Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 18, 2025
Visit Reason
A complaint survey was initiated on 06/18/2025 and concluded on 06/20/2025 to investigate allegations against the facility.
Findings
The facility was found not to have any regulatory violations and no deficiencies were issued related to KY00046542.
Complaint Details
Complaint survey initiated and concluded with no deficiencies issued; facility found compliant.
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 5
May 9, 2025
Visit Reason
An off-site Revisit Survey was conducted to determine if the facility had achieved substantial compliance following a prior abbreviated survey and plan of correction related to deficiencies.
Findings
The facility was found to be in substantial compliance as of 05/07/2025 based on the implementation of the acceptable Plan of Correction. The revisit survey concluded on 05/09/2025 with no new deficiencies issued.
Severity Breakdown
D: 3
E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| The facility failed to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and to formulate an advance directive for 3 of 6 residents reviewed. | D |
| The facility did not provide a clean, sanitary, comfortable, and homelike environment for 1 resident due to a leaking catheter bag causing odor and carpet issues. | E |
| The facility failed to notify residents and representatives of transfer or discharge in writing and in a language they understand, and failed to send a copy of the notice to the Office of State Long-Term Care Ombudsman for 2 residents. | D |
| The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 nourishment refrigerators. | E |
| The facility did not set up and incorporate an infection prevention and control program designed to ensure a safe, sanitary, and comfortable environment, and failed to prevent transmission of communicable diseases for 2 of 6 sampled residents. | D |
Report Facts
Survey Census: 45
Sample Size: 14
Supplemental Residents: 7
Deficiency Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Named in relation to providing re-education and training on policies and procedures for Advanced Directives, infection control, food safety, and transfer/discharge notifications | |
| Assistant Director of Health Services | Named in relation to providing re-education and training on policies and procedures for Advanced Directives, infection control, food safety, and transfer/discharge notifications | |
| Executive Director | Oversight of effective plans, training, and quality assurance meetings; involved in re-education and policy enforcement | |
| Director of Nursing | Interviewed regarding admissions and documentation processes; involved in staff education and quality assurance | |
| Social Services Director | Involved in notification processes and re-education regarding transfer/discharge policies | |
| Admissions Coordinator | Responsible for reviewing Advanced Directives with residents and responsible parties at admission | |
| Medical Director | Participated in quality assurance meetings regarding cited deficiencies |
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