Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Nicholasville Nursing And Rehabilitation during CMS and state inspections, most recent first.
Improper Medication Storage and Labeling: Surveyors found opened medications without opened dates, an expired medication in a med cart, and a refrigerator temperature log that was missing or incomplete. The facility’s policy required daily temp logs and proper inspection of med rooms, and staff acknowledged the importance of keeping refrigerated meds within range and discarding expired or improperly stored products.
The facility failed to maintain accurate records of controlled drugs, with numerous missing signatures on narcotic count sheets during shift changes. Staff interviews revealed inconsistencies in the process of counting and wasting narcotics, with unclear procedures for returning or crediting medications. The DON and Administrator expected timely and accurate narcotic counts for resident safety.
The facility failed to label medications according to professional standards, with undated opened medications found in all four medication carts. The facility's policy required staff to check expiration dates and label multi-dose containers with the date opened, but observations revealed non-compliance. Interviews with the DON and Administrator confirmed the expectation for proper medication storage and dating to ensure resident safety.
The facility failed to maintain an effective infection prevention and control program, with several residents lacking appropriate signage and PPE. Staff did not consistently adhere to Enhanced Barrier Precautions, and there were lapses in hand hygiene and medication handling practices. Interviews revealed inconsistencies in staff understanding of infection prevention policies.
The facility failed to provide adequate nursing staff, resulting in delayed care for residents. Three residents reported long wait times for assistance, with call light response times ranging from 10 to 69 minutes. Staff interviews revealed difficulties in managing workloads due to staffing shortages. The DON was unaware of these issues, while the Administrator acknowledged the problem and mentioned using agency staff to fill gaps.
The facility failed to document influenza and pneumococcal vaccinations or declinations for four residents, despite policies requiring assessment and documentation upon admission. Interviews with the DON, Administrator, and Medical Director confirmed the absence of records in the EMR, highlighting a lapse in following infection control policies.
A facility failed to maintain a homelike environment for two residents due to persistent odors of urine and an open wound in their shared room. One resident, who managed his own urostomy and colostomy care, often refused assistance with personal care and cleaning, contributing to the odor. Despite daily cleaning efforts and attempts to replace the mattress, the facility could not eliminate the smell, resulting in a deficiency finding.
A resident's discharge assessment was not completed and submitted within the required timeframe, leading to a deficiency. The resident, admitted with conditions like malnutrition and hypertension, was discharged to acute care. The MDS Nurse misunderstood the submission timeline, resulting in a delay of several months. The DON and Administrator acknowledged the expectation for timely submission.
A facility failed to create a person-centered care plan for a resident with end-stage renal disease, inaccurately including interventions for a fistula instead of a dialysis catheter. The care plan lacked the resident's name and did not reflect individualized care. Staff interviews revealed a lack of understanding and implementation of appropriate interventions, and the facility lacked a policy for developing resident-centered care plans.
A resident's care plan was not revised after readmission to the facility, despite having significant medical conditions such as stroke and malnutrition. The facility lacked a policy for updating care plans upon readmission, and staff absences contributed to the oversight. The MDS Coordinator and DON acknowledged the care plan should have been updated to guide care, but it was not.
A facility failed to update a resident's Advance Directives, leading to a discrepancy in code status documentation. The resident, with a history of atrial fibrillation and diabetes, was cognitively intact and had changed their code status from Full Code to DNR. However, the Code Status Book still listed them as Full Code. Interviews revealed a lack of consistent procedures for updating these records.
A resident at risk for inadequate nutrition and dehydration was readmitted to a facility without a comprehensive nutritional assessment by the RD, as required by facility policies. Despite the resident's history of malnutrition and failure to thrive, the RD did not perform the necessary assessment, and the facility failed to document or verify diet and tube feeding orders. Interviews with staff revealed communication gaps and a lack of follow-up on the resident's nutritional needs.
A resident with severe cognitive impairment and respiratory needs was not provided with the prescribed oxygen therapy at 3 L/m, as observations showed lower settings of 2 L/m and 2.5 L/m. The facility's policy required adherence to the care plan, which was not followed, and the oxygen tubing was not labeled with the date of change. Interviews with nursing staff and administration confirmed the expectation to follow physician orders and care plans.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals in medication rooms and refrigerators. On the A Unit, surveyors observed an opened Aplisol vial in the medication refrigerator with no opened date recorded, a bisacodyl suppository for Resident 20 with an expiration date of 7/31/2025, and Azelastine ophthalmic solution in a medication cart with no opened date marked. On the B Unit, surveyors observed the medication refrigerator temperature at 40 degrees Fahrenheit, but the August 2025 temperature log was not readily visible and, when found, only documented temperatures from 08/16/2025 through 08/20/2025. The B Unit refrigerator also contained an opened Aplisol vial with no opened date marked. The facility policy required refrigerated products to be maintained between 36 and 46 degrees Fahrenheit with temperatures recorded daily, and medication rooms to be inspected for outdated or improperly labeled medications. Package inserts reviewed by surveyors stated that Aplisol vials in use more than 30 days should be discarded and that Azelastine bottles should be discarded 28 days after opening. The refrigerator on the B Unit contained multiple medications and vaccines, including insulin products, vaccines, and daptomycin, while staff interviews confirmed the importance of temperature logs, proper storage, and discarding expired medications. The DON stated the refrigerator log could not be located and a new log was started, and later stated the pharmacist consultant advised that medications stored in the refrigerator without a log must be discarded.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain accurate recordkeeping of controlled drugs, which compromised the inventory of medications received, dispensed, and administered. Observations and reviews of narcotic count sheets revealed that staff did not consistently sign inventory sheets for controlled narcotics or sign narcotic count sheets at the change of shift. Specifically, the review of narcotic books for four medication carts showed numerous instances where two signatures from licensed personnel were missing during shift changes. This issue was observed across multiple medication carts, with significant discrepancies noted in the narcotic count sheets over several months. Interviews with various staff members, including State Registered Nurse Aides, a Registered Nurse, and the Director of Nursing (DON), highlighted inconsistencies in the process of counting and wasting narcotics. Staff members indicated that narcotic waste was typically done by two people, and the DON was responsible for wasting discontinued narcotics. However, there was a lack of clarity among staff regarding the process for returning or crediting controlled medications. The DON and the Administrator both expressed expectations that narcotic counts should be conducted timely and accurately, in accordance with facility policy, to ensure resident safety.
Medication Labeling Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that all drugs used in the facility were labeled in accordance with professional standards, as evidenced by the presence of undated opened medications in all four medication carts. The facility's policy, which was last revised in August 2020, required staff to check expiration dates and label multi-dose containers with the date they were opened. However, observations revealed multiple instances of non-compliance. For example, the B Hall front cart contained an opened, undated vial of purified protein derivative (PPD) and several other medications, including Linzess, Fiasp insulin, and various inhalers and eye drops, that were opened and not dated. Additionally, a bottle of Unisom, which was not labeled or dated, was found in the same cart, reportedly confiscated from a resident's personal order. Further observations showed similar issues in the other medication carts. The B Hall back cart contained undated Chloraseptic throat lozenges, calcium antacid, and guaifenesin. The A Hall even cart had undated Milk of Magnesia, Spiriva inhaler, Symbicort inhaler, Flonase nasal spray, and an ipratropium albuterol nebulizer. The A Hall odd cart contained undated MiraLAX, Milk of Magnesia, ipratropium albuterol nebulizer, Enulose, and an albuterol inhaler. Interviews with the Director of Nursing and the Administrator confirmed that the expectation was for staff to properly store and date medications, and to check and discard expired medications to ensure resident safety.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Several residents, including those with orders for Enhanced Barrier Precautions (EBP), did not have appropriate signage or personal protective equipment (PPE) available at their room doors. Staff were observed not adhering to EBP protocols, such as failing to don PPE during high-contact activities and not performing hand hygiene after resident interactions. Specific instances included a resident's catheter bag and tubing touching the floor, and staff entering rooms without the required PPE. Additionally, there were lapses in medication administration procedures. A registered nurse was observed dropping medications on the medication cart and then placing them back into a cup for administration, which is against safe medication handling practices. The nurse admitted to disinfecting the cart before starting medication administration but did not follow proper protocol when the medication touched the cart surface. Interviews with various staff members, including State Registered Nurse Aides, Licensed Practical Nurses, and the Director of Nursing, revealed inconsistencies in understanding and implementing the facility's infection prevention policies. Some staff were unclear about when PPE was required, and there was a lack of consistent hand hygiene practices. The Director of Nursing, who was also the interim Infection Preventionist, acknowledged the expectations for staff to follow EBP protocols and perform hand hygiene, but the observations indicated these were not consistently met.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the necessary competencies and skills to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of residents. This deficiency was identified for three residents, who reported long wait times for assistance, particularly with call lights. The facility's staffing levels, as documented, were inadequate, with only two aides and one nurse on each unit during certain shifts. The facility's call light audit revealed response times ranging from 10 to 69 minutes, with one resident reporting waiting up to four hours for assistance. Interviews with staff and residents highlighted the staffing shortages, with staff members expressing difficulty in managing their workload and residents experiencing delays in receiving care. The Director of Nursing was unaware of the staffing shortages and the lengthy call light response times, while the Administrator acknowledged the staffing issues and mentioned the use of agency staff to fill gaps. Despite hiring new aides, the facility continued to struggle with maintaining adequate staffing levels, impacting the quality of care provided to residents.
Failure to Document Vaccinations for Residents
Penalty
Summary
The facility failed to provide proof of vaccinations or declinations for four out of five sampled residents, specifically for influenza and pneumococcal vaccinations. The facility's policies required that each resident be assessed for these vaccines upon admission, offered the vaccines unless contraindicated, and provided education on the benefits and potential side effects. However, documentation was missing for Residents 14, 16, 32, and 60. For Resident 14, there was no record of influenza vaccination or declination. Resident 16's medical record lacked documentation of pneumococcal immunization or declination. Resident 32 had a signed consent form for the pneumococcal vaccine, but no documentation of the vaccine being administered. Resident 60's record showed a family refusal for the influenza vaccine, but consent forms for both vaccines were signed later, with no documentation of administration. Interviews with the Director of Nursing, Administrator, and Medical Director revealed that the facility's electronic medical records did not contain the necessary vaccination documentation for these residents. The Director of Nursing acknowledged the importance of vaccinations for resident and staff safety, while the Administrator and Medical Director emphasized the need to follow facility guidelines and infection control policies. Despite the acknowledgment of the importance of these vaccinations, the facility failed to maintain proper documentation, leading to the deficiency noted in the report.
Failure to Maintain a Homelike Environment Due to Persistent Odor
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as evidenced by the persistent odor of urine and an open wound in their shared room. The facility's policies on maintaining a homelike environment and respecting resident rights were not effectively implemented, as the room continued to emit strong odors despite daily cleaning efforts. The room's condition was noted during multiple observations by the State Survey Agency Surveyor, who reported the smell both inside and outside the room. One of the residents, who had a urostomy and colostomy, was identified as the primary source of the odor. This resident managed his own care, including wound management for a large sore on his coccyx, and often refused assistance with bathing, changing bed linens, and cleaning the room. The facility struggled to obtain the correct urostomy bags due to supply issues, leading to leaks that contributed to the odor. Staff interviews confirmed that the resident's refusal to accept care and the leaking urostomy bag were significant factors in the room's condition. Despite efforts by housekeeping staff to clean the room multiple times daily and replace the mattress, the odor persisted. The facility's administration acknowledged the issue but emphasized the resident's autonomy in refusing care and cleaning. The other resident sharing the room did not perceive the odor as unpleasant and declined to move to another room. The facility's inability to effectively address the odor and maintain a homelike environment for the residents resulted in a deficiency finding.
Failure to Timely Submit Discharge Assessment
Penalty
Summary
The facility failed to complete and electronically transmit a discharge assessment within the required timeframe for a resident. The resident, who was admitted with diagnoses including protein-calorie malnutrition, hypertension, and atrial fibrillation, was discharged to acute care. Despite the requirement to complete the Minimum Data Set (MDS) within 14 days of discharge, the facility did not submit the MDS until several months later. The resident's discharge date was in late May, but the MDS was not submitted until mid-September. Interviews with facility staff revealed a misunderstanding of the timeline for completing and submitting the discharge assessment. The Minimum Data Set Nurse indicated that she believed she had seven days to complete the assessment and an additional seven days to submit it, but she did not add the necessary discharge information when the resident did not return within 23 hours. The Director of Nursing and the Administrator both acknowledged the expectation for timely submission according to the Resident Assessment Instrument manual, but the assessment was not submitted on time, leading to the deficiency.
Failure to Develop Person-Centered Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for Resident 267, which did not include measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. The care plan inaccurately included interventions such as assessing for a bruit and thrill, which are applicable to a fistula, while the resident had a dialysis central venous catheter. Additionally, the care plan contained multiple instances where the resident's name was not documented, using the generic term 'Resident Name' instead. Resident 267 was admitted with chronic kidney disease, end-stage renal disease, and diabetes mellitus type II, requiring hemodialysis. The resident's care plan, dated shortly after admission, aimed to prevent complications related to dialysis but included incorrect interventions. The facility's policy on dialysis care required assessment of catheter sites every shift, but the care plan did not reflect this accurately. Interviews with staff revealed a lack of understanding and implementation of appropriate care plan interventions for the resident's specific needs. The facility did not have a policy for developing and implementing resident-centered care plans, as confirmed by the Administrator. The MDS Nurse acknowledged that care plans were initially generic and needed to be individualized within seven days of a resident's arrival. The Director of Nursing and Assistant Director of Nursing confirmed that the care plan for Resident 267 was not individualized and did not reflect the care being provided. The Administrator also recognized that the care plan was not resident-centered due to improper interventions and the use of generic terms instead of the resident's name.
Failure to Revise Care Plan After Resident Readmission
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as R167, following their readmission after an acute care hospital stay. The care plan, which initially focused on nutritional needs and dietary assessment, was not updated to reflect the resident's current condition after readmission. The facility's policies did not include specific guidelines for revising care plans upon readmission, and the Registered Dietician's recommendations were not incorporated into the care plan. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that the care plan should have been updated to guide care, but this was not done due to staff absences. R167 was readmitted to the facility with diagnoses including stroke, hemiplegia, hemiparesis, protein-calorie malnutrition, and adult failure to thrive. Despite these conditions, the care plan was not revised to address the resident's nutritional needs after readmission. The MDS Coordinator acknowledged that the care plan should have been updated, but it was not due to her and the DON's absence. The Administrator confirmed that facility guidelines should have been followed, but there was no policy in place for revising care plans upon readmission.
Failure to Update Resident's Code Status in Advance Directives
Penalty
Summary
The facility failed to update and accurately maintain the Advance Directives and code status for a resident, identified as R9, which led to a discrepancy in honoring the resident's wishes for emergency care. R9 was admitted with diagnoses including unspecified atrial fibrillation, type II diabetes mellitus with unspecified complications, and hypertensive urgency. The resident was assessed to be cognitively intact with a BIMS score of 15 out of 15. Initially, R9's care plan indicated a Full Code status, but it was later revised to reflect a Do Not Resuscitate (DNR) directive. Despite this change, the Code Status document in the facility's Code Status Book incorrectly listed R9 as Full Code. Interviews with facility staff revealed a lack of consistent procedures for updating the Code Status Books. The Minimum Data Set Nurse confirmed the care plan update to DNR, but the Code Status Book was not updated accordingly. The Director of Nursing acknowledged the absence of a policy or designated person to audit the Code Status Books, relying instead on team audits during morning meetings. The Administrator admitted the books were inaccurate and expressed an expectation for them to be up-to-date, although no specific corrective actions were detailed in the report.
Failure to Conduct Comprehensive Nutritional Assessment for At-Risk Resident
Penalty
Summary
The facility failed to perform a comprehensive nutritional assessment for a resident, identified as R167, who was at risk for inadequate nutrition and dehydration. R167 was readmitted to the facility following a hospital stay due to a fall and had a history of conditions such as stroke, hemiplegia, hemiparesis, protein-calorie malnutrition, and adult failure to thrive. Despite these risks, the Registered Dietician (RD) did not conduct a full nutritional assessment upon readmission, as required by the facility's policies and the RD's job description. The RD admitted to failing to perform the assessment, citing being at another facility and not reviewing R167's information at the time. The facility's policies required the RD to review the nutritional status of residents and make recommendations within four business days, and for the Interdisciplinary Team (IDT) to review residents with risk conditions weekly. However, there was no documentation of a nutritional assessment or recommendations for R167, and the facility was unable to provide the RD's recommendations form. The RD's contract also stipulated that a full nutritional assessment should be completed by day 14 of readmission, which was not done for R167. The lack of a comprehensive assessment and follow-up on nutritional needs contributed to R167's risk of malnutrition and dehydration. Interviews with facility staff, including the Director of Nursing (DON) and Nurse Practitioners (NPs), revealed a lack of communication and follow-up regarding R167's nutritional needs. The DON acknowledged that the RD should have performed another nutritional assessment upon readmission, and the Medical Director noted a disconnect between the sending hospital and the facility concerning diet orders. Despite the facility's process for reviewing discharge orders, there was no clear documentation or verification of R167's diet and tube feeding orders, leading to inadequate nutritional support for the resident.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as R55, who required oxygen therapy. R55 had a physician's order to receive oxygen at 3 Liters per minute (L/m) via nasal cannula, but observations on multiple occasions revealed the resident was receiving oxygen at lower rates of 2 L/m and 2.5 L/m. The facility's policy on oxygen administration required adherence to professional standards and the resident's care plan, which was not followed in this case. Interviews with nursing staff, including an LPN and RN, confirmed that the oxygen settings should match the orders in the resident's medical chart, and the oxygen tubing and humidification bottles should be dated and changed weekly. R55 was admitted with diagnoses including hypertension, heart failure, and chronic kidney disease, and was assessed to have severe cognitive impairment and dyspnea. The resident's comprehensive care plan included interventions to manage respiratory distress, such as administering oxygen as ordered and monitoring for signs of respiratory compromise. Despite these directives, the oxygen concentrator settings did not align with the prescribed orders, and the tubing was not labeled with the date of the last change. Interviews with the DON, ADON, and the Medical Director highlighted the expectation for staff to follow physician orders and care plans, emphasizing the potential risk of under-oxygenation if the prescribed oxygen rate was not maintained.
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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 Nicholasville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thomson-hood Veterans Center | 4.5 mi | ★★★★★ | 3 | 0 |
| The Willows At Fritz Farm | 6.5 mi | ★★★★★ | 3 | 0 |
| Sayre Christian Village Nursing Home | 6.9 mi | ★★★★★ | 0 | 0 |
| Hartland Park Health & Rehabilitation | 7.4 mi | ★★★★★ | 4 | 0 |
| Bluegrass Care & Rehabilitation Center | 8.3 mi | ★★★★★ | 0 | 0 |
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