Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: 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.
Complaint Details
Complaint survey initiated and concluded with no deficiencies issued; facility found compliant.
Findings
The facility was found not to have any regulatory violations and no deficiencies were issued related to KY00046542.
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 5
Date: 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.
Deficiencies (5)
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.
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.
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.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 nourishment refrigerators.
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.
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 |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 4, 2025
Visit Reason
Routine inspection of The Willows at Fritz Farm nursing home to assess compliance with resident rights, environment, transfer/discharge procedures, food safety, and infection control.
Findings
The facility failed to consistently inform residents about advance directives, maintain a clean and odor-free environment, provide timely written transfer/discharge notices, properly label resident food, and fully implement infection prevention and control protocols including enhanced barrier precautions and medication administration hygiene.
Deficiencies (5)
F 0578: 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.
F 0584: The facility failed to provide a clean, sanitary, comfortable, and homelike environment for 1 of 4 hallways, the 100 Hall, due to persistent urine odor from catheter leaks and carpet contamination.
F 0623: The facility failed to notify residents and their representatives in writing of transfers or discharges and failed to send copies of notices to the State Long-Term Care Ombudsman for 2 residents.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety, including failure to label resident food items with resident names and dates.
F 0880: The facility failed to establish and maintain an infection prevention and control program, including failure to use gowns and gloves consistently for residents on Enhanced Barrier Precautions and improper medication administration hygiene.
Report Facts
Residents reviewed for advance directives: 6
Residents affected by advance directive deficiency: 3
Hallways inspected for environment: 4
Residents investigated for hospitalizations: 2
Unlabeled food items observed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Observed not following infection control procedures and medication administration hygiene |
| Director of Nursing | Director of Nursing | Provided statements on advance directives, environment, and infection control expectations |
| Executive Director | Executive Director | Provided statements on advance directives, environment, transfer/discharge notifications, and infection control |
| Admissions Coordinator | Admissions Coordinator | Described admission process for advance directives |
| Social Services Director | Social Services Director | Described ombudsman notification process for transfers |
| CRCA1 | Certified Registered Care Aide | Provided statements on infection control practices |
| CRMA3 | Certified Registered Medication Aide | Provided statements on infection control and medication administration |
| RN1 | Registered Nurse | Provided statements on infection control and EBP signage |
| IPN/DON | Infection Prevention Nurse / Director of Nursing | Provided statements on infection control education and expectations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2020
Visit Reason
The inspection was conducted to investigate complaints regarding the unsafe installation and use of transfer poles in resident rooms, which posed a risk of entrapment and falling hazards.
Complaint Details
The investigation was complaint-driven, focusing on the safety of transfer pole installations after reports of potential entrapment hazards. The complaint was substantiated with findings of improper pole placement and lack of staff awareness of safety recommendations.
Findings
The facility failed to ensure transfer poles were installed according to the manufacturer's recommendations, placing residents at risk of entrapment due to insufficient clearance around the poles. Several residents required assistance with transfers and were unable to safely ambulate around the poles. Staff and management were unaware of the manufacturer's safety guidelines.
Deficiencies (1)
F 0689: The facility failed to install transfer poles per the manufacturer's recommendations, resulting in poles being placed too close to beds or furniture, creating entrapment and fall hazards for residents.
Report Facts
Residents affected: 6
Distance measurements: 2.5
Distance measurements: 10
Distance measurements: 12
Distance measurements: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #11's use of transfer pole. |
| RN #2 | Registered Nurse | Interviewed regarding Resident #5's condition and transfer pole use. |
| SRNA #1 | State Registered Nurse Assistant | Interviewed about training and use of transfer poles. |
| SRNA #2 | State Registered Nurse Assistant | Interviewed about Resident #5's use of transfer pole. |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #25's use of transfer pole. |
| Occupational Therapist #1 | Occupational Therapist | Interviewed about transfer pole evaluations and Resident #44. |
| Physical Therapist #1 | Physical Therapist | Interviewed about transfer pole recommendation for Resident #25. |
| Director of Therapy program/Speech | Therapy Director | Interviewed about therapy assessments and transfer pole placement. |
| Maintenance Director | Maintenance Director | Interviewed about installation and monitoring of transfer poles. |
| Director of Nursing | Director of Nursing | Interviewed about expectations for transfer pole use and safety monitoring. |
| Facility Administrator | Administrator | Interviewed about facility policies and awareness of manufacturer warnings. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 7, 2019
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to treat a resident with dignity and respect during wound care and to assist the resident with bathroom needs as requested.
Complaint Details
The complaint investigation substantiated that Resident #28 was denied timely assistance to the bathroom during wound care, violating dignity and respect rights. Staff interviews acknowledged the failure and recognized it as a dignity violation.
Findings
The facility failed to treat Resident #28 with dignity and respect by denying timely assistance to the bathroom during wound care, despite the resident's repeated requests. Additionally, the facility failed to store and label food items properly, serving some outdated food products.
Deficiencies (2)
F 0550: The facility failed to treat Resident #28 with dignity and respect by not assisting the resident to the bathroom during wound care despite repeated requests, causing distress. Staff interviews confirmed the failure to assist was due to concerns about wound protection and oversight.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including unlabeled and undated open food packages and serving outdated food items.
Report Facts
Residents sampled: 14
BIMS score: 6
Food items with outdated use-by dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in dignity violation for not assisting Resident #28 to bathroom during wound care |
| ADON | Assistant Director of Nursing / Wound Care Nurse | Named in dignity violation for not assisting Resident #28 to bathroom during wound care |
| Director of Health Services | Interviewed regarding expectations for resident care and dignity | |
| Licensed Nursing Home Administrator | Interviewed regarding expectations for resident dignity and care | |
| Interim Director of Food Services | Interviewed regarding food storage policy adherence | |
| Dining Service Support #1 | Interviewed regarding food storage policy adherence | |
| Dining Service Support #2 | Interviewed regarding food storage policy adherence | |
| Administrator | Interviewed regarding food storage policy adherence |
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