Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 2
Sep 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident privacy and confidentiality, infection prevention and control practices, including the use of personal protective equipment (PPE) and hand hygiene.
Findings
The facility failed to ensure confidentiality of medical records for one resident by leaving medical information visible on an unattended computer. Additionally, the facility failed to maintain an effective infection prevention and control program, including failure to use PPE for a resident on contact precautions and failure to perform hand hygiene during medication administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure confidentiality of medical records for one resident by leaving medical information visible on an unattended computer during medication pass. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection prevention and control program, including failure to use PPE for a resident on contact precautions and failure to perform hand hygiene before and after resident contact. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 11
Residents reviewed for infection control: 8
Residents affected: 1
Residents affected: 2
Date of medication pass observation: Sep 2, 2025
Date of infection control observation: Sep 3, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 1 | Certified Nurse Aide | Named in confidentiality and hand hygiene findings during medication pass |
| Admissions Director | Admissions Director | Named in infection control deficiency for failure to wear PPE while providing care |
| Infection Prevention nurse | Infection Prevention nurse | Interviewed regarding staff education and infection control expectations |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for PPE use and hand hygiene |
| Administrator | Administrator | Interviewed regarding expectations for confidentiality, PPE use, and hand hygiene |
Inspection Report
Deficiencies: 2
Jun 27, 2024
Visit Reason
The inspection was conducted to evaluate compliance with Medicare/Medicaid regulations, specifically regarding beneficiary protection notification and accuracy of resident assessments.
Findings
The facility failed to provide estimated costs for continued therapy services to three residents whose Medicare benefits were exhausted, preventing informed decisions. Additionally, the facility did not accurately reflect hospice status for one resident and communication ability for another in their Minimum Data Set assessments.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents received notice of Medicaid/Medicare coverage and potential liability for services not covered, specifically not providing estimated costs on the SNF ABN Form CMS-10055 for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure two residents' Resident Assessment Instruments accurately reflected hospice designation and communication ability. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sample size: 42
Residents affected: 3
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding knowledge of filling estimated cost on SNF ABN Form CMS-10055 | |
| Director of Nursing | Interviewed regarding policy on Minimum Data Set Assessments | |
| MDS 1 and MDS 2 | Interviewed regarding coding of hospice status and communication ability in MDS assessments |
Inspection Report
Routine
Deficiencies: 9
Feb 21, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, incomplete assessments after significant changes in condition, inadequate development and implementation of comprehensive care plans, failure to provide necessary assistance with activities of daily living, inadequate supervision to prevent accidents, failure to maintain accurate medical records, and improper food safety practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with respect and dignity, including incidents involving staff neglect and belittling behavior. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete significant change assessments for residents with notable declines in condition. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive person-centered care plans with measurable objectives and appropriate assistance levels. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to review and revise comprehensive care plans after falls and changes in condition. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary assistance with activities of daily living including bathing and oral care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate supervision and interventions to prevent accidents and falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain accurate and complete medical records, including incorrect documentation of dialysis site monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including lack of interventions for decline in continence. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, distribute and serve food in accordance with professional standards, including improper thermometer use and improper dish storage. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 33
Residents affected: 2
Residents affected: 2
Residents affected: 6
Residents affected: 3
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nurse Aide | Named in dignity and respect deficiency related to neglect and belittling residents |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations and deficiencies in care and documentation |
| CNA #6 | Certified Nurse Aide | Named in dignity and respect deficiency |
| RN #3 | Registered Nurse | Named in dignity and respect deficiency |
| CNA #4 | Certified Nurse Aide | Interviewed regarding care plan assistance levels |
| CNA #1 | Certified Nurse Aide | Interviewed regarding care plan assistance levels |
| CNA #7 | Certified Nurse Aide | Interviewed regarding bathing assistance and assignment sheets |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding care plan updates and fall interventions |
| LPN #3 | Licensed Practical Nurse | Completed fall investigation and interviewed about fall causes |
| LPN #4 | Licensed Practical Nurse | Completed fall investigation and interviewed about fall causes |
| CNA #2 | Certified Nurse Aide | Interviewed regarding oral care for Resident #427 |
| CNA #3 | Certified Nurse Aide | Interviewed regarding oral care for residents with tube feeding |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding admission assessment and oral care documentation |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and dish storage practices |
| Registered Dietician | Registered Dietician | Interviewed regarding food temperature practices |
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