Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Letcher Manor during CMS and state inspections, most recent first.
A resident with intact cognition and multiple comorbidities developed fever and abnormal urinalysis results consistent with a UTI, for which an NP ordered a single 3 g dose of Fosfomycin. The MAR showed the antibiotic order and later an entry placing it on hold due to unavailability from pharmacy, without a corresponding provider order or documentation explaining the delay or who was contacted. The medication was not administered until four days after the original order, during which time the resident reported going without treatment and later required ED transfer, where a complicated UTI was diagnosed and treated with IM Rocephin and Toradol.
A facility failed to transmit a resident's discharge MDS Assessment within the required 14-day period as per CMS RAI Manual guidelines. The resident, with diagnoses including muscle wasting and chronic kidney disease, was discharged, but the assessment was not transmitted due to an oversight. MDS Nurses acknowledged the importance of timely transmission, and the Administrator expected adherence to guidelines.
A facility failed to develop a comprehensive care plan for a resident who repeatedly refused wound care for a stage three pressure ulcer. Despite having physician's orders, the resident's refusals were not addressed in the care plan, leaving staff without guidance on managing the situation. Interviews with MDS Coordinators highlighted the need for a care plan to document interventions and their effectiveness.
The facility failed to maintain proper food temperatures, with hot foods below 135 degrees F and cold foods above 41 degrees F, during meal service. Plates were removed from the warmer and allowed to cool, potentially affecting food safety. The Dietary Manager and Administrator acknowledged the issue, emphasizing the importance of serving food at safe temperatures.
The facility failed to maintain proper infection control practices, as evidenced by improper storage of medical and personal care supplies for four residents. Opened packages of briefs were found on bathroom floors, and oxygen and nebulizer tubing were left uncovered, contrary to facility policy. Interviews with the Infection Preventionist and Administrator confirmed these practices were not compliant with infection prevention protocols.
A resident with moderate cognitive impairment and a history of wandering was allowed to enter other residents' rooms and hallways without adequate supervision or implementation of diversional activities as outlined in the care plan. This lack of supervision led to a confrontation with another resident, resulting in physical contact and near injury before staff intervened. Staff interviews confirmed that increased monitoring was not formally documented or consistently provided.
An investigation revealed that an LPN was suspected of being under the influence while on duty, leading to their removal from resident care. Residents reported missing medications, including narcotic opioids and benzodiazepines. Staff members observed the LPN exhibiting impaired behavior and expressed discomfort in performing narcotic counts. The LPN was terminated due to the misappropriation of medications, as confirmed by the DON and Administrator.
The facility had a medication error rate of 13.04%, with errors including incorrect insulin preparation and incomplete administration of crushed medications. Two residents were affected, one with diabetes and another with multiple medication orders.
Delayed Administration of Ordered Antibiotic for UTI
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pharmaceutical services and administer an ordered antibiotic for a resident with a suspected urinary tract infection (UTI). The resident, who had intact cognition and diagnoses including arthropathic psoriasis and morbid obesity, was care planned for elimination deficits with interventions such as PRN straight catheterization for urinalysis and monitoring for UTI signs and symptoms. On one occasion, the resident developed a fever of 102°F, and a urinalysis showed significant abnormalities, including 3+ leukocytes, 3+ bacteria, and red blood cells too numerous to count. Based on these findings, the nurse practitioner ordered a single 3 g dose of Fosfomycin to treat the UTI while awaiting culture results. The medication order for Fosfomycin was entered with a start date of the day after the follow-up note, but the drug was not administered as ordered. The MAR showed that the Fosfomycin was to be given one time by mouth for UTI, and a subsequent entry documented that the medication was on hold because it was not available from the pharmacy. There was no documented physician order to hold the medication, and no progress note was found explaining the delay, who was contacted, or what actions were taken when the medication was reportedly unavailable. The Fosfomycin was ultimately documented as administered four days after the original order date, indicating a significant delay in treatment. Interviews and record reviews further clarified the circumstances leading to the deficiency. The infection preventionist stated that the facility followed McGeer criteria for antibiotic use and that the urinalysis did not meet those criteria, but he was not aware of this specific incident. The DON stated she did not know why the Fosfomycin was not given as ordered, noted that this medication was commonly used and readily available from the pharmacy, and confirmed it was not stocked in the emergency medication supply. The DON also stated her expectation that medications be received timely from the pharmacy and administered to residents, and that any delay in antibiotics could possibly lead to sepsis and pain. The resident reported having gone without treatment for approximately three weeks after developing a UTI, stated she never received the originally ordered one-time antibiotic dose, and later required transfer to the emergency department where she was diagnosed with a complicated UTI and treated with IM Rocephin and Toradol for pain.
Failure to Transmit Discharge Assessment Timely
Penalty
Summary
The facility failed to electronically transmit the discharge assessment for one resident within the required 14-day period as outlined in the CMS Resident Assessment Instrument (RAI) Manual. The resident, who was discharged on an unspecified date, had a Discharge Minimum Data Set (MDS) Assessment that was not transmitted by 02/27/2025. The MDS Assessment, with an Assessment Reference Date (ARD) of 10/07/2024, was completed and signed by the MDS Coordinator on 10/10/2024, but it was listed as Exported and not Accepted, indicating it had not been transmitted and accepted as required. The resident, admitted on 08/28/2024, had diagnoses including muscle wasting and atrophy, chronic kidney disease, anxiety, and anemia. Interviews with MDS Nurses revealed that the failure to transmit the MDS Assessment was due to an oversight, and they acknowledged the importance of adhering to the RAI Manual guidelines for timely transmission. The facility's Administrator also expressed an expectation for MDS staff to complete and transmit assessments in a timely manner according to the RAI Manual.
Failure to Address Resident's Wound Care Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as R88, who had numerous refusals of wound care. R88 was admitted with diagnoses including osteoarthritis, difficulty in walking, and muscle wasting and atrophy. The resident had a documented deep tissue injury to the coccyx, which was assessed as a stage three pressure ulcer. Despite having physician's orders for wound care, the resident repeatedly refused treatment on several occasions. The facility's care plan did not address these refusals or include interventions to manage the resident's noncompliance with wound care. Observations and interviews revealed that the facility did not have a documented care plan for the resident's refusals of wound care. The MDS Coordinators acknowledged the importance of having a care plan to document attempted interventions and their effectiveness in encouraging the resident to accept wound care. The lack of a comprehensive care plan meant that staff did not have a guide to manage the resident's refusals, potentially impacting the resident's skin integrity and overall care.
Food Temperature and Sanitation Deficiency
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner and in accordance with professional standards for food service safety. During a test tray observation, hot food temperatures were found to be below 130 degrees Fahrenheit, and cold food items were above 41 degrees Fahrenheit, which did not meet the facility's policy requirements. Specifically, the turkey was measured at 102.5 degrees F, mashed potatoes at 129.7 degrees F, carrots at 110.9 degrees F, and milk at 43.7 degrees F. The Dietary Manager was unable to explain why the food temperatures were out of range. Additionally, observations revealed that plates were being removed from the plate warmer and placed on the hot bar, allowing them to cool before use in the meal tray line. The Dietary Manager acknowledged that the plate warmer was insufficient to hold all the plates needed during meal service, leading to the cooling of plates and potentially affecting food temperatures. The Administrator confirmed that serving food outside of the safe handling zone could lead to foodborne illnesses and stated the expectation for food to be served at appropriate temperatures.
Infection Control Deficiencies in Supply Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by observations of improper storage of medical and personal care supplies for four residents. Resident 37 and Resident 100 had opened packages of adult protective briefs lying on the bathroom floor, which is against the facility's policy that requires such supplies to be stored in closets or dressers. Resident 95's oxygen nasal cannula was found lying uncovered on the floor, and their nebulizer tubing was uncovered on the bedside table. Similarly, Resident 113's nebulizer tubing was also found uncovered on the bedside table. Interviews with the Infection Preventionist and the Administrator confirmed that these practices were not in compliance with the facility's infection prevention policies. The Infection Preventionist emphasized that oxygen and nebulizer tubing should be stored in bags when not in use to prevent bacterial contamination, and that incontinent supplies should not be left on the bathroom floor or under the sink due to potential infection risks. The Administrator reiterated that incontinent supplies should be stored properly and checked every two hours to prevent infection control issues.
Failure to Provide Adequate Supervision for Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to ensure the safety of its residents, specifically for one resident with moderate cognitive impairment and a history of wandering. This resident, who had diagnoses including vascular dementia, bipolar disorder, and Moyamoya disease, was observed roaming into other residents' hallways and rooms without staff intervention or the provision of diversional activities as outlined in the care plan. Staff interviews confirmed that there were no specific orders or documentation for increased supervision, and redirection was only provided when the resident was seen in inappropriate areas. The care plan for this resident included interventions for increased wandering, but these were not consistently implemented during the observed period. An incident occurred in which another resident, also with moderate cognitive impairment and a history of anxiety and hemiplegia, confronted the wandering resident after alleging that smokeless tobacco had been taken from his room. The confrontation escalated, with one resident grabbing the other's arm and wheelchair, nearly causing a fall, before staff intervened. Staff and administrative interviews revealed that supervision was generally limited to hourly checks, and increased monitoring was only communicated verbally during shift changes, not formally documented or ordered. The lack of consistent supervision and failure to implement care plan interventions led to the deficiency.
Misappropriation of Controlled Substances by LPN
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of property, specifically controlled substances/medications, as evidenced by the misappropriation of medications from eight sampled residents. The investigation revealed that on 03/17/2024, there was reasonable suspicion that Licensed Practical Nurse (LPN) 1 was under the influence, leading to their removal from resident care. Subsequent interviews with residents confirmed that medications were missing, including narcotic opioids, benzodiazepines, and other controlled substances. Residents reported not receiving their prescribed medications, indicating a breach in the administration and documentation of medication by LPN1. Witness accounts from staff members, including State Registered Nurse Aides and Kentucky Medication Aides, detailed observations of LPN1's concerning behavior on the day of the incident. LPN1 was seen falling asleep at the nurse's station, exhibiting impaired judgment, and displaying signs of being under the influence. Staff members expressed discomfort in performing narcotic counts due to LPN1's condition, highlighting a lack of clarity in facility policies and procedures for handling such situations. LPN1's termination was ultimately attributed to the failure to ensure residents' freedom from misappropriation of property and diversion of medications, as confirmed by the Director of Nursing and Administrator.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure it was free of a medication error rate of five percent or greater. During a medication pass observation, there were nine instances out of 69 opportunities where medications were not administered according to manufacturer recommendations and/or the facility's medication policy, resulting in an error rate of 13.04%. This affected two residents, one of whom had their insulin injection prepared incorrectly, and another who did not receive the full dose of eight crushed medications. One resident, diagnosed with diabetes and chronic kidney disease, had an order for Tresiba insulin to be administered twice daily. However, during an observation, an LPN used a regular insulin syringe to draw up the insulin from a prefilled Tresiba flex pen, contrary to the manufacturer's recommendations. The LPN was unaware of the proper technique and the potential adverse reactions. The Director of Nursing and the Pharmacist confirmed that the correct method was to use needle adapters designed for the flex pen. Another resident had orders for eight different medications to be crushed and administered with food. During an observation, an LPN mixed the crushed medications with applesauce, but the resident did not consume the entire mixture, leaving approximately 25% of the medications in the cup. The LPN did not ensure that the resident received the full dose, which was against the facility's policy. The Director of Nursing stated that staff were educated on the proper administration of crushed medications and expected them to follow the facility's policies.
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What surveyors actually found near you
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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 Whitesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norton Community Hospital Snf Unit | 15.5 mi | ★★★★★ | 6 | 0 |
| Tri Cities Rehabilitation And Healthcare Center | 15.8 mi | ★★★★★ | 0 | 0 |
| Heritage Hall Big Stone Gap | 16.7 mi | ★★★★★ | 0 | 0 |
| Knott County Health & Rehabilitation Center | 16.8 mi | ★★★★★ | 3 | 0 |
| Heritage Hall Wise | 17 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 July 2026) and official state health department websites.