Inspection Reports for The Pavilion at Kenton
401 EAST 20TH STREET, COVINGTON, KY, 41014
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 28, 2025, found the facility to be in substantial compliance with no deficiencies cited. Earlier inspections were not provided for review, so broader patterns or trends cannot be assessed. No complaint investigations were substantiated during the latest survey, and no enforcement actions such as fines or license suspensions were listed in the available reports. The facility met regulatory requirements at this time, with no noted issues in resident care, safety, or other areas. This suggests the facility was maintaining compliance as of the most recent inspection.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Feb 28, 2025
Visit Reason
A Re-certification and Complaint survey was conducted from 02/25/2025 to 02/28/2025 at The Pavilion at Kenton.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 Subpart B. No deficiencies were issued related to the cited Kentucky facility numbers.
Complaint Details
The survey was a Re-certification and Complaint survey. No deficiencies were issued related to the complaint investigation.
Report Facts
Survey Census: 79
Sample Size: 18
Supplemental Residents: 42
Inspection Report
Routine
Deficiencies: 3
Feb 28, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage, food safety, infection prevention and control, and related regulatory requirements at The Pavilion at Kenton nursing home.
Findings
The facility failed to ensure proper storage of medications, with multiple expired medications found in medication carts. Food safety violations included improper refrigeration and poor hygiene practices during meal service. Infection prevention and control deficiencies were noted, including failure to maintain appropriate transmission-based precautions, improper use of personal protective equipment (PPE), and inadequate hand hygiene by staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure appropriate storage of residents' oral and topical medications, with multiple medications in use exceeding labeled expiration dates in 5 of 6 medication and treatment carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store food safely, including lunch tray carts containing pre-plated foods and drinks not under refrigeration and dietary staff not changing gloves or washing hands during meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including lack of proper signage for transmission-based precautions, failure of staff to don PPE as required, and failure to perform hand hygiene during resident care and meal service. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Expired medications observed: 25
Residents affected: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Interviewed regarding medication cart audits and expectations for discarding expired medications. |
| RN3 | Registered Nurse | Interviewed about medication cart audits and infection control practices. |
| Pharmacist 1 | Pharmacist | Interviewed about monthly medication reviews and expectations for facility staff audits. |
| DON | Director of Nursing | Interviewed about expectations for medication cart audits, infection control, and transmission-based precautions. |
| Administrator | Administrator | Interviewed about medication storage, infection control, and staff expectations. |
| STNA1 | State Trained Nurse Aide | Observed and interviewed regarding glove use and hand hygiene during meal tray distribution. |
| STNA2 | State Trained Nurse Aide | Observed giving lunch trays without hand hygiene and assisting resident in contact isolation without PPE. |
| STNA3 | State Trained Nurse Aide | Observed passing lunch trays and feeding resident on enhanced barrier precautions without hand hygiene or PPE. |
| EVS Supervisor | Environmental Services Supervisor | Observed entering resident room on Contact Precautions without donning PPE and interviewed about PPE use. |
| ADON | Assistant Director of Nursing | Interviewed about removal of Contact Precautions signage and responsibilities for transmission-based precautions. |
| RN1 | Registered Nurse | Observed providing care to resident on enhanced barrier precautions without wearing gown. |
| RN2 | Registered Nurse | Interviewed about knowledge of transmission-based precautions and signage. |
| STNA9 | State Trained Nurse Aide | Interviewed about removal of Contact Precautions signage and knowledge of precautions. |
| Physician Assistant-Certified | PA-C | Interviewed about catheter care and infection prevention expectations. |
| Central Supply Manager | Central Supply Manager | Interviewed about expectations for PPE use in rooms with Contact Precautions. |
Inspection Report
Routine
Deficiencies: 3
Jul 15, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical services, medication reconciliation, medical record documentation, and infection prevention and control practices.
Findings
The facility failed to ensure accurate medication reconciliation and administration for Resident #273, including failure to transcribe and administer four prescribed medications. The facility also failed to maintain complete and accurate medical records, including oxygen therapy orders and SpO2 monitoring documentation. Additionally, the facility did not consistently enforce infection prevention and control policies, with multiple staff observed not wearing masks properly and dietary staff failing to perform hand hygiene and proper food handling.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide pharmaceutical services to meet the needs of each resident, including accurate medication reconciliation and administration for Resident #273. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain complete and accurately documented resident records, including oxygen therapy orders and SpO2 monitoring for Resident #273. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including improper use of PPE and hand hygiene by staff. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medications not transcribed: 4
SpO2 monitoring missing documentation: 12
Resident admission date: Jun 2, 2021
Resident discharge date: Jun 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Started admission for Resident #273 but did not complete medication reconciliation or admission checklist |
| RN #4 | Registered Nurse | Completed admission for Resident #273 but did not verify medication orders as required |
| LPN #3 | Licensed Practical Nurse | Assisted with medication reconciliation and described facility protocol for admission and medication order verification |
| Consultant Pharmacist | Reported no process to ensure medication orders were reconciled correctly by admitting nurse | |
| Nurse Practitioner | Relied on nursing staff to notify providers of resident changes and expected accurate medication reconciliation | |
| Physician | Relied on nursing staff to send correct medications and expected accurate documentation | |
| Director of Nursing | DON | Reported policy and expectations for admission completion and medication reconciliation |
| Administrator | Expected staff to follow established procedures and complete admission checklist | |
| LPN #1 | Licensed Practical Nurse | Observed wearing mask below nose, acknowledged importance of mask wearing and infection control training |
| LPN #2 | Licensed Practical Nurse | Observed wearing mask below nose, acknowledged infection control training and importance of mask wearing |
| Kentucky Medication Aide #1 | Observed wearing mask below nose, reported infection control training and monitoring | |
| Dietary Aide #2 | Observed not wearing gloves and failing hand hygiene while serving meals | |
| Dietary Aide #3 | Observed not wearing mask and failing hand hygiene | |
| Housekeeping Aide #1 | Observed wearing mask below nose while cleaning near residents | |
| SRNA #5 | State Registered Nurse Aide | Observed wearing mask below chin while talking to resident |
| SRNA #2 | State Registered Nurse Aide | Reported infection control training and monitoring, noted some staff noncompliance |
| LPN #4 | Licensed Practical Nurse | Observed sitting at nurses' station without mask |
Inspection Report
Routine
Deficiencies: 2
Nov 21, 2019
Visit Reason
The inspection was conducted to assess compliance with resident rights and hydration needs, focusing on dignity during meal assistance and ensuring residents receive adequate hydration consistent with their needs and preferences.
Findings
The facility failed to treat residents with respect and dignity during meal assistance, as staff were observed standing rather than sitting while assisting residents, which compromised resident dignity. Additionally, the facility failed to ensure adequate hydration for nine of thirteen sampled residents, with multiple gaps in hydration pass documentation and resident complaints about inconsistent passing of ice and fluids.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to treat each resident with respect and dignity during meal assistance; staff were standing instead of sitting while assisting residents with eating. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure each resident receives hydration consistent with resident needs and preferences; multiple gaps in hydration pass documentation and resident complaints about inconsistent passing of ice and fluids. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 6
Residents affected: 9
BIMS scores: 3
BIMS scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Interviewed about meal assistance and resident rights, acknowledged standing while assisting residents and stated she should have sat down. |
| State Registered Nurse Aide #4 | State Registered Nurse Aide (SRNA) | Interviewed about meal assistance, acknowledged standing while assisting residents and stated she should have sat down. |
| Unit Manager/Registered Nurse #1 | Registered Nurse (RN) | Interviewed about meal assistance, acknowledged standing while assisting residents and stated she should have sat down. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about expectations for staff to maintain resident dignity and hydration practices. |
| Administrator | Administrator | Interviewed about staff responsibilities for resident rights during meals and hydration pass. |
| Kentucky Medication Aide #1 | Kentucky Medication Aide (KMA) | Interviewed about hydration pass, acknowledged some residents complained about inconsistent passing of ice and fluids. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed about hydration pass, stated ice and fluids were passed every shift and documented. |
| State Registered Nurse Aide #3 | State Registered Nurse Aide (SRNA) | Interviewed about hydration pass, stated SRNAs were supposed to pass ice and water routinely and upon request. |
| State Registered Nurse Aide #5 | State Registered Nurse Aide (SRNA) | Interviewed about hydration pass, stated SRNAs tried to pass ice during day shift but sometimes lacked time. |
| Nurse Aide Manager | Nurse Aide Manager | Interviewed about hydration pass documentation and staff responsibilities. |
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