Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 3, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report and properly investigate allegations of abuse and neglect involving residents at Treyton Oak Towers.
Findings
The facility failed to timely report allegations of abuse to the Administrator and State Agencies for two residents and failed to thoroughly investigate alleged violations of abuse and theft for two residents. Documentation and staff interviews were incomplete or missing, and the facility did not notify authorities promptly as required.
Complaint Details
The complaint investigation involved allegations of abuse and neglect for residents R23, R201, and R42. The facility failed to report abuse allegations timely and did not conduct thorough investigations, including missing staff interviews and incomplete documentation. Unauthorized use of a resident's credit card was reported but not fully investigated or communicated to police.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse to the Administrator and State Agencies within required timeframes for 2 of 4 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to all alleged violations, including incomplete investigations and lack of documented staff interviews for 2 of 4 residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse prohibition: 4
Unauthorized credit card transactions: 3
Dates of incidents: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA12 | Certified Nursing Assistant | Named in abuse allegation for rough handling of resident R23. |
| CNA15 | Certified Nursing Assistant | Failed to report abuse allegation immediately after being informed. |
| CNA14 | Certified Nursing Assistant | Reported abuse allegation to Assistant Director of Nursing. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Expected immediate reporting of abuse allegations; noted failure to report by CNA15. |
| Director of Nursing | Director of Nursing (DON) | Stated expectation for immediate reporting and thorough investigations. |
| Licensed Practical Nurse 4 | Licensed Practical Nurse (LPN) | Notified DON within 30 minutes of injury of unknown source for resident R201. |
| Administrator | Facility Administrator | Expected immediate reporting of abuse and injuries; acknowledged incomplete investigations. |
| Responsible Party RP17 | Resident's Responsible Party | Reported unauthorized credit card use and dissatisfaction with investigation. |
| Social Service Director | Social Service Director (SSD) | Communicated with family and credit card company; unclear if staff interviews conducted. |
| Detective2 | Police Detective | Reported lack of communication from facility and family hindered investigation of theft. |
| Registered Nurse 3 | Registered Nurse (RN) | Heard about missing credit card but was not interviewed. |
| Registered Nurse 6 | Registered Nurse (RN) | Heard suspicions about staff member but was not interviewed. |
| Registered Nurse 7 | Registered Nurse (RN) | Heard about missing card but was not interviewed. |
| Hospice Registered Nurse 8 | Hospice Registered Nurse (RN) | Not contacted by facility regarding missing credit card. |
| Former Interim Director of Nursing | Interim Director of Nursing (DON) | Not aware of theft incidents or investigations during tenure. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 26, 2024
Visit Reason
The investigation was initiated due to a complaint regarding neglect of Resident #1 following a fall on 01/26/2024, where the facility allegedly failed to perform ordered neurological checks and apply a cold pack as prescribed.
Findings
The facility failed to protect Resident #1 from neglect after a fall, as Licensed Practical Nurse (LPN) #1 did not perform the required neuro checks or apply a cold pack as ordered, despite documentation stating otherwise. Video evidence confirmed the neglect, leading to serious injury including a bilateral subarachnoid hemorrhage and orbital fracture. The facility removed Immediate Jeopardy status on 02/24/2024 but remained non-compliant at a lower severity level.
Complaint Details
The complaint investigation substantiated neglect by LPN #1 who failed to perform neuro checks and apply cold compress as ordered after Resident #1's fall on 01/26/2024. Video footage confirmed the neglect. LPN #1 was terminated and a complaint was filed with the Kentucky Board of Nursing. The facility was notified of Immediate Jeopardy on 02/22/2024 and removed it on 02/24/2024.
Severity Breakdown
Immediate Jeopardy (IJ) at Scope and Severity J: 1
Substandard Quality of Care (SQC) at Scope and Severity D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to perform ordered neurological checks and apply cold pack following Resident #1's fall. | Immediate Jeopardy (IJ) at Scope and Severity J |
| Failure to protect residents from neglect and abuse as per 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600). | Substandard Quality of Care (SQC) at Scope and Severity D |
Report Facts
Number of neuro checks required: 13
Blood pressure reading: 192
Blood pressure reading: 102
BIMS score Resident #1: 7
BIMS score Resident #7: 13
Dates: Feb 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to perform neuro checks and apply cold pack as ordered after Resident #1's fall; terminated for unsatisfactory performance. |
| RN #2 | Registered Nurse | Assessed Resident #1 on 01/27/2024 and documented neurological decline and elevated blood pressure; notified physician and arranged hospital transfer. |
| Director of Nursing | Director of Nursing (DON) | Conducted investigation, interviewed staff, and terminated LPN #1 for neglect and failure to follow facility policy. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Participated in investigation, reviewed video footage, and confirmed LPN #1's failure to perform neuro checks. |
| LPN #3 | Licensed Practical Nurse | Provided report of Resident #1's fall to LPN #1 on 01/26/2024. |
| CNA #6 | Certified Nursing Assistant | Observed Resident #1's condition post-fall and notified LPN #1 of changes; did not recall ice pack being applied. |
| APRN | Advanced Practice Registered Nurse | Provided expert opinion on importance of neuro checks and stated neglect occurred due to failure to provide necessary care. |
Inspection Report
Routine
Deficiencies: 16
Jun 24, 2021
Visit Reason
Routine inspection of Treyton Oak Towers nursing home to assess compliance with regulatory requirements including resident rights, abuse reporting, care planning, infection control, and staff competencies.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and rights, failure to timely report and investigate abuse, failure to develop and implement baseline and comprehensive care plans, failure to revise care plans timely after falls, failure to provide adequate ADL care, failure to ensure safe environment and supervision, failure to provide staff with appropriate competencies and training, failure to maintain infection control practices, and failure to designate a hospice coordinator.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 3
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to honor resident's right to a dignified existence; staff toileted resident without closing doors compromising privacy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse and conduct thorough investigation; CNA caused skin tear and failed to report. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to create and implement baseline care plan within 48 hours for resident requiring hand feeding and wheelchair bound. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans meeting all resident needs; improper transfers and lack of adherence to care plans resulted in falls and injuries. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plan timely with effective interventions to prevent recurring falls; resident fell and fractured clavicle after delayed care plan revision. | Level of Harm - Actual harm |
| Failed to provide adequate ADL care for residents with dementia and cognitive impairments; delayed response to call lights and unmet toileting needs observed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe environment and adequate supervision; multiple falls and injuries occurred due to lack of adherence to care plans and unsafe practices. | Level of Harm - Actual harm |
| Failed to ensure nursing staff had appropriate competencies and skill sets upon hire and annually; lack of documented orientation and competency assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct and document facility-wide assessment to determine resources necessary to care for residents competently; no part-time staff educator hired as planned. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and services to resident with dementia; resident exhibited agitation and restlessness with inadequate staff education and medication management. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure food from approved sources and serve food in sanitary manner; dietary staff cross contaminated food with improper hand hygiene and sanitization logs were incomplete. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer the facility in a manner that enables effective and efficient use of resources; inadequate training, orientation, and competency documentation for new and existing staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct and document facility-wide assessment to determine resources necessary to care for residents competently; no part-time staff educator hired and annual training not documented. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to arrange for provision of hospice services or designate hospice coordinator; hospice care plan not integrated and no hospice coordinator appointed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection prevention and control program; staff failed to perform hand hygiene during medication administration and infection control practices were inadequate. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a safe, easy to use, clean and comfortable environment; residents' multiple-use shower room was unsanitary with soiled equipment and supplies. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 36
New hires: 9
Falls: 5
Days delay: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #11 | Certified Nursing Assistant | Named in dignity and ADL care deficiencies, failure to follow care plan, and cross contamination |
| CNA #13 | Certified Nursing Assistant | Named in abuse and injury incident, failure to report, and improper transfer causing resident injury |
| LPN #2 | Licensed Practical Nurse | Named in abuse incident investigation and skin assessment |
| RN #1 | Registered Nurse | Named in medication administration and fall event reporting |
| DON | Director of Nursing | Named in multiple interviews regarding care plan, staff training, abuse investigation, and facility administration |
| ADON | Assistant Director of Nursing | Named in interviews regarding staff training, abuse counseling, and care plan oversight |
| Administrator | Facility Administrator | Named in interviews regarding facility administration, staff training, and hospice coordination |
| DSD | Dietary Service Director | Named in interviews regarding food service and sanitation |
| Chef | Facility Chef | Named in interviews regarding food service and sanitation |
| QA Nurse | Quality Assurance Nurse | Named in interviews regarding staff training and infection control |
| RM | Risk Manager | Named in interviews regarding medication management and behavior monitoring |
| SSC | Social Service Coordinator | Named in interview regarding dementia care and staff education |
| CNA #10 | Certified Nursing Assistant | Named in interviews regarding feeding and care of Resident #196 |
| RN #3 | Registered Nurse | Named in abuse incident and transfer injury investigation |
| LPN #4 | Licensed Practical Nurse | Named in interviews regarding care plan knowledge and new hire training |
| CNA #14 | Certified Nursing Assistant | Named in interview regarding transfer assistance |
| LPN #3 | Licensed Practical Nurse | Named in interviews regarding fall prevention and resident redirection |
| RN #4 | Registered Nurse | Named in interviews regarding resident behavior and fall prevention |
| CNA #9 | Certified Nursing Assistant | Named in interview regarding dementia care and resident reassurance |
| LPN #1 | Licensed Practical Nurse | Named in interviews regarding resident behavior and agitation medication |
| CNA #15 | Certified Nursing Assistant | Named in interview regarding shower room cleaning and infection control |
| LPN #5 | Licensed Practical Nurse | Named in observation of medication administration |
| CMT #2 | Certified Medication Technician | Named in interview regarding new hire orientation and training |
| CNA #20 | Certified Nursing Assistant | Named in interview regarding mechanical lift training |
Inspection Report
Routine
Deficiencies: 4
Mar 20, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, food safety, and infection control at Treyton Oak Towers nursing home.
Findings
The facility was found deficient in multiple areas including failure to implement care plans (e.g., missing padded rails for Resident #23), improper labeling of medications and food items, and inadequate infection prevention and control practices, particularly related to the use and cleaning of a shared INR meter which posed immediate jeopardy to resident health.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement the care plan for Resident #23 by not providing padded rails in the bathroom as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label opened drugs and biologicals, including a bottle of liquid multivitamin and flax oil. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label opened food containers (spices) with the date opened. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective infection prevention and control program, including improper cleaning and use of a shared INR meter among residents, including those in isolation, causing immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents sampled: 12
Residents affected: 1
Containers of spices unlabeled: 3
Residents sampled for infection control: 6
Residents affected by infection control deficiency: 4
Residents receiving INR checks: 4
Licensed nurses educated: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #4 | Interviewed regarding lack of padding on Resident #23's toilet rail | |
| Director of Nursing (DON) | Interviewed regarding care plan implementation and medication labeling | |
| Registered Nurse (RN) #1 | Interviewed regarding medication labeling and INR meter use | |
| Director of Nursing (DON)/Risk Management Nurse | Educated licensed nurses on discontinuation of PT/INR meter and monitored compliance | |
| Infection Preventionist/Healthcare Risk Manager | Interviewed regarding infection control program and cleaning of INR meter | |
| Prep Cook | Interviewed regarding food labeling practices | |
| Dietary Manager (DM) | Interviewed regarding food labeling and safety | |
| Administrator | Interviewed regarding facility policies and actions taken to remove immediate jeopardy |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 11, 2018
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the survey.
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