Inspection Reports for
The Willows at Hamburg
2531 OLD ROSEBUD ROAD, LEXINGTON, KY, 40509
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 2
Date: Aug 8, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage, labeling, and food safety standards in the facility.
Findings
The facility failed to properly store and label medications according to regulatory guidelines, with several expired and undated medications observed. Additionally, food safety practices were deficient as cleaning cloths were not kept in sanitizer buckets during food preparation, risking cross-contamination.
Deficiencies (2)
F 0761: The facility failed to store medications according to regulatory guidelines, with undated opened medications and expired medical supplies found in medication carts and rooms. Nursing staff were responsible for checking expiration dates and proper storage but failed to do so.
F 0812: The facility failed to ensure food was served and stored properly in sanitary conditions, as cleaning cloths were not kept in sanitizer buckets during food production, risking cross-contamination.
Report Facts
Sampled residents with medication storage issues: 3
Sampled residents: 22
Expired medical supplies: 6
Date of last pharmacy visit: Jul 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 7 | Interviewed regarding responsibility for checking expiration dates and medication storage. | |
| Licensed Practical Nurse (LPN) 1 | Interviewed about facility policy on dating opened medications and risks of expired medications. | |
| Contracted Pharmacy Account Manager | Interviewed about quarterly visits and responsibilities regarding medication and medical supplies. | |
| Director of Health Services | Interviewed about expectations for medication labeling and cleaning cloth sanitization. | |
| Dietary Manager | Interviewed about proper cleaning cloth sanitization during food preparation. | |
| Executive Director | Interviewed about staff expectations for following facility guidelines and checklists. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of physical and verbal abuse of Resident 7 by Certified Registered Medication Aide (CRMA) 7 on 06/07/2024.
Complaint Details
The complaint investigation involved allegations of physical and verbal abuse by CRMA7 against Resident 7 on 06/07/2024. The abuse was reported late (approximately 30 minutes after the incident), and the alleged perpetrator was not immediately removed from the facility. The investigation was inconclusive regarding intent and injury, but CRMA7 was terminated for not following company standards.
Findings
The facility failed to protect Resident 7 from physical and verbal abuse by staff, resulting in Immediate Jeopardy and Substandard Quality of Care findings. The investigation revealed inconsistent witness statements, no visible injuries, and the termination of CRMA7. The facility also failed to immediately secure the resident's safety and did not have an abuse policy that adequately addressed communication with the QAPI program.
Deficiencies (2)
F600: The facility failed to protect Resident 7 from physical and verbal abuse by CRMA7, who was observed smacking the resident's face and restraining her. Witnesses heard the resident's head hit the wall, but no visible marks were documented.
F607: The facility failed to immediately secure the safety of Resident 7 after abuse allegations and did not have an abuse policy that included guidance on communication and coordination with the QAPI program.
Report Facts
Residents affected: 1
Incident time: 550
Time until staff notified: 30
CRMA7 clock-out time: 639
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CRMA7 | Certified Registered Medication Aide | Named in physical and verbal abuse findings and terminated following investigation. |
| CRCA6 | Certified Resident Care Aide | Witness to the abuse incident and reported to Director of Health Services. |
| CRCA10 | Certified Resident Care Aide | Witness to the abuse incident. |
| LPN2 | Licensed Practical Nurse | Witness to the incident and performed skin assessment on Resident 7. |
| Director of Health Services | Director of Health Services | Received abuse report and involved in investigation. |
| Executive Director | Executive Director | Involved in decision to terminate CRMA7. |
| Corporate Clinical Support Nurse | Corporate Clinical Support Nurse | Interviewed regarding abuse policy and facility response. |
Inspection Report
Routine
Deficiencies: 2
Date: May 6, 2022
Visit Reason
The inspection was conducted to assess compliance with food safety, infection prevention and control, and medication administration standards in the facility.
Findings
The facility failed to maintain proper sanitation in food preparation areas, including inadequate cleaning of equipment and improper sanitizing solution levels. Infection control deficiencies were observed in medication handling, glucometer cleaning, and laundry operations, including improper PPE use and failure to maintain separation between clean and dirty laundry areas.
Deficiencies (2)
F 0812: The facility failed to store, prepare, and distribute food in a safe and sanitary manner, including gummy residue on the can opener base and preparation tables, and sanitizing solution not meeting required PPM levels.
F 0880: The facility failed to implement an infection prevention and control program, including improper medication handling by staff, inadequate glucometer cleaning, and failure to maintain PPE use and separation of clean and dirty laundry areas.
Report Facts
Sanitizing solution PPM: 200
Sanitizing solution PPM: 50
Kitchen Sanitation Audit score: 86.17
Kitchen Sanitation Audit score: 85.06
Medication administration frequency: 4
Insulin administration frequency: 3
Years worked: 7
Years worked: 4
Years worked: 5
Years worked: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KMA #1 | Kentucky Medication Aide | Named in findings related to improper medication handling and glucometer cleaning. |
| RN #1 | Registered Nurse | Provided expert opinion on medication handling and glucometer cleaning deficiencies. |
| Garment Service Technician #1 | Named in findings related to improper PPE use and laundry infection control. | |
| Director of Food Services | Referenced in food sanitation deficiencies and cleaning policy failures. | |
| Executive Director | Interviewed regarding facility expectations for infection control and sanitation. | |
| Assistant Director of Health Services/Infection Preventionist | Provided infection control expectations and audit information. | |
| Director of Environmental Services | Interviewed regarding laundry infection control and PPE use. | |
| Senior Director of Plant Operations | Interviewed regarding laundry door closure and infection control. |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 1
Date: Aug 22, 2019
Visit Reason
The inspection was conducted as part of a regulatory survey to assess compliance with food preparation and serving standards in the facility's Legacy Dining Room.
Findings
The facility failed to prepare and serve food under sanitary conditions, with staff holding large serving bowls against their bodies, potentially causing cross contamination. The facility lacked a policy addressing infection control during food service.
Deficiencies (1)
F 0812: The facility failed to prepare and serve food under sanitary conditions, with staff holding large serving bowls against their bodies, risking cross contamination. The facility's policy did not address infection control during food service.
Report Facts
Residents affected: 32
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