Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, specifically regarding the use and care of peripherally inserted central catheters (PICCs).
Findings
The facility failed to follow infection control precautions for three of four sampled residents with PICCs by not placing protective caps on the catheter hubs as ordered. Interviews with nursing staff confirmed inconsistent adherence to the policy, posing a potential infection risk.
Deficiencies (1)
F 0880: The facility failed to place protective caps on the hubs of peripherally inserted central catheters for three of four sampled residents, contrary to physician orders and facility policy. This failure increased the risk of infection for residents R41, R197, and R6.
Report Facts
Residents affected: 3
Sampled residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing, acting Infection Preventionist | Interviewed regarding infection control practices and follow-up on catheter hub caps | |
| Registered Nurse (RN) 2 | Interviewed about catheter hub cleaning and capping procedures | |
| Assistant Director of Nursing | Interviewed about nursing staff responsibilities for catheter hub cleaning and capping | |
| RN3 | Interviewed about catheter hub cleaning and recapping procedures | |
| Administrator | Interviewed about expectations for staff adherence to facility policies |
Inspection Report
Routine
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, specifically related to the care of residents with peripherally inserted central catheters.
Findings
The facility failed to follow infection control precautions for three of four sampled residents with peripherally inserted central catheters by not placing protective caps on the catheter hubs as ordered. Interviews with nursing staff confirmed inconsistent adherence to the policy, posing a potential risk of infection.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program by not placing protective caps on the hubs of peripherally inserted central catheters for three of four sampled residents, contrary to physician orders and facility policy.
Report Facts
Residents affected: 3
Sampled residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing, acting Infection Preventionist | Interviewed regarding infection control practices and follow-up on catheter hub caps | |
| Registered Nurse (RN) 2 | Interviewed about catheter hub cleaning and capping procedures | |
| Assistant Director of Nursing | Interviewed about nursing staff responsibilities for catheter hub cleaning and capping | |
| RN3 | Interviewed about catheter hub cleaning and recapping procedures | |
| Administrator | Interviewed about expectations for staff compliance with facility policies |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: May 1, 2025
Visit Reason
A recertification and complaint survey was conducted from 04/29/2025 to 05/01/2025 to assess compliance with 42 CFR 483 Subpart B.
Complaint Details
The survey was complaint-related and the facility was found not in substantial compliance with infection prevention and control requirements. The complaint was substantiated based on observations and interviews regarding infection control practices.
Findings
The facility was found not to be in substantial compliance due to failure to follow infection control precautions related to peripheral inserted central catheters for three residents. No deficiencies were issued for other listed residents. The facility implemented corrective actions including education, policy review, and monitoring plans.
Deficiencies (1)
Failure to follow infection control precautions for three residents with peripheral inserted central catheters, specifically not placing protective caps on catheter hubs.
Report Facts
Survey Census: 55
Survey Dates: From 2025-04-29 to 2025-05-01
Sample Size: 55
Number of residents with catheter issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acting Infection Preventionist | Interviewed on 04/30/2025 regarding catheter hub caps |
| Registered Nurse 2 | RN | Interviewed on 05/01/2025 about catheter cleaning practices |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed on 05/01/2025 about nursing cleaning procedures |
| Director of Health Services | Director of Health Services | Completed comprehensive reviews and involved in corrective actions |
| Assistant Director of Health Services | Assistant Director of Health Services | Completed comprehensive reviews and involved in corrective actions |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 3, 2022
Visit Reason
The inspection was conducted to assess compliance with medication administration, self-administration policies, medication cart security, and food safety standards at Westport Place Health Campus.
Findings
The facility failed to ensure proper assessment for medication self-administration, resulting in a medication error rate exceeding 5%. Additionally, medication carts were found unsecured, and one ice machine was not kept clean, posing potential risks to residents and staff.
Deficiencies (4)
F 0554: The facility failed to assess one resident for self-administration of medication before allowing the resident to keep medication at bedside.
F 0759: The facility failed to maintain a medication error rate below 5%, with two errors observed during 32 medication administration opportunities.
F 0761: The facility failed to ensure medication carts were locked when unattended, observed with an unlocked medication cart on the 200 Hall.
F 0812: The facility failed to keep one of three ice machines clean and sanitary, with black, brown, and pink moist substances observed on the ice dispenser.
Report Facts
Medication administration opportunities: 32
Medication errors observed: 2
Medication error rate: 6.25
Medications administered to Resident #142: 6
Medications administered to Resident #143: 11
Nystatin suspension dosage: 5
Nystatin suspension frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication administration errors and self-administration assessment findings |
| LPN #2 | Licensed Practical Nurse | Responsible for medication cart found unsecured |
| Executive Director | Provided interview statements regarding self-administration assessments and medication cart security | |
| Director of Health Services | Provided interview statements regarding self-administration assessments, medication cart security, and ice machine cleanliness | |
| Director of Food Services | Provided interview statements regarding ice machine cleaning schedules |
Inspection Report
Deficiencies: 0
Date: Apr 17, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction for Westport Place Health Campus, related to a regulatory survey completed on April 17, 2019.
Findings
No health deficiencies were found during the inspection.
Viewing
Loading inspection reports...
