Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Westminster Village Kentuckiana during CMS and state inspections, most recent first.
Kitchen sanitation and food service equipment were not kept clean and sanitary. Surveyors observed soil, grease, crumbs, and food particles on the dish machine, steam table, food carts, grill, fryer, toasters, slicer, convection oven, hot box, and meal carts, with some items remaining dirty across multiple observations. An open box of cod filets was also found in the freezer, and the Dietary Manager stated the dish machine traps were cleaned nightly and the slicer had been used without cleaning after prior use.
Glucometers were not cleaned per infection control guidance after blood sugar checks for multiple residents. An LPN returned one resident’s glucometer to its holder without cleaning it, another LPN wrapped a glucometer in a Sani-Cloth wipe and placed it on the cart, and the same glucometer was used for two other residents with inconsistent and incomplete cleaning between uses. The DON and IP stated staff should clean glucometers after each use, and the facility policy required Sani-Cloth contact time of 2 minutes with the device staying wet.
Meal tray cards were not consistently followed, and multiple residents received foods they had listed as dislikes or did not receive requested items such as gravy, yogurt, peanut butter, fortified foods, potatoes, and tomato soup. Residents and a family member reported repeated problems, and the resident council also voiced concerns that food preferences were not being honored. The Dietary Manager stated staff were supposed to use check-off sheets and tray cards to ensure preferences were followed, but survey observations showed repeated errors during meal service.
Failure to Provide Timely Incontinence Care: A resident with dementia, Parkinson's disease, chronic pain, and a history of UTIs was observed with a urine-soaked brief and saturated bed pad, along with a strong odor of urine and feces in the room. The resident was dependent on staff for toileting hygiene, always incontinent of bladder, and at risk for pressure ulcers. A CNA said the resident was frequently incontinent of a large amount of urine, and a confidential informant reported the resident was often soaked and that night shift did not always change residents before leaving.
A resident with a history of UTIs and an indwelling catheter was observed multiple times with the catheter bag and tubing on the floor, including while in a wheelchair and while in bed. Staff noted the bag kept falling to the floor, and the care plan did not include an intervention to keep the drainage system off the floor. The resident was cognitively intact, always incontinent of stool, and required partial assistance for transfers.
A resident with COPD, dysphagia, essential tremor, weakness, and cognitive impairment was observed drinking liquids from regular plastic cups even though the tray card, care plan, and physician order specified a two-handled cup for all liquids. Staff interviews confirmed the resident had hand issues and used the cup because of the way he grasped items and tended to spill things without it.
A resident with chronic pain and other conditions did not receive a prescribed narcotic pain medication after a pharmacy delivery was signed for by an LPN and reportedly handed off to another LPN. The medication was not found in the medication cart during subsequent counts, and staff interviews revealed confusion about its whereabouts. The LPN last in possession of the medication left her position and refused a drug screen, and the missing medication was reported to the DON for investigation.
A resident with chronic pain and other conditions received PRN oxycodone with acetaminophen from a QMA on multiple occasions without the required assessment or authorization from a licensed nurse, and without the nurse's co-signature on the controlled drug record, contrary to facility policy and QMA scope of practice.
A resident with a diagnosis of fibromyalgia received prescribed oxycodone with acetaminophen as needed for pain, but the administration of this narcotic was not consistently documented on the medication administration record (MAR) as required. Staff interviews and facility policy confirmed that all administered medications should be recorded on the MAR, but this was not done for multiple instances, resulting in incomplete medical records.
The facility failed to maintain a clean and sanitary kitchen, affecting all 59 residents receiving food. Rodent droppings and a rodent trap with a rodent were found in the kitchen and storage areas. The Dietary Manager admitted there was no cleaning schedule for January 2025, and the deep cleaning schedule for December 2024 was missing. A sanitization policy from 2008 was not being followed.
A facility failed to ensure timely availability of medications for a resident discharged with multiple health conditions, including heart failure and diabetes. Despite attempts to fax the medication list to the pharmacy, it was not received, and the family had to visit the facility to obtain medications. The facility's policy required a physician's order for sending medications home, which was not in place for this resident.
The facility failed to maintain a sanitary environment for two residents, as rodent droppings were found in their personal storage areas. A resident with diabetes, hypertension, and anemia reported believing the mouse problem was resolved, but droppings were found in his drawers. Another resident with hemiparesis, diabetes, and multiple sclerosis reported seeing a mouse, and droppings were also found in her drawers. Despite pest control services, the issue persisted.
The facility failed to maintain proper dishwasher temperatures, adhere to infection control practices during dining, and keep a resident snack refrigerator sanitary. The dishwasher's rinse temperature was consistently below the required 180 degrees, and a CNA did not wash her hands while serving meals. Additionally, the resident snack refrigerator contained undated and expired food items, contrary to facility policy.
The facility failed to keep heater vents clean in six resident rooms, with a black substance observed on the vents. A resident reported sneezing due to suspected black mold, but the Maintenance Supervisor identified it as dirt buildup. There was no cleaning schedule, and staff were unaware of the issue, relying on maintenance to address it when informed.
The facility failed to complete discharge MDS assessments for two residents who were discharged with no anticipated return. The MDS Coordinator acknowledged the oversight, which was contrary to the facility's policy requiring timely assessments by the Interdisciplinary Assessment Team.
A resident with a history of stroke and incontinence developed a skin impairment due to improper brief placement or incorrect sizing. Despite treatment, the wound persisted, and staff interviews revealed a lack of training on proper brief management. Facility policies emphasized skin protection, but there was no system for ensuring correct brief sizes.
An LPN failed to prime insulin kwikpens before administering doses to two residents, resulting in incorrect insulin administration. Resident 160 received an incorrect dose due to lack of priming, and Resident 56's high blood sugar was not properly addressed due to similar errors. The facility's DON was unaware of the priming requirement, contributing to the deficiency.
The facility failed to document meal consumptions for two residents as required by their care plans, with multiple instances of missing records across several months. This deficiency was confirmed by a CNA and related to a specific complaint, highlighting issues with adherence to documentation standards.
The facility failed to provide appropriate dinnerware for two residents, both diagnosed with left-sided hemiplegia and hemiparesis, who were served meals in styrofoam containers with plastic utensils. This made it difficult for them to eat, impacting their dignity and ability to exercise their rights.
The facility failed to complete quarterly smoking assessments for two residents as required by their care plans. Both residents had their last assessments in August 2023, with no documentation for November 2023. The Director of Nursing acknowledged the oversight, which was identified during a complaint investigation.
Kitchen sanitation and food equipment not maintained clean
Penalty
Summary
The facility failed to ensure kitchen equipment, floors, and meal carts were clean and sanitary. During the initial kitchen tour, the dish machine had long white lime streaks down the front, the steam table had heavy yellow, brown, and black soil inside the lower doors and along the sliding edges, and two closed food carts contained multiple brown and white spills on the bottoms. The floor under the flat top grill had brown spills and grease, the fryer contained brown particles in the oil and on the inside shelf and was greasy and sticky on the front and sides, and the conveyor toaster and four-slice toaster had brown crumbs inside. The cart holding the slicer had brown crumbs around it, the sides had brown and white streaks, the hot box contained a large amount of tan and white crumbs, and one box of cod filets was open to air in the walk-in freezer with no ice observed on the fish even though fish was on the lunch menu that day. During a later kitchen and meal observation, the same concerns remained. The area under the flat top grill still had brown soil and grease, the fryer still had crumbs in the oil and shelf, and the flat top grill had dried yellow egg and brown food and grease crumbs in the creases. Two closed food carts and two open shelf food carts still had brown and white particles on the bottoms and tray shelves. The dish washer food traps contained a heavy amount of brown and yellow food pieces along with plastic and bread ties, the top of the dishwasher had tan and brown particles, and the same streaks remained on the front with brown and tan particles in them. Steam table pans were observed in racks above food particles, and the hot plate machine had streaks down the sides with white spots around the dish storage openings. On a subsequent kitchen observation, heavy food particles were still present in the dish machine traps and included green beans, red pepper, paper, bacon, sausage, and egg pieces. The Dietary Manager stated the machine was drained and all food traps were cleaned every night, and if it was a bad day they would be changed sooner. The slicer had a light pink substance on the blade, which the Dietary Manager said was not present earlier and must have been used since then without cleaning. The top convection oven had heavy black particles inside the bottom and brown and black particles on the outer side, the four-slice toaster still had a heavy buildup of brown crumbs, the food carts still had brown and white spills, the fryer shelf remained dirty and the fryer sides were greasy and sticky, and the hot box still contained a large amount of tan and white crumbs with two uncovered pans of baked sweet potatoes inside.
Glucometers Not Cleaned Between Blood Sugar Checks
Penalty
Summary
The facility failed to ensure glucometers were cleaned according to infection control guidelines after blood sugar checks for four residents. During observation, an LPN completed an accu-check for a resident with type 2 diabetes mellitus, diabetic neuropathy, anemia, morbid obesity, and hyperlipidemia, then returned the glucometer to the resident’s holder without cleaning it. The LPN later stated the glucometers were usually cleaned after all residents’ blood sugars were obtained, then cleaned the device after the observation and indicated it should dry in the holder, although the holder was still wet. For another resident with type 2 diabetes mellitus with hyperglycemia, morbid obesity, and pure hypercholesterolemia, an LPN cleaned the glucometer by wrapping it in a Sani-Cloth wipe and placing it on the medication cart on a tissue. The LPN stated she would let it sit for over 2 minutes and explained that the glucometer should be cleaned for 2 minutes, but also said she did not feel it would be cleaned well if it was only wrapped and not wiped. The glucometer had no visible blood or stains. For two additional residents, an LPN used a glucometer that was laying freely in the medication cart rather than the resident-designated glucometer in the top drawer. The LPN cleaned the device for only 15 seconds before one blood sugar check, then left it on the cart and returned later to clean it for 10 seconds and place it on a tissue. For the next resident, the same glucometer was used again and left uncleaned on the cart while the LPN left to check on another resident. The LPN stated she probably did not clean the glucometer between residents and that residents were usually not sharing the same glucometer, but supplies were unavailable. The DON and IP both stated staff should clean the glucometer after each use, and the IP stated it should be thoroughly cleaned with a paper towel underneath and allowed to dry.
Meal Tray Cards Not Followed
Penalty
Summary
The facility failed to ensure residents’ food preferences, dislikes, and special food requests listed on tray cards were honored during meal service. Surveyors observed multiple residents receiving items that were specifically marked as dislikes or not receiving items that were listed as required on their tray cards, including missing gravy, yogurt, peanut butter, fortified items, potatoes, and requested soups. The deficient practice affected 19 of 64 residents reviewed for tray cards, including residents who were observed in the dining room and in their rooms during breakfast and lunch meal services. Several residents and a family member reported that the same problems were occurring repeatedly. One resident stated she frequently did not receive what was ordered on her tray card, and another resident reported that the kitchen was not following the tray card instructions and that she regularly received sausage and eggs despite those items being listed as dislikes. A resident council meeting also reflected resident concerns that the kitchen was not honoring food preferences and dislikes, with the council president stating he ordered corn flakes every morning and had never received them as requested. A family member of another resident reported that the resident was vegetarian, disliked eggs, gravy, and meat, and was no longer being offered tomato soup even though it had previously been provided and was needed to soften his grilled cheese sandwich. The Dietary Manager stated that dietary staff were supposed to follow a check-off sheet to ensure all items were on the tray and that residents were not served foods they did not like. She also stated that she saw residents on admission to obtain likes, dislikes, and special requests, and that the Registered Dietitian saw residents after admission, readmission, or when changes occurred. The facility’s policy required meal ID cards to include food and beverage preferences, dislikes, and other applicable information, and stated that the cards were to be used during meal service to assure the correct diet was served and food preferences were honored. Despite this, survey observations documented repeated omissions and incorrect items on meal trays across multiple residents and meal periods.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a resident who was incontinent of urine received needed ADL care, including timely brief changes and keeping the bed padding from becoming overly saturated with urine. During observation, the resident was found in bed with a strong odor of urine and feces in the room, and the draw pad under her had a light brown stain covering nearly the entire pad. Her brief and the pad underneath were saturated with urine, and a later observation showed the soiled pad still on the bed and wet to the touch while the resident was in an activity. The resident had diagnoses including Parkinson's disease without dyskinesia, rheumatoid arthritis, dementia, chronic pain, and a history of UTIs. Her quarterly MDS showed severe cognitive impairment, dependence on staff for toileting hygiene, always incontinent of bladder, and risk for pressure ulcers. The care plan identified her as always incontinent of bowel and bladder with large amounts of urine and included checking as required for incontinence. The Braden Scale indicated moderate risk for pressure sores and that linens needed to be changed at least once a shift. A CNA stated she changed the resident at the start of her shift and that the resident was frequently incontinent of a large amount of urine, while a confidential informant stated the resident was often soaked and that night shift did not always change residents before leaving.
Catheter drainage bag repeatedly left on the floor
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter drainage system for a resident with a history of UTIs. During observations, the resident’s catheter collection bag and tubing were repeatedly found sitting on the floor while the resident was in the dining room, lying in bed after breakfast, and wheeling down the hall, with the resident dragging the catheter tubing and bag. Multiple staff members were present in the dining room during one of the observations, and an LPN stated the resident’s catheter was always falling to the floor. The resident’s record showed diagnoses including obstructive and reflux uropathy, hydronephrosis, urinary retention, chronic kidney disease stage 3, and a personal history of UTIs. The care plan identified the resident as at risk for complications related to chronic UTIs and later noted an indwelling catheter, with interventions focused on monitoring tubing, discomfort, and signs of UTI. The care plans did not include any documented intervention to keep the catheter collection bag off the floor. The resident was cognitively intact, had an indwelling catheter, was always incontinent of stool, and required partial assistance for transfers.
Failure to Provide Ordered Adaptive Drinking Equipment
Penalty
Summary
The facility failed to ensure that Resident 9 was provided the adaptive eating equipment ordered and identified in the care plan. During dining room observations, the resident was seen drinking tea, water, and a shake from regular plastic cups, and no two-handled cup was present. The tray card indicated the resident was to have a two-handled cup for liquids, but staff observed that it was not available during meals. Resident 9’s record showed diagnoses including COPD, transient cerebral ischemic attack, generalized muscle weakness, essential tremor, and oropharyngeal dysphagia. The quarterly MDS indicated moderate cognitive impairment, supervision and assistance for eating after tray set up, and impairment of bilateral upper extremity ROM. The care plan stated the resident had a nutritional problem related to a mechanically altered and therapeutic diet, was underweight, received hospice care, had dysphagia, and included the intervention of a two-handled cup at all times. The physician’s order also specified a two-handled cup for liquids, and staff interviews confirmed the resident had hand issues and used the cup because of the way he grasped items and tended to spill things without it.
Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's property, specifically a narcotic pain medication prescribed for a resident with diagnoses including diabetes, depression, and chronic pain. The resident had a physician's order for Hydrocodone-Acetaminophen to be administered as needed. According to pharmacy records, a delivery of 30 tablets was made and signed for by an LPN, who reported handing the medication to another LPN responsible for the resident's medications. However, the medication was not found in the medication cart during subsequent counts, and staff interviews revealed confusion and lack of clarity regarding the medication's whereabouts. The LPN who was last reported to have received the medication left her position shortly after the incident and refused a drug screen when requested. Multiple staff members, including a QMA and several LPNs, were involved in the medication ordering, delivery, and counting process, but none could account for the missing medication. The narcotic count sheets and medication cards were reported as correct during one count, but the medication was still unaccounted for. The incident was reported to the Director of Nursing, and an investigation was initiated after it was discovered that the resident's narcotic pain medication had disappeared between the time of delivery and the next scheduled administration.
Failure to Obtain Nurse Assessment and Authorization for PRN Narcotic Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses including fibromyalgia, depression, and pain received as needed (PRN) narcotic pain medication, specifically oxycodone with acetaminophen, without the required assessment and authorization from a licensed nurse. The clinical record review showed that a Qualified Medication Aide (QMA) administered the PRN narcotic pain medication on multiple occasions, but there was no documentation of a licensed nurse assessment or co-signature on the controlled drug record for these administrations. Facility policy and the QMA Scope of Practice require that a licensed nurse assess the resident's need for PRN narcotic pain medication, provide authorization, and co-sign the medication administration record. Interviews confirmed that QMAs are expected to obtain permission from a licensed nurse and document this in the resident's record, including the nurse's co-signature by the end of the shift. However, these steps were not followed, as evidenced by the lack of assessment and authorization documentation for the resident who received the PRN narcotic pain medication.
Failure to Document Narcotic Administration on Medication Record
Penalty
Summary
The facility failed to ensure that a resident's medication administration record (MAR) accurately reflected the administration of a prescribed narcotic pain medication. Specifically, for a resident diagnosed with fibromyalgia and prescribed oxycodone with acetaminophen to be given every four hours as needed for pain, the August controlled drug record showed multiple instances where the medication was administered. However, the corresponding MAR lacked documentation of these administrations on the listed dates and times. Interviews with staff confirmed that when as-needed pain medication is given, it should be documented both on the controlled drug record and the MAR. The facility's own policy, provided by the Director of Nursing, requires that all medications administered be immediately documented on the MAR, including the signature and title of the person administering the medication. The failure to document the administration of the narcotic medication on the MAR constituted a deficiency in maintaining accurate and complete medical records in accordance with professional standards.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect all 59 residents receiving food from the kitchen. During an inspection, rodent droppings and jelly packets were found behind shelves in the dry storage area, and a rodent trap containing a rodent was observed under a shelf with large canned foods. Additionally, rodent droppings were found near the ice machine in the kitchen area. The Dietary Manager admitted there was no cleaning schedule for January 2025, as they were transitioning to a new system with more detailed forms, which had not yet been implemented. Furthermore, the deep cleaning schedule for December 2024 could not be located. The Executive Director provided a sanitization policy dated October 2008, which stated that food service areas should be clean and free from rodents, but this policy was not being followed.
Failure to Provide Timely Medication Upon Discharge
Penalty
Summary
The facility failed to ensure that a resident's medications were available in a timely manner upon discharge. Resident B, who had multiple diagnoses including congestive heart failure, acute respiratory failure with hypoxia, heart disease, diabetes, hypertension, and atrial fibrillation, was discharged to her home. The facility's progress notes indicated that the resident's medication orders were faxed to the pharmacy of choice. However, the complainant reported that the medication list was not sent to the pharmacy, and despite multiple attempts to fax the list, the pharmacy did not receive it. The family member had to visit the facility to obtain some medications that were still in stock. The Director of Nursing was unable to provide fax confirmation for the medication list being sent to the pharmacy. The facility's policy required a physician's order for medications to be sent home with Medicare residents, which Resident B did not have. The facility's policy also stated that medications would be sent with a discharged resident only under conditions that protect the resident and comply with the law. Despite these policies, the family was not provided with the necessary medications in a timely manner, leading to a deficiency in the discharge process.
Rodent Droppings Found in Residents' Drawers
Penalty
Summary
The facility failed to maintain a sanitary environment for two residents, identified as Resident F and Resident G, as evidenced by the presence of rodent droppings in their personal storage areas. Resident F, who has diagnoses including diabetes, hypertension, and anemia, reported that he believed the mouse problem had been resolved, although rodent droppings were found in multiple drawers of his nightstand and chest during an observation. Staff Member 7 confirmed that there had been a rodent issue for a couple of months and had previously cleaned and organized the residents' drawers. Resident G, with diagnoses including left dominant side hemiparesis, diabetes, and multiple sclerosis, also reported seeing a mouse in the bathroom, indicating an ongoing issue. Observations revealed rodent droppings in the drawers of Resident G's nightstand. Despite pest control services being provided on 11 occasions between November and January, the problem persisted, leading to the citation related to Complaint IN00449149.
Deficiencies in Dishwasher Temperatures, Infection Control, and Refrigerator Maintenance
Penalty
Summary
The facility failed to adhere to guidelines regarding dishwasher temperatures, infection control during dining, and maintaining a sanitary resident snack refrigerator. During an observation, the dishwasher's rinse temperature was found to be consistently below the required 180 degrees, with records showing this issue persisted throughout November. The Dietary Manager acknowledged the problem and indicated that the staff had been instructed to stop washing dishes until the issue was resolved. The facility's policy required dishwashing machine rinse temperatures to be at least 180 degrees, which was not met. In another observation, a CNA was seen handling food trays without washing or sanitizing her hands after touching various surfaces and adjusting her clothing. This occurred during meal service, where the CNA served multiple residents without adhering to proper hand hygiene practices. The facility's policy mandated that employees wash their hands after activities that could contaminate them, which was not followed in this instance. Additionally, the resident snack refrigerator contained several undated and expired food items, including a pumpkin pie and a pecan pie with use-by dates that had passed. The facility's policy required perishable foods to be discarded after three days, and the night shift staff were responsible for cleaning the refrigerators on specific days. However, this policy was not followed, as evidenced by the presence of outdated food items in the refrigerator.
Facility Fails to Maintain Cleanliness of Heater Vents in Resident Rooms
Penalty
Summary
The facility failed to maintain cleanliness in resident rooms, specifically regarding the heater vents in six of the 26 rooms reviewed. During a tour, a black spotty substance was observed covering the heater vents in rooms 105, 107, 111, 114, 115, and 120. A resident reported experiencing sneezing upon waking, attributing it to black mold on the heater vents. However, the Maintenance Supervisor later identified the substance as dirt buildup, not black mold. Despite this, there was no established cleaning schedule for the vents, and maintenance relied on staff to report when vents needed cleaning. Interviews with staff revealed a lack of awareness and responsibility regarding the cleanliness of the heater vents. A CNA stated that nursing staff did not clean the vents but would inform maintenance if cleaning was needed, although she was unaware of any vents requiring attention. Similarly, an RN indicated that staff could clean the vents if they noticed dirt, but they would also notify maintenance. The RN was not aware of the dirty vents. The Maintenance Director's job description emphasized maintaining the facility's physical environment, but the absence of a cleaning schedule contributed to the oversight.
Failure to Complete Discharge MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete discharge Minimum Data Set (MDS) assessments for two residents, identified as Residents 14 and 25, out of 19 MDS records reviewed. Resident 14 was admitted to the facility and discharged with no anticipated return on July 1, 2024, yet the MDS listings lacked a completed discharge assessment. Similarly, Resident 25 was admitted and discharged on the same date, also without a completed discharge assessment. During an interview, the MDS Coordinator acknowledged that discharge assessments for these residents had been missed and should have been completed. The facility's policy, titled 'Resident Assessment Instrument' and revised in September 2021, states that the Assessment Coordinator is responsible for ensuring timely resident assessments by the Interdisciplinary Assessment Team.
Improper Brief Management Leads to Resident Skin Impairment
Penalty
Summary
The facility failed to prevent a skin impairment for a resident who was reviewed for quality of care. The resident, who was cognitively intact, had a history of stroke, anemia, hemiplegia/hemiparesis, and depression, and was always incontinent of bowel and bladder. An open area was reported on the resident's upper right posterior thigh, which was attributed to trauma from the brief. The wound was initially noted by a CNA and measured 2.5 cm by 1.0 cm by 0.2 cm. A Wound MD classified the wound as non-pressure and initiated a treatment order. Despite the treatment, the wound persisted, and the care plan included interventions such as medication administration, physician contact as needed, and regular turning and repositioning. Interviews with staff revealed that the wound was believed to be caused by improper brief placement or incorrect sizing. The Infection Preventionist/Wound Nurse and the DON acknowledged the issue but indicated that staff had not been in-serviced on proper brief placement or sizing. CNAs reported that they were unsure about education on correct brief placements, and there was no list available for staff to reference the correct brief sizes for residents. The facility's policies on urinary continence and perineal care emphasized maintaining dignity, comfort, and skin protection, but the deficiency highlighted a gap in staff training and awareness regarding brief management.
Failure to Prime Insulin Kwikpens Leads to Dosage Errors
Penalty
Summary
The facility failed to ensure proper administration of insulin for two residents, leading to deficiencies in pharmaceutical services. During an observation, an LPN administered insulin to Resident 160 without priming the needle of the Humalog kwikpen, which is necessary to remove air and ensure the correct dose is delivered. The LPN initially administered 3 units of insulin when the resident's blood sugar reading required 4 units according to the physician's sliding scale order. The LPN then administered an additional unit without priming the needle again. The physician's order specified the insulin dosage based on blood sugar levels, but the LPN did not follow the correct procedure for priming, as outlined in the manufacturer's instructions. Similarly, for Resident 56, the LPN administered insulin without priming the needle. The resident's blood sugar reading was significantly high, and the LPN attempted to administer 12 units of insulin. However, the kwikpen only contained 5 units, which were administered without priming. The LPN then retrieved another kwikpen to administer the remaining 7 units, again without priming the needle. The facility's Director of Nursing incorrectly believed that priming was not necessary for the kwikpens, despite the manufacturer's instructions indicating otherwise. The facility's insulin administration policy required verification of the insulin type, dosage, and method of administration, but these procedures were not followed, leading to the deficiency.
Failure to Document Meal Consumptions for Residents
Penalty
Summary
The facility failed to document meal consumptions for two residents, Resident B and Resident C, as required by their care plans. Resident B's clinical record review revealed multiple instances in August and September 2024 where meal consumptions were not documented. Specifically, there were missing records for various meals, including breakfast, lunch, and dinner on several dates. This lack of documentation was confirmed during an interview with a CNA, who stated that all resident meals should be documented in the system. Similarly, Resident C's clinical record review showed numerous undocumented meal consumptions across August, September, and October 2024. The resident's care plan required setup assistance with meals and documentation of the percentage eaten, but this was not consistently followed. The missing documentation spanned multiple meals and dates, indicating a pattern of non-compliance with the care plan requirements. The facility's failure to document meal consumptions was further highlighted by the provision of two documents by the Director of Nursing and the Infection Preventionist. These documents outlined the protocol for documenting dietary intake and preparing residents for meals, emphasizing the importance of maintaining accurate records. The deficiency was related to a specific complaint, indicating a broader issue with the facility's adherence to documentation standards.
Failure to Provide Appropriate Dinnerware for Residents
Penalty
Summary
The facility failed to ensure that residents were served meals on appropriate dinnerware, impacting their dignity and ability to eat comfortably. Resident B, diagnosed with left-sided hemiplegia and hemiparesis, was observed eating from a styrofoam container with plastic utensils, which made it difficult for her to cut food due to her condition. She expressed that she had been receiving meals in this manner for over a year and found it challenging to eat with the provided utensils. The Assistant Dietary Manager and the Executive Director confirmed that the use of styrofoam and plastic utensils was due to a supply issue after their contracted company left, taking the dishware with them. They were waiting on new supplies, including plate warmers and tray carts, which had been delayed due to other expenditures and supply chain issues. Similarly, Resident C, also diagnosed with left-sided hemiplegia and hemiparesis, was observed with styrofoam meal containers on his bedside table. He reported difficulties eating from the high-edged containers. The facility's meal service policy indicated that disposable dining dishes and flatware should only be used during emergency meal service, which was not the case here. The Executive Director provided a document outlining resident rights, which included the right to a dignified existence and dignity, highlighting the facility's failure to uphold these rights in meal service. This deficiency was related to Complaint IN00428146.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to ensure quarterly smoking assessments were completed for two residents, Resident B and Resident C, as required by their care plans. Resident B, diagnosed with left-sided hemiplegia, hemiparesis, bipolar disorder, and major depressive disorder, had a care plan indicating the need for quarterly smoking assessments. However, the last assessment was completed in August 2023, and there was no documentation of a quarterly assessment for November 2023. The Director of Nursing acknowledged that the smoking assessments were not included when the quarterly assessments were set up in the new system, despite the facility policy requiring them to be completed quarterly. Similarly, Resident C, diagnosed with left-sided hemiplegia, hemiparesis, and dementia, also had a care plan indicating the need for quarterly smoking assessments. The last assessment for Resident C was also completed in August 2023, with no documentation for November 2023. The Director of Nursing provided a copy of the facility's smoking policy, which stated that residents' ability to smoke safely should be re-evaluated quarterly. This deficiency was identified during a complaint investigation.
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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 Clarksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clark Rehabilitation And Skilled Nursing Center | 1.1 mi | ★★★★★ | 3 | 0 |
| Wedgewood Healthcare Center | 1.1 mi | ★★★★★ | 12 | 0 |
| Rolling Hills Healthcare Center | 2.2 mi | ★★★★★ | 4 | 0 |
| Charlestown Place At New Albany | 2.3 mi | ★★★★★ | 33 | 1 |
| Riverview Village | 2.3 mi | ★★★★★ | 1 | 0 |
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