Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Elliott Nursing And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to accurately code MDS assessments for two residents by listing antiplatelet drugs as anticoagulants in the N0415 high-risk drug class section. One resident with a history of CVA and moderate cognitive impairment was taking clopidogrel for blood clot prevention, and another resident with CHF and severe cognitive impairment was taking ticagrelor for blood thinner therapy; both were incorrectly coded as receiving anticoagulants. The RNAC stated she misclassified both medications, and the DON confirmed that ticagrelor and clopidogrel are antiplatelet medications, not anticoagulants.
A resident with psychiatric diagnoses and severe cognitive impairment had repeated missed and delayed risperidone IM doses, with MAR entries showing omissions, “on order” notes, and gaps of 17 and 29 days between injections. A second resident with AFib, CHF, and HTN had multiple MAR entries showing metoprolol, verapamil, and midodrine were documented as given even when BP was outside the ordered hold parameters. Interviews with the RN, LPN, pharmacist, NP, DON, and ED confirmed the omissions and incorrect administrations were inconsistent with the physician orders and MAR documentation practices.
Failure to perform hand hygiene and glove changes during wound care. A resident with bilateral heel wounds, diabetes, HF, HTN, and lymphedema received wound care when the DON removed soiled dressings, then used the same gloves to handle sterile gauze, wound cleanser, and cleanse both heels without hand hygiene or glove changes between wounds. RN2 stated she would change gloves and perform hand hygiene between dirty and clean tasks, and the ADON/IP stated staff were expected to do so during wound care.
Improper Dumpster and Refuse Disposal: The facility failed to dispose of refuse in a sanitary manner. Observation showed dumpsters in a fenced area outside the kitchen with scattered trash, including gloves, empty glove boxes, and a garbage bag left in the corner. One dumpster lid was open and remained open on later observations. The DM, Maintenance Director, DON, and ED each stated staff or anyone using the dumpsters were responsible for keeping the area clean and the lids closed.
Surveyors found that medications, including insulin and ophthalmic solutions, were stored at incorrect temperatures, not properly labeled or dated, and kept in unsanitary conditions. Staff, including LPNs, RNs, and the DON, were unable to state correct storage requirements, and expired medications were present in medication carts and refrigerators. Facility policy on medication storage, labeling, and separation was not consistently followed, as confirmed by staff interviews and direct observation.
Two residents with specific dietary needs and food dislikes did not have their preferences honored, despite communicating them to staff. One resident with diabetes continued to receive bread, pasta, and desserts, while another received broccoli and cauliflower despite expressing a dislike. Menu tickets and dietary records did not consistently reflect these preferences, and staff interviews revealed inconsistent processes for collecting and updating food preferences.
The facility failed to ensure staff cleaned and disinfected the glucometer after use on a resident, leading to potential cross-contamination among residents, including one with viral hepatitis. The LPN admitted to forgetting to disinfect the glucometer and used an inappropriate disinfectant when prompted. Interviews confirmed that the facility's policy required the use of Micro-Kill wipes for disinfection, which was not followed.
The facility failed to develop and implement comprehensive care plans for two residents, leading to a stage 3 pressure ulcer in one resident and unmet medication timing preferences in another. Staff did not consistently follow care plan interventions, and resident preferences were not documented or communicated effectively.
A resident with multiple health conditions developed a stage 3 pressure ulcer due to the facility's failure to consistently turn and reposition her every two hours as required by the care plan. The facility lacked a policy on skin care and pressure ulcer prevention, and staff did not document or perform the necessary interventions, leading to the ulcer's development.
A resident with congestive heart failure, atrial fibrillation, and primary hypertension expressed a preference to receive her blood pressure medication at 8:00 AM, but often had to wait until between 10:00 AM and 11:00 AM. The facility's policy to honor residents' medication administration preferences was not followed, and staff were unaware of the resident's expressed preference.
The facility failed to protect a resident from abuse when another resident with severe dementia physically assaulted him, causing a nosebleed. The incident occurred after the aggressor entered the victim's bathroom and became agitated when told to leave. Despite the facility's policies, the incident was not prevented, indicating a deficiency in abuse prevention measures.
Inaccurate MDS Coding for Antiplatelet Medications
Penalty
Summary
The facility failed to accurately code MDS assessments for 2 residents, R1 and R50, by misclassifying antiplatelet medications as anticoagulants in the N0415 high-risk drug class section. The facility policy titled Accurate Assessment stated that residents must receive an accurate assessment reflective of their status, and the CMS RAI Manual instructed that high-risk drug classes be coded by pharmacological classification, with antiplatelet medications such as clopidogrel and ticagrelor not coded as anticoagulants. R1 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction. On the significant change in status MDS, the resident had a BIMS score of 11 out of 15, indicating moderate cognitive impairment, and the MDS indicated anticoagulant use during the 7-day lookback period with an indication noted. However, the order recap showed an order for clopidogrel 75 mg daily for blood clot prevention and no anticoagulant orders. The RNAC stated she incorrectly coded the assessment because she thought clopidogrel was an anticoagulant. R50 was admitted with chronic systolic heart failure and had a BIMS score of 5 out of 15 on the annual and quarterly MDS assessments, indicating severe cognitive impairment. Those assessments also indicated anticoagulant use during the lookback period with an indication noted, but the order recap showed ticagrelor 90 mg twice daily for blood thinner and no anticoagulant orders. The RNAC stated she reviewed orders and MARs to determine medications and coded R50's assessments incorrectly because she thought ticagrelor was an anticoagulant. The DON stated both ticagrelor and clopidogrel were antiplatelet medications, not anticoagulants, and should be coded appropriately.
Medication administration errors with missed psychotropic doses and blood pressure medications given outside ordered parameters
Penalty
Summary
The facility failed to keep residents free from significant medication errors for two residents. One resident had diagnoses including generalized anxiety disorder, bipolar disorder, major depressive disorder with psychotic symptoms, and psychotic disorder with hallucinations due to a known physiological condition, and had severe cognitive impairment with a BIMS score of 5 out of 15. The resident’s care plan directed staff to administer psychotropic medications as ordered. Review of the order recap and MAR showed repeated risperidone 25 mg IM orders scheduled every 14 days, but the MAR also showed multiple missed administrations and delayed doses, including gaps of 17 days and 29 days between injections. Progress notes documented that the medication was not available or was on order, and staff documented that the pharmacy was aware or that the medication was on order. Interviews showed staff expected to document omissions and notify the physician and family or resident when medication was unavailable, but the RN who documented one omission stated she did not know why there was a delay, and another RN stated she ordered immediate delivery but did not know whether the medication was later administered. The pharmacist stated risperidone was scheduled every 14 days because of its pharmacokinetics and that the wide gaps could affect therapeutic levels. The psychiatric nurse practitioner stated she had not been contacted about the unavailability of risperidone and expressed concern that the medication could become subtherapeutic and the resident might decompensate quickly if it wore off. The DON and ED both stated they expected medications to be administered promptly and physicians to be notified when doses were not given. A second resident had diagnoses including atrial fibrillation, congestive heart failure, and hypertension, and had severe cognitive impairment with a BIMS score of 4 out of 15. The resident’s care plan identified risk for impaired cardiac output and directed staff to administer medications as ordered and check vital signs as ordered. The resident had orders for midodrine, metoprolol tartrate, and verapamil with specific hold parameters based on blood pressure and pulse. Review of the MARs for multiple months showed numerous instances where metoprolol and verapamil were documented as administered even though the resident’s blood pressure was below the ordered parameters, and one instance where midodrine was documented as administered when the systolic blood pressure was above the ordered parameter. During interview, the LPN stated that if vital signs were out of range the medication should be held, and if the MAR did not show a hold code then the medication was considered given. The LPN reviewed the MARs and stated she was not aware she had not followed the physician’s orders so many times. RN2, the NP, the DON, and the ED all stated that giving medications outside ordered parameters was a medication error and that staff were expected to follow the physician’s orders and document accurately whether medications were given or held.
Failure to Perform Hand Hygiene and Glove Changes During Wound Care
Penalty
Summary
The facility failed to ensure nursing staff completed hand hygiene and glove changes between wound care tasks during treatment of one resident with bilateral heel wounds. The resident was admitted with diagnoses including type 2 diabetes with hyperglycemia, heart failure, essential hypertension, and lymphedema, and had a significant change MDS showing moderate cognitive impairment with one unstageable pressure ulcer and pressure ulcer care needs. The care plan identified an unstageable pressure area to the right heel, and active orders directed daily wound care to both heels. During observation of wound care, the DON assisted RN2 with the resident’s bilateral heel treatments. The DON removed the dressings from both heels with gloved hands and discarded them, then without removing her gloves or performing hand hygiene, handled sterile gauze and wound cleanser from the bedside table and cleansed the right heel. Without changing gloves or performing hand hygiene between wounds, the DON then grabbed another stack of gauze and cleansed the left heel with the same gloves. The remainder of the treatment was completed by RN2. During interview, RN2 stated she would change gloves and perform hand hygiene after removing soiled dressings, after cleansing each wound, and at the end of the procedure, and said cross-contamination could occur if two wounds were addressed at the same time. The ADON, who was also the IP, stated staff were expected to perform hand hygiene and glove changes between dirty and clean aspects of wound care and should not address more than one wound at a time, especially when wounds were close together. The DON acknowledged she did not change gloves after removing the soiled dressings, used the same gloves to wash both heel wounds, and touched the wound cleanser bottle, stating she knew better and had been trying to help RN2.
Improper Dumpster and Refuse Disposal
Penalty
Summary
The facility failed to dispose of refuse in a sanitary manner. Review of the facility policy titled, Garbage and Refuse, dated 10/01/2025, showed that garbage and refuse containers were to be kept clean and covered when not in use, and outside dumpsters were to be monitored to remain clean, free of surrounding litter, with lids closed and inaccessible to pests. Observation of the dumpsters with the Dietary Manager revealed dumpsters inside a wooden fenced area just outside the kitchen near the front of the facility, but the area was not closed or gated. Trash was scattered around the dumpster area, including six gloves, two empty boxes for medical gloves, and a garbage bag in the corner of the fenced area. One dumpster lid was open, and later observations showed the lids remained open. The Dietary Manager stated maintenance was responsible for keeping the dumpster area clean and the lids closed. The Maintenance Director stated he was responsible for the dumpster area and that the lids were found open on a regular basis. The DON stated staff were expected to close the dumpster lids when discarding items, and the ED stated anyone using the dumpsters was responsible for making sure the lids were closed and for cleaning up debris if seen.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage practices, including improper labeling, unsanitary conditions, and failure to maintain required temperature ranges for drugs and biologicals. Observations revealed that unopened insulin was stored below the recommended temperature range of 36°F to 46°F in one of two medication refrigerators, with temperature logs showing readings as low as 30°F. Staff members, including LPNs, RNs, and the DON, were unable to state the correct temperature range for refrigerated medications, and the temperature log did not reference the correct parameters or actions to take when temperatures were out of range. Additionally, the main medication refrigerator contained expired medications and medications for discharged residents, and some medications were stored in wet or unsanitary conditions. Further inspection of medication carts revealed unsanitary conditions, with drawers containing trash, spilled liquids, and medications not separated from equipment such as glucometers and blood pressure cuffs. Medications were not consistently labeled or dated, and some insulin pens in use were not stored in a sanitary manner, being placed together in a single section of the drawer without individual bags. Expired medications were found in the carts, and ophthalmic and otic medications were not stored separately as required by facility policy. Staff interviews confirmed a lack of knowledge regarding proper storage, labeling, and separation of medications, as well as the need to discard expired medications. The facility's policy required medications to be stored according to manufacturer recommendations, with regular monitoring of storage conditions and immediate removal of outdated or deteriorated medications. However, observations and staff interviews indicated that these policies were not consistently followed. The consultant pharmacist confirmed the accepted temperature range for refrigerated medications and the need to follow manufacturer guidelines, but also noted uncertainty about some storage practices. The deficiencies were identified through direct observation, record review, and staff interviews, highlighting failures in maintaining safe and effective medication storage.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to honor food preferences for two residents, both of whom had communicated specific dietary needs and dislikes. One resident with diabetes mellitus, who was on a special diet, had requested to avoid bread, pasta, and desserts due to their impact on blood sugar levels, but continued to receive these items on her meal trays. Another resident expressed a dislike for broccoli and cauliflower but continued to receive these vegetables in her meals. Both residents had intact cognition and had communicated their preferences to staff, but these preferences were not consistently reflected in their menu tickets or the facility's dietary records. Observations and interviews revealed inconsistencies between the posted menus and the actual food served, with substitutions being made due to unavailable ingredients. Residents reported that the posted menus were not always followed, and they were not regularly given choices or asked about their food preferences. The facility's policy required that food preferences be identified and honored, with alternatives offered when residents refused certain foods, but this was not consistently implemented. Staff interviews indicated that food preferences were supposed to be collected upon admission, quarterly, and as needed, with changes communicated through clinical meetings and entered into a computer system. However, there were gaps in communication and documentation, as some staff were unaware of specific resident preferences, and the meal tracking system did not always account for dislikes in mixed vegetables. The Registered Dietitian and Account Manager did not consistently visit residents to update preferences, and the process for updating and honoring food preferences was not reliably followed.
Failure to Disinfect Glucometer After Use
Penalty
Summary
The facility failed to ensure staff cleaned and disinfected the blood glucose monitor (glucometer) after obtaining a blood glucose reading on one of seven residents who shared the glucometer on the 100 hall. Specifically, a Licensed Practical Nurse (LPN) did not disinfect the glucometer after using it on a resident diagnosed with type 2 diabetes, chronic kidney disease, and unspecified dementia. The glucometer was then placed back in the medication cart drawer without disinfection, creating a potential risk for cross-contamination among residents, including one diagnosed with viral hepatitis, a bloodborne illness. Observations revealed that the LPN used the glucometer on a resident and failed to disinfect it before placing it back in the medication cart. The LPN admitted to forgetting to disinfect the glucometer and used an inappropriate disinfectant (Medline alcohol swabs) when prompted. Interviews with other staff members, including the Infection Preventionist and the Director of Nursing Services, confirmed that the facility's policy required the use of Micro-Kill wipes for disinfection, which was not followed. The facility lacked an auditing process to ensure compliance with the glucometer cleaning policy after staff orientation.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to significant deficiencies. One resident, admitted with hemiplegia, type 2 diabetes, and cognitive communication disorder, developed a stage 3 pressure ulcer. Despite being assessed as dependent on staff for repositioning and at risk for pressure ulcers, the facility did not consistently turn and reposition the resident as per the care plan. Observations and documentation revealed that the resident was not repositioned routinely, and staff failed to turn the resident every two hours, resulting in the development of a pressure ulcer that was not present upon admission. Interviews with staff confirmed the lack of adherence to the care plan and the vagueness of the intervention instructions regarding repositioning frequency. Another resident, admitted with congestive heart failure, atrial fibrillation, and primary hypertension, expressed a preference for receiving her blood pressure medication at 8:00 AM. However, the resident often did not receive the medication until two to three hours later. The facility failed to include this preference in the resident's care plan, and there was no documentation specifying the time the medication was administered. Interviews with staff revealed that the resident's preference was not communicated or documented in the care plan, and the staff were unaware of the resident's specific request for medication timing. The Executive Director and Director of Nursing Services acknowledged the deficiencies, stating that the facility did not have a specific care planning policy and relied on the Resident Assessment Instrument (RAI) manual. The lack of individualized care plans and failure to accommodate resident preferences and needs led to the identified deficiencies, as confirmed by observations, interviews, and record reviews conducted by the State Survey Agency (SSA) Surveyor.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident at risk for developing pressure ulcers received care consistent with professional standards. The resident, who was admitted with diagnoses including hemiplegia following a stroke, type 2 diabetes, and cognitive communication disorder, developed a stage 3 pressure ulcer. The facility's care plan required staff to turn and reposition the resident every two hours, but documentation revealed that staff did not consistently follow this intervention. Observations and interviews confirmed that the resident was not repositioned as required, leading to the development of the pressure ulcer. The facility did not have a policy on skin care and pressure ulcer prevention, and staff failed to document turning and repositioning the resident according to the care plan. The resident's medical records showed that staff did not turn the resident every two hours on 11 of 17 sampled days, with gaps ranging from one to seven hours between turns. Continuous observation also revealed that the resident was left in a supine position for over three hours without being repositioned, which contributed to the development of the pressure ulcer. Interviews with staff, including the Director of Nursing Services (DNS) and the Medical Director, indicated a lack of compliance with the care plan and a failure to perform audits or root cause analyses to investigate staff compliance with repositioning interventions. The DNS and Executive Director both stated that they trusted staff to follow repositioning standards, but the Medical Director did not consider the wound to be unavoidable, noting that the resident had not significantly declined from her baseline. The facility's interdisciplinary team had not identified any staff noncompliance with repositioning interventions, despite the resident's development of a stage 3 pressure ulcer.
Failure to Honor Resident's Medication Administration Preferences
Penalty
Summary
The facility failed to accommodate a resident's right to set her own daily schedule with respect to medication administration. Resident 65, who was admitted with diagnoses including congestive heart failure, atrial fibrillation, and primary hypertension, expressed a preference to receive her blood pressure medication at 8:00 AM. However, observations and interviews revealed that the resident often had to wait until between 10:00 AM and 11:00 AM to receive her medication. The facility's policy stated that staff should honor residents' preferences for medication administration times, but this was not followed in the case of Resident 65. Interviews with staff members indicated that the delay was due to the medication administration process followed by the Kentucky Medication Aide (KMA), who prioritized residents with more disruptive behaviors and took blood pressure readings for all residents before administering medications. The Director of Nursing Services and the Executive Director were not aware of Resident 65's preference for medication administration times, despite the resident expressing this preference to staff members. The facility's failure to adhere to its own policy resulted in the resident not receiving her medication at her preferred time.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving two residents. Resident 48 reported that Resident 64a hit him in the chest and punched him in the nose, causing a nosebleed. The incident occurred when Resident 64a, who has severe dementia and other behavioral disturbances, entered Resident 48's bathroom. When Resident 48 told Resident 64a that it was not his bathroom, Resident 64a became agitated and physically assaulted Resident 48. Resident 48, who has moderate dementia and is cognitively intact, was sent to the hospital for evaluation, where it was confirmed that his nose was not broken. Both residents were eventually returned to the facility, and psychiatric consultations were initiated for both. The facility's policy on abuse, neglect, and exploitation was reviewed and found to be inadequate in preventing this incident. Staff interviews revealed that the incident was first observed by a State Registered Nurse Aide, who saw Resident 48 covered in blood and reported the assault. The Executive Director confirmed that Resident 64a was placed on one-to-one supervision following the incident. Despite these measures, the facility failed to protect Resident 48 from abuse, highlighting a deficiency in the implementation of their abuse prevention policies.
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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 Sandy Hook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Liberty Nursing And Rehabilitation | 12.8 mi | ★★★★★ | 9 | 0 |
| Life Care Center Of Morehead | 18.1 mi | ★★★★★ | 6 | 0 |
| Carter Nursing And Rehabilitation | 20.8 mi | ★★★★★ | 11 | 0 |
| Salyersville Nursing And Rehabilitation Center | 22.7 mi | ★★★★★ | 2 | 0 |
| Mountain Manor Of Paintsville | 25.6 mi | ★★★★★ | 0 | 0 |
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