Inspection Reports for
Lake Way Rehabilitation and Healthcare Center
2607 MAIN STREET HWY 641 SOUTH, BENTON, KY, 42025
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control program requirements, specifically focusing on the designation and responsibilities of an Infection Preventionist (IP).
Findings
The facility failed to have a designated Infection Preventionist responsible for the infection prevention and control program, potentially affecting all 84 residents. The Administrator and nursing leadership acknowledged the vacancy and described ongoing efforts to train staff and manage infection control duties in the interim.
Deficiencies (1)
F 0882: The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program, affecting all residents. The Administrator confirmed the position was vacant following the resignation of the former ICP and that the Assistant Director of Nursing and Director of Nursing were temporarily overseeing infection control duties.
Report Facts
Residents affected: 84
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
A Standard Recertification Survey and an Abbreviated Survey investigating specific complaint numbers KY00039881, KY00040437, KY00043353, and KY00045679 were conducted from 07/07/2025 to 07/09/2025.
Complaint Details
The survey investigated complaints KY00039881, KY00040437, KY00043353, and KY00045679. No deficiencies were issued related to these complaints.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B, with regulatory violations cited at scope and severity level 'F'. No deficiencies were issued related to the specific complaints investigated. The main deficiency was failure to designate an infection preventionist with completed specialized training.
Deficiencies (1)
The facility failed to have a designated Infection Preventionist (IP) with completed specialized training in infection prevention and control.
Report Facts
Survey Census: 84
Sample Size: 22
Supplemental Residents: 2
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
A Standard Recertification Survey and an Abbreviated Survey investigating multiple facility IDs were conducted to assess compliance with federal regulations.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B, with regulatory violations cited at scope and severity level 'F'. No deficiencies were issued related to the specific facility IDs investigated. The main deficiency involved failure to designate a qualified Infection Preventionist as required.
Deficiencies (1)
Facility failed to have a designated Infection Preventionist (IP) responsible for the Infection Control Program affecting 84 residents.
Report Facts
Survey Census: 84
Sample Size: 22
Supplemental Residents: 2
Inspection Report
Deficiencies: 0
Date: May 12, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Lake Way Rehabilitation and Healthcare Center, summarizing the results of a regulatory survey completed on May 12, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 8, 2020
Visit Reason
The inspection was conducted due to concerns about medication misappropriation and related complaints involving narcotics for two residents, as well as issues with expired medications and incomplete medical record documentation.
Complaint Details
The complaint investigation was substantiated, revealing medication misappropriation for two residents, expired medications accessible in medication carts, and incomplete medication administration documentation for one resident.
Findings
The facility failed to prevent misappropriation of narcotic medications for two residents, had expired medications accessible in a medication cart, and failed to ensure complete and accurate documentation of medication administration for one resident. The facility conducted investigations, notified authorities, and implemented corrective actions including audits, education, and monitoring.
Deficiencies (3)
F 0602: The facility failed to protect residents from misappropriation of medications for two residents, with sixty narcotics missing for each. An investigation revealed inconsistent logging and counting of narcotics, and corrective actions including audits and staff education were implemented.
F 0761: The facility failed to ensure expired medications were not stored and accessible in one medication cart, with fifteen expired Lorpermide capsules found. There was no facility policy for auditing medication carts, and nursing staff were expected to check expiration dates before administration.
F 0842: The facility failed to ensure complete and accurate documentation of medication administration for one resident, with multiple dates showing Hydrocodone/APAP administered but not documented on the MAR. Staff cited workload and forgetfulness as reasons for missing documentation.
Report Facts
Missing narcotics: 60
Expired medication count: 15
Medication administration dates undocumented: 16
Medication cart audits frequency: 3
Education completion date: Jun 12, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Notified Director of Nursing about inability to reorder narcotics and concerns about missing medications |
| Director of Nursing | Director of Nursing | Led investigation into missing narcotics and implemented corrective actions |
| Medical Director | Medical Director | Attended Quality Assurance meeting regarding missing narcotics and action plan |
| Staff Development Coordinator | Staff Development Coordinator | Provided education on narcotic reconciliation and misappropriation to staff |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Administered Hydrocodone/APAP to Resident #30 but failed to document administrations |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Administered Hydrocodone/APAP to Resident #30 but failed to document administrations |
| Registered Nurse #1 | Registered Nurse | Provided education on narcotic reconciliation and confirmed documentation policies |
Inspection Report
Routine
Capacity: 75
Deficiencies: 18
Date: Jan 10, 2019
Visit Reason
Routine inspection of Lake Way Rehabilitation and Healthcare Center to assess compliance with regulatory requirements including resident rights, care planning, infection control, and safety.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, resident self-determination, notification procedures, care planning, infection control, food safety, and fall prevention. Several residents experienced issues such as verbal abuse, inadequate care planning, improper medication administration, and lapses in supervision leading to falls.
Deficiencies (18)
F 0550: Facility failed to ensure residents were treated with dignity and respect, including inappropriate staff comments and entering rooms without knocking.
F 0561: Facility failed to promote and facilitate resident self-determination by not allowing Resident #49 to choose daily clothing.
F 0582: Facility failed to issue required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to residents discharged from Medicare services.
F 0600: Facility failed to protect Resident #17 from verbal abuse by staff and failed to investigate and respond appropriately to abuse allegations.
F 0610: Facility failed to respond appropriately to abuse allegations and failed to investigate thoroughly or prevent further potential abuse during investigations.
F 0623: Facility failed to notify the Ombudsman of resident transfers/discharges for three residents as required by regulation.
F 0625: Facility failed to notify residents or representatives in writing about bed-hold policies prior to hospital transfers or therapeutic leaves for three residents.
F 0656: Facility failed to develop and implement comprehensive person-centered care plans for Residents #15, #18, and #75, including failure to ensure use of pressure relieving boots and care plans for infections.
F 0657: Facility failed to ensure interdisciplinary team reviewed and revised Resident #38's care plan to address decline in bowel and bladder continence.
F 0658: Facility failed to provide services according to accepted clinical standards for Resident #65, including crushing a 'do not crush' medication.
F 0677: Facility failed to provide adequate oral hygiene, nail care, and personal hygiene for Residents #45, #5, and #8, resulting in dry mouth, dirty nails, and dead skin buildup.
F 0686: Facility failed to provide appropriate pressure ulcer care for Resident #15, including failure to ensure pressure relieving boot was worn as ordered.
F 0688: Facility failed to provide appropriate care to maintain range of motion and prevent foot drop for Resident #75, including failure to ensure use of multi Podus AFO boots.
F 0689: Facility failed to provide adequate supervision and assistive devices to prevent falls for Resident #65, resulting in a fall when left unattended during toileting.
F 0690: Facility failed to provide appropriate care to prevent urinary tract infections and maintain continence for Residents #18 and #38, including improper perineal care and failure to implement toileting programs.
F 0812: Facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional food safety standards, including expired foods in refrigerator and improper food handling by staff.
F 0842: Facility failed to maintain complete and accurate medical records for Resident #34, including inaccurate fall risk assessments and failure to document fall history and device use.
F 0880: Facility failed to ensure proper incontinent/perineal care for Residents #45 and #74, including failure to change gloves between tasks and before touching clean items.
Report Facts
Residents receiving food from kitchen: 75
Fall risk score threshold: 10
Length of unstageable pressure wound: 0.3
Width of unstageable pressure wound: 2.9
BIMS score: 15
BIMS score: 14
BIMS score: 14
BIMS score: 13
BIMS score: 8
BIMS score: 8
BIMS score: 15
Fall risk assessments: 2
Fall risk assessments: 2
Days resident #45 oral care not initialed: 11
Days expired food in refrigerator: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #1 | State Registered Nurse Aide | Named in verbal abuse and mistreatment findings for Resident #17 |
| RN #1 | Registered Nurse | Witnessed verbal abuse incident with Resident #17 |
| LPN #1 | Licensed Practical Nurse | Received family complaint about SRNA #1 |
| RN #3 | Registered Nurse Weekend Supervisor | Did not report abuse incident to Administrator |
| GCA #1 | General Care Assistant | Entered resident rooms without knocking |
| Administrator | Facility Administrator | Interviewed regarding multiple findings and policies |
| DON | Director of Nursing | Interviewed regarding multiple findings and policies |
| SRNA #4 | State Registered Nurse Aide | Assisted Resident #49 with clothing choices |
| SRNA #3 | State Registered Nurse Aide | Assisted Resident #49 with clothing choices |
| LPN #2 | Licensed Practical Nurse | Provided wound care to Resident #15 |
| RN #2 | Registered Nurse Unit Manager | Interviewed regarding wound care and medication error |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding oral care and foot care |
| Wound Care Nurse | Wound Care Nurse | Interviewed regarding wound care and foot care |
| CNA #11 | Certified Nursing Assistant | Failed to change gloves during incontinent care |
| CNA #12 | Certified Nursing Assistant | Failed to change gloves during incontinent care |
| CNA #13 | Certified Nursing Assistant | Failed to change gloves during incontinent care |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and expired foods |
| CNA #8 | Certified Nursing Assistant | Handled food with bare hands |
| CNA #9 | Certified Nursing Assistant | Handled food with bare hands |
| GCA #2 | General Care Assistant | Handled straws with bare hands |
| MDS Coordinator #2 | MDS Coordinator | Interviewed regarding care planning and Podus boots |
| Director of Therapy Services | Director of Therapy Services | Interviewed regarding therapy and Podus boots |
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