Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide written notification to a resident's representative about hospital transfer and to assess compliance with infection prevention practices during meal service.
Complaint Details
The complaint investigation found that the facility verbally notified the resident's representative of the hospital transfer but did not provide written documentation of the transfer or bed hold policy. The facility acknowledged not mailing the Transfer/Discharge and Bed Hold Policy Notification to representatives and relied on phone calls and providing copies to residents. The complaint was substantiated with minimal harm.
Findings
The facility failed to provide written notification to the resident's representative about the resident's hospital transfer and bed hold policy. Additionally, staff failed to observe proper hand hygiene practices during meal service, potentially affecting 45 residents.
Deficiencies (2)
F 0628: The facility failed to provide the resident representative with written notification of the resident's transfer to the hospital and bed hold policy for 1 of 5 sampled residents.
F 0812: The facility failed to ensure staff observed required hand hygiene practices during plating and serving of food, potentially affecting 45 residents.
Report Facts
Residents affected: 1
Residents affected: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admission Coordinator | Observed failing to perform hand hygiene before serving food | |
| Dietary Aide 1 | Observed failing to change gloves and perform hand hygiene after contamination | |
| Dietary Manager | Provided statements on hand hygiene expectations | |
| Assistant Director of Health Services | Provided statements on hand hygiene expectations | |
| Director of Health Services | Provided statements on hand hygiene expectations and bed hold notification process | |
| Executive Director | Provided statements on hand hygiene expectations and bed hold notification process | |
| Business Office Manager | Provided statements regarding mailing of notifications | |
| Social Services Director | Provided statements regarding bed hold policy and notification to Ombudsman | |
| Admission Coordinator | Interviewed regarding bed hold policy and notification procedures |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 4, 2021
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care, including care planning, wound care, activities, medication administration, safety, and facility operations.
Findings
The facility failed to develop and implement person-centered comprehensive care plans for residents, ensure wound care was provided per physician orders, provide activities consistent with resident preferences, maintain adequate supervision to prevent elopement, ensure safe respiratory care, properly store and label medications, and maintain proper sanitation in the kitchen.
Deficiencies (7)
F0656: The facility failed to develop and implement person-centered comprehensive care plans with measurable objectives and timeframes for three residents, including failure to follow physician orders for wound dressing changes and provide preferred activities.
F0679: The facility failed to provide an ongoing program to support residents in their choice of activities, resulting in one resident not participating in preferred activities such as music and religious services.
F0684: The facility failed to provide treatment and care according to physician orders and resident preferences for one resident, including failure to change wound dressings as ordered.
F0689: The facility failed to ensure adequate supervision to prevent elopement for one resident, who was observed without a required wandering system bracelet/device despite physician orders.
F0695: The facility failed to provide safe and appropriate respiratory care for two residents, including unlabeled oxygen tubing, lack of oxygen use signage, crimped tubing, and empty humidifier bottles.
F0761: The facility failed to ensure drugs and biologicals were labeled, stored properly, and not expired, including medication refrigerators with improper temperatures, loose tablets without resident identification, and expired medications on medication carts.
F0812: The facility failed to ensure proper sanitation procedures in the kitchen, including two large steam table pans stored wet, creating potential for bacterial growth.
Report Facts
Temperature of medication refrigerator: 32
Temperature of medication refrigerator: 48
Number of loose tablets: 2
Discontinued medication date: Oct 20, 2021
Number of residents with deficient care plans: 3
Number of residents affected by activity deficiency: 1
Number of residents affected by elopement supervision deficiency: 1
Number of residents affected by wound care deficiency: 1
Number of residents affected by respiratory care deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in wound care deficiency for Resident #12 |
| LPN #2 | Licensed Practical Nurse | Named in elopement supervision deficiency for Resident #29 |
| LPN #4 | Licensed Practical Nurse | Named in medication storage deficiency |
| LPN #5 | Licensed Practical Nurse | Named in medication administration observation |
| Director of Health Services | Interviewed regarding care plan, wound care, elopement, medication storage, and respiratory care deficiencies | |
| Executive Director | Interviewed regarding facility expectations for care plans, activities, elopement prevention, medication storage, and kitchen sanitation | |
| Dietary Manager | Interviewed regarding kitchen sanitation deficiency | |
| Life Enrichment Director | Interviewed regarding activities deficiency for Resident #38 | |
| State Registered Nursing Assistant #2 | Interviewed regarding elopement supervision and activities deficiencies | |
| State Registered Nursing Assistant #3 | Interviewed regarding elopement supervision and activities deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 9, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at The Willows at Citation nursing home.
Findings
No health deficiencies were found during the inspection.
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