Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Abbreviated Survey
Census: 25
Deficiencies: 1
Feb 20, 2025
Visit Reason
A Recertification and Abbreviated Survey was conducted to assess the facility's compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance due to deficient practices identified at KY00044006 related to notice requirements before transfer/discharge. No deficient practices were identified at other surveyed locations.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide proper notice before transfer or discharge to residents and their representatives, including reasons for transfer, timing, and appeal rights. | SS=F |
Report Facts
Survey Census: 25
Sample Size: 13
Supplemental Residents: 15
Residents Investigated for Deficient Practice: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| F31 | Family Member | Named as resident's caretaker and involved in transfer notification deficiency |
| R2 | Resident involved in transfer notification deficiency | |
| Licensed Practical Nurse (LPN) 1 | Licensed Practical Nurse | Nurse who sent resident R2 to hospital and involved in transfer notification process |
| R15 | Resident involved in transfer notification deficiency | |
| R25 | Resident involved in transfer notification deficiency | |
| F5 | Family Member | Family member of resident R5 involved in transfer notification deficiency |
| R12 | Resident involved in transfer notification deficiency | |
| R14 | Resident involved in transfer notification deficiency | |
| R10 | Resident involved in transfer notification deficiency | |
| R17 | Resident involved in transfer notification deficiency | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding notification process and transfer paperwork |
| BOM | Business Office Manager | Signed bed hold agreements and involved in transfer consent process |
Inspection Report
Renewal
Census: 25
Deficiencies: 3
Feb 17, 2025
Visit Reason
A Relicensure and Complaint Survey was conducted from 02/17/2025 through 02/20/2025 to assess compliance with regulatory requirements and investigate complaint allegations.
Findings
No deficient practice was identified with KY00035235, KY00036992, KY00042351, or KY00043228. Deficient practice was identified with KY00044006 at tags F623 and F625 related to notice requirements before transfer/discharge and bed hold policy. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Complaint Details
The complaint investigation identified deficient practice related to failure to provide proper transfer/discharge notices and bed hold policy notices for 9 out of 9 residents investigated. The facility failed to notify residents and their representatives in writing of transfer reasons, dates, appeal rights, and failed to provide written bed hold policy notices. The complaint was substantiated.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide proper notice before transfer or discharge, including notifying the resident and representative in writing with reasons, timing, and appeal rights. | SS=F |
| Failure to provide written notice of bed-hold policy before or upon transfer, including duration and reserve bed payment policy. | SS=F |
| Failure to store drugs and biologicals in accordance with accepted professional principles, including maintaining proper temperature controls in medication refrigerator. | SS=F |
Report Facts
Survey Census: 25
Sample Size: 13
Supplemental Residents: 15
Number of residents with deficient practice: 9
Temperature readings: 50
Temperature range: 36
Temperature range: 46
Low oxygen saturation: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 1 | Licensed Practical Nurse | Nurse who sent resident R2 to hospital and stated she was responsible for checking medication refrigerator temperatures |
| Director of Nursing (DON) | Director of Nursing | Stated nurse assigned to resident was responsible for notifying family of condition changes and transfer; also stated facility identified process inconsistencies and planned quality assurance improvements |
| Administrator | Facility Administrator | Stated facility identified need to fix inconsistencies in transfer paperwork and expected medication refrigerator temperature logs to be completed per policy |
| Pharmacy Account Manager | Pharmacy Account Manager | Provided information about medication refrigerator temperature audits |
| Registered Pharmacist (RPh) | Registered Pharmacist | Stated medication refrigerator temperature of 50 degrees F was too warm and medications would need replacement |
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