Inspection Report
Re-Inspection
Census: 162
Capacity: 164
Deficiencies: 7
May 29, 2025
Visit Reason
A Revisit/Follow-up Survey was conducted to verify correction of previously cited deficiencies. The survey was initiated and concluded on 05/29/2025.
Findings
The facility was found to have corrected their deficiencies as of 05/19/2025 based on the implementation of an acceptable Plan of Correction.
Severity Breakdown
SS=D: 3
SS=E: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure residents had the right to reasonable accommodation of needs and preferences, including call light accessibility and bed comfort for sampled residents. | SS=D |
| Failure to ensure binding arbitration agreements were properly explained, optional, and included required language about rescinding within 30 days for reviewed residents. | SS=E |
| Failure to establish and maintain an infection prevention and control program, including catheter care, equipment disinfection, medication pass procedures, and food handling. | SS=E |
| Failure to ensure delayed egress door released within 15 seconds as required by NFPA standards. | SS=D |
| Failure to maintain smoke barriers to restrict smoke transfer due to unsealed cable penetrations in smoke barrier walls. | SS=E |
| Failure to prohibit portable space heaters in healthcare occupancies or ensure heating elements do not exceed 212°F. | SS=D |
| Failure to maintain power strips and extension cords in accordance with NFPA standards, including improper use of power strips for personal electronics and overloading. | SS=E |
Report Facts
Survey Census: 162
Total Capacity: 164
Sample Size: 34
Supplemental Residents: 32
Delayed Egress Door Release Time: 30
Delayed Egress Door Release Time Corrected: 15
BIMS Score: 13
BIMS Score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding call light accessibility and catheter care |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for call light accessibility and catheter care |
| Administrator | Administrator | Interviewed regarding call light accessibility, arbitration agreements, infection control, and door release issues |
| Maintenance Manager | Maintenance Manager | Interviewed regarding delayed egress door release and power strip usage |
| Physical Therapy/Occupational Therapy Assistant | PTA/OTA | Observed and interviewed regarding gait belt disinfection |
| Kentucky Medication Aide 1 | KMA | Observed and interviewed regarding blood pressure cuff disinfection and medication pass procedures |
| Registered Nurse 1 | RN | Interviewed regarding equipment disinfection and food handling |
| Cook | Cook | Observed with badge resting in food and interviewed about badge policy |
| Dietary Manager | Dietary Manager | Interviewed regarding badge policy and food contamination |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control policies and catheter care |
| Social Services Director | Social Services Director | Interviewed regarding resident bed comfort and follow-up |
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