Inspection Reports for
Pioneer Trace Group, LLC
115 PIONEER TRACE, FLEMINGSBURG, KY, 41041
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
82% occupied
Based on a January 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 8, 2026
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation or exploitation of a resident's belongings, specifically controlled medications, at the facility.
Complaint Details
The complaint investigation involved one resident with severe cognitive impairment whose controlled medication (lorazepam) was found missing. The investigation included interviews with nursing staff, pharmacy, police, and administration. Staff involved were suspended pending investigation. No police report was filed at the time due to delays and staff absences.
Findings
The facility failed to ensure a resident was free from abuse due to missing lorazepam tablets. An internal investigation revealed discrepancies in narcotic counts, leading to suspension of involved staff and ongoing investigation with no police report at the time.
Deficiencies (1)
F 0602: The facility failed to protect residents from wrongful use of their belongings by not ensuring accurate counts and secure storage of controlled medications, resulting in missing lorazepam tablets for one resident.
Report Facts
Lorazepam tablets missing: 5
Residents sampled: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Assigned to resident, involved in medication count and administration, suspended pending investigation. |
| SRNA/KMA3 | State Registered Nurse Aide/Kentucky Medication Aide | Involved in medication count and reporting missing tablets, suspended pending investigation. |
| LPN7 | Licensed Practical Nurse | Night shift nurse involved in medication cart handling, suspended pending investigation. |
| RN2 | A Hall Unit Manager | Received report of missing medication and took action to suspend involved staff. |
| RN3 | Hospice Nurse | Brought narcotics from contracted pharmacy for resident. |
| Director of Nursing | Director of Nursing | Expected clinical staff to count all narcotics and took disciplinary actions. |
| Administrator | Facility Administrator | Communicated with police and planned education and policy reinforcement. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
An Abbreviated Survey investigating KY00045071 was conducted on 02/21/2025.
Findings
No deficient practice was identified during the abbreviated survey.
Inspection Report
Abbreviated Survey
Census: 75
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
An Abbreviated Survey was conducted from 01/14/2025 to 01/16/2025 at the facility.
Findings
No deficiencies were issued related to KY00044354, KY00044381, or KY00044057 during this abbreviated survey.
Report Facts
Survey Dates: Survey conducted from 01/14/2025 to 01/16/2025
Survey Census: 75
Inspection Report
Routine
Census: 76
Deficiencies: 3
Date: Oct 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to residents' rights, food safety, infection prevention, and water management in the facility.
Findings
The facility failed to ensure residents had the right to send and receive mail on Saturdays, failed to prevent cross-contamination due to gnats in the kitchen, and lacked a documented water management program to prevent Legionella and other waterborne pathogens.
Deficiencies (3)
F 0576: The facility failed to ensure residents had the right to send and receive mail on Saturdays, limiting their reasonable access and privacy in communication.
F 0812: The facility failed to prepare food safely to prevent cross-contamination, as gnats were observed flying around uncovered food preparation areas and trash cans.
F 0880: The facility failed to establish a written water management program based on nationally accepted standards to prevent Legionella and other waterborne pathogens for all residents (census 76).
Report Facts
Residents census: 76
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 14, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to the development, implementation, and revision of Comprehensive Care Plans (CCP) for residents, focusing on pressure ulcer prevention and care.
Findings
The facility failed to implement and revise person-centered Comprehensive Care Plans for residents with pressure ulcers, specifically failing to ensure residents wore prescribed heel protection devices. Observations and interviews confirmed residents were found without heel boots despite physician orders and care plan interventions.
Deficiencies (2)
F 0656: The facility failed to implement a person-centered Comprehensive Care Plan for Resident #69, who had pressure ulcers, resulting in the resident being in bed without prescribed heel protection on multiple days.
F 0657: The facility failed to ensure the Comprehensive Care Plan was reviewed and revised by an interdisciplinary team for Resident #35, who had a physician's order for heel boots but no documented CCP revision, and was observed without heel boots while in bed.
Report Facts
Residents sampled: 19
Residents affected: 1
BIMS score: 12
BIMS score: 4
Pressure ulcer measurements: 1.2
Pressure ulcer measurements: 1.3
Pressure ulcer measurements: 3
Pressure ulcer measurements: 0.01
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Stated Resident #69 should have had bilateral heel boots to decrease risk for skin breakdown | |
| Licensed Practical Nurse (LPN) #2 | Provided information on heel protection and care plan use for Residents #69 and #35 | |
| State Registered Nursing Assistant (SRNA) #1 | Reported using care plan as a guide and importance of heel boots for Resident #35 | |
| Director of Nursing (DON) | Expressed expectations for CCP implementation and revision per RAI guidelines | |
| Administrator | Expected CCP interventions to be implemented and revised to prevent skin breakdown |
Inspection Report
Routine
Deficiencies: 10
Date: Sep 13, 2018
Visit Reason
Routine state inspection survey of Pioneer Trace Group LLC nursing home to assess compliance with regulatory requirements related to resident care, medication management, infection control, nutrition, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, inconsistent documentation of residents' code status, inadequate provision of resident-centered activities, improper medication storage and expired medications, failure to provide bedtime snacks and juice, improper food storage labeling, lack of a comprehensive quality assurance plan, inadequate infection prevention and control program, and absence of an effective antibiotic stewardship program.
Deficiencies (10)
F 0558: The facility failed to ensure call lights were within reach and accessible for three residents, increasing risk of falls and unmet needs.
F 0578: The facility failed to maintain consistent and accurate documentation of Resident #70's code status, risking care not aligned with resident wishes.
F 0659: The facility failed to provide resident-centered one-to-one activities as required by Resident #11's care plan, resulting in insufficient engagement.
F 0679: The facility failed to provide ongoing activities meeting residents' interests and needs, particularly for Resident #11.
F 0761: The facility failed to ensure proper medication storage including dating and discarding expired insulin, glucometer control solutions, and other medications.
F 0809: The facility failed to provide nourishing snacks at bedtime and failed to have juice available on request for multiple residents.
F 0812: The facility failed to label and date food and drink items stored in nourishment refrigerators, risking resident safety.
F 0865: The facility lacked a written Quality Assurance and Performance Improvement (QAPI) plan describing processes for identifying and correcting quality deficiencies.
F 0880: The facility failed to establish and maintain an infection prevention and control program including surveillance, isolation precautions, and staff adherence to protocols.
F 0881: The facility failed to implement an effective antibiotic stewardship program with protocols and monitoring to optimize antibiotic use and reduce resistance.
Report Facts
Residents sampled: 23
Residents on antibiotics: 28
Residents without pathogen identified: 26
Residents without antibiotic start date: 9
Residents without antibiotic stop date: 10
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