Bardstown Health & Rehabilitation
120 Life Care Way, Bardstown, KY 40004 · For profit - Limited Liability company · 100 certified beds · (502) 348-4220 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent May 2021
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.0% | 13.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 13.5% | 6.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 28.5% | 17.7% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.6% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 41.8% | 29.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.6% | 19.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.9% | 16.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.7% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 85.0% | 83.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 8.7% | 24.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.5% | 13.7% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.37 | 1.94 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.88 | 2.14 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
52.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 126 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 44 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 52.7%CMS range 43.9–62.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 8.2–13.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 34.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 34.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.2%CMS range 5.1–12.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 100 beds and averages 46.5 residents a day — about 46% occupied, or roughly 54 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.78 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.32 hrs/resident/day on weekends vs 4.95 on weekdays — 13% thinner on weekends. RN hours go from 0.80 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Ecited before2025-07-18 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility policies and medication guidelines, the facility failed to store, label and dispose of medications in accordance with accepted professional standards for 1 of 2 medication rooms and 2 of 2 medication carts. Observation of the East Medication Room refrigerator on 07/14/2025, revealed an opened ampule of Tubersol without an expiration date or opened date. Observation of the Medication Cart 2 Narcotics bin on 07/16/2025, revealed an unidentified tablet secured with tape into a blister pack containing one milligram Lorazepam tablets. Observation of Medication Cart 1, on 07/17/2025, revealed 14 unidentified loose pills, tablets and capsules in the cart drawer with the medication blister packs. The findings include: Review of the facility policy entitled, Medication Storage, last reviewed 02/2025, revealed the Home (facility) must store all drugs and biologicals in a safe, secure and orderly manner. The facility was to ensure no expired or discontinued medications were stored within stock, house, routine or PRN (as necessary)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of facility policy, it was determined the facility failed to revise the Comprehensive Care Plan for 1 of 15 sampled residents, Resident (R)42. Specifically, the facility failed to revise R42's Care Plan with interventions to address weight loss after the resident sustained a 32.6 pound (18.09%) severe weight loss in less than one month.The finding Include: Review of the facility's Care Planning-Interdisciplinary Team policy, undated, revealed .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which may include, but is not necessarily limited to the following personnel: a. the resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; d. The Social Services Worker responsible for the resident; e. The Activity Director/Coordinator; f. Therapists (speech, occupational, recreational, etc.), as applicable; g. Consultants (as appropriate); h. The Director of Nursing (as applicable); i. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of facility policy, the facility failed to ensure that a resident receives and maintains acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates that this is not possible for 1 of 2 sampled residents reviewed for nutrition, Resident (R)42. Specifically, the facility failed to identify and respond to R42's 32.6 pound (18.09%) severe weight loss in less than one month.The finding include: Review of the facility's Weight Assessment and Intervention policy revealed. 4. Any weight change of 5% or more [unless otherwise specified in the resident's care plan or Physician's order] since the last weight will be retaken for confirmation. If the weight is verified, nursing will immediately notify the physician/practitioner and dietary team. Per policy. 7. The physician/ practitioner, resident and resident representative will be informed of significant weight change [gain/loss]. Review of R42's Face Sheet, revealed the facility admitted the resident on 03/17/2023 with diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-05-01 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to protect four (4) of thirty-one (31) residents from resident to resident abuse. The facility failed to protect Resident #10 from abuse resulting in a skin tear to the hand. The facility failed to protect Resident #35, #366 and #313 from verbal abuse. The findings include: Review of the facility policy titled, Abuse Prevention Program, updated 05/02/2017, revealed it is the policy of the facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. The policy also stated each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. The policy further revealed any incident or allegation involving abuse or mistreatment will result in an abuse investigation. Review of the facility policy titled Resident Behaviors and Facility Practices, undated, it stated that residents have the right to be free…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-05-01 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of facility policy, the facility failed to ensure the temperature of each cooked food item was checked before served per facility policy for 57 meals between 04/01/2021 and 04/25/2021. The findings include: Review of the facility's policies Monitoring food temperatures for Meal Service undated revealed the temperature for each food item shall be recorded in the Temperature Log Book. Observation on 04/26/2021 at 4:39 PM revealed the Dietary Manager took temperatures of each cooked food item on the steam table for the resident's dinner meal. The Dietary Manager then documented the food temperatures in a log book. Review of the Temperature Log Book revealed that for the month of April, 2021, facility staff had failed to document food temperatures for all three (3) meals for 19 of 25 days in April, 2021. Meal temperatures were not documented on the following days: 04/01-11/2021, 04/13/2021, 04/15-16/2021, 04/20/2021 and 04/22-25/2021. Interview with Dietary Manager, on 04/28/2021 at 8:48 AM, revealed Temperatures are supposes to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of facility policy, it was determined the facility failed to ensure the physician was notified of a resident change in condition for one (1) of thirty-one (31) sampled residents (Resident #313). On [DATE], a change in skin condition was noted on Resident #313's nose; however, the physician was not notified until [DATE]. The findings include: Review of facility policy titled Change in Residents Condition or Status undated, revealed it was the policy of the facility to ensure that the residents' attending physicians and representatives were notified of changes in the resident condition or status. Further review revealed the nurse would record in the resident's medical record any changes in the resident's medical condition or status. Review of a witness statement by LPN #9 revealed on [DATE], Resident #313 was noted to have a reddened area with what looked like a white head pimple coming up on his/her nose. Review of a wound assessment dated [DATE] revealed the area to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy, the facility failed to protect the right to privacy and confidentiality for two (2) of thirty-one (31) sampled residents (Resident #363 and Resident #364). The facility failed to ensure the privacy and confidentiality of Resident #363 and Resident #364 when Resident #365 took photographs in the facility common area of both residents and posted them on his/her public social media page without the knowledge or consent of Resident #363 or Resident #364 or their resident representatives. Findings include: Review of facility policy titled, Resident Rights, (undated) revealed residents have the right of privacy over personal and clinical records. Privacy will include personal care, medical treatments, telephone use, visits, letters, and meetings or resident groups. Further review revealed the policy stated residents may approve or refuse release of records, except in the event of a transfer or legal situation. Review of facility photo consent policy,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of facility policy, it was determined the facility failed to protect two (2) of thirty-one (31) sampled residents (Residents #11 and #47) from misappropriation of resident property (controlled medications). The Controlled medication count was not correct for Resident #11 and #47 on 04/28/2021. The findings include: A review of the facility abuse policy titled Abuse Prevention undated, revealed it was the policy of the facility to prevent misappropriation of resident property. A review of the facility policy for controlled substance accountability titled Policy and Procedure Controlled Substances undated revealed it was policy to maintain individual record of receipt and distribution of all controlled drugs in sufficient detail to enable an accurate reconciliation. Further review of the policy revealed records shall be maintained by authorized nursing personnel of all controlled drugs administered to residents at the facility. 1. Review of the medical record for Resident #11 revealed the facility admitted the resident on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review, it was determined the facility failed to report an allegation of verbal abuse timely for one (1) of thirty one (31) sampled residents (Resident #9). State Registered Nurse Aide (SRNA) #18 failed to immediately report an allegation of verbal abuse toward Resident #9 by SRNA #19. The findings include: Review of the facility policy titled, Abuse Prevention Program, updated 05/02/2017, revealed employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the administrator. Review of the medical record for Resident #9, revealed the resident was readmitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Cerebrovascular Disease, Morbid Obesity, Muscle Wasting Atrophy, Hemiplegia and Hemiparesis. Review of the Minimum Data Set (MDS) quarterly assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to ensure an abuse allegation was thoroughly investigated for one (1) of thirty-one (31) sampled residents (Resident #163). The facility investigated an abuse allegation related to a nurse making an inappropriate statement to Resident #163 when the resident requested pain medication on [DATE]. Although, the facility investigated the statement made by the nurse to the resident, the facility failed to investigate the if the resident received the pain medication as requested. The findings include: Review of the facility policy titled, Abuse Prevention Program, updated [DATE], revealed it is the policy of the facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. The policy also stated each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. The policy further revealed any incident or allegation involving abuse or mistreatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Dcited before2021-05-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review, the facility failed to revise/update the comprehensive plan of care for two (2) of thirty one (31) sampled residents (Resident #25 and Resident #313) related to safety concern and a change in skin condition. The findings include: Review of facility's policy Incidents/Accidents and Falls undated, revealed resident care plans will be addressed to ensure that any needed points of focus have measurable goals with appropriate goals interventions in place. Review of facility policy titled Resident Care Manual, Subject Care Plan Review, undated revealed the resident should be assessed visually and verbally, as well as obtain information from the Health Care Records and interview Nursing Assistants prior to completing the MDS and reviewing the Plan of Care. 1. Review of the medical record for Resident #25 revealed the facility admitted the resident on [DATE] with a diagnosis of Heart Failure, Chronic Kidney Disease, Atrial Fibrillation, Anxiety Disorder and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to provide care and services to ensure one (1) of thirty-one (31) sampled residents (Resident #14) received assistance with bathes and showers. The facility assessed Resident #14 to require extensive assistance of staff for bathing/showers. However, from 01/12/2021 through 01/20/2021, the facility staff failed to assist the resident with bathes or showers. The findings include: Review of the facility's policies Activities of Daily Living (ADL) Routine Care not dated, revealed Activity of Daily Living (ADL) care of the resident includes: Assisting the resident in personal care such as bathing and showering. Review of Resident #14's medical record revealed the facility admitted the resident on 01/31/2016 originally and the latest readmission date of 11/16/2020. The resident's diagnoses included Schizoaffective Disorder, Borderline Personality, Anxiety, auditory and visual Hallucinations, and Cerebral Vascular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure care was provided to a surgical wound in accordance with professional standards of practice for one (1) of thirty-one (31) sampled residents (Resident #54). Observations during wound care revealed the nurse did not wash her hands between glove changes while performing the wound care. The findings include: Review of the facility policy titled, Handy Hygiene Guidelines, undated, revealed hand hygiene should be done when hands are visibly soiled, exposure to a spore forming organism has been suspected or proven, before and after eating, and after using the restroom hands should be washed with a non-microbial soap or anti-microbial soap. Review of Resident #54's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses of Cellulitis of Left Lower Limb, Congestive Heart Failure, Diabetes Mellitus Type II and Unspecified Open Wound Left Lower Leg. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a resident with a pressure ulcer received the necessary treatment to promote healing and prevent infection for (1) of thirty-one (31) sampled residents (Resident #24). Observations during wound care revealed the nurse did not wash her hands between glove changes while performing the wound care. The findings include: Review of the facility policy titled, Handy Hygiene Guidelines, undated, revealed hand hygiene should be done when hands are visibly soiled, exposure to a spore forming organism has been suspected or proven, before and after eating, and after using the restroom hands should be washed with a non-microbial soap or anti-microbial soap. Record review revealed the facility admitted Resident #24 on 03/11/2020 with diagnosis to include presence of Left Artificial Hip Joint, Nutritional Deficiency unspecified, Pressure Ulcer of right heel Stage IV, and Osteoporosis. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and a review of the facility policy, it was determined the facility failed to provide appropriate treatment/services (incontinent care) to prevent urinary tract infections for one (1) of thirty-one (31) sampled residents (Resident #58) who was incontinent of urine. The findings include: A review of the facility policy for incontinent care titled Policy and Procedure Perineal Care undated revealed to ensure that residents receive personal hygiene after periods of incontinence to prevent infection, odors, and promote comfort, the perineum to include the genitalia was to be cleaned, rinsed and patted dry. A review of the medical record for Resident #58 revealed the facility admitted the resident on 06/25/2013 with diagnoses, which included Morbid Obesity, Intracranial Injury, Dementia, and Muscle Weakness. A review a significant change minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of three (3)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, it was determined the facility failed to coordinate care with outside dialysis center that provided services to one (1) of thirty-one (31) sampled residents (Resident #20). Resident #20 required outpatient hemodialysis treatments three (3) times a week due to end stage renal failure. Per transportation records, Resident #20 had seventeen (17) treatments from 03/15/2021 to 04/26/2021. However, there was no communication forms/documented evidence that the facility coordinated care with the dialysis center between 03/15/2021 and 04/26/2021. The findings include: Review of the facility's dialysis policy (undated), revealed that the facility assures coordination of care for residents requiring hemodialysis including that all residents that are admitted to the facility with needs for hemodialysis will have coordination of services between the facility and the hemodialysis prior to admission. It further stated that a dialysis communication sheet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-01 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and a review of the facility policy for medication administration, it was determined the facility failed to ensure one (1) of thirty-one (31) sampled residents (Resident #53) was free of significant medication errors. Resident #53 was ordered to have Dilantin (a medication to control seizures) 150 milligrams (mg) every day. However, the resident received the incorrect dose of Dilantin (100 mg instead of 150 mg) for three (3) days in April (on 04/26/2021, 04/27/2021 and 04/28/2021). The findings include: A review of the facility policy for medication administration errors titled Policy and Procedure Medication Administration Errors, undated, revealed if a resident missed a dose of medication it was considered an error. The administration of the medication dose was less that what was ordered, or if the medication was not delivered to the resident/facility in a timely manner, it was considered a medication error. A review of the medical record for Resident #53 revealed the facility admitted the resident on 05/18/2019 with diagnoses which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-06-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of facility policy, it was determined the facility failed to follow the dishwasher manufacturer recommendations for the high temperature wash cycle in the facility kitchen. Observation during survey revealed the dishwasher temperature reached one hundred forty (140) degrees Fahrenheit for several wash cycles. In addition, other observations during survey revealed the Dietary [NAME] #2 was unsure of the correct calibration process for the thermometer. The findings include: 1. Review of the facility Census and Condition, dated 06/18/19, revealed seventy-three (73) of seventy-three (73) residents received their meals from the kitchen. Review of the facility policy Dishwashing: Machine, dated 2017, revealed the Dining Services staff maintained the operation of the dishwashing machine according to established procedures and manufacturer guidelines. Following these procedures and guidelines ensured effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. The policy stated for staff to check the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-06-21 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and facility policy it was determined the facility failed to ensure medications were properly labeled and dated for two (2) of three (3) medication rooms in the [NAME] and Rehab Nursing Stations. Observations revealed opened bottles of Tubersol (a purified protein derivative of the Mycobacterium tubercula used with the detection of tuberculosis (TB)) were not labeled with a date and time the agent was opened. In addition the facility failed to ensure one (1) of three (3) refrigerated medication lock boxes were properly secured to the refrigerator. Other observations revealed one (1) of four (4) medication room doors were unsecured for four (4) of four (4) days and one (1) of four (4) medication carts unlocked and unsupervised. The findings include: 1. Review of the facility policy titled, Medication Storage in the Facility, dated 04/2018, revealed medications were to be stored safe, secured, and properly. The medications were to be accessible only by licensed personnel, pharmacy or staff members' authorized to administer medication.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to implement care plan interventions for one (1) of thirty-eight (38) sampled residents, Residents #63. Observations revealed the facility failed to provide dining assistance as care planned. The findings include: Record review of the facility's policy, Baseline Care Plan Assessment/Comprehensive Care Plans, undated, revealed the Comprehensive Care Plan would be a person-centered plan of care approach for each resident, which included measurable objectives and timetables, and implemented to meet the resident's nursing, physical functioning, mental, and psychosocial needs. Review of Resident #63's clinical record revealed the facility admitted the resident on 05/15/19 with the diagnoses including Dysphagia, Dementia, and Neuroleptic Induced Parkinsonism. Review of the admission Assessment for Resident #63, dated 05/15/19, revealed the facility assessed the resident's weight as one hundred and nineteen (119) pounds. Review of the Quarterly Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-06-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility program Skin, and Weight Assessment Team (SWAT), it was determined the facility failed to provide care and services to maintain or address a resident's nutritional status for one (1) of thirty-eight (38) sampled residents, Resident #63. Observations revealed Staff did not provide or assist Resident #63 with meals after the facility identified the resident with potential for alteration in nutritional status. The findings include: Review of the SWAT Program, undated, revealed the facility identified residents at nutritional risk. The facility assessed the nutritional status of the resident, and aggressively reviewed and addressed those residents with significant weight loss. The facility monitored the identified residents weekly with a goal to improve the residents' nutritional status. The facility assessed, observed, and reviewed the clinical and dietary interventions implemented to address the identified factors for the altered nutritional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of thirty-eight (38) residents, Resident #63, was free from unnecessary psychotropic medication and as needed (PRN) psychotropic medication (Ativan). In addition, the facility did not monitor behaviors or for side effects of a psychoactive medication. (Ativan/Lorazepam). The findings include: Review of the facility policy, Medication Regimen Review, undated, revealed the consulting pharmacist reviewed resident medications in detail and followed federal mandated standards of care. Additionally, the consulting pharmacist reviewed all as needed orders to include condition, side effects, and the potential unnecessary medication usage. The pharmacist reported irregularities to the attending physician or care provider. Review of the facility policy, Unnecessary Drugs, undated, revealed a full assessment of the resident was required to substantiate the need to administer psychotropic medications. The physician and clinical pharmacist consultant reviewed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-21 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure dining choices were honored for one (1) of eleven (11) sampled residents, Resident #42. The findings include: Review of the policy Meal Service, undated, revealed the facility would serve each resident a diet that was appropriate for the physical, cognitive, and psychosocial needs of the resident. Review of the policy Resident Preferences, undated, revealed the facility ensured the resident received care as to their preference and choice as part of a person centered approach to care. The objective was to deliver care while honoring the resident's likes and not subjecting to them any dislikes developed over a lifetime of experiences in living. Review of the clinical record revealed the facility admitted Resident #42 on 06/27/18 with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Dysphagia, Gastroesophageal Reflux Disease (GERD), and Type 2 Diabetes Mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/17/19, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review it was determined the facility failed to implement an effective infection control program as evidenced by clean personal care items stored in one (1) of three (3) soiled utility rooms located on the Rehab unit. The findings include: Review of the policy Infection Prevention and Control revealed the Infection Preventionist would make facility wide rounds at least weekly to identify any visible breaches within the physical environment, identify and correct any potential deficits as discovered. Observation of the 100 Hall soiled utility room, on 06/18/19 at 9:55 AM, with the Transportation Driver revealed clean bedpans stacked on a counter top. Interview during observation revealed the bedpans should be stored inside the cabinet. Observation of the 100 Hall soiled utility room, on 06/19/19 at 8:40 AM, with Licensed Practical Nurse (LPN) #2 revealed two (2) boxes of new urinals stored on top of a cabinet located across from a hopper sink. Interview with LPN #2 during observation revealed clean items should not be stored in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kentucky Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 185149. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.