIVE, KY, 40336

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Inspection Report Summary

The most recent inspection on March 21, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed some deficiencies, including issues with resident privacy, food temperature control, infection prevention, and the resident call system, all cited in February 2025 at a high severity level. The complaints investigated were all unsubstantiated, and no fines or enforcement actions were listed in the available reports. Prior reports noted concerns mainly related to infection control and facility operations rather than direct resident care. The inspection history suggests some improvement, with the latest survey showing no deficiencies after earlier issues were identified.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

15% better than Kentucky average
Kentucky average: 4.7 deficiencies/year

Deficiencies per year

4 3 2 1 0
2025
Inspection Report Abbreviated Survey Deficiencies: 0 Mar 21, 2025
Visit Reason
An abbreviated survey was conducted to investigate complaints KY00045420 and KY00045473.
Findings
No deficient practice was identified during the investigation.
Complaint Details
The survey was complaint-related, investigating complaints KY00045420 and KY00045473, with no deficiencies found.
Inspection Report Complaint Investigation Deficiencies: 4 Feb 10, 2025
Visit Reason
A Standard Recertification and Abbreviated Survey was initiated to investigate multiple complaints identified by their codes KY34651, KY35885, KY36133, KY38473, KY39986, KY40443, KY40780, KY44991, and KY45067. The survey was conducted from 02/10/2025 to 02/13/2025.
Findings
The Division of Healthcare determined all complaints were unsubstantiated; however, deficient practices were identified and cited at the highest scope and severity level 'E'. Deficiencies included breaches in personal privacy/confidentiality of records, failure to maintain food at safe and appetizing temperatures, and failure to maintain an effective infection prevention and control program. Multiple interviews, observations, and policy reviews supported these findings.
Complaint Details
The investigation was complaint-driven, covering multiple complaint IDs. The Division of Healthcare found all complaints unsubstantiated but identified deficient practices at the highest severity level 'E'.
Severity Breakdown
E: 4
Deficiencies (4)
DescriptionSeverity
Failure to ensure security and confidentiality of medical records for one of twenty-nine sampled residents, including unauthorized disclosure of medical information. E
Failure to provide food served at safe and appetizing temperatures, with hot foods below 135°F and cold foods above 41°F. E
Failure to maintain an infection prevention and control program that provides a safe, sanitary, and comfortable environment, including improper hand hygiene and glove use by staff. E
Failure to maintain an adequate resident call system, with call lights not accessible or functioning properly for multiple residents. E
Report Facts
Sampled residents: 29 Residents expressing food concerns: 5 Residents attending group meeting: 17 Residents with call light issues: 4 Residents with call light verification: 3 Compliance date: Mar 8, 2025
Employees Mentioned
NameTitleContext
Physician 1 Named in relation to breach of confidentiality and communication with resident's family
Registered Nurse 1 RN Observed breaching confidentiality and improper infection control practices
Director of Nursing DON Provided statements on notification policies and hand hygiene expectations
Dietary Manager DM Observed food temperature issues and provided education on food safety
District Dietary Manager DDM Verified food temperatures and discussed food safety concerns
Administrator Acknowledged food complaints and facility policies
Education Training Director Provided education on privacy, infection control, and call light system

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