Inspection Reports for
Owenton Healthcare and Rehabilitation
905 HWY 127 NORTH, OWENTON, KY, 40359
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2026
Visit Reason
The inspection was conducted to investigate complaints of resident-to-resident physical abuse incidents involving residents R60, R65, and R70.
Complaint Details
The complaint investigation substantiated resident-to-resident physical abuse involving R60, R65, and R70. The incidents were witnessed by staff and confirmed by the facility's investigation. The Director of Nursing and Administrator both acknowledged the incidents as physical abuse and expected residents to be free from abuse and feel safe.
Findings
The facility failed to protect residents from physical abuse by other residents in two separate incidents involving R60, R65, and R70. Investigations confirmed that R60 swatted R70 and R65 hit R60, both incidents were witnessed by staff and deemed physical abuse by the Director of Nursing and Administrator.
Deficiencies (1)
F 0600: The facility failed to protect residents from physical abuse by other residents in two incidents involving R60, R65, and R70. Both incidents were confirmed after investigation and involved physical contact such as swatting and hitting.
Report Facts
BIMS score: 9
BIMS score: 11
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Assistant 5 | Activities Assistant | Witnessed the incident between R60 and R70 and considered it physical abuse |
| Director of Nursing | Director of Nursing | Acknowledged both incidents as physical abuse and expected residents to be free from abuse |
| Certified Nursing Assistant 3 | Certified Nursing Assistant | Witnessed the incident between R65 and R60 and considered it physical abuse |
| Administrator | Administrator | Stated expectation that residents be free of abuse and kept safe in the facility |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 30, 2024
Visit Reason
The investigation was conducted following a complaint regarding improper administration of vaginal medication to Resident 3 (R3), which resulted in a foreign object (Monistat applicator) being left in the resident's vaginal canal causing pain and injury.
Complaint Details
The complaint investigation was substantiated. Resident 3 experienced pain and discomfort after vaginal medication administration. A foreign object (Monistat applicator) was found in her vaginal canal during hospital evaluation. The facility was unable to determine which staff member was responsible but provided immediate education to nursing staff.
Findings
The facility failed to ensure proper administration of Monistat 7 vaginal cream to R3, resulting in the applicator being left inside the resident causing pain, discomfort, and humiliation. The facility conducted an investigation, provided education to nursing staff, and notified appropriate medical and administrative personnel.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, resulting in a Monistat vaginal cream applicator being left in Resident 3's vaginal canal causing actual harm.
Report Facts
Length of Monistat administration: 4
Foreign body size: 12
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Administered Monistat 7 to Resident 3 on 12/02/2024 and reported discomfort during administration. |
| DON | Director of Nursing | Provided in-service education to nursing staff on proper administration of vaginal medications after incident. |
| Administrator | Facility Administrator | Acknowledged the incident and investigation, confirmed education and expectations for staff compliance. |
| UM | Unit Manager | Notified and involved in assessment and follow-up of Resident 3's condition. |
| Pharmacist 1 | Contract Pharmacist | Provided expert opinion on Monistat applicator as a foreign body and risk for infection. |
| Pharmacist 2 | Contract Pharmacist | Confirmed Monistat 7 supply included one reusable plunger-type applicator. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 9, 2024
Visit Reason
The inspection was conducted due to complaints alleging failure to timely report suspected abuse, neglect, or theft and failure to respond appropriately to alleged violations involving residents.
Complaint Details
The complaint investigation substantiated that the facility failed to report abuse allegations within the required timeframe and failed to prevent potential further abuse during investigations involving residents R2, R48, and R86.
Findings
The facility failed to timely report alleged abuse incidents within the required two-hour window for 3 of 23 sampled residents and failed to prevent further potential abuse during ongoing investigations. Investigations revealed delays in reporting to the State Survey Agency and inadequate suspension of staff during investigations.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for 3 of 23 sampled residents, with reports delayed beyond the required two-hour timeframe.
F 0610: The facility failed to respond appropriately to alleged violations by allowing a staff member under investigation for abuse to return to work on another unit before the investigation was completed.
Report Facts
Residents sampled: 23
Residents affected: 3
BIMS score: 0
BIMS score: 14
Inspection Report
Routine
Deficiencies: 4
Date: Aug 9, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, dietary accommodations, adaptive equipment, and infection prevention and control practices at Owenton Healthcare and Rehabilitation.
Findings
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for multiple residents. The facility also failed to provide residents with ordered dietary supplements, assistive devices, and special eating equipment. Additionally, staff did not consistently follow infection prevention protocols during medication administration, including hand hygiene.
Deficiencies (4)
F 0656: The facility failed to develop and implement complete care plans with measurable objectives and timeframes for 7 of 28 sampled residents, resulting in residents not receiving assistive devices or nutritional supplements as care planned.
F 0806: The facility failed to provide food that accommodated resident allergies, intolerances, and preferences for 5 of 7 sampled residents, including failure to provide ordered nutritional supplements and double portions.
F 0810: The facility failed to provide special adaptive eating equipment and utensils for 5 of 15 sampled residents when consuming meals and snacks, including failure to use small coated spoons, divided plates, and scoop plates as ordered.
F 0880: The facility failed to ensure staff performed hand hygiene and maintained infection control measures during medication administration for 3 of 39 sampled residents, increasing risk for healthcare-associated infections.
Report Facts
Sampled residents with care plan deficiencies: 7
Sampled residents with dietary accommodation failures: 5
Sampled residents with adaptive equipment failures: 5
Sampled residents with infection control failures: 3
Total sampled residents for infection control observation: 39
Inspection Report
Routine
Census: 100
Deficiencies: 9
Date: Oct 31, 2019
Visit Reason
Routine inspection of Owenton Healthcare and Rehabilitation to assess compliance with regulatory requirements including resident safety, care planning, medication administration, food service, and facility maintenance.
Findings
The facility was found deficient in maintaining a safe, clean environment, proper use of restraints, comprehensive care planning, restorative nursing program implementation, medication administration, fall prevention, and food safety including food temperature and sanitation.
Deficiencies (9)
F 0584: Facility failed to provide maintenance services necessary to maintain a safe, clean, and comfortable environment for 100 residents, evidenced by dust accumulation in ceiling vents on the 100 unit hall.
F 0604: Facility failed to ensure residents were free from physical restraints unless medically necessary, demonstrated by Resident #33's self-releasing alarming seatbelt used without proper physician order documentation and malfunctioning alarm.
F 0656: Facility failed to develop and implement comprehensive care plans with measurable objectives and timely interventions for four residents, including Resident #33, related to restraint use, restorative nursing, and functional needs.
F 0657: Facility failed to review and revise comprehensive care plans by an interdisciplinary team after falls for Residents #33 and #56, lacking root cause analysis and appropriate interventions.
F 0688: Facility failed to provide appropriate restorative nursing care to maintain or improve range of motion and mobility for four residents, including Residents #9, #33, #42, and #56, with no documented evidence of implementation of restorative nursing plans in September and October 2019.
F 0689: Facility failed to ensure adequate supervision and accident prevention for Residents #33 and #56, with incomplete fall investigations and lack of care plan revisions to prevent future falls.
F 0760: Resident #55 did not receive ordered Lantus insulin 10 units daily from 10/01/19 through 10/30/19 due to omission from the medication administration record, resulting in a significant medication error.
F 0804: Facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures, with observations of cold foods at room temperature and some foods not palatable on the 200 unit.
F 0812: Facility failed to prepare and store food under sanitary conditions, including unlabeled and undated beverage pitchers, dusty kitchen environment, improper sanitizer use, and unlabeled/undated supplements in nourishment refrigerators.
Report Facts
Residents affected: 100
Residents sampled: 22
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Temperature readings: 70
Temperature readings: 152
Temperature readings: 54
Temperature readings: 69
Temperature readings: 134
Blood glucose average: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Acknowledged missing Lantus insulin on October 2019 MAR for Resident #55 |
| LPN #2 | Licensed Practical Nurse | Responsible for Restorative Nursing Program, identified as ineffective in maintaining RNP |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding care plan expectations, fall management, and restorative nursing |
| Administrator | Facility Administrator | Provided multiple interviews regarding expectations for medication administration, food safety, and facility maintenance |
| Dietary Manager in Training | Dietary Manager in Training | Observed and interviewed regarding kitchen sanitation and sanitizer use |
| District Dietary Manager | District Dietary Manager | Interviewed regarding food safety, kitchen sanitation, and cleaning procedures |
| Maintenance Director | Maintenance Director | Interviewed regarding kitchen maintenance and cleaning schedules |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 22, 2018
Visit Reason
Routine inspection to assess compliance with health and safety regulations, including maintenance of a homelike environment, medication storage and administration, infection control, and documentation practices.
Findings
The facility failed to maintain a homelike environment due to damaged wall protectors and broken cabinet drawers in several resident rooms. Expired intravenous fluids and supplies were found on the emergency IV fluid cart. Medication administration documentation errors were observed where medications were documented as given prior to administration. Infection control lapses were noted with uncovered nebulizer masks and mouthpieces, risking resident infections.
Deficiencies (4)
F 0584: The facility failed to maintain a homelike environment in eight of fifty-one resident rooms due to damaged wood wall protectors and broken cabinet drawers that did not close properly.
F 0761: The facility failed to ensure all medications and biologicals were not expired on the emergency IV fluid cart, which contained fourteen expired items.
F 0842: The facility failed to ensure staff documented medication administration per policy for one resident; medications were documented as administered prior to actual administration.
F 0880: The facility failed to maintain an infection control program on the 200 Hall, as uncovered nebulizer masks and mouthpieces were observed, risking resident infections.
Report Facts
Expired IV fluid items: 14
Resident rooms with damaged wall protectors: 6
Resident rooms with broken cabinet drawers: 2
Sampled residents for medication documentation: 19
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