Inspection Reports for
Salyersville Nursing and Rehabilitation Center
662 PARKWAY DRIVE, SALYERSVILLE, KY, 41465
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 1, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify responsible parties of resident transfers, incomplete and non-individualized care plans, inadequate supervision to prevent resident accidents, and failure to comply with tuberculosis testing requirements for staff.
Complaint Details
The complaint investigation substantiated failures in notifying responsible parties of resident transfers, developing adequate care plans, providing sufficient supervision to prevent resident altercations, and ensuring staff compliance with tuberculosis testing requirements.
Findings
The facility failed to notify the responsible party of a resident transfer to the hospital, did not develop or implement comprehensive and individualized care plans for several residents, failed to provide adequate supervision during meal times leading to resident altercations, and did not ensure all staff were compliant with required annual tuberculosis testing.
Deficiencies (4)
F580: The facility failed to notify the responsible party when a resident was transferred to the hospital on 06/18/2025.
F657: The facility failed to develop and implement comprehensive, person-centered care plans for four of 14 sampled residents, including reactive rather than proactive interventions.
F689: The facility failed to provide adequate supervision during meal service on 07/28/2025, resulting in a resident altercation with only one staff member present instead of the required three.
F836: The facility failed to ensure all staff received required annual tuberculosis testing, with 61 of 131 active employees lacking current TB test records.
Report Facts
Residents sampled: 14
Active employees: 131
Employees without TB records: 61
Employees with lapsed TB testing: 47
Staff required in dining room: 3
Staff present during meal service: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN3 | Registered Nurse | Assigned to Resident 3 on 06/18/2025 and involved in transfer notification issue |
| UM1 | Unit Manager | Assisted with Resident 3 transfer and responsible for transfer paperwork; no longer employed |
| Director of Nursing | Interim Director of Nursing | Provided expectations regarding transfer notifications and care plan implementation |
| Administrator | Facility Administrator | Provided expectations regarding transfer notifications, care plans, supervision, and TB testing compliance |
| Minimum Data Set Coordinator | MDS Coordinator | Responsible for implementing care plans; interviewed regarding care plan deficiencies |
| Social Services Director | SSD | Responsible for updating care plans; interviewed regarding care plan deficiencies |
| KMA1 | Kentucky Medication Aide | Reported being the only staff member present during the dining room altercation on 07/28/2025 |
| Activities Assistant 2 | Activities Assistant | Scheduled to be in dining room on 07/28/2025 but left early |
| Activities Director | Activities Director | Responsible for ensuring activities staff coverage during meals; failed to schedule replacement on 07/28/2025 |
| RN3 | Registered Nurse | Commented on difficulty of supervision with only one staff member in dining room |
| LPN1 | Licensed Practical Nurse | Unaware of dining room assignment on 07/28/2025; commented on importance of staff presence during meals |
| Registered Nurse | Local Health Department RN | Provided information on TB testing requirements |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 19, 2025
Visit Reason
The inspection was conducted due to complaints alleging failure to protect residents from abuse and neglect, including inappropriate sexual comments and neglect in responding to call lights.
Complaint Details
The complaint investigation involved allegations of sexual abuse and neglect. The facility failed to report incidents to the state survey agency and failed to provide timely care to a resident who pressed her call light for over two hours. The investigation confirmed neglect and inadequate response to abuse allegations.
Findings
The facility failed to protect residents from abuse and neglect for 2 of 84 sampled residents, including failure to report alleged abuse incidents to appropriate agencies and failure to provide timely care. The facility also failed to develop and implement comprehensive care plans addressing resident behaviors and interactions.
Deficiencies (4)
F 0600: The facility failed to protect residents from all types of abuse, including sexual abuse, for 2 residents. Inappropriate sexual comments were made by one resident to another, and the facility did not report the incident to state agencies as required.
F 0609: The facility failed to timely report suspected abuse and neglect and failed to implement its abuse policy for 2 residents. Neglect was confirmed where a resident waited over two hours for incontinence care, and the facility did not report the incident to the state survey agency.
F 0610: The facility failed to respond appropriately to alleged violations by not thoroughly investigating abuse allegations involving 2 residents and not reporting the results to enforcement agencies within required timeframes.
F 0656: The facility failed to develop and implement comprehensive person-centered care plans for 2 residents involved in altercations, lacking interventions to monitor and prevent further incidents between them.
Report Facts
Residents sampled: 84
Residents affected: 2
BIMS score: 5
BIMS score: 9
Call light wait time: 2
Residents sampled: 87
Residents affected: 2
BIMS score: 0
BIMS score: 3
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Filed grievances and reported abuse allegations; involved in investigation and grievance follow-up |
| Interim Administrator | Interim Administrator | Facility administrator during investigation; admitted failure to report abuse and neglect incidents |
| Director of Nursing | Director of Nursing (DON) | Aware of neglect grievance; provided staff education on call light response and supervision |
| Registered Nurse 2 | Registered Nurse (RN) 2 | Observed altercation between residents and reported incident |
| Nursing Assistant Instructor | Certified Nursing Assistant (CNA) Instructor | Reported resident's complaint of inappropriate comments to SSD and Administrator |
| State Registered Nurse Aide 11 | SRNA 11 | Found asleep during neglect incident; reprimanded by Administrator |
| State Registered Nurse Aide 12 | SRNA 12 | Responsible aide during neglect incident; reported delays in care due to staffing |
| Licensed Practical Nurse 6 | Licensed Practical Nurse (LPN) 6 | On duty during neglect incident; unaware of aide sleeping and call light delay |
| Unit Manager | Unit Manager (UM) | Set expectations for call light response and staff supervision |
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Provided abuse education and policy review |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, as well as issues related to wound care and skin assessments for residents.
Complaint Details
The complaint investigation found immediate jeopardy conditions related to pressure ulcer care and wound management. The facility failed to conduct required skin assessments, missed repositioning schedules, and lacked proper wound documentation and treatment. Residents experienced worsening wounds, hospitalizations, and one resident expired after transfer to hospital. The facility also failed to replace the wound care nurse during medical leave, contributing to systemic failures.
Findings
The facility failed to ensure residents received proper skin and wound care, including consistent weekly skin assessments, timely repositioning, and appropriate documentation. Multiple residents developed pressure ulcers and wounds that were not properly identified or treated, leading to immediate jeopardy to resident health and safety.
Deficiencies (1)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in immediate jeopardy to resident health or safety for some residents.
Report Facts
Residents sampled: 37
Residents affected: 2
BIMS score: 0
BIMS score: 3
Missed repositioning intervals: 15
Meal intake percentage: 77
Fluid intake: 500
Wound measurements: 4
Wound measurements: 3.4
Wound measurements: 0.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | LPN | Stated she did not conduct head-to-toe skin assessments |
| Registered Nurse 1 | RN | Reported wound care staff were responsible for skin assessments |
| Registered Nurse 2 | RN | Stated wound care and skin assessments were delegated to wound care staff |
| Director of Nursing | DON | Acknowledged failure to identify wounds and expected weekly skin assessments |
| Administrator | Facility Administrator | Expected weekly skin assessments and physician orders to be followed |
| Unit Manager | Unit Manager | Completed skin assessment identifying new wounds but delayed physician notification |
| Interim Director of Nursing | IDON | Reported wound care nurse on medical leave and no replacement designated |
| Wound Care Physician | WCP | Identified discrepancies in wound documentation and facility-wide failures |
| Wound Care Nurse | WCN | Observed lack of skin assessments and inadequate documentation |
| Regional Quality Manager | RQM | Reported involvement in mock survey and identified ongoing deficiencies |
| Licensed Practical Nurse 2 | LPN | Noted resident decline and reported concerns but unsure of follow-up actions |
| State Registered Nurse Aide 7 | SRNA7 | Reported resident decline and limited fluid intake before hospitalization |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: May 17, 2025
Visit Reason
The inspection was conducted due to allegations of abuse, neglect, and concerns related to resident care including medication errors, wound care, nutrition, and pain management.
Complaint Details
The investigation was complaint-driven based on allegations of abuse including sexual and verbal abuse, neglect in wound care and pain management, medication errors, and failure to maintain accurate clinical records. Some allegations were substantiated, others were unsubstantiated but revealed systemic failures.
Findings
The facility failed to protect residents from abuse, including sexual and verbal abuse, failed to report and investigate allegations properly, failed to provide adequate wound care and pain management, failed to maintain accurate resident weights and nutritional monitoring, and failed to administer medications as ordered. Immediate Jeopardy was identified related to abuse, quality of care, and facility administration.
Deficiencies (13)
F600: The facility failed to protect residents from abuse including a Medical Director showing a pornographic image to a resident and verbal abuse by staff to residents. Reporting and investigation of abuse allegations were inadequate.
F609: The facility failed to timely report allegations of sexual and verbal abuse to State Agencies and law enforcement within required timeframes for two residents.
F610: The facility failed to thoroughly investigate allegations of abuse for two residents, allowing potential ongoing harm and failing to protect residents.
F656: The facility failed to develop and implement a comprehensive care plan for impaired skin integrity for one resident, including failure to perform weekly skin assessments and identify wounds.
F684: The facility failed to provide appropriate treatment and care for a resident's surgical wound, including failure to monitor and assess the wound, provide effective pain management, and follow physician orders.
F685: The facility failed to maintain accurate and complete clinical records, including falsified resident weights for 79 residents, compromising nutritional assessments and care planning.
F686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for one resident, including failure to identify wounds and follow physician orders.
F692: The facility failed to utilize its resources effectively to ensure nutrition and hydration status maintenance, including failure to identify significant weight changes and implement interventions for 79 residents.
F697: The facility failed to provide safe and appropriate pain management for a resident with a surgical wound, including failure to assess pain adequately and notify the physician.
F760: The facility failed to ensure residents were free from significant medication errors, resulting in missed doses of critical medications for six residents.
F835: The facility failed to administer the facility in a manner that enabled effective use of its resources to attain and maintain the highest practicable well-being of residents, including failures in abuse investigations, wound care, pain management, and medication administration.
F842: The facility failed to safeguard resident-identifiable information and maintain complete and accurate medical records, including falsified weights and inaccurate documentation for 79 residents.
F865: The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address systemic problems including weight management and documentation issues.
Report Facts
Residents affected by abuse: 3
Deficiency counts: 12
Weight loss: 30.2
Weight gain: 93
Weight loss: 152
Missed medication doses: 3
Medication overstock: 13
Residents with inaccurate weights: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R73 Medical Director | Medical Director | Named in sexual abuse allegation involving showing inappropriate image to resident R73. |
| RN1 | Registered Nurse | Involved in notification chain for abuse allegation of R73 but did not provide formal statement. |
| SRNA9 | State Registered Nurse Aide | Notified RN1 of abuse allegation by R73 and involved in initial response. |
| Administrator | Facility Administrator | Responsible for abuse investigation and overall facility administration; failed to report abuse properly. |
| DON | Director of Nursing | Responsible for nursing services and abuse reporting; unaware of some abuse allegations and failed to notify authorities. |
| LPN3 | Licensed Practical Nurse | Named in verbal abuse allegations by residents R98 and others. |
| RN2 | Registered Nurse | Acknowledged failure to notify physician of resident R320's pain and refusal of care. |
| Pharmacy Tech 1 | Pharmacy Technician | Reported pharmacy delivery issues and medication shortages. |
| Pharmacy Client Manager | Pharmacy Client Manager | Performed medication cart audits and reported overstock issues. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 17, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan development and implementation, specifically focusing on skin assessments and prevention of pressure ulcers for residents.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for one resident, R26, by not providing evidence of weekly skin assessments as required. This failure resulted in unidentified pressure ulcers and wounds, leading to hospitalization and surgical intervention for the resident.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan for resident R26, including weekly skin assessments. This failure led to unidentified pressure ulcers and wounds requiring hospitalization and surgical debridement.
Report Facts
Residents sampled: 37
Resident R26 BIMS score: 0
Dates of Bath/Shower Sheet review: From 2025-02-27 through 2025-05-08
Dates of missed preventive treatment: 2
Hospital admission date: Resident admitted on 03/20/2025 with multiple diagnoses and skin breakdown
Surgical debridement date: Surgical debridement performed on 03/21/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Care Physician Assistant | Assessed resident R26's head wound but did not assess other wounds | |
| License Practical Nurse (LPN) 3 | Conducted skin assessments only on exposed skin during medication pass, not head-to-toe | |
| Registered Nurse (RN)1 | Never conducted skin assessments during shift; stated wound care staff responsible | |
| Registered Nurse (RN)2 | Did not complete weekly head-to-toe skin assessments; task delegated to wound nurse | |
| Director of Nursing (DON) | Instructed staff that wound care staff were responsible for skin assessments; acknowledged failure to identify wounds on resident R26 | |
| Administrator | Expected weekly skin assessments and physician orders to be followed |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 8, 2021
Visit Reason
The inspection was conducted to assess compliance with food service safety, equipment maintenance, and overall facility regulatory standards.
Findings
The facility failed to properly label and date stored food items and did not adequately clean kitchen equipment, including the convection oven and steamer. Additionally, a non-functioning ice machine was observed, which posed a potential risk for food contamination.
Deficiencies (2)
F 0812: The facility failed to store, serve, and prepare food in accordance with professional standards. Unlabeled and undated cups of Jell-O and frozen breadsticks were found, and dust and food debris were observed on kitchen equipment.
F 0908: The facility failed to maintain mechanical equipment in safe operating condition. A non-functioning ice machine was observed in the kitchen, which had been broken for approximately three months.
Report Facts
Number of Jell-O cups unlabeled: 16
Date capital expenditure request submitted: Feb 1, 2021
Duration ice machine non-functional: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Acting Dietary Manager | Interviewed regarding food labeling, kitchen cleaning, and ice machine status | |
| Cook | Interviewed regarding cleaning of kitchen equipment | |
| Maintenance Director | Interviewed regarding ice machine repair request | |
| Administrator | Interviewed regarding awareness of broken ice machine and purchase request |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Feb 6, 2019
Visit Reason
Complaint investigation triggered by concerns regarding Resident #117's respiratory care and other care issues.
Complaint Details
Complaint investigation related to Resident #117's respiratory care, medication administration, supervision, and grievance handling. Immediate jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to notify physicians of changes in residents' conditions, failed to provide adequate respiratory and tracheostomy care, failed to resolve grievances promptly, failed to develop and implement comprehensive care plans, failed to administer medications properly, failed to post nurse staffing data as required, and failed to maintain proper medication storage temperatures.
Deficiencies (11)
F580: The facility failed to notify physicians of changes in residents' conditions including oxygen refusal and elevated blood glucose levels for three residents.
F585: The facility failed to ensure prompt resolution of grievances for Resident #117, resulting in immediate jeopardy.
F656: The facility failed to develop and implement comprehensive, person-centered care plans for four residents, including inadequate respiratory and medication care plans.
F689: The facility failed to provide adequate supervision to prevent accidents for Resident #117, resulting in resident's death.
F695: The facility failed to provide tracheostomy care and suctioning as ordered for three residents.
F732: The facility failed to post nurse staffing data at the beginning of each shift as required.
F760: The facility failed to ensure Resident #117 was free from significant medication errors related to insulin administration.
F835: The facility Administrator failed to use resources effectively and efficiently to ensure Resident #117 received respiratory care and to investigate family grievances.
F761: The facility failed to ensure drugs and biologicals were stored properly, including expired medication and refrigerator temperatures outside required range.
F807: The facility failed to provide drinks consistent with resident preferences, serving only decaffeinated coffee despite resident preference for caffeinated coffee.
F842: The facility failed to maintain accurate medical records for two residents by documenting tracheostomy care that was not provided.
Report Facts
Residents sampled: 47
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 4
Temperature: 26
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Unit Manager | Named in failure to provide tracheostomy care and medication administration. |
| RN #1 | Registered Nurse | Named in failure to notify physician and medication administration. |
| RN #11 | Registered Nurse | Named in expired medication application. |
| Director of Nursing | Director of Nursing | Named in failure to ensure policies and oversight of respiratory care. |
| Administrator | Facility Administrator | Named in failure to investigate grievances and ensure effective facility administration. |
| Social Services Director | Social Services Director | Named as Grievance Officer responsible for grievance process. |
| Respiratory Therapy Director | Respiratory Therapy Director | Named in respiratory care education and oversight. |
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