Deficiencies (last 2 years)
Deficiencies (over 2 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 3, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements related to resident care, medication administration, food safety, and infection control at The Willows at Springhurst nursing home.
Findings
The facility was found deficient in coordinating pre-admission screening and resident review (PASRR) referrals for residents with new qualifying diagnoses, ensuring timely and proper medication administration including insulin timing and infection control practices, maintaining sanitary food preparation conditions, and adhering to infection prevention protocols during injectable medication administration.
Deficiencies (5)
F 0644: The facility failed to refer a resident with newly evident serious mental disorders for Level II PASRR evaluation and lacked a specific PASRR policy.
F 0760: The facility failed to ensure insulin was administered at the correct times based on blood glucose readings, risking improper medication timing for a diabetic resident.
F 0760: The facility failed to follow infection prevention procedures by administering insulin without gloves and not sanitizing hands, increasing infection risk.
F 0812: The facility failed to ensure food service employees wore hair restraints properly, exposing food to contamination for 51 of 52 residents.
F 0880: The facility failed to implement infection prevention and control practices during injectable medication administration, including hand hygiene and glove use.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 51
Residents affected: 52
Blood glucose readings: 255
Insulin dose: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Named in medication administration timing and infection control deficiencies |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding medication administration and infection control practices |
| Director of Health Services | Provided statements on expectations for PASRR referrals, medication administration, and infection control | |
| Executive Director | Provided statements on facility policy adherence and expectations | |
| Social Services Director | Discussed PASRR screening responsibilities and system access | |
| MDS Coordinator | Discussed PASRR referral submission and follow-up | |
| Director of Food Services | Interviewed regarding hair restraint policy and observations | |
| Infection Preventionist | Discussed infection prevention education and audits |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 3, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, staff performance evaluations, food safety, and facility maintenance.
Findings
The facility failed to ensure implementation of a resident's care plan regarding the use of a palm guard, failed to complete annual nurse aide performance evaluations, failed to store and label food items properly and maintain temperature logs, and failed to remove unused kitchen equipment from the delivery area.
Deficiencies (5)
F 0656: The facility failed to implement Resident #14's care plan intervention for use of a palm guard on the right hand, risking skin breakdown and injury.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, as Resident #14 was observed without the prescribed palm guard.
F 0730: The facility failed to complete annual performance evaluations for six nurse aides, lacking documented evidence of such evaluations.
F 0812: The facility failed to store, prepare, and distribute food safely, with undated opened food items, moldy strawberries, and incomplete refrigerator and freezer temperature logs.
F 0814: The facility failed to remove and dispose of unused kitchen equipment stored outside the delivery area, creating potential trip hazards and pest attraction.
Report Facts
Residents sampled: 19
Nurse aides personnel files reviewed: 6
Commercial coffee makers/dispensers observed: 6
Commercial beverage dispensers observed: 2
Empty milk crates observed: 3
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 5, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements, including the accuracy of the facility-wide assessment for resident care needs and the safety of kitchen equipment.
Findings
The facility failed to accurately determine the number of residents with respiratory diagnoses requiring specialized care, including tracheostomy and COVID-19 care. Additionally, the facility failed to ensure safe operating conditions of kitchen equipment, including improper storage in the walk-in freezer and liquid on the floor under the fryer, creating fire and fall hazards.
Deficiencies (2)
F 0838: The facility failed to conduct and document an accurate facility-wide assessment to determine resources necessary to competently care for residents with respiratory diagnoses, including tracheostomy and COVID-19 care.
F 0908: The facility failed to ensure safe operating conditions of the fryer and freezer in the kitchen, including boxes stored too close to the ceiling and liquid substance on the floor under the fryer, creating fire and fall hazards.
Report Facts
Residents with tracheostomy care: 3
Residents requiring closed unit and isolation for COVID-19 care: 10
Boxes in close proximity to ceiling in walk-in freezer: 4
Boxes in close proximity to ceiling in walk-in freezer: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Interviewed regarding facility assessment process and kitchen safety issues |
| Director of Nursing | Director of Nursing | Interviewed regarding facility assessment accuracy and resident care needs |
| Medical Director | Medical Director | Interviewed regarding resident care requirements for tracheostomy and COVID-19 |
| Director of Food Services | Director of Food Services | Interviewed regarding kitchen safety and cleaning practices |
| Chief Engineer | Chief Engineer | Interviewed regarding kitchen safety rounds and fire hazard concerns |
| Cook | Cook | Interviewed regarding fryer oil change and cleaning practices |
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