Inspection Reports for Somerwoods Nursing and Rehabilitation Center
KY, 42501
Back to Facility Profile
Inspection Report
Complaint Investigation
Census: 105
Capacity: 166
Deficiencies: 7
Feb 21, 2025
Visit Reason
A Recertification Survey was conducted from 02/17/2025 to 02/21/2025 due to allegations of abuse, neglect, exploitation, or mistreatment. The facility was found not to be in substantial compliance with 42 CFR 483 Subpart B.
Findings
The facility failed to report a possible incident of resident-to-resident abuse within the required timeframe. Deficiencies were cited related to abuse reporting, medication storage and administration, food safety, infection control, and life safety code violations including stairways, smokeproof enclosures, corridor doors, and electrical systems.
Complaint Details
The complaint investigation was substantiated as the facility failed to report a resident-to-resident abuse incident within the required timeframe. The incident involved Resident #78 pushing Resident #13's wheelchair down the hallway. The facility was aware but chose not to report it to the state survey agency. Interviews and record reviews confirmed the incident and deficiencies in abuse reporting.
Severity Breakdown
Scope and Severity F: 4
Scope and Severity D: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to report a possible incident of resident-to-resident abuse to the state survey agency within two hours for two residents reviewed for abuse. | Scope and Severity F |
| Medication cart was left unlocked in the hallway while administering medications in resident rooms. | Scope and Severity F |
| Failed to store food in accordance with accepted professional standards; leftover food items were not labeled with product name or use-by date. | Scope and Severity F |
| Failed to maintain infection prevention and control program; staff did not consistently wear personal protective equipment when providing care to residents on contact precautions. | Scope and Severity F |
| Failed to maintain stairways and smokeproof enclosures free of obstructions and properly labeled. | Scope and Severity D |
| Failed to maintain corridor doors to resist passage of smoke and fire as required by NFPA 101 Life Safety Code. | Scope and Severity D |
| Failed to maintain electrical systems including the main generator annunciator panel to be staffed and monitored 24 hours per day. | Scope and Severity D |
Report Facts
Total census: 105
Total capacity: 166
Deficiency count: 7
BIMS score: 15
Medication cart observations: 35
Random staff interviews: 15
Random audits: 5
Food safety components: 58
Fall mats observed: 2
Resident observations: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 11 | Registered Nurse | Observed administering medications with medication cart unlocked |
| RN 27 | Registered Nurse | Informed about resident-to-resident abuse incident but did not report it |
| SRNA 26 | State Registered Nurse Aide | Witnessed and reported resident-to-resident abuse incident |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse incident reporting and medication cart policies |
| Administrator | Facility Administrator | Confirmed abuse incident and chose not to report it; involved in audits and education |
| Maintenance Director | Maintenance Director | Verified findings related to stairwell obstructions and electrical system deficiencies |
| Consultant Pharmacist | Consultant Pharmacist | Conducted rounds and observed medication cart practices |
| RN Unit Manager | RN Unit Manager | Provided immediate re-education related to infection control and PPE use |
| SDC | Staff Development Coordinator | Conducted education related to medication storage |
Loading inspection reports...
