Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
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 |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, infection prevention and control, and arbitration agreement disclosures at Sayre Christian Village Nursing Home.
Findings
The facility failed to reasonably accommodate resident needs and preferences for 2 sampled residents, did not properly inform residents about arbitration agreements for 5 residents, and failed to maintain an effective infection prevention and control program affecting 6 residents. Observations included call lights out of reach, improper catheter bag placement, inadequate cleaning of shared equipment, and food contamination risks.
Deficiencies (3)
F 0558: The facility failed to ensure call lights were within reach for 2 residents, R34 and R120, compromising their safety and comfort.
F 0847: The facility failed to inform 5 residents and their representatives that arbitration agreements were optional and could be rescinded within 30 days, and residents did not recall signing or discussing these agreements.
F 0880: The facility failed to implement an effective infection prevention and control program, including improper catheter bag placement on the floor, inadequate disinfection of shared equipment, improper medication handling, and food contamination risks affecting 6 residents.
Report Facts
Residents sampled: 34
Residents affected: 2
Residents affected: 5
Residents affected: 6
BIMS scores: 13
BIMS scores: 14
BIMS scores: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA 3 | State Registered Nurse Aide | Interviewed regarding call light safety and catheter care |
| SRNA 11 | State Registered Nurse Aide | Interviewed regarding call light safety and catheter care |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding call light accessibility and catheter bag placement |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding catheter bag placement and rounds |
| PTA/OTA | Physical Therapy/Occupational Therapy Assistant | Observed and interviewed regarding gait belt disinfection |
| KMA 1 | Kentucky Medication Aide | Observed and interviewed regarding blood pressure cuff cleaning and medication handling |
| RN 1 | Registered Nurse | Interviewed regarding shared equipment cleaning |
| SRNA 7 | State Registered Nurse Aide | Interviewed regarding shared equipment cleaning |
| IP | Infection Preventionist | Interviewed regarding infection control training and expectations |
| DON | Director of Nursing | Interviewed regarding call light and infection control expectations |
| Administrator | Facility Administrator | Interviewed regarding call light, arbitration agreements, and infection control policies |
| Admissions Coordinator | Admissions Coordinator | Interviewed regarding arbitration agreement presentation and resident understanding |
| Dietary Manager | Dietary Manager | Interviewed regarding badge policy and food contamination prevention |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding resident abuse and failure to follow care plans, specifically concerning incidents involving Resident #20 and Resident #2.
Complaint Details
The investigation was complaint-driven, focusing on allegations of abuse and failure to follow care plans. Resident #21 reported being struck by Resident #20. Resident #2 was injured during a bath provided by a single staff member despite requiring two. The facility's investigation and interviews revealed failures in supervision, training, and care planning.
Findings
The facility failed to protect residents from abuse and failed to ensure adequate supervision and adherence to care plans, resulting in injuries to residents. Resident #20 struck Resident #21, and Resident #2 was bathed by a single staff member despite requiring two, leading to self-inflicted injuries. The facility's care plans and staff training were inadequate or not followed.
Deficiencies (4)
F 0600: The facility failed to protect residents from abuse when Resident #20 struck Resident #21 with an iPad, causing injury. The facility did not determine the cause but placed Resident #20 on supervision and moved him/her to another room.
F 0604: The facility failed to ensure residents were free from physical restraints used for discipline or convenience when SRNA #3 held Resident #2's hands to prevent hitting, resulting in self-inflicted injuries including a laceration to the right eye.
F 0656: The facility failed to develop and implement a comprehensive care plan specifying the number of staff required to assist Resident #2 with bathing, resulting in one staff member providing care alone and the resident sustaining injuries.
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents when Resident #2 was bathed alone despite requiring two staff, resulting in combative behavior and injuries.
Report Facts
Residents sampled: 44
BIMS score: 9
BIMS score: 4
Staff required for bathing: 2
Date of incident: Mar 30, 2023
Date of incident: Oct 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #3 | State Registered Nursing Assistant (Agency Aide) | Provided bath to Resident #2 alone, held resident's hands to prevent hitting, resulting in injury |
| Unit Manager #1 | Unit Manager | Removed Resident #21 from room and placed Resident #20 on 1:1 supervision after abuse incident |
| Administrator | Facility Administrator | Oversaw investigation, confirmed abuse, and stated expectations for staff adherence to care plans |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding SRNA #3's actions and facility policies on restraints and care plans |
| RN #5 | Registered Nurse | Charge nurse on 03/30/2023, assessed Resident #2 after injury, unaware of restraint use |
| Medical Director | Medical Director | Evaluated Resident #2's injuries and commented on care plan adherence and resident behavior |
| MDS Nurse #1 | Minimum Data Set Nurse | Explained care plan development and documentation practices |
| MDS Nurse #2 | Minimum Data Set Nurse | Discussed care plan updates and agency staff orientation |
| Shower Aide #1 | Shower Aide | Advised SRNA #3 to have two staff assist Resident #2 during bath, but SRNA #3 bathed resident alone |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 6, 2020
Visit Reason
The inspection was conducted to assess compliance with food service safety standards and clinical record maintenance at Sayre Christian Village Nursing Home.
Findings
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, specifically with undated snacks found in nourishment rooms. Additionally, the facility failed to maintain accurate clinical records for one resident, with missing documentation of wound care treatments.
Deficiencies (2)
F0812: The facility failed to store, prepare, distribute, and serve food according to professional standards, as undated snacks were found in nourishment rooms on the 100 and 200 units, posing potential infection control concerns.
F0842: The facility failed to maintain accurate clinical records for one resident, with no documented evidence of wound care treatments being signed out from 01/22/2020 to 02/06/2020, despite treatments being performed.
Report Facts
Undated snacks observed: 22
Sampled residents: 24
Resident #8 wound care treatments missing documentation: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding missing documentation in Treatment Administration Record. |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for food labeling and clinical record accuracy. |
| Administrator | Administrator | Interviewed regarding food safety policies and clinical record documentation. |
Inspection Report
Routine
Deficiencies: 11
Date: Feb 14, 2019
Visit Reason
Routine inspection of Sayre Christian Village Nursing Home to assess compliance with regulatory requirements including resident care, medication management, safety, and infection control.
Findings
The facility was found to have multiple deficiencies including failure to ensure timely response to call lights, failure to maintain resident dignity, failure to protect resident confidentiality, failure to implement and revise comprehensive care plans, improper medication management, unsafe environment and supervision leading to accidents, and inadequate infection prevention and control program.
Deficiencies (11)
F 0550: Facility failed to ensure timely response to call lights, resulting in residents waiting up to 59 minutes for assistance, compromising dignity and quality of life.
F 0583: Facility failed to maintain confidentiality of resident medical information by leaving electronic medication administration record (E-MAR) visible and accessible to unauthorized persons.
F 0656: Facility failed to implement the comprehensive care plan for Resident #108 related to pacemaker checks, with no documented evidence pacemaker checks were performed since 2016.
F 0657: Facility failed to revise comprehensive care plans for Residents #52, #84, and #94 after incidents including bruises and falls, lacking root cause analysis and targeted interventions to prevent recurrence.
F 0684: Facility failed to provide treatment and care according to orders and professional standards for Resident #108 by not ensuring pacemaker checks were performed or ordered.
F 0689: Facility failed to ensure a safe environment and adequate supervision to prevent accidents, including allowing Resident #71 to use oxygen under a hair dryer and failure to investigate and prevent injuries for Residents #52, #84, and #94.
F 0756: Facility failed to ensure monthly drug regimen review identified and acted upon irregularities related to prolonged use of PRN psychotropic medication for Resident #94.
F 0757: Facility failed to ensure Resident #94's drug regimen was free from unnecessary drugs by allowing PRN psychotropic medication to be prescribed for 84 days without documented rationale.
F 0761: Facility failed to ensure proper storage of drugs and biologicals by having unlabeled loose pills in medication carts on multiple occasions.
F 0880: Facility failed to establish an infection prevention and control program that included annual review of policies and program updates.
F 0881: Facility failed to implement an antibiotic stewardship program including antibiotic use protocols and monitoring system to optimize treatment and reduce adverse events.
Report Facts
Call light wait times: 59
PRN psychotropic medication duration: 84
PRN psychotropic medication stop date delay: 11
Medication carts with unlabeled pills: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reviewed Resident #108 medical record and unaware of pacemaker checks |
| SRNA #16 | State Registered Nurse Aide | Reported discoloration and swelling to Resident #94's left foot |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including pacemaker checks, medication reviews, infection control |
| Administrator | Facility Administrator | Interviewed regarding expectations for quality care, infection control, and medication management |
| Consultant Pharmacist | Pharmacist | Conducted monthly drug regimen reviews and communicated irregularities |
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