Inspection Reports for
Nicholasville Nursing &Amp; Rehabilitation
100 SPARKS AVENUE, NICHOLASVILLE, KY, 40356
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
81% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 1
Date: Aug 22, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically related to COVID-19 precautions and compliance with CMS and CDC guidelines.
Findings
The facility failed to maintain an effective infection prevention and control program for COVID-19, including improper use of PPE such as wearing surgical masks under N-95 masks, lack of proper signage for droplet precautions on COVID-positive rooms, and staff not following proper donning and doffing procedures, which posed a risk of spreading infection.
Deficiencies (1)
F 0880: The facility failed to establish and maintain an infection prevention and control program designed to prevent and control communicable diseases, including improper PPE use and lack of proper signage for COVID-positive rooms.
Report Facts
Residents sampled: 27
Residents affected: 4
Dates of positive COVID-19 tests: R21 tested positive on 2025-08-13, R34 on 2025-08-16, R39 on 2025-08-13, R41 on 2025-08-18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Observed wearing surgical mask under N-95 in COVID-positive room and interviewed about PPE training | |
| Director of Nursing Services | Director of Nursing Services | Provided one-on-one PPE training and infection control in-services; interviewed about PPE policies |
| State Registered Nurse Aide 4 | State Registered Nurse Aide | Observed wearing N-95 mask over surgical mask and improper PPE disposal; interviewed about PPE training |
| State Registered Nurse Aide 6 | State Registered Nurse Aide | Interviewed about PPE use and training |
| State Registered Nurse Aide 5 | State Registered Nurse Aide | Interviewed about infection control training |
| State Registered Nurse Aide 9 | State Registered Nurse Aide | Interviewed about PPE training and proper mask use |
| State Registered Nurse Aide 16 | State Registered Nurse Aide | Interviewed about PPE use, reported wearing surgical mask under N-95 |
| Occupational Therapist | Occupational Therapist | Observed wearing and disposing of N-95 mask improperly; interviewed about infection control training |
| Executive Director | Executive Director and Infection Preventionist | Provided infection control training and expectations; interviewed about facility policies |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 22, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage and infection prevention and control regulations at Nicholasville Nursing and Rehabilitation.
Findings
The facility failed to maintain proper environmental controls for medication storage, including incomplete temperature logs and unlabeled or expired medications in refrigerators. Additionally, the infection prevention and control program was deficient, with improper use of PPE, lack of proper signage on Covid-positive rooms, and inconsistent staff training leading to potential risk of infection spread.
Deficiencies (2)
F 0761: The facility failed to ensure medication refrigerators had complete temperature logs and that medications were properly labeled and not expired. Observations revealed missing temperature logs, unlabeled opened medications, and expired medications in medication storage areas.
F 0880: The facility failed to implement an effective infection prevention and control program. Observations and interviews revealed improper PPE use, including wearing surgical masks under N-95 masks, lack of proper signage on Covid-positive rooms, and inconsistent staff training on infection control procedures.
Report Facts
Medication refrigerator temperature log dates: 5
Number of bisacodyl suppositories in refrigerator: 8
Number of Novalog Flex pens in refrigerator: 21
Number of residents sampled for infection control: 27
Number of residents affected by infection control deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services (DNS) | Provided interviews regarding medication storage and infection control policies and monitoring |
| Executive Director | Executive Director and Infection Preventionist | Provided interviews on infection control expectations and staff training |
| Licensed Practical Nurse 4 | Licensed Practical Nurse (LPN) | Interviewed about importance of medication temperature logs and discarding expired medications |
| Licensed Practical Nurse 7 | Licensed Practical Nurse (LPN) | Interviewed about medication storage temperature and expiration importance |
| Registered Nurse 3 | Registered Nurse (RN) | Interviewed about medication stability and expiration |
| Business Office Manager | Business Office Manager (BOM) | Observed and interviewed regarding PPE use in Covid-positive rooms |
| State Registered Nurse Aide 4 | State Registered Nurse Aide (SRNA) | Observed and interviewed about PPE donning and doffing practices |
| State Registered Nurse Aide 6 | State Registered Nurse Aide (SRNA) | Interviewed about PPE use and training |
| State Registered Nurse Aide 5 | State Registered Nurse Aide (SRNA) | Interviewed about infection control training |
| State Registered Nurse Aide 9 | State Registered Nurse Aide (SRNA) | Interviewed about PPE use and training |
| State Registered Nurse Aide 16 | State Registered Nurse Aide (SRNA) | Interviewed about PPE use including wearing surgical mask under N-95 |
| Occupational Therapist | Occupational Therapist (OT) | Observed and interviewed about PPE use and infection control training |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Date: Sep 12, 2024
Visit Reason
The inspection was conducted following a complaint alleging that Resident 167 had not been receiving tube feedings for two weeks, raising concerns about inadequate nutrition and dehydration.
Complaint Details
The complaint alleged that Resident 167 had not been receiving tube feedings for two weeks. The complaint was substantiated based on interviews, record reviews, and observations confirming the failure to provide adequate nutritional care and assessments.
Findings
The facility failed to perform a comprehensive nutritional assessment by the Registered Dietician for Resident 167 upon readmission, resulting in inadequate monitoring and failure to ensure proper tube feeding. Additionally, the facility had insufficient nursing staff to meet resident needs, causing delays in care and response times.
Deficiencies (2)
F 0692: The facility failed to perform a comprehensive nutritional assessment by the Registered Dietician for Resident 167, who was at risk for inadequate nutrition and dehydration. The resident was not receiving prescribed tube feedings for two weeks, leading to suspected dehydration and failure to thrive.
F 0725: The facility failed to have sufficient nursing staff with appropriate competencies to provide nursing and related services for 3 of 64 residents, resulting in delayed call light responses and inadequate care.
Report Facts
Resident census: 64
Nurse staffing: 5
Nurse aide staffing: 8
Call light response time: 69
Call light response time: 10
Average meal intake: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to nutritional assessment failure and communication about Resident 167's care |
| Nurse Practitioner 1 | Nurse Practitioner | Provided observations and verbal orders related to Resident 167's nutritional care |
| Registered Dietician | Registered Dietician | Failed to perform required nutritional assessment on Resident 167 upon readmission |
| Administrator | Administrator | Provided statements regarding facility guidelines and staffing expectations |
Inspection Report
Routine
Deficiencies: 12
Date: Sep 12, 2024
Visit Reason
Routine state inspection survey of Nicholasville Nursing and Rehabilitation to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment, incomplete and untimely resident assessments and care plans, improper respiratory care, insufficient nursing staff, medication management issues including narcotic counts and medication labeling, infection prevention and control deficiencies, and failure to document vaccinations properly.
Deficiencies (12)
F 0584: The facility failed to provide a safe, clean, and homelike environment for residents R20 and R59 due to persistent urine and wound odors in their shared room.
F 0640: The facility failed to complete and electronically transmit the discharge assessment within 14 days for resident R36.
F 0656: The facility failed to develop a person-centered care plan with measurable objectives for resident R267, including inaccurate dialysis care interventions.
F 0657: The facility failed to revise the comprehensive care plan after readmission for resident R167, neglecting nutritional needs updates.
F 0678: The facility failed to update the Code Status Book to reflect resident R9's Do Not Resuscitate (DNR) status accurately.
F 0692: The facility failed to perform a comprehensive nutritional assessment and ensure adequate nutrition and hydration for resident R167 after readmission.
F 0695: The facility failed to provide respiratory care as ordered for resident R55, with oxygen concentrator settings lower than prescribed and unlabeled tubing.
F 0725: The facility failed to maintain sufficient nursing staff with appropriate skills to meet resident needs, resulting in delayed call light responses and inadequate care for residents R5, R6, and R117.
F 0755: The facility failed to maintain accurate narcotic counts and ensure narcotic count sheets were signed by licensed personnel at shift changes for all medication carts.
F 0761: The facility failed to ensure all drugs were labeled with opening dates and stored according to professional standards, with undated opened medications found in all medication carts.
F 0880: The facility failed to maintain an effective infection prevention and control program, including failure to post Enhanced Barrier Precautions signage, improper use of PPE by staff and physicians, and improper catheter care for residents R24, R55, R60, R63, and R267.
F 0883: The facility failed to provide proof of influenza and pneumococcal vaccinations or declinations for residents R14, R16, R32, and R60.
Report Facts
Residents sampled: 25
Residents affected: 64
Narcotic count sheet missing signatures: 107
Call light response times: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in respiratory care and dialysis care plan findings |
| DON | Director of Nursing | Named in multiple interviews regarding care plan, staffing, narcotic counts, and infection control |
| ADON | Assistant Director of Nursing | Named in interviews regarding respiratory care and infection control |
| Administrator | Facility Administrator | Named in interviews regarding staffing, infection control, and vaccination policies |
| MDS Nurse | Minimum Data Set Nurse | Named in interviews regarding care plan and staffing issues |
| RN2 | Registered Nurse | Named in medication administration observation |
| SRNA3 | State Registered Nurse Aide | Named in infection control and odor findings |
| SRNA8 | State Registered Nurse Aide | Named in odor and infection control findings |
| Medical Director | Medical Director | Named in interviews regarding infection control and care expectations |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 13, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the improper discharge of Resident #19 while an appeal for continued insurance coverage was pending.
Complaint Details
The complaint investigation focused on Resident #19's discharge despite an active insurance appeal. The appeal was approved after discharge, and the resident and family were not properly notified or provided discharge instructions. Interviews revealed multiple staff were unaware of the appeal or discharge policies, and the facility lacked proper discharge planning and documentation.
Findings
The facility failed to ensure Resident #19 was not discharged during an active insurance appeal, failed to develop and implement appropriate discharge and care plans, and did not provide necessary discharge documentation or communication to the resident and family. Additionally, the facility failed to complete discharge summaries for multiple residents.
Deficiencies (4)
F 0622: The facility discharged Resident #19 while an insurance appeal was pending, without proper notification or documentation, violating transfer and discharge policies.
F 0656: The facility failed to develop and implement comprehensive, person-centered care plans related to discharge goals for Residents #19, #20, and #21.
F 0660: The facility failed to plan Resident #19's discharge to meet his/her goals and needs, discharging the resident with non-weight bearing status without proper notification or provision of discharge instructions.
F 0661: The facility failed to provide discharge summaries including medication reconciliation and post-discharge plans for eleven sampled residents, and failed to document transfers or discharges in medical records.
Report Facts
Residents sampled: 29
Residents with deficient care plans: 3
Residents with missing discharge documentation: 11
BIMS score: 14
Date of discharge: Jun 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Involved in discussions about Resident #19's appeal and discharge decisions | |
| Director of Nursing Services | Provided statements about discharge process and expectations | |
| Social Services Director | Responsible for discharge planning and equipment orders | |
| Transportation Aide | Expressed concerns about Resident #19's readiness for discharge and assisted with transport | |
| Licensed Practical Nurse #2 | Aware of appeal status and discharge timing for Resident #19 | |
| Registered Nurse #1 | Discussed discharge documentation and processes | |
| Minimum Data Set Coordinator | Discussed care plan development and discharge planning |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: May 5, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident abuse, failure to prevent resident-to-resident altercations, inadequate care plan interventions for aggressive behaviors and falls, improper discharge planning and notification, and failure to provide discharge summaries.
Complaint Details
The complaint investigation focused on allegations of resident-to-resident abuse, failure to prevent falls, improper discharge procedures including discharging a resident during an active appeal without notification, and failure to complete discharge summaries and care plans. The investigation substantiated these issues.
Findings
The facility failed to protect residents from abuse by other residents, failed to develop and implement effective care plans to prevent aggressive behaviors and falls, discharged a resident without proper notification or discharge planning, and failed to complete discharge summaries for multiple residents. The facility also failed to provide adequate supervision to prevent accidents for a resident with a history of falls.
Deficiencies (6)
F0600: The facility failed to protect residents from abuse by other residents, resulting in multiple resident-to-resident altercations causing minimal harm.
F0622: The facility failed to ensure a resident was not transferred or discharged while an appeal was pending, resulting in discharge without proper notification or preparation.
F0656: The facility failed to develop and implement care plan interventions to prevent escalation of aggressive behaviors and falls for three residents, resulting in resident-to-resident abuse and multiple falls with injuries.
F0660: The facility failed to develop and implement an effective discharge planning process, resulting in inadequate preparation and transition for a resident discharged with non-weight bearing status.
F0661: The facility failed to provide discharge summaries and ensure documentation of transfers and discharges for eleven residents, resulting in lack of communication and coordination of post-discharge care.
F0689: The facility failed to provide adequate supervision and an effective system to prevent accidents for a resident with a history of falls, resulting in multiple falls and fractures.
Report Facts
Residents sampled: 16
Residents sampled: 29
Resident-to-resident abuse incidents: 3
Fall incidents: 3
BIMS scores: 6
BIMS scores: 2
BIMS scores: 4
Supervision frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Mentioned in relation to care plan and supervision of Resident #3 and Resident #5 |
| SRNA #4 | State Registered Nursing Assistant | Mentioned in relation to supervision and incident response for Residents #3, #5, and #6 |
| Executive Director | Conducted investigations and provided statements on incidents and discharge processes | |
| Social Services Director | Involved in discharge planning and interviews regarding Resident #19 | |
| MDS Nurse/Coordinator | Provided information on care planning and assessments | |
| Transportation Aide | Reported concerns about Resident #19 discharge and transport | |
| RN #1 | Registered Nurse | Mentioned in relation to discharge process and medication reconciliation for Resident #19 |
| DNS | Director of Nursing Services | Provided statements on care plan expectations and discharge process |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Aug 29, 2019
Visit Reason
The investigation was conducted due to complaints regarding failure to honor residents' advance directives, failure to protect residents from abuse, failure to develop baseline care plans, improper use of bed rails, and improper storage and handling of medications and food.
Complaint Details
The complaint investigation was triggered by allegations of failure to honor advance directives, resident-to-resident sexual abuse, inadequate care planning, improper use of bed rails, and improper medication and food storage.
Findings
The facility failed to consistently honor residents' advance directives regarding code status, failed to protect a resident from sexual abuse by another resident, failed to develop and implement baseline care plans, failed to properly assess and document use of bed rails, and failed to maintain proper storage and temperature monitoring of medications and food.
Deficiencies (7)
F 0578: The facility failed to establish mechanisms for documenting and communicating residents' code status and advance directives, resulting in conflicting orders and care plans for two residents.
F 0600: The facility failed to ensure residents were free from sexual abuse when Resident #9 was witnessed with his/her hand on Resident #35's groin area.
F 0655: The facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care for Resident #305.
F 0657: The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team based on changing resident needs, resulting in conflicting DNR and Full Code care plans for Resident #19.
F 0700: The facility failed to assess, obtain informed consent, and have physician orders for the use of bilateral half side rails for Resident #10, and failed to document risks and benefits or include side rail use in the care plan.
F 0761: The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and failed to ensure authorized personnel only had access to keys, with incomplete medication refrigerator temperature logs.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including failure to maintain proper temperature logs and failure to date food brought from outside sources in the nourishment refrigerator.
Report Facts
Days with missing medication refrigerator temperature documentation: 10
Days with missing nourishment refrigerator temperature documentation: 12
BIMS score: 6
BIMS score: 3
BIMS score: 6
BIMS score: 4
BIMS score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Admitting nurse for Resident #1 who received and documented verbal physician order for Full Code status |
| SRNA #3 | State Registered Nursing Assistant | Witnessed Resident #9 with hand on Resident #35's groin and reported incident |
| SRNA #4 | State Registered Nursing Assistant | Reported Resident #9's inappropriate behavior toward staff and considered hand on groin as sexual abuse |
| RN #1 | Registered Nurse | Responsible for medication refrigerator temperature monitoring and care of Resident #10 |
| Interim DON | Interim Director of Nursing | Provided multiple interviews regarding care plan deficiencies, side rail use, medication and food storage |
| Administrator | Facility Administrator | Provided expectations for honoring advance directives, care plan updates, and medication/food storage policies |
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