Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Bluegrass Care & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including acute respiratory failure and dementia, was started on hospice care, but this status was not accurately documented in the MDS assessments. The MDS nurse confirmed that hospice care should have been coded in section O, but it was omitted. Both the DON and Administrator expected the MDS to reflect the resident's care status accurately.
Two residents were admitted with significant care needs—one requiring dialysis and continuous oxygen therapy, and another with severe speech impairment due to dysarthria. The baseline care plans completed within 48 hours of admission failed to document these critical needs, omitting dialysis and oxygen requirements for one resident and lacking communication strategies for the other. Staff interviews and record reviews confirmed that these omissions did not align with facility policy or expectations, and resulted in incomplete guidance for care delivery.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
The facility failed to store medications properly, as a CMA stored prepared medications in a cart instead of administering them immediately, risking medication errors. Additionally, expired medications were found in the medication room refrigerators, which staff acknowledged could cause harm if used. The DON and Administrator were unaware of these expired medications, despite facility policy requiring their removal.
The facility failed to notify the State LTC Ombudsman about a resident's discharge, as required by policy. The resident, who had been admitted with multiple diagnoses, was discharged to a group home without the Ombudsman being informed. The Social Services Director typically sent a monthly discharge list to the Ombudsman, but this procedure was not followed, resulting in the oversight.
A resident admitted after a fall with a vertebrae fracture and facial bruises did not have a Baseline Care Plan for pain management developed within 48 hours as required. The resident experienced pain and requested medication, but the prescribed oxycodone was not administered until several days later. An LPN admitted to an error in the care plan documentation, and the facility administrator expected adherence to care plan policies.
A resident with a cervical fracture did not receive scheduled oxycodone for pain management because the nurse claimed it was unavailable, despite it being in the emergency medication kit (EMK). The LPN and Unit Manager failed to use the EMK or consult the APRN present. The medication was eventually given later in the day. The DON and Administrator acknowledged the oversight.
A facility failed to implement enhanced barrier precautions for a resident with a suprapubic catheter. An LPN was observed administering medication and taking the resident's blood pressure without using the required gown and gloves, contrary to the facility's EBP policy. The LPN misunderstood the policy, thinking PPE was only needed for physical care activities. This issue was identified by the IP Nurse, who noted a gap in the LPN's understanding of the updated policy.
Failure to Accurately Document Hospice Care in MDS Assessment
Penalty
Summary
The facility failed to accurately document a resident's hospice care status in the Minimum Data Set (MDS) assessments. A resident admitted with diagnoses including acute respiratory failure, dementia, and anxiety began receiving hospice care prior to the completion of both a Significant Change MDS and a Quarterly MDS. However, review of these assessments showed that hospice care was not coded in section O as required. The MDS nurse confirmed during interview that hospice care should have been indicated in section O, and acknowledged that it was not documented for this resident in either assessment. Both the DON and the Administrator stated their expectation that MDS records should accurately reflect each resident's care status.
Failure to Accurately Complete Baseline Care Plans for Immediate Resident Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that accurately reflected the immediate needs of two residents. For one resident admitted with end stage renal disease (ESRD) requiring dialysis and chronic respiratory failure requiring continuous oxygen therapy, the baseline care plan did not document the need for dialysis or oxygen use, despite these needs being clearly indicated in the hospital discharge summary, physician orders, and clinical orders. The care plan instead marked that the resident was not receiving dialysis and did not check the box for oxygen usage. Interviews with staff confirmed that the baseline care plan should have included these needs, and that missing or inaccurate information could result in improper care. Another resident was admitted with a history of cerebral infarction, dysphasia, and Alzheimer's disease, and had a moderate cognitive impairment. The baseline care plan for this resident did not include any goals or interventions for staff to use when communicating with the resident, despite clear evidence of significant speech difficulties and dysarthria. Observations and interviews with staff revealed that the resident struggled to communicate, was often not understood by staff, and became frustrated as a result. The care plan and supporting documentation did not indicate the resident's speech impairment, and staff acknowledged that the assessment tools used did not adequately capture or communicate the resident's communication needs. Facility policy required that a baseline care plan be developed and implemented within 48 hours of admission, including all initial goals and interventions based on admission and physician orders, therapy services, and other relevant information. However, the facility did not ensure that the baseline care plans for these residents included the minimum necessary healthcare information to properly care for them, specifically omitting critical needs related to dialysis, oxygen therapy, and communication strategies for speech impairment. Interviews with facility leadership and staff confirmed that these omissions were not in line with expectations and could result in residents not receiving appropriate care.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Deficiencies in Medication Storage and Administration
Penalty
Summary
The facility failed to store medications and biologicals in accordance with professional standards, as observed during a survey. Certified Medication Aide (CMA) 11 was found to have prepared medications for two residents, R121 and R122, but did not administer them immediately. Instead, the medications were stored in the top drawer of the medication cart, which is against the facility's policy. The North Unit Manager (NUM) observed this practice and informed CMA11 that it was unacceptable, as it could lead to medication errors and hinder residents' rights to refuse medication. CMA11 admitted to storing the medications in the cart to avoid delays in his schedule. Additionally, the facility's medication storage practices were found to be deficient. During an inspection of the medication room refrigerators, expired medications were discovered. R34's Magic Mouthwash and several doses of the antibiotic Daptomycin for residents R106 and R211 were found to be expired. Licensed Practical Nurses (LPN) 3 and 4 acknowledged the presence of expired medications and the potential harm they could cause if administered. The Director of Nursing (DON) and the Administrator were not aware of the expired medications, although the facility's policy required staff to remove such medications from stock. The facility's failure to adhere to its medication administration and storage policies resulted in deficiencies related to the improper handling and storage of medications. The survey highlighted the need for staff to follow established procedures to ensure the safe and effective administration of medications, as well as the removal of expired medications from inventory.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman about the discharge of a resident, identified as R111, as required by their policy. The facility's policy mandates that the Ombudsman be informed of any facility-initiated transfer or discharge. However, in the case of R111, who was discharged on November 12, 2021, no such notification was made. The resident had been admitted to the facility with diagnoses including renal and perinephric abscess, schizoaffective disorder (bipolar type), and dementia with behavioral disturbances. The discharge note indicated that R111 was medically stable and safe to return to his group home, where he would receive 24/7 care. The Social Services Director (SSD) admitted during an interview that she typically compiled a list of discharges at the end of each month and sent it to the Ombudsman at the beginning of the following month. However, she acknowledged that there was no documentation of R111's discharge being included in this notification process. The facility's Administrator confirmed that the procedure of sending a monthly discharge list to the Ombudsman was not followed in this instance, leading to the oversight.
Failure to Implement Timely Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement a Baseline Care Plan within 48 hours for a resident, identified as R212, who was admitted after a fall resulting in a vertebrae fracture and facial bruises. The care plan for pain management was not developed within the required timeframe. The facility's policy mandates the creation of a comprehensive person-centered care plan that includes measurable objectives and time frames to address a resident's medical, nursing, mental, and psychosocial needs. However, the 48-hour care plan for R212, dated the day after admission, lacked documented evidence of interventions for pain management. Observations and interviews revealed that R212 was experiencing pain, particularly in the right arm, and had requested pain medication, which was not available at the time. The resident did not receive the prescribed pain medication, oxycodone, until several days after admission. Instead, Tylenol was administered, which provided some relief. An LPN responsible for documenting the care plan admitted to mistakenly not addressing pain management in the care plan. The facility administrator stated that staff are expected to provide pain relief and adhere to care plan policies when a resident is in pain.
Failure to Administer Pain Medication from Emergency Kit
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R212, who required such services. R212, who had been admitted with a displaced fracture of the sixth cervical vertebra and other conditions, had an order for oxycodone to manage pain. On the morning of 08/26/2024, R212 requested pain medication, but the nurse informed her that it was unavailable, despite the medication being present in the facility's emergency medication kit (EMK). The resident experienced pain but was able to eat breakfast and lunch. The Licensed Practical Nurse (LPN) and Unit Manager did not consider using the oxycodone from the EMK or obtaining a one-time order from the Advanced Practice Registered Nurse (APRN) who was present at the facility. The APRN was later called to write a stat prescription and confirmed the resident's moderate pain. The medication was eventually administered in the afternoon after being withdrawn from the EMK. The Director of Nursing and the Administrator acknowledged that the pain medication should have been administered from the EMK when initially requested by the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during medication administration and resident care for one resident, identified as R53, who was under EBP due to having a suprapubic catheter. On the specified date, an LPN was observed administering medication and taking the resident's blood pressure without donning the required gown and gloves, as mandated by the facility's EBP policy. The policy required the use of personal protective equipment (PPE) for high-contact activities, including those involving residents with indwelling medical devices. The LPN misunderstood the policy, believing that gown and gloves were only necessary for physical care activities such as dressing changes or catheter care. This misunderstanding was identified when the Infection Prevention (IP) Nurse entered the room and addressed the LPN's failure to use PPE. The IP Nurse confirmed that the staff had been educated on the updated EBP policy, which was enacted in May 2024, but acknowledged a gap in the LPN's understanding of the requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 65 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hartland Park Health & Rehabilitation | 0.9 mi | ★★★★★ | 4 | 0 |
| Mayfair Manor | 1.8 mi | ★★★★★ | 7 | 0 |
| Sayre Christian Village Nursing Home | 1.9 mi | ★★★★★ | 0 | 0 |
| Lexington Premier Nursing & Rehab | 2.7 mi | ★★★★★ | 0 | 0 |
| The Willows At Fritz Farm | 3.1 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bluegrass Care & Rehabilitation Center.
100% money-back within 48 hours.
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.