Inspection Reports for
Letcher Manor
73 PIEDMONT DRIVE, WHITESBURG, KY, 41858
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% worse than Kentucky average
Kentucky average: 4.7 deficiencies/year
Deficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
84% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Abbreviated Survey
Census: 119
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
An Abbreviated Survey was conducted from 06/24/2025 to 06/25/2025 to investigate KY00046599.
Findings
The facility was found to have no deficient practice during the abbreviated survey.
Report Facts
Sample Resident Size: 3
Inspection Report
Abbreviated Survey
Census: 116
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
A recertification and abbreviated survey were conducted from 02/24/2025 to 02/27/2025, including investigation of multiple complaints. The facility was found not to be in substantial compliance with 42 CFR 483, Subpart B.
Complaint Details
Multiple complaints were investigated (KY00042649, KY00042990, KY00043252, KY00043290, KY00044784, KY00044912, KY00045172). The facility was found to be in compliance with regulatory practice for all complaints except KY00043731, which resulted in a cited deficiency.
Findings
The facility was cited for a deficiency related to failure to electronically transmit the discharge assessment within 14 days, and failure to develop and implement a comprehensive care plan for a resident with wound care refusals. Additional deficiencies included food safety violations and infection prevention and control issues. The facility provided plans of correction and education to address these issues.
Deficiencies (4)
Failure to electronically transmit the discharge Minimum Data Set (MDS) assessment within 14 days as required.
Failure to develop and/or implement a comprehensive person-centered care plan to meet the needs of a resident who refused wound care.
Failure to prepare and serve food in a sanitary manner and maintain proper food temperatures.
Failure to maintain an infection prevention and control program to prevent communicable diseases and infections.
Report Facts
Survey Census: 116
Sample Size: 31
Deficiencies cited: 1
Completion Dates: Plans of correction completion dates ranged from 03/14/2025 to 03/18/2025
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
The investigation was conducted due to a complaint regarding inadequate supervision and safety concerns involving resident R39 wandering into other residents' hallways and rooms, leading to an incident with resident R8.
Complaint Details
The complaint investigation was substantiated. The incident involved resident R39 wandering unsupervised into other residents' rooms and hallways, leading to a physical altercation with resident R8. The facility placed both residents on one-to-one supervision and relocated R39 to another hall during the investigation.
Findings
The facility failed to provide adequate supervision and assistance devices to ensure the safety of resident R39, who was observed roaming freely into other residents' areas without proper supervision. An incident occurred where resident R8 grabbed R39's arm and wheelchair, prompting staff intervention and placement of both residents on one-to-one supervision during the investigation.
Deficiencies (1)
F0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents for resident R39. R39 was allowed to roam freely into other residents' hallways and rooms without adequate supervision, resulting in an altercation with resident R8.
Report Facts
Residents sampled: 31
BIMS score: 8
BIMS score: 9
Date of incident: Sep 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Witnessed the incident between residents R8 and R39 and intervened |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Nurse for the hall where R39 resided, provided information on supervision practices |
| Social Services Director | Social Services Director | Completed conflict resolution between residents R8 and R39 |
| State Registered Nursing Assistant 9 | State Registered Nursing Assistant | Redirected resident R39 when found in unauthorized areas |
| Administrator | Administrator | Provided information about the incident and supervision measures taken |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident assessments, care planning, food service safety, infection control, and other facility operations.
Findings
The facility failed to timely transmit a discharge assessment for one resident, did not develop a comprehensive care plan addressing wound care refusals for another resident, served food at unsafe temperatures, and failed to maintain proper infection prevention practices including improper storage of oxygen and incontinent supplies.
Deficiencies (4)
F 0640: The facility failed to electronically transmit the discharge Minimum Data Set (MDS) Assessment within 14 days for 1 of 31 sampled residents, resulting in noncompliance with CMS Resident Assessment Instrument guidelines.
F 0656: The facility failed to develop and implement a comprehensive care plan addressing wound care refusals for 1 of 31 sampled residents, despite multiple documented refusals of wound care.
F 0812: The facility failed to prepare and serve food at safe temperatures, with hot foods below 135°F and cold foods above 41°F, potentially affecting all residents consuming food prepared in the kitchen.
F 0880: The facility failed to maintain an infection prevention and control program by improperly storing oxygen tubing, nebulizer tubing, and incontinent supplies on bathroom floors and bedside tables for 4 of 31 sampled residents.
Report Facts
Residents sampled: 31
Residents affected: 1
Residents affected: 1
Residents affected: 4
Food temperature observations: 102.5
Food temperature observations: 129.7
Food temperature observations: 110.9
Food temperature observations: 43.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse 1 | Interviewed regarding transmission of discharge assessment | |
| MDS Nurse 2 | Interviewed regarding transmission of discharge assessment and care planning | |
| Administrator | Interviewed regarding expectations for MDS transmission, food service, and infection control | |
| Dietary Manager | Interviewed regarding food temperature issues and meal service | |
| Infection Preventionist | Interviewed regarding infection control practices and storage of supplies | |
| MDS Coordinator 1 | Interviewed regarding care planning for wound care refusals | |
| MDS Coordinator 2 | Interviewed regarding care planning for wound care refusals |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Date: Apr 5, 2024
Visit Reason
The investigation was initiated due to reasonable suspicion that a Licensed Practical Nurse (LPN1) was under the influence while on duty and misappropriated controlled substances/medications from residents.
Complaint Details
The complaint investigation was substantiated. The investigation found LPN1 under the influence on 03/17/2024, missing narcotics from residents, and failure to administer medications as required. LPN1 was terminated following the investigation.
Findings
The facility failed to ensure residents were free from misappropriation of property, specifically controlled substances, which were missing from eight of 89 sampled residents. LPN1 was observed impaired, removed from resident care, and subsequently terminated for diversion of medications and violation of facility policies.
Deficiencies (1)
F 0602: The facility failed to protect residents from wrongful use of their belongings or money, specifically misappropriation of controlled substances from eight residents. Twelve narcotic medications were unaccounted for without proper documentation or signatures.
Report Facts
Residents sampled: 89
Residents affected: 8
Missing narcotics: 12
BIMS scores: 14
BIMS scores: 13
BIMS scores: 10
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in medication misappropriation finding and termination |
| DON | Director of Nursing | Conducted investigation and interviews, oversaw narcotic counts |
| Administrator | Facility Administrator | Informed of staff concerns, involved in decision to terminate LPN1 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 5, 2024
Visit Reason
The investigation was initiated due to reasonable suspicion of medication misappropriation by a Licensed Practical Nurse (LPN1) and concerns about medication administration errors.
Complaint Details
The complaint investigation was substantiated, revealing that LPN1 was under the influence during medication administration, leading to diversion of narcotics and failure to administer medications properly. LPN1 was terminated following the investigation.
Findings
The facility failed to ensure residents were free from misappropriation of property, specifically controlled substances, involving eight residents. Additionally, medication administration errors were identified, including improper insulin administration and incomplete delivery of crushed medications, affecting two residents.
Deficiencies (2)
F 0602: The facility failed to protect residents from misappropriation of property, with 12 narcotics/controlled substances missing without proper documentation, linked to LPN1 who was under the influence during medication pass.
F 0759: The facility failed to maintain medication error rates below 5%, with a 13.04% error rate during medication administration, including improper insulin preparation and incomplete administration of crushed medications.
Report Facts
Residents sampled: 89
Narcotics missing: 12
Medication administration opportunities: 69
Medication errors: 9
Medication error rate: 13.04
Residents affected by medication errors: 2
Medications not fully administered: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in medication misappropriation and impairment finding; terminated after investigation |
| LPN3 | Licensed Practical Nurse | Observed improperly administering insulin and crushed medications |
| DON | Director of Nursing | Conducted investigation and interviews; provided policy and procedural information |
| Administrator | Facility Administrator | Provided expectations for nursing staff and employment decisions related to findings |
| Pharmacist (RPh)1 | Pharmacist | Provided expert opinion on proper insulin administration |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 7, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident assessments, care planning, respiratory care, and discharge procedures.
Findings
The facility failed to accurately assess and document residents' range of motion, develop comprehensive person-centered care plans addressing oxygen therapy details and range of motion limitations, ensure discharge summaries included a full recapitulation of the resident's stay, and provide respiratory care according to care plans for two residents.
Deficiencies (4)
F0636: The facility failed to accurately complete an assessment of range of motion for Resident #110, who had limited range of motion to bilateral hands but was coded as having no impairment.
F0656: The facility failed to develop and implement a person-centered comprehensive care plan addressing oxygen therapy details for Residents #68 and #94 and range of motion limitations for Resident #110.
F0661: The facility failed to ensure discharge summaries included a recapitulation of the resident's stay with pertinent treatment and consultation information for Resident #115.
F0695: The facility failed to provide respiratory care according to the person-centered care plan for Residents #68 and #94, as the care plans did not specify oxygen liter flow or route.
Report Facts
Residents sampled: 29
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Oxygen liter flow: 2
BIMS score: 6
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Registered Nursing Assistant | Mentioned in relation to Resident #110's care and assessment | |
| Therapy Director | Interviewed regarding Resident #110's therapy and range of motion limitations | |
| MDS Coordinator | Interviewed regarding Resident #110's assessment and care plan development | |
| Director of Nursing | Interviewed regarding monitoring of MDS accuracy and care plans | |
| RN #1 | Registered Nurse | Interviewed regarding rounds and oxygen monitoring for Residents #68 and #94, and completion of discharge summary for Resident #115 |
| Social Services Director | Interviewed regarding discharge summary process for Resident #115 | |
| Unit Coordinator | Interviewed regarding discharge summary content and process | |
| MDS Coordinator #1 | Responsible for developing care plans for Residents #68 and #94 |
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