Deficiencies (last 1 years)
Deficiencies (over 1 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Re-Inspection
Census: 162
Capacity: 164
Deficiencies: 7
Date: 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.
Deficiencies (7)
Failure to ensure residents had the right to reasonable accommodation of needs and preferences, including call light accessibility and bed comfort for sampled residents.
Failure to ensure binding arbitration agreements were properly explained, optional, and included required language about rescinding within 30 days for reviewed residents.
Failure to establish and maintain an infection prevention and control program, including catheter care, equipment disinfection, medication pass procedures, and food handling.
Failure to ensure delayed egress door released within 15 seconds as required by NFPA standards.
Failure to maintain smoke barriers to restrict smoke transfer due to unsealed cable penetrations in smoke barrier walls.
Failure to prohibit portable space heaters in healthcare occupancies or ensure heating elements do not exceed 212°F.
Failure to maintain power strips and extension cords in accordance with NFPA standards, including improper use of power strips for personal electronics and overloading.
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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