Inspection Reports for
Stonecreek Health and Rehabilitation
4747 ALBEN BARKLEY DRIVE, PADUCAH, KY, 42001
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
99% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 3
Date: Dec 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication administration, and infection control at Stonecreek Health and Rehabilitation.
Findings
The facility failed to maintain a safe environment due to an unstable commode for one resident, had a medication error rate exceeding 5 percent affecting one resident, and did not properly implement infection prevention and control protocols for four residents on contact precautions.
Deficiencies (3)
F 0584: The facility failed to provide a safe, clean, and homelike environment by not securing the commode for Resident 21, causing it to be unstable and a potential safety hazard.
F 0759: The facility failed to ensure medication error rates were less than 5 percent, with one of eight residents missing a dose of hydrocodone-acetaminophen and a probiotic due to unavailability and documentation issues.
F 0880: The facility failed to provide and implement an infection prevention and control program, resulting in staff not consistently donning personal protective equipment (PPE) for residents on contact precautions, risking transmission of infections.
Report Facts
Residents sampled for commode safety: 26
Residents sampled for medication observation: 8
Residents sampled for infection control: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Named in medication error finding for missed doses and documentation |
| Maintenance Assistant | Reported commode was unstable and unsafe, involved in commode installation issue | |
| Director of Nursing | Director of Nursing | Provided statements on medication reordering and PPE compliance |
| Administrator | Administrator | Provided statements on commode repair plans and infection control education |
| Certified Nurse Aide 2 | Certified Nurse Aide | Interviewed regarding contact precautions for Resident 95 |
| Certified Occupational Therapy Assistant 2 | Certified Occupational Therapy Assistant | Observed and interviewed regarding PPE use with Resident 95 |
| Certified Nursing Assistant 8 | Certified Nursing Assistant | Observed entering isolation room without PPE |
| Housekeeper 1 | Housekeeper | Observed removing trash without PPE in isolation room |
| Staff Development Coordinator/Infection Prevention Nurse | Staff Development Coordinator/Infection Prevention Nurse | Provided education on PPE and contact precautions |
| Assistant Director of Nursing | Assistant Director of Nursing | Discussed staff education and signage for contact precautions |
Inspection Report
Routine
Deficiencies: 7
Date: Dec 6, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident safety, care planning, pressure ulcer prevention and treatment, medication administration, and infection control.
Findings
The facility was found deficient in maintaining a safe environment, accurate resident assessments, comprehensive and updated care plans, appropriate pressure ulcer care, medication administration accuracy, and infection prevention and control practices, including proper use of personal protective equipment (PPE) for residents on contact precautions.
Deficiencies (7)
F 0584: The facility failed to provide a safe, clean, and homelike environment for 1 of 26 sampled residents due to an unstable commode that was improperly installed and posed a safety hazard.
F 0641: The facility failed to ensure the admission Minimum Data Set (MDS) Assessment accurately reflected the resident's current status for 1 of 4 residents sampled, with inaccurate coding of pressure ulcers present on admission.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 1 of 26 sampled residents, missing care plans for current pressure ulcers.
F 0657: The facility failed to review and revise the comprehensive person-centered care plan after assessments for 1 of 26 sampled residents, resulting in missing interventions such as fall mats on both sides of the bed.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for 1 of 4 residents sampled, with wounds developing after admission and inconsistent wound care practices.
F 0759: The facility failed to ensure a medication error rate less than 5 percent, with missed doses of hydrocodone-acetaminophen and saccharomyces boulardiii due to unavailable medication and delayed recognition.
F 0880: The facility failed to maintain an effective infection prevention and control program, with multiple staff failing to don required PPE for residents on contact precautions, risking transmission of infections.
Report Facts
Residents sampled: 26
Residents sampled for MDS assessments: 4
Residents sampled for pressure ulcers: 4
Residents sampled for medication observation: 8
Missed medication doses: 2
Pressure ulcer measurements: 9.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | LPN | Named in medication error finding for Resident R50 and admission assessment for Resident R91 |
| Director of Nursing | DON | Interviewed regarding care plan expectations, pressure ulcer care, medication administration, and infection control |
| Administrator | Interviewed regarding facility expectations for safety, care plans, medication administration, and infection control | |
| Certified Nursing Assistant 4 | CNA | Interviewed regarding familiarity with Resident R91 and care plan adherence |
| Certified Nursing Assistant 12 | CNA | Interviewed regarding care for Resident R91 and wound care observation |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan implementation and infection control education |
| Certified Nursing Assistant 8 | CNA | Observed entering Resident R91's room without PPE |
| Certified Occupational Therapy Assistant 2 | COTA | Observed pushing Resident R95 in wheelchair without PPE despite contact precautions |
| Housekeeper 1 | HK | Observed removing trash from contact isolation room without PPE or gloves |
| Staff Development Coordinator/Infection Prevention Nurse | SDC/IP Nurse | Interviewed regarding staff education on PPE and contact precautions |
Inspection Report
Abbreviated Survey
Census: 89
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
An abbreviated survey was conducted to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found to be in substantial compliance with no deficiencies issued.
Report Facts
Survey Census: 89
Sample Size: 1
Supplemental Residents: 0
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 0
Date: Jul 25, 2025
Visit Reason
An abbreviated survey was conducted to assess the facility's compliance with 42 CFR 483 subpart B.
Findings
The facility was found to be in substantial compliance with no regulatory deficiencies identified during the survey.
Report Facts
Sample Size: 8
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, treatment, and safety at Stonecreek Health and Rehabilitation.
Findings
The facility failed to develop comprehensive, person-centered care plans with measurable objectives and timeframes for residents, and failed to follow care plans for safe resident transfers. Additionally, the facility did not enter wound treatment orders timely or provide wound care as ordered for two residents, resulting in minimal harm or potential for harm.
Deficiencies (3)
F 0656: The facility failed to develop and implement complete care plans with measurable timeframes and actions for three residents, including safe smoking practices and use of lock boxes for cigarettes.
F 0656: The facility failed to ensure staff followed care plans requiring two-person assistance and mechanical lift for transfers, resulting in one staff member transferring a resident alone.
F 0684: The facility failed to enter wound treatment orders timely and did not provide wound vac treatment as ordered for two residents with stage 4 pressure ulcers.
Report Facts
Residents sampled: 25
Residents affected: 3
Residents affected: 2
BIMS scores: 15
BIMS score: 14
BIMS score: 5
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 17 | Certified Nursing Assistant | Observed transferring resident R14 alone despite care plan requiring two staff |
| Activities Director | Activities Director | Responsible for developing residents' smoking care plans and managing lock boxes |
| MDS Coordinator | MDS Coordinator | Responsible for ensuring smoking care plans included lock box use |
| LPN 5 | Licensed Practical Nurse | Unaware of wound treatment orders for resident R237 and did not document dressing changes |
| LPN 6 | Licensed Practical Nurse | Admitting nurse for resident R237 who did not see wound care orders and did not apply wound vac |
| LPN 9 | Licensed Practical Nurse | Provided wound care for resident R237 and charted treatments |
| Medical Doctor 19 | Physician | Physician for resident R237 who gave wound care orders and expected nursing staff to follow them |
| Regional Resource Nurse | Regional Resource Nurse | Validated wound care timeline and provided education on order entry |
| Former Unit Manager/LPN 4 | Licensed Practical Nurse | Provided wound care treatments for resident R99 and was very involved in care |
| Director of Nursing | Director of Nursing | Expected timely entry of orders and adherence to care plans |
| Administrator | Administrator | Expected nursing staff to follow policies and care plans |
Inspection Report
Routine
Deficiencies: 8
Date: Aug 1, 2024
Visit Reason
Routine state survey inspection conducted to assess compliance with regulatory requirements related to resident rights, care planning, wound care, safety, medication storage, food safety, and infection control.
Findings
The facility failed to ensure residents could view survey results, develop comprehensive care plans with measurable outcomes, follow wound care orders timely, provide adequate supervision for smoking safety, ensure safe transfers, properly store medications and food, maintain sanitary conditions in the kitchen, and follow infection control protocols during wound care.
Deficiencies (8)
F 0577: Facility failed to ensure residents could easily view the nursing home's survey results and communicate with advocate agencies. Survey results were not readily accessible and no signage was posted to inform residents and visitors of their location.
F 0656: Facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents, including plans for smoking safety and transfer assistance.
F 0684: Facility failed to enter wound treatment orders timely and provide wound care as ordered for two residents, resulting in delayed wound vac application and incomplete documentation.
F 0689: Facility failed to ensure adequate supervision and accident prevention related to smoking in prohibited areas and improper use of smoking paraphernalia for three residents. Also failed to ensure safe transfers using mechanical lift with two staff for one resident.
F 0761: Facility failed to ensure drugs and biologicals were stored according to manufacturer specifications and professional nursing principles. Medication room contained undated multidose vial and expired wound care products.
F 0812: Facility failed to thaw, store, label, and date food in accordance with professional standards. Observed meat thawing improperly and expired/outdated food items in walk-in cooler.
F 0814: Facility failed to ensure garbage was stored appropriately and covered, away from food preparation areas in the kitchen.
F 0880: Facility failed to maintain safe and sanitary infection control precautions during wound care for one resident. Staff reused non-sterile dressings with contaminated gloves.
Report Facts
Residents sampled: 25
Wound care products expired: 62
BIMS scores: 15
BIMS score: 14
BIMS score: 5
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 17 | Certified Nursing Assistant | Named in finding for unsafe transfer of resident R14 using mechanical lift alone |
| LPN 5 | Licensed Practical Nurse | Named in wound care finding for resident R237, unaware of wound treatment orders |
| LPN 6 | Licensed Practical Nurse | Performed wound care with infection control breach and named in wound care finding |
| LPN 9 | Licensed Practical Nurse | Named in wound care finding for resident R237, involved in wound care documentation |
| Medical Doctor 19 | Physician | Named in wound care finding for resident R237, provided wound care orders |
| Activities Director | Named in smoking safety finding, responsible for discussing survey results and smoking care plans | |
| Director of Nursing | DON | Named in multiple findings including smoking safety, wound care, and care plan compliance |
| Administrator | Named in multiple findings including survey results posting, smoking safety, wound care, and policy enforcement | |
| Staff Development Coordinator 2 | SDC | Named in infection control finding, responsible for staff education and competency |
| Dietary Manager | Named in food safety and garbage storage findings | |
| Regional Director of Operations | Named in food safety and garbage storage findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 22, 2023
Visit Reason
The inspection was conducted following a complaint regarding failure to properly document medication administration for Resident #6, specifically the discrepancy between narcotic control records and the Medication Administration Record (MAR).
Complaint Details
The complaint was substantiated. Resident #6's spouse reported that the MAR was blank despite the resident receiving pain medication. The facility investigation confirmed licensed staff were not signing the MAR after administering medications, only the narcotic control logs.
Findings
The facility failed to maintain accurate clinical records for Resident #6 by not documenting seventeen doses of Norco on the MAR, although these doses were signed out on the narcotic control record. Licensed staff were only signing the narcotic book and not the MAR, which was confirmed through interviews and record reviews.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards by not documenting seventeen doses of Norco on the Medication Administration Record for Resident #6.
Report Facts
Doses of Norco not documented on MAR: 15
Total doses of Norco signed out: 17
Duration of MAR audits: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding MAR and narcotic control logs discrepancy on 11/22/2023. |
| Director of Nursing | Director of Nursing | Interviewed about the investigation and corrective actions on 11/21/2023. |
| Administrator | Administrator | Interviewed about the investigation and corrective actions on 11/22/2023. |
| Medical Director | Medical Director | Participated in Ad HOC QAPI meeting and telephone discussions regarding the issue. |
| Unit Manager | Conducted MAR audits starting 11/09/2023. | |
| Kentucky Medication Aide #1 | Kentucky Medication Aide | Interviewed about recent education on signing out PRN medication. |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed about recent education on signing out PRN medication. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about recent education on signing out PRN medication. |
| Kentucky Medication Aide #2 | Kentucky Medication Aide | Interviewed about recent education on signing out PRN medication. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to timely report and investigate an injury of unknown origin involving Resident #3, specifically a right distal femur fracture, and to assess compliance with care plan revisions and medical record documentation.
Complaint Details
The complaint investigation focused on the facility's failure to timely report and investigate an injury of unknown origin involving Resident #3's right distal femur fracture. The investigation found the facility did not report the injury within two hours as required, did not conduct a thorough investigation, and failed to notify the attending physician and hospice in a timely manner.
Findings
The facility failed to report and investigate Resident #3's injury of unknown origin within the required timeframe. The care plans for Residents #2 and #3 were not revised following significant changes in condition. Additionally, medical records for Resident #3 were not accurately documented, including failure to notify the attending physician and hospice of the fracture in a timely manner.
Deficiencies (4)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for Resident #3's injury of unknown origin, a right distal femur fracture.
F 0610: The facility failed to conduct a thorough investigation concerning Resident #3's injury of unknown origin, the right distal femur fracture, and did not report it as required.
F 0657: The facility failed to review and revise comprehensive person-centered care plans for Residents #2 and #3 after significant changes in condition, including Resident #3's right distal femur fracture and Resident #2's refusal and noncompliance with care.
F 0842: The facility failed to ensure medical records for Resident #3 were accurately documented, including failure to notify the attending physician and hospice of the right distal femur fracture in a timely manner.
Report Facts
Residents sampled: 5
Residents reviewed for care plans: 14
BIMS score: 1
BIMS score: 2
Staff tenure: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented Resident #3's pain and bruising, notified Nurse Practitioner of injury |
| Hospice Nurse/RN #4 | Registered Nurse | Assessed Resident #3, ordered X-ray, notified Hospice Supervisor, involved in care |
| Nurse Practitioner (NP) | Facility Nurse Practitioner | Assessed Resident #3, ordered X-ray, did not notify Physician of injury |
| Former Director of Nursing | Director of Nursing | Spoke with Resident #3's POA, did not report injury as injury of unknown origin |
| Administrator | Licensed Nursing Home Administrator | Stated expectation for timely investigation and reporting of injuries of unknown origin |
| Physician | Attending Physician | Notified of Resident #3's femur fracture, described fracture as pathological |
| Unit Manager | Unit Manager | Reported Resident #3's fracture and care plan update expectations |
| MDS Coordinator #1 | MDS Coordinator | Reviewed care plans, stated expectations for updates after status changes |
| MDS Nurse #2 | MDS Nurse | Stated care plans should be updated by nurses on the floor |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Reported Resident #3's fracture in interview |
Inspection Report
Routine
Deficiencies: 11
Date: Sep 2, 2021
Visit Reason
Routine inspection survey of Stonecreek Health and Rehabilitation to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide privacy covers for urinary catheter bags, incomplete advance directive information, inaccurate resident assessments, incomplete care plans, inadequate behavior monitoring for psychotropic medication use, failure to provide dental services, food safety violations, and lapses in infection prevention and control practices.
Deficiencies (11)
F 0550: Facility failed to provide privacy covers for urinary catheter drainage bags for two residents, compromising dignity.
F 0578: Facility failed to ensure two residents were provided information about advance directives and assistance to formulate them.
F 0641: Facility failed to accurately assess one resident's dental status, missing broken and missing teeth.
F 0645: Facility failed to include mental health diagnoses on PASRR Level I and failed to complete required PASRR Level II screening for one resident.
F 0656: Facility failed to develop and implement a comprehensive care plan for urinary catheter use for one resident.
F 0657: Facility failed to update a resident's care plan with new interventions after falls.
F 0684: Facility failed to ensure nursing completed neurological checks properly after falls for one resident, including obtaining new vital signs with each check.
F 0758: Facility failed to monitor behaviors and provide non-pharmacological interventions for residents on psychotropic medications.
F 0791: Facility failed to provide dental services for one resident with missing and broken teeth.
F 0812: Facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including expired food, cross contamination risks, poor hygiene, and unclean kitchen conditions.
F 0880: Facility failed to implement infection prevention and control program adequately, including failure to follow transmission-based precautions, improper PPE use, and lapses in hand hygiene during medication administration.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 77
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Named in catheter privacy cover and finger stick blood sugar deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including catheter privacy, advance directives, care plans, infection control |
| Certified Dietary Manager | Certified Dietary Manager | Named in food safety deficiencies |
| LPN #88 | Licensed Practical Nurse | Named in neurological checks and infection control deficiencies |
| Speech Therapist #99 | Speech Therapist | Interviewed regarding dental care deficiency |
| Occupational Therapist #93 | Occupational Therapist | Named in infection control deficiency |
| CNA #50 | Certified Nursing Assistant | Named in food handling deficiency |
| CNA #62 | Certified Nursing Assistant | Named in food handling deficiency |
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