Inspection Reports for Pine Meadows Post Acute
1608 HILL RISE DRIVE, LEXINGTON, KY, 40504
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Census: 117
Deficiencies: 2
Sep 5, 2025
Visit Reason
The inspection was conducted to assess compliance with food safety, infection prevention, and control standards in the facility's kitchen and resident care equipment.
Findings
The facility failed to maintain a safe and sanitary food production and storage environment, including unlabeled and undated food items, improper storage of personal items in food areas, missing temperature logs, and condensation issues. Additionally, the facility failed to disinfect one of nine Hoyer lifts observed, risking infection transmission.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Level of Harm - Minimal harm or potential for actual harm |
| Provide and implement an infection prevention and control program. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 117
Residents affected: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Interviewed regarding food safety practices and temperature logs |
| Certified Nursing Assistant 9 | CNA | Observed failing to disinfect Hoyer lift after use |
| Certified Nursing Assistant 3 | CNA | Interviewed about cleaning process for Hoyer lifts |
| Certified Nursing Assistant 5 | CNA | Interviewed about cleaning process for Hoyer lifts |
| Certified Nursing Assistant 6 | CNA | Interviewed about cleaning process for Hoyer lifts |
| Certified Nursing Assistant 1 | CNA | Interviewed about cleaning process for Hoyer lifts |
| Certified Nursing Assistant 7 | CNA | Interviewed about infection control training and cleaning process for Hoyer lifts |
| Infection Prevention Nurse | Infection Prevention Nurse | Interviewed about infection control training and cleaning protocols |
| Director of Nursing | Director of Nursing | Interviewed about expectations for food safety and infection control |
| Administrator | Administrator | Interviewed about infection control policies and personal items storage |
| Maintenance Director | Maintenance Director | Interviewed about condensation issues in kitchen ceiling |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 30, 2023
Visit Reason
The inspection was conducted as a standard annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 30, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure prompt treatment of a pressure ulcer for one of five residents reviewed for pressure ulcers (Resident #264).
Findings
The facility failed to provide timely treatment for Resident #264's unstageable pressure ulcer on the right heel, with treatment orders and administration delayed by four days after admission. Interviews with nursing staff and the Director of Nursing revealed a breakdown in communication and documentation regarding wound treatment orders.
Complaint Details
The complaint investigation found that Resident #264 was admitted with a deep tissue injury to the right heel but did not receive treatment until four days later. The admitting nurse documented the wound on the incorrect heel initially, and there was no treatment order prior to 05/14/2022. Interviews indicated uncertainty about why treatment was delayed and emphasized the expectation that treatment should begin immediately upon wound identification.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure prompt treatment of a pressure ulcer for Resident #264. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days delay in treatment: 4
Residents reviewed for pressure ulcers: 5
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #18 | Licensed Practical Nurse | Admitting nurse for Resident #264 who documented the wound on the incorrect heel initially. |
| LPN #2 | Licensed Practical Nurse | Interviewed nurse who stated the admitting nurse should have contacted the physician for treatment orders. |
| LPN #17 | Unit Manager | Stated the importance of immediate treatment orders and was unsure why treatment was delayed. |
| Director of Nursing | Director of Nursing (DON) | Reviewed documentation to identify breakdown and stated expectations for wound assessment and treatment. |
| Wound Care Specialist | Stated that treatment should be initiated immediately once a wound is identified. | |
| Administrator | Administrator | Left decisions regarding pressure ulcers to the clinical team. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 30, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to properly coordinate assessments with the pre-admission screening and resident review program (PASARR), develop individualized care plans, and provide activities meeting residents' needs.
Findings
The facility failed to ensure one resident with a newly evident serious mental disorder was referred for appropriate PASARR review, failed to develop an individualized, person-centered activities care plan for one resident, and failed to provide an ongoing program of activities designed to meet that resident's interests. Interviews with staff confirmed gaps in PASARR reassessment, care planning, and activity documentation.
Complaint Details
The complaint investigation focused on PASARR referral failures for Resident #94 with new mental health diagnoses, lack of individualized activities care plan, and inadequate activity programming for Resident #56. Interviews with the Social Services Director, MDS Nurse, Director of Nursing, Administrator, Activity Director, and Assistant Activity Director revealed procedural and documentation deficiencies related to PASARR reassessment and activity provision.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure one resident with a newly evident or possible serious mental disorder was referred to the appropriate state-designated mental health or intellectual disability authority for review. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop an individualized, person-centered activities care plan for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide an ongoing program of activities designed to meet the resident's interests for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for PASARR: 3
Sampled residents for activities care plan and programming: 23
PASARR screening date for Resident #94 admission: Dec 1, 2022
Onset dates of diagnoses for Resident #94: Psychotic disorder 2023-10-10, dementia 2023-08-30, major depressive disorder 2023-02-27, adjustment disorder 2023-02-27.
Assessment Reference Date for Resident #94 MDS: Nov 11, 2023
Assessment Reference Date for Resident #56 MDS: Mar 18, 2023
Assessment Reference Date for Resident #56 quarterly MDS: Sep 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding PASARR screening and referral process. | |
| MDS Nurse | Interviewed about PASARR reassessment procedures. | |
| Director of Nursing | Interviewed about PASARR expectations and care planning. | |
| Administrator | Interviewed about PASARR compliance and activity programming. | |
| Activity Director | Interviewed about resident activities and documentation. | |
| Assistant Activity Director | Interviewed about one-to-one resident activities. |
Inspection Report
Deficiencies: 9
Aug 12, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including infection prevention and control, medication storage, care planning, food safety, and resident rights.
Findings
The facility was found deficient in multiple areas including failure to ensure mail delivery on Saturdays, failure to maintain a safe and homelike environment due to staff smoking on premises, failure to develop and implement comprehensive care plans for nutrition, improper medication storage and labeling, unsanitary food storage and handling, ineffective quality assurance program, multiple breaches in infection prevention and control protocols, failure to conduct COVID-19 testing per guidelines, and failure to document COVID-19 vaccination exemptions for staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure residents had the right to receive mail delivered to the facility on Saturdays. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents had a safe, clean, comfortable and homelike environment due to staff smoking on facility grounds. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a comprehensive person-centered care plan in the care area of nutrition for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals were stored per currently accepted professional principles and appropriate environmental controls were used. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to serve and store food under sanitary conditions including dented cans, unlabeled food, dust and water dripping in kitchen vents, and undated or outdated food items. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer the facility in a manner that uses resources effectively and efficiently, including failure to ensure infection prevention and control policies and protocols were adhered to. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including multiple breaches in PPE use, hand hygiene, disinfection of glucometers, quarantine procedures, and mask wearing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to perform COVID-19 testing on residents and staff according to CDC guidelines and facility policies, including failure to test newly admitted residents immediately upon admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure staff were vaccinated for COVID-19 or have documented exemptions for those who declined vaccination. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 32
Staff tested positive for COVID-19: 7
Facility staff total: 123
Staff fully vaccinated: 103
Staff with religious exemption: 20
Dated cans observed: 0
Cigarette butts counted: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in glucometer cleaning deficiency |
| LPN #3 | Licensed Practical Nurse | Named in glucometer cleaning deficiency |
| LPN #5 | Licensed Practical Nurse | Named in glucometer cleaning deficiency |
| RN #1 | Registered Nurse | Named in glucometer cleaning deficiency |
| LPN #6 | Licensed Practical Nurse | Named in glucometer cleaning deficiency |
| QA/IP Nurse | Quality Assurance/Infection Preventionist Nurse | Named in infection control and COVID-19 testing deficiencies |
| DON | Director of Nursing | Named in infection control, care planning, and COVID-19 testing deficiencies |
| Administrator | Facility Administrator | Named in infection control, care planning, and COVID-19 vaccination deficiencies |
| Dietary Manager | Dietary Manager | Named in food safety deficiencies |
| LPN #2 | Licensed Practical Nurse/Unit Manager | Named in medication storage deficiency |
| RN #2 | Registered Nurse/Unit Manager | Named in medication storage deficiency |
| RDCS | Regional Director of Clinical Services | Named in infection control and COVID-19 testing deficiencies |
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