Inspection Reports for
Rosedale Green
4250 GLENN AVENUE, COVINGTON, KY, 41015
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 29, 2025
Visit Reason
This document is a statement of deficiencies and plan of correction related to the facility's regulatory compliance.
Findings
Based on the implementation of the acceptable Plan of Correction (POC), the deficiencies were deemed to be corrected on 2025-05-18.
Report Facts
Plan of Correction completion date: May 18, 2025
Inspection Report
Routine
Deficiencies: 2
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control regulations, specifically focusing on the implementation of Enhanced Barrier Precautions (EBP) and cleaning protocols for mechanical lifts.
Findings
The facility failed to properly clean mechanical lifts after use for two residents and did not place one resident with a chronic wound on Enhanced Barrier Precautions as required by updated policies and CMS guidance. Staff interviews revealed inconsistent understanding and application of infection control policies.
Deficiencies (2)
Failure to clean mechanical lifts after use for residents R1 and R117.
Resident R117 with a chronic wound requiring dressing changes was not placed on Enhanced Barrier Precautions as required.
Report Facts
Resident BIMS score: 99
Admission date: Apr 20, 2006
Admission date: Jan 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA1 | State Trained Nursing Assistant | Observed failing to disinfect mechanical lift after use with R1. |
| STNA4 | State Trained Nursing Assistant | Observed failing to disinfect mechanical lift and lift pad after use with R117. |
| STNA6 | State Trained Nursing Assistant | Interviewed about cleaning mechanical lifts before and after use. |
| STNA7 | State Trained Nursing Assistant | Interviewed about cleaning mechanical lifts between resident use. |
| Infection Preventionist | Interviewed about mechanical lift cleaning and infection control policy updates. | |
| Assistant Director of Nursing | ADON | Interviewed about use of PPE and Enhanced Barrier Precautions. |
| Director of Nursing | DON | Interviewed about policy interpretation and expectations for disinfecting mechanical lifts and EBP. |
| Administrator | Interviewed about expectations for staff compliance with infection control policies and mechanical lift cleaning. |
Inspection Report
Routine
Deficiencies: 6
Date: Oct 11, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations, including review of complaints, care plans, fall prevention, food safety, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (e.g., providing appropriately sized beds), late submission of Minimum Data Set (MDS) assessments, incomplete care plans leading to resident falls with injury, inadequate supervision and assistive device use to prevent falls, unsafe food storage in resident refrigerators, and failure to maintain clean wheelchairs for residents.
Deficiencies (6)
Failed to ensure each resident receives services with reasonable accommodation of resident needs and preferences, specifically failure to provide a longer bed for a tall resident causing discomfort and pain.
Failed to submit Minimum Data Set (MDS) Assessments to CMS within the required timeframe for one resident.
Failed to develop and implement a complete care plan that meets all the resident's needs, including failure to include use of gait belt for transfers and ambulation, contributing to a fall with major injury.
Failed to ensure adequate supervision and assistive devices to prevent accidents, resulting in a resident fall with a fractured femoral neck and subsequent hip arthroplasty.
Failed to ensure safe storage, handling, and consumption of foods brought to residents by family and visitors, including expired and spoiled food in resident refrigerators.
Failed to provide a safe, functional, sanitary, and comfortable environment, specifically failure to maintain clean wheelchairs for residents.
Report Facts
Residents sampled: 33
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
MDS Assessment late submission days: 40
Fall date: 2019
Wheelchair cleaning schedule frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Assessed Resident #95 after fall and administered Tylenol |
| State Registered Nurse Aide #2 | State Registered Nurse Aide | Transferred and ambulated Resident #95 without gait belt or walker, contributing to fall |
| MDS Coordinator #1 | MDS Coordinator | Failed to finalize and submit Resident #1's MDS Assessment on time |
| Director of Nursing | Director of Nursing | Provided interviews regarding care plan expectations and fall prevention policies |
| Administrator | Administrator | Provided interviews regarding facility policies and expectations for resident care and safety |
| Unit Manager for 700 Unit | Unit Manager | Unaware of Resident #220's need for longer bed |
| Clinical Care Coordinator Nurse | Clinical Care Coordinator Nurse | Interviewed regarding care plan implementation and fall incident |
| State Registered Nurse Aide #7 | State Registered Nurse Aide | Interviewed regarding monitoring of resident refrigerators |
| Director of Dining Services | Director of Dining Services | Interviewed regarding monitoring of resident refrigerators |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding responsibilities for cleaning and monitoring resident refrigerators |
| State Registered Nurse Aide #15 | State Registered Nurse Aide | Interviewed regarding wheelchair cleaning schedule and condition of Resident #108's wheelchair |
| State Registered Nurse Aide #14 | State Registered Nurse Aide | Interviewed regarding wheelchair cleaning expectations |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 16, 2018
Visit Reason
The inspection was conducted to investigate complaints related to failure to revise the Comprehensive Care Plan for a resident with skin impairment, improper storage of expired medications, and improper food storage practices.
Complaint Details
The investigation was complaint-driven, focusing on Resident #18's care plan and medication and food storage practices. The complaint was substantiated with findings of minimal harm or potential for harm.
Findings
The facility failed to revise the Comprehensive Care Plan for Resident #18 to include new treatments and interventions related to skin impairment. Expired medication (Pilocarpine 2% eye drops) was found on the medication cart. Food items in multiple unit kitchens and freezers were found unlabeled, undated, unsealed, and some expired, violating food safety standards.
Deficiencies (3)
Failure to revise the Comprehensive Care Plan to include treatment/interventions for skin impairment and use of Heel Lift Boots for Resident #18.
Expired Pilocarpine 2% eye drops found on the medication cart, not properly disposed of.
Food items in kitchenettes and freezers were not labeled, dated, sealed, and some were expired, risking resident health.
Report Facts
Residents sampled: 31
Expired medication days: 13
Waffles count: 12
Bread expiration date: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Performed skin assessment on Resident #18 and failed to place Heel Lift Boots. |
| State Registered Nurse Aide #1 | State Registered Nurse Aide | Assigned to Resident #18, aware of Heel Lift Boots requirement but did not ensure placement. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Removed expired Pilocarpine 2% eye drops from medication cart. |
| Care Coordinator #1 | Care Coordinator | Responsible for updating Comprehensive Care Plans, failed to revise Resident #18's plan. |
| Director of Nursing | Director of Nursing | Confirmed importance of revising Comprehensive Care Plans and responsibility of Clinical Coordinator. |
| Clinical Coordinator of the 700 Unit | Clinical Coordinator | Expected to ensure expired medications are removed and care plans updated. |
| Pharmacist | Pharmacist | Stated expired medications should be removed and disposed of per policy. |
| Assistant Director of Nursing | Assistant Director of Nursing | Expected staff to follow policy on disposing expired medications. |
| Administrator | Administrator | Stated Care Plans should be revised promptly and expected staff to follow medication storage policy. |
| Dietary Manager | Dietary Manager | Stated food items must be labeled, dated, and sealed to prevent use of expired items. |
| Dietary Staff #2 | Dietary Staff | Acknowledged importance of labeling and sealing food items to prevent illness. |
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