Inspection Reports for Somerwoods Nursing and Rehabilitation Center
KY, 42501
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 21, 2025, identified deficiencies related to abuse reporting, medication administration, food safety, infection control, and life safety code compliance. Earlier inspections were not provided for comparison, so broader inspection patterns are unclear. The main issues involved failure to report a resident-to-resident abuse incident promptly, unsecured medication carts, improper food labeling, inconsistent use of protective equipment, and maintenance problems with stairways, corridor doors, and electrical systems. The complaint investigation was substantiated regarding the delayed abuse report, but fines or enforcement actions were not listed in the available reports. Without previous reports for context, it is not possible to determine a clear trend in compliance.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Date: Feb 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident abuse reporting, medication storage security, food safety, and infection prevention and control practices.
Findings
The facility failed to timely report a resident-to-resident abuse incident to the state survey agency, left medication carts unlocked during medication administration, improperly stored and labeled food items, and failed to ensure staff wore appropriate personal protective equipment (PPE) for residents on contact precautions.
Deficiencies (4)
Failed to timely report suspected resident-to-resident abuse to the state survey agency within two hours for two residents.
Failed to store medications securely; medication cart was left unlocked while administering medications.
Failed to store food in accordance with professional standards; leftover food items were unlabeled and raw meat was stored above cooked food.
Failed to ensure staff donned personal protective equipment (PPE) when providing care to residents on contact precautions.
Report Facts
Residents reviewed for abuse: 4
Medication carts observed: 5
BIMS scores: 15
BIMS scores: 14
Vancomycin dosage: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Registered Nurse Aide 26 | State Registered Nurse Aide | Reported and described the resident-to-resident abuse incident |
| Registered Nurse 27 | Registered Nurse | Determined the abuse incident was not reportable |
| Director of Nursing | Director of Nursing | Stated it was up to the Administrator to determine what was reported |
| Registered Nurse 11 | Registered Nurse | Observed leaving medication cart unlocked during medication administration |
| RN 13 | Unit Manager | Stated medication cart should be locked when nurse enters resident rooms |
| Dietary Supervisor | Dietary Supervisor | Confirmed food items were unlabeled and raw meat stored improperly |
| Dietary Aide 18 | Dietary Aide | Described proper labeling and storage procedures for leftover food |
| State Registered Nurse Aide 2 | State Registered Nurse Aide | Observed providing care without PPE to resident on contact precautions |
| Administrative Licensed Practical Nurse 30 | Infection Preventionist | Stated staff must wear gown and gloves for residents on contact precautions |
| State Registered Nurse Aide 7 | State Registered Nurse Aide | Observed not wearing PPE when serving meal tray to resident on contact precautions |
| State Registered Nurse Aide 8 | State Registered Nurse Aide | Observed not wearing PPE when serving meal tray to resident on contact precautions |
| Administrator | Administrator | Confirmed abuse incident was not reported and stated PPE expectations |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 166
Deficiencies: 7
Date: 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.
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.
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.
Deficiencies (7)
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.
Medication cart was left unlocked in the hallway while administering medications in resident rooms.
Failed to store food in accordance with accepted professional standards; leftover food items were not labeled with product name or use-by date.
Failed to maintain infection prevention and control program; staff did not consistently wear personal protective equipment when providing care to residents on contact precautions.
Failed to maintain stairways and smokeproof enclosures free of obstructions and properly labeled.
Failed to maintain corridor doors to resist passage of smoke and fire as required by NFPA 101 Life Safety Code.
Failed to maintain electrical systems including the main generator annunciator panel to be staffed and monitored 24 hours per day.
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 |
Inspection Report
Routine
Deficiencies: 5
Date: Jul 24, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, accurate resident assessments, pressure ulcer care, urinary tract infection prevention, and food safety practices.
Findings
The facility was found deficient in posting Ombudsman information accessible to all residents, conducting accurate Minimum Data Set assessments, providing appropriate pressure ulcer and catheter care, and ensuring sanitary food handling practices. Several staff failed to perform hand hygiene between glove changes, and the dietary staff did not change gloves after handling pot holders before plating food.
Deficiencies (5)
Failed to ensure Ombudsman information was posted in accessible locations on all floors.
Failed to ensure an accurate significant change Minimum Data Set (MDS) assessment for one resident enrolled in hospice.
Failed to provide appropriate pressure ulcer care; hand hygiene was not performed between glove changes during wound care.
Failed to provide appropriate catheter and incontinence care; hand hygiene was not performed between glove changes.
Failed to ensure food was served under sanitary conditions; dietary staff did not change gloves or perform hand hygiene after handling pot holders.
Report Facts
Residents sampled: 30
Residents affected: 1
Residents affected: 1
Residents affected: Many
Residents affected: Few
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in wound care hand hygiene deficiency |
| SRNA #1 | State Registered Nurse Aide | Named in catheter and incontinence care hand hygiene deficiency |
| Dietary worker | Named in food service glove hygiene deficiency | |
| Administrator | Interviewed regarding Ombudsman posting | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and expectations |
| MDS Coordinator | Responsible for MDS assessment coding | |
| Infection Control Nurse | Interviewed regarding infection control practices | |
| Assistant Dietary Manager | Interviewed regarding dietary glove change policy |
Inspection Report
Routine
Deficiencies: 2
Date: May 10, 2018
Visit Reason
The inspection was conducted to ensure compliance with medication storage requirements, specifically verifying that medications were stored at appropriate temperatures in the medication refrigerator.
Findings
The facility failed to maintain the medication refrigerator temperature within the required range, with observed temperatures as low as 11 degrees F and excessive ice buildup. Staff did not report temperature issues as required, resulting in inappropriate storage conditions for multiple medications.
Deficiencies (2)
Medications were stored in the refrigerator at 11 degrees F, below the required temperature range of 36-46 degrees F, with excessive ice buildup in the freezer compartment.
Staff failed to report refrigerator temperature issues to Maintenance or Unit Manager as required.
Report Facts
Medication vials and pens stored: 339
Medication vials and pens stored: 23
Medication vials and pens stored: 23
Medication vials and pens stored: 15
Medication vials and pens stored: 10
Medication vials and pens stored: 9
Medication vials and pens stored: 8
Medication vials and pens stored: 6
Medication vials and pens stored: 3
Medication vials and pens stored: 2
Medication vials and pens stored: 2
Medication vials and pens stored: 2
Medication vials and pens stored: 1
Medication vials and pens stored: 1
Medication vials and pens stored: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding refrigerator temperature monitoring and failure to report temperature issues |
| Unit Manager | Third Floor Unit Manager | Interviewed regarding awareness of refrigerator temperature problems |
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