Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Renewal
Census: 131
Deficiencies: 3
Date: Jun 12, 2025
Visit Reason
A Recertification and Abbreviated Survey was conducted to assess the facility's compliance with regulatory standards.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to labeling, storage, and administration of drugs and biologicals, food safety, and infection prevention and control.
Deficiencies (3)
Failure to ensure drugs and biologicals were current for use and properly labeled with expiration dates; medications and nutritional supplements were opened but not labeled with a discard date.
Failure to store food in accordance with professional standards; opened and expired foods were not dated or discarded appropriately.
Failure to establish and maintain an infection prevention and control program; inadequate use of personal protective equipment and hand hygiene by staff; failure to follow isolation precautions.
Report Facts
Survey Census: 131
Sample Size: 27
Supplemental Residents: 0
Medication Rooms Affected: 3
Medication Carts Affected: 2
Inspection Report
Routine
Deficiencies: 5
Date: Jun 12, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication storage and labeling, food safety, infection prevention and control, and medication administration practices at the facility.
Findings
The facility failed to ensure medications and nutritional supplements were properly labeled with opening dates, stored securely, and expired items discarded. Food items were found expired or undated, posing potential foodborne illness risks. Infection control practices were inadequate, including failure to post signage for contact precautions, improper use of PPE, and failure to restrict resident movement appropriately. Medication administration lapses included handling medications with bare hands, failure to discard dropped pills, and improper cleaning of reusable glucometers.
Deficiencies (5)
F 0761: Medications and nutritional supplements were opened but not labeled with opening dates, and some medications were loose and unlabeled in medication rooms and carts.
F 0812: Opened and expired foods were stored and served to residents, including expired juices and salads, risking foodborne illness.
F 0880: Infection prevention and control program failures included lack of signage for contact precautions, inadequate PPE use by staff and visitors, and allowing a resident on contact precautions to leave room without proper precautions.
F 0880: Staff administered medications with bare hands, failed to discard pills dropped on medication carts, and did not perform hand hygiene as required.
F 0880: Reusable glucometers were not disinfected according to manufacturer instructions; cleaning was insufficient and equipment was placed on clean supplies before drying.
Report Facts
Residents affected: 3
Residents affected: 129
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Interviewed regarding medication labeling, infection control practices, and expectations for staff. |
| CMA 1 | Certified Medication Aide | Observed administering medications with bare hands and failing to perform hand hygiene. |
| CMA 4 | Certified Medication Aide | Observed improperly cleaning glucometer and placing it on clean supplies before drying. |
| RN 1 | Registered Nurse | Interviewed about medication storage and infection control practices. |
| Executive Director | Interviewed regarding infection control policies, PPE use, and medication administration expectations. | |
| Director of Nursing | Interviewed about medication storage, infection control, and medication administration policies. |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 13, 2020
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident assessments, care planning, fall prevention, and use of safety alarms in the nursing home.
Findings
The facility failed to ensure accurate Minimum Data Set (MDS) assessments reflecting residents' current status, failed to revise Comprehensive Care Plans (CCP) timely for acute conditions and falls, and did not complete required assessments for sensor alarms to ensure they were the least restrictive and effective devices for fall prevention.
Deficiencies (3)
F0641: The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected residents' status for infections and falls for two sampled residents.
F0657: The facility failed to ensure Comprehensive Care Plans (CCP) were reviewed and revised by an interdisciplinary team to reflect acute infections and fall events for three sampled residents.
F0689: The facility failed to ensure sensor alarms used as fall prevention devices were assessed prior to implementation and monitored quarterly to ensure efficacy and least restrictive use for three sampled residents.
Report Facts
Sampled residents: 34
Residents affected: 3
Residents affected: 3
Days antibiotic medication received: 6
Dates of falls: 2
Assessment delay: 10
Assessment delay: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | MDS Coordinator | Named in relation to inaccurate MDS assessments and care plan revisions |
| Director of Nursing | Named in relation to expectations for accurate MDS assessments and care plan revisions | |
| Executive Director | Named in relation to facility policy on MDS assessment accuracy | |
| LPN #3 | Named in relation to care plan revision responsibilities | |
| LPN #2 | Named in relation to care plan revision responsibilities | |
| Assistant Director of Nursing | Interim Manager | Named in relation to care plan revision responsibilities |
| State Registered Nursing Assistant #1 | SRNA | Named in relation to sensor alarm awareness |
| State Registered Nursing Assistant #2 | SRNA | Named in relation to sensor alarm awareness |
| State Registered Nursing Assistant #3 | SRNA | Named in relation to sensor alarm awareness |
Inspection Report
Routine
Deficiencies: 7
Date: Jan 4, 2019
Visit Reason
Routine inspection to assess compliance with regulatory requirements for nursing home care, including resident assessments, care planning, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to complete required Minimum Data Set (MDS) Re-entry assessments, inadequate implementation of comprehensive person-centered care plans, improper sterile technique during tracheostomy care, failure to provide appropriate pressure ulcer care, inadequate incontinent care leading to infection risk, failure to verify feeding tube placement, and lapses in infection prevention practices such as hand hygiene.
Deficiencies (7)
F0640: The facility failed to complete a required Minimum Data Set (MDS) Re-entry assessment for one resident who returned from the hospital.
F0656: The facility failed to develop and implement comprehensive person-centered care plans for three residents, including failure to follow sterile technique for tracheostomy care and failure to implement care plan interventions for pressure ulcer prevention and urinary tract infection management.
F0686: The facility failed to provide appropriate pressure ulcer care for one resident by not ensuring foot protectors were on both feet and a pillow or blanket was placed between the resident's knees.
F0690: The facility failed to provide appropriate incontinent care for two residents, including failure of staff to wash hands before and after care, increasing risk of urinary tract infections.
F0693: The facility failed to verify feeding tube placement prior to flushing and administering medication for one resident with a feeding tube.
F0695: The facility failed to provide tracheostomy care using aseptic technique for one resident, resulting in contamination of the sterile field multiple times during care.
F0880: The facility failed to maintain infection prevention practices when a licensed nurse failed to change gloves and wash hands before administering flush/medications via a feeding tube after repositioning a resident.
Report Facts
Sampled residents: 46
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to contamination of sterile field during tracheostomy care and failure to check feeding tube placement and hand hygiene |
| CNA #3 | Certified Nursing Assistant | Named in findings related to failure to wash hands during incontinent care |
| LPN #4 | Licensed Practical Nurse | Named in findings related to pressure ulcer care and rounds |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding expectations for care plans, sterile technique, and infection control |
| Administrator | Administrator | Named in interviews regarding expectations for MDS assessments and infection control |
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