Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jordan Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to Follow Transfer Care Plan: Staff failed to follow a resident’s care plan requiring a mechanical lift for transfers. The resident had dementia, stroke, reduced mobility, and severe cognitive impairment. CNA8 and CNA9 transferred the resident back to bed without the lift, while an LPN reported the resident was resisting and hitting staff. The DON and Administrator stated staff were expected to follow the care plan.
Failure to Obtain Medication-Specific Informed Consent for Psychotropic Drugs: The facility used blanket behavior modification consent forms that did not identify the specific psychotropic meds, doses, routes, indications, risks, benefits, alternatives, or monitoring for several residents receiving antipsychotics, antidepressants, anxiolytics, and sedative-hypnotics. Records showed residents with dementia or severe cognitive impairment, as well as one cognitively intact resident, were receiving meds such as quetiapine, haloperidol, lorazepam, aripiprazole, sertraline, venlafaxine, trazodone, mirtazapine, zolpidem, diazepam, amitriptyline, and cariprazine without medication-specific informed consent documentation.
The facility failed to maintain its infection prevention and control program when a resident with shingles did not have transmission-based precaution signage posted and a CNA entered the room without the required PPE. The report also found that shared sinks serving two resident rooms were covered and unusable, and staff used a mechanical lift for multiple residents without disinfecting it between uses, despite policy and staff training requiring cleaning after each resident use.
The facility failed to maintain comprehensive, person-centered care plans for residents with repeated falls. Three residents with dementia and other conditions had multiple fall incidents, but their CCPs mainly documented physician evaluation and did not consistently include resident-specific interventions tied to the causes of the falls, and some interventions were not reflected on the CNA Kardex used by staff for daily care.
Failure to provide clean clothing, clean linens, and grooming assistance for a dependent resident. The resident had dementia, limited mobility, and severe cognitive impairment, and the care plan called for total ADL assistance, including dressing and grooming. Surveyors observed the resident in a stained shirt with stained bed linens and disheveled hair on repeated observations, even after staff had reportedly provided personal care. Staff, the DON, and the Administrator stated residents were expected to be kept clean, dressed in clean clothing, and well-groomed.
Failure to provide meaningful one-to-one activities for two residents with severe cognitive impairment. One resident had dementia, anxiety, psychosis, and was non-ambulatory and dependent for multiple ADLs; the other had cerebral infarction, TBI, severe dementia, and was bedbound and fully dependent. Records showed care plan preferences for one-to-one visits and reading, but documentation was incomplete or marked N/A, and survey observations repeatedly found both residents in bed with eyes closed and no active or passive activities observed.
The facility did not consistently provide substantial bedtime snacks to residents who required assistance, resulting in a period exceeding 14 hours between supper and breakfast. Observations and interviews revealed that snacks were not always available or distributed after supper, and nourishment refrigerators were not adequately stocked, despite staff expectations that all residents would be offered snacks.
Surveyors found that food items in storage were not labeled or dated, and staff failed to follow proper procedures for food thermometer use and food cart sanitation. Food thermometers were inserted through plastic wrap, risking cross contamination, and food trays were placed on wet utility carts. These actions did not comply with facility policies or professional standards for safe food handling.
Residents did not receive mail on Saturdays because there were no staff available to deliver it, and mail was held at the post office until Monday. Interviews with two residents confirmed the lack of Saturday mail delivery, and staff acknowledged that activities staff, who deliver mail, do not work weekends. The Social Services Director reported that this practice has been in place since 2021 to prevent residents from accessing undelivered mail, and the Administrator was unaware of the ongoing issue.
A resident with a history of service-related PTSD did not have this diagnosis or related triggers documented in their care plan, despite staff interviews and assessments indicating its presence. The care plan only addressed preferences for individual activities and pharmacological treatment for depression and anxiety, omitting PTSD-specific needs. Key staff were unaware of the PTSD diagnosis, and the trauma questionnaire was incomplete, resulting in the resident's care plan not reflecting all identified needs.
A resident was observed vaping while receiving oxygen via nasal cannula in her room, exposing her roommate to secondhand aerosol. Facility policies and educational materials did not address the risks of vaping around oxygen or the storage of nicotine liquid, and staff were unaware of the dangers. Both residents involved were cognitively intact, and the care plan did not specifically address the risk of vaping while on oxygen.
A resident's tube feeding and CBI tubing were left uncovered and open to air after being disconnected, contrary to facility policy and manufacturer instructions. Staff interviews confirmed that the required protective caps were not used, and the nurse responsible was unaware of the specific covers, resulting in a failure to maintain proper infection control practices.
A resident was observed using a vape while receiving oxygen via nasal cannula in the presence of another resident, and the facility's policy did not address vaping with oxygen, secondhand exposure, or storage of nicotine liquid. Staff and residents reported not receiving education on these risks, and leadership acknowledged gaps in the policy and understanding of vaping safety.
Failure to Follow Transfer Care Plan
Penalty
Summary
The facility failed to follow the care plan for one sampled resident, R4, who was identified as requiring a mechanical lift for transfers. R4 was admitted with diagnoses including dementia, stroke, and reduced mobility, and had a BIMS score of 5 out of 15, indicating severe cognitive impairment. Her care plan, initiated on 12/04/2025, stated she was totally dependent on two staff for transfers with use of a mechanical lift. On 05/08/2026, CNA8 and CNA9 transferred R4 back to bed without using the mechanical lift. During interview, LPN1 stated she was called to the room while the CNAs were attempting to get R4 back to bed and that R4 was swinging her arms and hitting the CNAs. LPN1 stated she did not know R4 required a mechanical lift for transfers. The DON stated the mechanical lift was not used for the transfer and that staff were expected to follow the care plan for resident transfers. The Administrator also stated he expected staff to follow the care plan for all residents concerning transfers.
Failure to Obtain Medication-Specific Informed Consent for Psychotropic Drugs
Penalty
Summary
The facility failed to ensure that residents were fully informed in advance of the risks and benefits of proposed care, treatment alternatives, and treatment options, and failed to document that residents or responsible parties were given the opportunity to ask questions and make an informed decision regarding psychotropic medication treatment. Review of the facility’s resident rights document showed residents had the right to be fully informed in advance of the risks and benefits of proposed care and treatment alternatives. For six sampled residents, the Behavior Modification Consent forms were generic and did not identify the specific medication(s) being consented to. The forms also did not include the medication name, dosage, frequency, route, diagnosis or clinical indication, targeted behaviors or symptoms, expected benefits, potential material risks or adverse effects, alternative treatment options, duration of treatment, monitoring parameters, or documentation that the resident or responsible party had an opportunity to ask questions and make an informed decision. The residents involved included one with severe cognitive impairment and active sertraline therapy, one cognitively intact resident receiving multiple psychotropic medications including lorazepam, cariprazine, venlafaxine, trazodone, mirtazapine, and zolpidem, and several residents with severe cognitive impairment or dementia who were receiving antipsychotic or sedative medications. The record review showed active orders for psychotropic medications such as quetiapine, aripiprazole, haloperidol, lorazepam, diazepam, amitriptyline, sertraline, venlafaxine, trazodone, mirtazapine, zolpidem, and cariprazine, but the consent forms did not specify these medications or their associated information. Interviews with the DON and Administrator confirmed that the admission consent was a blanket consent and was not intended to serve as consent for specific medications, and that there was no separate consent process for individual psychotropic medications when ordered. The SVPRA stated the facility did not have a written policy for obtaining consent for psychotropic medications and relied on CMS guidelines for medication consent practices.
Infection Control Failures With Precautions, Handwashing Access, and Lift Cleaning
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 7 of 40 sampled and supplemental residents, including residents with shingles, residents in rooms with inaccessible sinks, and residents who used a mechanical lift without it being disinfected between uses. The report states the facility’s policy required transmission-based precautions for residents with infections or communicable diseases, required isolation signs to alert staff and visitors, and required staff to follow infection prevention procedures and demonstrate competence in those practices. Resident R66 was diagnosed with herpes zoster (shingles) on 04/10/2026 and had an antiviral order entered. However, observation on 04/14/2026 at 10:45 AM showed no transmission-based precaution signage posted outside the room. Later that day, a Contact Precaution sign was posted, but CNA4 entered the room with a lunch tray without gloves or a gown. CNA4 stated the sign was new and said she had never seen it before, and she believed the resident did not need precautions because he did not have anything going on. The record review also showed the contact precaution order was created by the IP on 04/14/2026 to begin on 04/10/2026, and staff interviews showed the ADON, DON, IP, and Administrator were aware the signage should have been posted and followed. The report also found that the common sinks shared between two resident-occupied rooms were completely covered in clear plastic and inaccessible for use, affecting residents R77, R35, and R13. CNA7 stated she would have to go to the shower room down the hall to wash her hands after caring for residents in those rooms, and the Maintenance Director stated the sinks had been out of order since 04/08/2026 because they shared a common drainpipe and parts had not yet been received. In addition, observations on 04/15/2026 and 04/16/2026 showed CNA3 and CNA10 used the mechanical lift for residents R42, R71, and R33 and did not disinfect it between resident uses. CNA3 stated she did not clean the lift after using it for R42, and CNA10 stated she did not clean it because she was in a hurry. The IP, DON, and Administrator all stated the lift was supposed to be cleaned between each use.
Incomplete Fall Care Plans and Missing Resident-Specific Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for residents with repeated falls. The deficiency involved 3 of 9 sampled residents, including residents with dementia and impaired cognition, whose assessments identified fall risk and related needs, but whose care plans did not consistently include resident-specific interventions tied to the causes of their falls. The facility’s policy required comprehensive care plans to address medical, nursing, mental, and psychosocial needs identified in the assessment and to be reviewed and revised by the IDT after assessments and changes in condition. For one resident with dementia, PTSD, and repeated falls, the record showed numerous fall incidents over several months, including falls with redness to the jawline, a knot to the head, red/purple discoloration to the arm and shoulder, a head laceration requiring hospital transfer and staples, and other falls with no injury. Although the resident’s care plan repeatedly documented only that a physician should evaluate, it did not consistently add resident-specific interventions after each fall. One fall record noted the resident refused footwear, but the care plan did not include an intervention to address that refusal, and the CNA Kardex did not reflect it. The CNA Kardex contained general fall-prevention measures such as shoes, call bell use, unobstructed pathways, safe environment, and low bed position. For a second resident with dementia, failure to thrive, gait and mobility problems, and muscle weakness, the record showed falls with no injury, redness to the knee, and a skin tear to the elbow. The care plan again primarily documented physician evaluation, and one fall-related intervention of mats by the bed was not reflected on the CNA Kardex. For a third resident with dementia, altered mental status, skin picking disorder, gait abnormalities, and muscle weakness, the record showed four falls in 120 days, including falls with no injury, discoloration to the hand, and redness to the face/cheek. The care plan documented physician evaluation after each fall, and the CNA Kardex listed general safety interventions, but the record did not show resident-specific fall interventions tied to the fall causes. Staff interviews confirmed that the CNA Kardex was used by CNAs for resident care, that fall interventions should be current on both the care plan and Kardex, and that the MDS nurse and clinical team were responsible for updating care plans, though audits to ensure accuracy were not confirmed.
Failure to Provide Clean Clothing, Linens, and Grooming Assistance
Penalty
Summary
The facility failed to provide necessary ADL care to maintain one dependent resident, R11, in a clean manner. R11 was admitted with dementia, atrial fibrillation, and limited mobility, and the quarterly MDS showed severe cognitive impairment, no BIMS score recorded, rarely or never making decisions, and dependence for bathing, dressing, and personal hygiene. The care plan identified total assistance needs for ADLs, including dressing and grooming, as well as bathing, toileting, transfers, bed mobility, and eating. During observation, R11 was found lying in bed wearing a t-shirt with dried brown stains around the neckline and chest area that were hardened to the touch, with similarly stained blanket and bed linens, and hair that was uncombed and disheveled. On a later observation, after staff had reportedly just provided personal care, R11 remained in the same stained shirt with the same stained linens and still had uncombed, disheveled hair. R11 repeatedly asked for a clean shirt. A family member stated R11 had previously been particular about personal cleanliness and preferred to be kept clean. Staff interviews confirmed responsibility for keeping residents clean, dressed in clean clothing, with clean linens, and receiving grooming assistance, and the DON and Administrator stated residents should be kept clean and well-groomed.
Failure to Provide Meaningful One-to-One Activities
Penalty
Summary
The facility failed to provide an ongoing activities program that supported residents’ choices based on their comprehensive assessments, care plans, and preferences, specifically one-to-one interaction for 2 sampled residents. The facility policy stated residents should receive an ongoing program of activities based on assessment, care plan, and preferences, and the Activity Director job description required development, implementation, supervision, and evaluation of activities to meet residents’ social, psychosocial, and therapeutic needs. Review of the records and observations showed that both residents were frequently observed in bed with eyes closed and no active or passive activities were observed during the survey period. Resident 12 was admitted with diagnoses including dementia, anxiety, psychosis, and mood disturbance disorder. Her care plan included a preference for self-directed activities such as watching television and an intervention encouraging one-to-one activities. Her MDS showed severe cognitive impairment, difficulty concentrating on television, non-ambulatory status, and dependence on staff for multiple ADLs. However, CNA documentation for one-to-one activities was marked Not Applicable for all opportunities, and the activity form listed items such as people watching and watching television on weekdays only, with no activities documented on weekends. During repeated observations, Resident 12 was lying in bed, dressed in bed clothing or a shirt and brief/pajama pants, with eyes closed, and no one-to-one interaction was observed. Resident 13 was admitted with diagnoses including cerebral infarction, traumatic brain injury, cognitive communication deficit, and severe dementia with agitation. Her care plan noted immobility, a preference for one-to-one visits from activity staff and social services, and being read to, while also documenting a preference to stay in bed. Her MDS showed severe cognitive impairment, a blank BIMS score, and total dependence for ADLs, with the resident bedbound and not using a wheelchair. Documentation showed limited one-to-one activity entries, one documented activity assistant entry, and group activity documentation, but the activity form did not show one-to-one activities or resident response. During repeated observations, Resident 13 was lying in bed with eyes closed, and no active or passive activities were observed.
Failure to Provide Substantial Bedtime Snacks to Residents Needing Assistance
Penalty
Summary
The facility failed to provide substantial snacks to residents who required assistance at meals, as evidenced by the time between supper and breakfast exceeding 14 hours. Observations revealed that total assist residents received supper at 4:30 PM and breakfast at 7:00 AM, with no substantial snacks available in the nourishment refrigerator on the unit. Resident Council members reported that snacks were not offered after supper, and although snacks were said to be available at the nurses' station, they were not distributed. Review of the facility's snack lists showed limited and inconsistent offerings, with some days lacking substantial options. Interviews with dietary and nursing staff indicated that not all residents received labeled snacks at bedtime, and extra snacks were not always available for those who were hungry later at night. The nourishment refrigerators were inconsistently stocked, and some staff assumed that snacks were being offered without direct verification. The Director of Nursing and Administrator both stated that snacks were sent out and should be offered to all residents, but evidence from observations and interviews contradicted this expectation, highlighting a gap in the actual provision of snacks to residents, particularly those needing assistance.
Deficient Food Storage and Unsafe Food Handling Practices
Penalty
Summary
Surveyors identified multiple failures in food storage and service practices within the facility's kitchen. During an initial tour, foods in the walk-in refrigerator, freezer, and dry storage were found not labeled or dated, including heads of lettuce, mixed peppers, and a case of whole tomatoes left open on the bottom shelf. Various frozen and dry food items were also observed out of their cases and not dated. These practices were not in accordance with the facility's own policy, which requires all foods to be labeled, dated, and rotated using the first-in, first-out (FIFO) method to ensure freshness and prevent bacterial growth. Further observations during the supper meal tray line revealed improper use of food thermometers, as the Dietary Manager was seen pushing thermometers through plastic wrap covering the food on the steam table, which caused the plastic to melt and posed a risk of cross contamination. Additionally, a Dietary Aide was observed using utility carts with wet top shelves to transport food trays, placing trays directly onto the wet surfaces. Interviews with staff, including the Dietary Manager and DON, confirmed that these actions were not in line with best practices or facility policy, and that proper procedures were not followed to ensure safe food handling and service.
Failure to Provide Saturday Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery of mail, letters, and packages. According to interviews with Resident Council members, residents did not receive mail on Saturdays. The facility's policy affirms residents' rights to exercise their rights as citizens, which includes receiving mail. The Postal Service Reform Act of 2022 mandates six-day mail delivery, but the facility did not provide for mail delivery on Saturdays. Interviews with staff revealed that activities staff were responsible for delivering mail, but no activities staff worked on weekends. As a result, mail delivered on Saturdays was not distributed to residents until Monday. The Social Services Director stated that mail was held at the post office on weekends to prevent residents from accessing undelivered mail, a practice in place since 2021. The Administrator was unaware that residents were not receiving mail on Saturdays and believed that mail delivery interruptions had ended after the pandemic. This practice had the potential to affect all 92 residents in the facility.
Failure to Develop and Implement Comprehensive Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of service-related PTSD, as required by policy. Although the resident's care plan noted a preference for individual activities and included pharmacological interventions for depression and anxiety, it did not document the resident's PTSD diagnosis, potential triggers, or specific interventions to address these needs. The resident's trauma questionnaire was incomplete and did not address emotional responses or physical injuries related to traumatic events. The diagnosis of PTSD was not included in the resident's MDS or the facility's matrix provided to surveyors. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and associated triggers. The Activities Team Leader was unaware of the PTSD diagnosis and did not participate in interdisciplinary meetings, relying solely on the care plan for information. The MDS Nurse acknowledged the omission of PTSD from the MDS assessment, and the DON was unaware of the diagnosis and its absence from the care plan. As a result, staff were not informed of the resident's specific needs related to PTSD, and the care plan was not updated to reflect all identified needs from the comprehensive assessment.
Failure to Prevent Accident Hazards Related to Vaping and Oxygen Use
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by allowing a resident to use a vape (e-cigarette) while receiving oxygen via nasal cannula in her room. Observation confirmed that the resident was using a vape while on four liters of oxygen, with her roommate present and exposed to secondhand vaping aerosol. The facility's policy on electronic cigarettes did not address the risks associated with oxygen use, storage of nicotine liquid, or the exposure risk of others to secondhand smoke. Additionally, educational materials provided to residents and families did not mention the dangers of vaping while using oxygen. Record review showed that the resident using the vape had diagnoses including COPD, chronic kidney disease, and type 2 diabetes mellitus, and was assessed as cognitively intact. The care plan and smoking assessment noted daily vaping and the need to monitor for safety concerns, but did not specifically address the risk of vaping while on oxygen. Interviews with staff, including a KMA and the DON, revealed a lack of awareness regarding the dangers of vaping around oxygen, with both initially believing it was safe. The roommate had not been educated on the risks of secondhand exposure from vaping.
Uncovered Medical Tubing Leads to Infection Control Deficiency
Penalty
Summary
A deficiency occurred when a resident's tube feeding tubing and continuous bladder irrigation (CBI) tubing were left uncovered and open to air after being disconnected from the resident. Observation revealed that the tubing remained connected to the source, but the ends intended for the resident were not protected with appropriate coverings, as required by both the manufacturer's directions for use and the facility's infection control policies. The facility's policies specified that protective caps or tip protectors should be used when tubing is not in use to prevent contamination. Interviews with staff, including the nurse responsible for the resident, the Infection Preventionist, and the Director of Nursing, confirmed that the expected practice was not followed. The nurse was unaware of the specific covers for the tubing and acknowledged that leaving the ends open could expose the resident to germs. The Infection Preventionist and DON both stated that staff were expected to adhere to infection control policies, and that failure to cover the tubing increased the risk of infection.
Failure to Address Vaping Safety with Oxygen and Secondhand Exposure
Penalty
Summary
The facility failed to develop and implement effective policies to ensure smoking safety for residents using electronic cigarettes (e-cigarettes or vapes). Specifically, the facility's policy did not address the use of vapes while on oxygen therapy, the storage of nicotine liquid (e-juice), or the exposure risk of others to secondhand vaping aerosol. Observations revealed that one resident used a vape while wearing a nasal cannula delivering four liters of oxygen, with another resident present in the same room. Both residents reported not receiving education on the dangers of vaping with oxygen or the risks of secondhand exposure. The facility's staff, including the DON and RN, acknowledged a lack of education and policy guidance regarding vaping in the presence of oxygen and secondhand exposure. Interviews with facility leadership and staff indicated that the dangers of vaping while on oxygen and the risks to bystanders were not considered during policy development. The DON and Medical Director expressed misconceptions about the safety of vaping with oxygen and did not address the risks of secondhand exposure or proper storage of nicotine liquids. The facility's current policy was found to be incomplete, lacking provisions for oxygen use, secondhand exposure, and safe storage of vaping materials, resulting in a failure to protect residents and staff from potential harm.
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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 Louisa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wayne Healthcare Center | 13.6 mi | ★★★★★ | 4 | 0 |
| Martin County Health Care Facility | 16.5 mi | ★★★★★ | 3 | 0 |
| Boyd Nursing And Rehabilitation | 21.2 mi | ★★★★★ | 7 | 0 |
| Mountain Manor Of Paintsville | 21.6 mi | ★★★★★ | 0 | 0 |
| Riverview Post Acute | 21.7 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.