Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth - Old Capitol during CMS and state inspections, most recent first.
Improper Food Labeling and Storage: Surveyors observed multiple food items in the kitchen that were opened, unlabeled, undated, or stored improperly, including items in the walk-in freezer and cooler and a floor bin of dry rice with an unsecured lid. The DM stated that staff were expected to monitor labeling each shift and discard expired items, and reported that dietary staff had already received training on food labeling and dating.
Medication Self-Administration Not Assessed Before Bedside Administration: A resident with vascular dementia, hemiplegia, and hemiparesis was found with medications at the bedside and stated he took his own meds. The DON and Administrator confirmed the resident had not been assessed for self-administration, and there was no physician order or care plan for self-administered meds. An LPN reported placing gabapentin, potassium chloride, and a liquid multivitamin/valproic acid combination at the bedside and was unsure whether the resident took them before she left the room.
Hand hygiene was not followed during wound care for a resident with wounds. An LPN changed gloves between steps of the procedure but did not sanitize or wash her hands between glove changes or between dirty and clean tasks. The facility policy required hand hygiene before and after resident contact, before donning gloves, and immediately after removing PPE. The LPN acknowledged the lapse, and the DON stated the expectation was for the nurse to follow infection prevention and hand hygiene during wound care.
A resident was hospitalized after receiving a benzodiazepine not prescribed by their physician, due to a medication error at the facility. The error occurred because an LPN prepared medications for two residents simultaneously without proper labeling. The facility failed to ensure nursing staff had the necessary competencies to prevent such errors, as ongoing competency assessments and monitoring were not conducted.
A resident in an LTC facility was hospitalized after receiving a benzodiazepine not ordered by a physician, due to an LPN's improper medication administration practice. The LPN prepared medications for multiple residents simultaneously, leading to the error. The resident, with multiple health conditions, was found unresponsive and tested positive for benzodiazepines at the hospital.
A resident in a LTC facility was hospitalized after receiving a benzodiazepine not ordered by a physician, due to ineffective oversight of medication administration practices. The Clinical Competency Coordinator failed to conduct regular audits, leading to a significant medication error. The facility's policy of preparing and administering medications one resident at a time was not followed.
The facility did not respond to resident council concerns about transportation for outings, despite ongoing requests from residents. Staff interviews revealed awareness of the issue, but no resolution was provided. The facility lacked its own transportation and relied on a contract for medical appointments only, with no arrangements for outings.
The facility failed to store controlled medications separately and under a double-lock system in two medication storage room refrigerators. Observations revealed that insulin pens, Aranesp, Risperdal, and Lorazepam were stored together without proper separation or security. The DHS was unaware of the storage requirements, and the Pharmacy Consultant's audits did not include checks for proper storage of controlled substances.
The facility failed to properly label and date food items after opening, as observed during kitchen walkthroughs. Open and unlabeled items, including pasta, cookies, juice, ranch dressing, and butter, were found in storage areas. The Dietary Manager and Administrator both expected adherence to the facility's policy on food labeling and storage.
The facility's QAPI committee failed to maintain a systematic program for performance improvement, affecting 83 residents. Despite a policy outlining the QAPI program's purpose and scope, there was no documentation of efforts to identify improvement areas or completed Performance Improvement Projects (PIPs). The Administrator confirmed the absence of meeting records and ongoing PIPs, indicating a significant deficiency.
The QAPI committee at the facility failed to document attendance and discussions during their required quarterly meetings, as per their policy. Despite claims of regular meetings with key staff, there were no sign-in sheets or minutes available for review, potentially affecting all 83 residents.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to ensure that food was properly labeled and stored in accordance with its policy titled Labeling, Dating, and Storage. During review of the policy, it was noted that food and beverage items were to have identifying labels and received/opened dates as applicable, prepared onsite foods were to have a use-by date, foods were to be stored in original or approved containers, and opened items were to be wrapped tightly. The deficiency was identified during a kitchen tour with the Dietary Manager, who observed multiple items that were not labeled, dated, or properly stored. In the walk-in freezer, surveyors observed one bag of diced pepper and one bag of waffles that were both opened and undated. In the walk-in cooler, there was one half of a block of butter that was unlabeled and undated, two bags of shredded cheese that were opened and unlabeled, and a bag of cooked chicken fajita in a small, tall plastic container with a discard date of 9/13/2025. Surveyors also observed a large floor bin of dry rice with the lid not secured, exposing the rice to the environment. The Dietary Manager closed the lid and stated that the rice had been exposed and that she would discard it. In interview, the Dietary Manager stated that staff were expected to monitor food labeling each shift and discard expired food items, and that dietary staff had received training on food labeling and dating.
Medication Self-Administration Not Assessed Before Bedside Administration
Penalty
Summary
The facility failed to ensure that one sampled resident, R43, was assessed for medication self-administration before medications were allowed at the bedside. The facility policy titled Self-Administration of Medication by Patients/Residents stated that if the licensed nurse determines the resident or family member is capable of self-administration, the attending physician must write an order that includes the specific medications based on the Self-Administration Medication Observation. Review of R43’s record showed diagnoses including vascular dementia, hemiplegia, and hemiparesis following cerebral infarction affecting the left non-dominant side. The Quarterly MDS dated 8/25/2025 showed a BIMS score of 15 and upper and lower extremity impairments on one side. There was no physician order for self-administered medications and no care plan for self-administering medication. During observation on 9/19/2025, a clear plastic medication cup containing one blue capsule and one yellow capsule, along with an eight-ounce cup containing an orange liquid, was seen at R43’s bedside. In interview, R43 stated that he took his own medications. In a concurrent interview and observation, the DON and Administrator confirmed that R43 stated he consumed medication by bedside, unsupervised, and confirmed that he was not assessed to self-administer medication. The LPN stated she provided medication to R43, was uncertain whether he had taken it before she left the room, and said she placed the medication by the bedside and thought she observed him reaching for it in an attempt to ingest it. The LPN identified the medications as gabapentin, potassium chloride, and a liquid combination of multivitamins and valproic acid.
Hand Hygiene Not Followed During Wound Care
Penalty
Summary
The facility failed to ensure infection control practices were followed during wound care for one resident with wounds. During observation of wound care, the LPN changed gloves between each step of the procedure but did not perform hand hygiene between glove changes or between dirty and clean tasks. The facility policy titled Infection Prevention-Hand Hygiene, revised October 2024, stated that hand hygiene is required before and after contact with the resident, before donning gloves, and immediately after removal of PPE. In interview, the LPN acknowledged not sanitizing or washing her hands after glove changes and stated she had received education on hand hygiene. The DON stated that her expectation was for the nurse to follow infection prevention and hand hygiene during wound care.
Medication Error Due to Inadequate Staff Competency
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skills to prevent medication errors, resulting in a significant incident involving a resident. A nurse administered a benzodiazepine, which was not prescribed by the physician, to a resident who was subsequently hospitalized. The incident was identified as Immediate Jeopardy due to the potential for serious harm, injury, impairment, or death. The resident involved had multiple diagnoses, including Parkinson's disease with dyskinesia and chronic diastolic heart failure. After receiving the incorrect medication, the resident exhibited symptoms of altered mental status and was unresponsive, requiring hospitalization. A urine drug screen confirmed the presence of benzodiazepines, which were not part of the resident's prescribed medication regimen. Interviews with facility staff revealed that the Clinical Competency Coordinator had not conducted medication administration observations until after the incident. The nurse involved admitted to a practice of preparing medications for two residents simultaneously without proper labeling, which led to the error. The facility's assessment tool and staff training protocols were reviewed, highlighting deficiencies in ongoing competency assessments and monitoring of medication administration practices.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who received a benzodiazepine that was not ordered by a physician. This error led to the resident's hospitalization. The resident, who was moderately cognitively impaired and had multiple diagnoses including congestive heart failure and Parkinson's disease, was administered a benzodiazepine, which was not part of her prescribed medications. The error was identified when the resident was found unresponsive and later tested positive for benzodiazepines at the hospital. The investigation revealed that the error occurred due to improper medication administration practices by an LPN. The LPN prepared medications for more than one resident at a time, placing them on a tray without labeling, and administered them to both residents in the same room. This practice was against the facility's policy, which required medications to be prepared and administered for one resident at a time. The LPN admitted to using this method for about a year for convenience, despite having received training on proper medication administration. The facility's policy on medication administration was not followed, leading to the potential for serious harm or death to the resident. The error was reported to the facility by the resident's family after the hospitalization, and the Director of Health Services confirmed the error during an observation of the LPN's medication administration. The Pharmacy Consultant and Medical Director were also informed of the incident, acknowledging the serious implications of such medication errors.
Medication Administration Oversight Failure
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to a significant medication error involving a resident who received a benzodiazepine that was not ordered by a physician. This error resulted in the resident's hospitalization. The deficiency was identified as Immediate Jeopardy due to the lack of effective oversight of nursing staff's medication administration practices. The Clinical Competency Coordinator (CCC) acknowledged that medication administration audits were not conducted until after the incident was reported by the resident's family member. Interviews revealed that the CCC was responsible for ensuring nursing staff possessed the necessary competencies for medication administration, but audits were not performed regularly. The Administrator expected the CCC to conduct ongoing audits and collaborate with the Director of Health Services (DHS) to address errors. However, the investigation showed that the CCC had not been conducting these audits continuously. The facility's policy required medications to be prepared and administered one resident at a time, but this was not followed, contributing to the medication error.
Failure to Address Resident Council's Transportation Concerns
Penalty
Summary
The facility failed to ensure a response was provided to the members of the resident council when concerns were identified related to transportation accommodations for outings. During a resident council meeting, four residents expressed complaints about the lack of transportation for outings and noted that they had not received a response. The facility's documentation indicated that transportation issues had been ongoing, with trips on hold due to unavailable vans. Despite repeated requests from residents, no resolution or response was provided by the facility. Interviews with various staff members, including the Director of Nursing, Social Services Director, Activities Director, and the Administrator, revealed awareness of the residents' requests for transportation. However, the facility did not have its own transportation vehicle and relied on a contract with a transportation company for medical appointments only. Attempts to borrow a van from sister facilities were unsuccessful, and the facility's previous contract for outing transportation was not renewed post-COVID-19. The facility's policy required that issues raised by the resident council be communicated and responded to promptly, but this was not adhered to, as no response was documented or communicated back to the residents.
Failure to Properly Store Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were stored separately from other medications and under a double-lock system in two medication storage room refrigerators. During an observation of the East Wing medication room, it was found that various insulin pens, Aranesp injections, Risperdal injections, and Lorazepam Intensol Oral Concentrate were stored together without separation or a double-lock system. Similarly, in the [NAME] Wing medication room, insulin pens, Lokelma, Dupixent, Veltassa, and Lorazepam oral concentrate were also stored together without the required separation and double-lock system. The Director of Health Services was unaware of the requirement for controlled medications to be stored separately and under a double-lock system. The Pharmacy Consultant, who audited the medication rooms monthly, confirmed that the facility's policy required controlled substances to be stored separately and under double lock but admitted that this task was not included in the audit tool. The facility's policy, revised in April 2021, clearly stated that controlled substances in Schedules II, III, IV, and V should be stored under double lock and separate from other medications.
Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that food items were securely closed, labeled, and dated after opening, as observed during a kitchen walkthrough with the Dietary Manager (DM). In the dry storage room, an open one-pound bag of macaroni spiral pasta and an opened bag of cookies, both undated and unlabeled, were found. Additionally, in the walk-in cooler, 15 cups of juice were observed to be undated and unlabeled. These observations were confirmed by the DM during the walkthrough. A second walkthrough revealed further deficiencies, including an open, undated, and unlabeled one-gallon container of ranch dressing and one pound of butter in the walk-in cooler. The DM acknowledged these issues and stated that she expected all foods to be stored properly, including being dated and labeled as required. The facility's policy on Labeling, Dating, and Storage mandates that food and beverage items have an identifying label, a received date, and an opened date, with a 'use by' date for items prepared on-site. The Administrator also expressed an expectation for staff to follow this policy.
QAPI Program Deficiency
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee at the facility failed to develop and maintain a systematic program aimed at performance improvement, potentially affecting all 83 residents. The facility's policy, dated 02/26/2016, outlined the purpose and scope of the QAPI program, emphasizing a proactive approach to care and engagement with stakeholders. The policy required each center to implement a comprehensive, data-driven QAPI program focusing on care outcomes and quality of life. It also mandated the use of standardized tools, such as meeting minutes templates and a quality management system for documenting Performance Improvement Projects (PIPs). However, upon review, there was no documentation available for the previous four quarters, indicating a lack of effort in identifying areas for improvement or determining underlying causes of problems. During an interview, the Administrator admitted that there were no sign-in sheets, meeting minutes, or records of discussions. Furthermore, there were no PIPs in progress or records of any completed projects, highlighting a significant deficiency in the facility's QAPI program.
QAPI Committee Meeting Documentation Deficiency
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee at the facility failed to ensure that the required members attended the quarterly meetings, as mandated by their policy. The facility's policy, dated February 26, 2016, outlines the necessity for a proactive approach to quality assurance and improvement, requiring all partners and contracted staff to participate in the QAPI program. However, upon review, there were no sign-in sheets or meeting minutes available for the previous four quarters, indicating a lack of documentation to confirm attendance or the occurrence of these meetings. During an interview, the Administrator stated that the QAPI committee meets at least quarterly, typically monthly, with the Medical Director, Director of Health Services, Infection Preventionist, and department heads usually in attendance. Despite this claim, there was no formal record of these meetings, including sign-in sheets or minutes, to verify who attended or what was discussed. This lack of documentation and adherence to the policy had the potential to affect all 83 residents living in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Comfort Creek Nursing And Rehabilitation Center | 9.5 mi | ★★★★★ | 10 | 0 |
| Gibson Health Opco Llc | 19.8 mi | ★★★★★ | 4 | 0 |
| Smith Medical Nursing Care Ctr | 22.8 mi | ★★★★★ | 0 | 0 |
| Heritage Inn Of Sandersville Health And Rehab | 22.9 mi | ★★★★★ | 0 | 0 |
| Washington Co Extended Care Facility | 23.1 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.