Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Park Grove Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors observed that food items in the kitchen refrigerator and freezer were not dated or properly sealed after opening, contrary to facility policy. Dietary staff and the manager confirmed that all food should be dated and securely covered, but these procedures were not consistently followed, potentially affecting all residents who consumed food from the kitchen.
A resident with severe cognitive and physical impairments had a care plan requiring the TV to be on at all times with animal shows for meaningful engagement. Multiple observations showed the TVs were often off and staff were unaware of the care plan details, resulting in the resident's psychosocial needs not being met as outlined in the plan.
A resident with Alzheimer's Disease and Unspecified Dementia, who required a wheelchair for mobility and was at risk for elopement, exited the facility unsupervised. Despite increased supervision by LPN and involvement of SRNAs, the resident was able to leave unnoticed due to a brief lapse in monitoring. The Maintenance Director acknowledged that the exit door on the 400 Hall did not close properly, contributing to the incident. The resident was found outside approximately five minutes later and brought back into the facility.
The facility did not ensure comprehensive care plans for residents assessed for elopement risk, pain management, activity preferences, and psychotropic medication use. A resident with dementia and Alzheimer's eloped undetected despite being care planned for elopement risk, lacking documented evidence of increased supervision. Another resident with carpal tunnel syndrome had no care plan for pain management despite reporting pain and being on medication. A resident with myelodysplastic syndrome and major depressive disorder lacked a care plan for activity preferences, leading to dissatisfaction. Additionally, a resident with severe cognitive impairment was not care planned for psychotropic medication use despite being on Clonazepam. Staff interviews revealed inconsistencies in care planning responsibilities and documentation, highlighting gaps in knowledge and execution among LPNs and nursing staff. The DON and ADON expressed expectations for comprehensive care planning, indicating a disconnect between policy requirements and staff actions.
The facility experienced challenges in maintaining food at palatable temperatures for residents, as observed during a survey. Both hot and cold foods were found to be outside acceptable temperature levels per the Kentucky Food Guide 2013 Food Code. Residents reported receiving cold meals, with one resident consistently receiving cold food due to being served last. Staff, including SRNAs and LPNs, acknowledged the complaints and attempted to mitigate the issue by reheating meals. Delays in serving meal trays were attributed to staffing shortages and high acuity resident care. The Dietary Manager and other staff were aware of the complaints, while the Administrator and DON were not fully aware of the problem's extent, noting potential health risks associated with improper food temperatures.
The facility did not provide the required twelve hours of in-service training for five State Registered Nurse Aides (SRNAs), including essential dementia management and resident abuse prevention training. This deficiency was identified through interviews, policy reviews, Resident Matrix examination, and personnel files review. The facility's policy emphasized the importance of nursing staff having appropriate skills and competency, but there was a lack of documented evidence of competency checks for the SRNAs. Interviews with SRNAs and facility leadership revealed gaps in education, training, and record-keeping processes, with some staff unsure of their last completed training or competency checks. The Resident Matrix indicated a census of 58 residents, with 28 diagnosed with Alzheimer's or dementia, highlighting the potential impact on all residents. Inconsistencies in required education and competency checks, along with challenges in accessing training records due to recent ownership changes, raised concerns about the facility's ability to ensure nurse aides have the necessary skills for resident care.
The facility did not ensure an ongoing program of activities to meet the individual needs of residents, particularly in providing outdoor activities. Several residents expressed a desire to go outside but reported feeling restricted to indoor activities. Staff interviews revealed that outdoor activities were infrequent due to delays in repairing wheelchair ramps and decks. Additionally, some staff were uncertain about safe outdoor spaces for residents. The DON was unaware of the complaints, and the new Administrator expressed a desire to enhance the activity program.
A resident's catheter bag was observed without a dignity cover, causing embarrassment and violating the facility's policy on dignity. Staff members, including SRNAs, an LPN, the DON, and the Administrator, confirmed that the catheter bag should have been covered to maintain the resident's dignity.
The facility failed to ensure that each resident had an active Advance Directive order in place for five of the 25 sampled residents. Reviews revealed inconsistencies and missing Physician's Orders for DNR or Full Code statuses, despite care plans indicating specific code statuses. Interviews with staff confirmed that a signed Physician's Order is required, but this protocol was not consistently followed.
The facility failed to record temperatures for one of the medication storage refrigerators for three consecutive days, despite policy requirements for daily monitoring. Interviews revealed staff were unclear about the protocol, leading to a lapse in ensuring medications were stored at appropriate temperatures.
Failure to Properly Date and Store Food Items in Dietary Department
Penalty
Summary
Surveyors found that the facility failed to store food in accordance with professional standards for food service safety. During an observation of the kitchen, multiple food items in the refrigerator, such as loaves of bread, hot dog buns, and rolls, were not dated at the time of storage. In the freezer, opened boxes of hamburger patties, roll dough, frozen cookie dough, and mixed vegetables were not sealed or covered to prevent contamination, despite being in their original containers. The facility's policy required all food to be covered, labeled, and dated before being refrigerated or frozen, but these procedures were not followed. Interviews with dietary staff and the Dietary Manager confirmed that all staff were responsible for dating and securely covering food items upon receipt and after opening. Staff acknowledged that undated or improperly stored food should be discarded, as there would be no way to determine how long it had been stored. The Dietary Manager, who was new to the position, stated that staff needed reeducation on food safety practices, including proper dating and sealing of food items. The Administrator also confirmed the expectation that dietary staff follow food safety guidelines and facility policy to ensure safe and nutritional meals for all residents.
Failure to Implement Person-Centered Care Plan for Psychosocial Needs
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan to address the mental and psychosocial needs of a resident with cerebral palsy, severe physical impairment, and anxiety disorder. The resident was dependent on staff for all activities of daily living and had significant cognitive impairment, including both short- and long-term memory loss. The care plan specified that the resident preferred to have the television on at all times, particularly with shows involving animals, as a means of meaningful engagement. However, multiple observations over several days revealed that neither of the two televisions in the resident's room were consistently turned on, and the remote was out of the resident's reach. When the television was eventually turned on, it was not set to the preferred programming as outlined in the care plan. Interviews with staff, including a CNA, the Activities Director, the MDS Director, and the DON, revealed a lack of awareness and monitoring regarding the specific interventions in the resident's care plan. The CNA was unaware that the television should be on at all times or that it should be tuned to animal shows. The Activities Director was not monitoring to ensure the intervention was implemented, and both the DON and Administrator stated that staff were expected to follow care plans as written. Despite these expectations, the care plan was not consistently followed, resulting in a failure to meet the resident's identified mental and psychosocial needs.
Elopement Incident Due to Inadequate Supervision and Faulty Exit Door
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to provide effective monitoring and supervision to prevent elopement for a resident assessed as at risk. Resident #13, admitted with diagnoses including Alzheimer's Disease and Unspecified Dementia, was assessed to require a wheelchair for mobility and was deemed at risk for elopement due to restlessness, impulsiveness, and a history of elopement. Despite interventions in place, on 03/14/2024, staff failed to monitor Resident #13 adequately, leading to the resident exiting the facility unsupervised. The incident occurred when Resident #13, who had been up and down out of her wheelchair throughout the day, was able to leave the facility unnoticed, only to be located outside approximately five minutes later. The report details the sequence of events surrounding Resident #13's elopement, including accounts from staff members involved. LPN #1, responsible for Resident #13 on the day of elopement, provided increased supervision due to the resident's behavior but lost sight of her briefly, leading to the elopement. SRNA #5 and SRNA #6 were also involved in locating Resident #13 outside the facility and bringing her back in. The Maintenance Director acknowledged issues with the exit door on the 400 Hall, which had not closed properly on the day of the elopement. Despite efforts to address the door's functionality post-incident, the deficiency in supervision had already resulted in Resident #13 leaving the facility.
Deficiencies in Comprehensive Care Planning for At-Risk Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for three residents assessed for elopement risk. Resident #13, diagnosed with dementia, anxiety disorder, and Alzheimer's Disease, was assessed as at risk for elopement but eloped undetected by staff. Despite being care planned for elopement risk, there was no documented evidence of increased supervision in the care plan. Resident #40, with carpal tunnel syndrome, did not have a care plan related to pain or potential pain interventions, despite reporting pain and being on pain medication. Resident #52, diagnosed with myelodysplastic syndrome and major depressive disorder, did not have a care plan for activity preferences, leading to feelings of restriction and dissatisfaction. Resident #53, with severe cognitive impairment, was not care planned for psychotropic medication use, despite being on Clonazepam. The facility's policies emphasized the importance of developing comprehensive, person-centered care plans with measurable objectives and timely revisions based on ongoing assessments. The Safety and Supervision of Residents policy highlighted the need for interventions to reduce individual risks, including adequate supervision. The Wandering and Elopements policy stressed the importance of identifying at-risk residents and including safety strategies in their care plans. Despite these policies, the facility failed to implement appropriate care plans for the residents in question, leading to serious deficiencies in care. Staff interviews revealed gaps in knowledge and execution of care planning responsibilities. LPNs and nursing staff showed inconsistencies in checking and documenting the placement of safety devices like the Wanderguard bracelet, as well as a lack of understanding regarding the importance of updating care plans with necessary interventions. The DON and ADON expressed expectations for comprehensive care planning and interventions to be followed diligently, indicating a disconnect between policy requirements and staff actions. These deficiencies in care planning and implementation have put residents at risk of harm and highlight the need for improved oversight and training within the facility.
Temperature Control Issues in Meal Service
Penalty
Summary
The facility failed to provide food at a palatable temperature for two residents, as evidenced by observations and interviews conducted during the survey. Point of service temperatures for both hot and cold foods were found to be outside acceptable levels according to the Kentucky Food Guide 2013 Food Code guidance. Residents, including Resident #1 and Resident #52, reported receiving cold meals, with Resident #52 noting that he was consistently one of the last residents to receive a tray and his food was always cold. Staff members, including State Registered Nurse Aides and Licensed Practical Nurses, acknowledged residents' complaints about cold food and mentioned warming up meals in the microwave to address the issue. During interviews with staff members, it was revealed that delays in serving meal trays due to staffing shortages and high acuity resident care contributed to food cooling down before reaching residents. The Dietary Manager and other staff members acknowledged residents' complaints and efforts to address the issue, such as warming up trays or preparing new meals. The Administrator and Director of Nursing mentioned being unaware of the extent of the problem, with the Administrator highlighting the potential health risks associated with consuming food kept at incorrect temperatures.
Inadequate In-Service Training for SRNAs in Dementia and Abuse Prevention
Penalty
Summary
The facility failed to provide at least twelve hours of required in-service training for nurse aides, including dementia management and resident abuse prevention training, for five State Registered Nurse Aides (SRNAs). The deficiency was identified through interviews, policy reviews, Resident Matrix examination, and personnel files review. Despite the facility's policy emphasizing the importance of nursing staff having appropriate skills and competency, there was a lack of documented evidence of competency checks being completed for the SRNAs in question. Interviews with the SRNAs and facility leadership revealed gaps in education, training, and record-keeping processes, with some staff members unsure of when they last completed required training or competency checks. The facility's Resident Matrix indicated a census of 58 residents, with 28 residents having a diagnosis of Alzheimer's or dementia. The deficiency in providing necessary in-service training for nurse aides, particularly in dementia care and abuse prevention, had the potential to impact all 58 residents. Interviews with staff members, including SRNAs and leadership, highlighted inconsistencies in the completion of required education and competency checks, as well as challenges in accessing and obtaining necessary training records due to recent ownership changes. The lack of documented evidence of staff training and competency checks raised concerns about the facility's ability to ensure nurse aides have the skills needed to effectively care for residents, especially those with specialized needs such as dementia.
Lack of Outdoor Activities for Residents Due to Facility Constraints
Penalty
Summary
The facility failed to ensure an ongoing program of activities was developed to meet the individual needs of four sampled residents (Residents #15, #38, #52, and #53). Despite the facility's policy stating that activities should be based on comprehensive assessments and resident preferences, residents reported a lack of outdoor activities. Resident #15 expressed a desire to go outside when the weather was nice but felt bored staying indoors. Resident #38 mentioned that staff claimed they did not have time to take residents outside, despite residents wanting to go outdoors. Resident #52 felt restricted to activities in his room and expressed a desire to sit outside in the sun, feeling dehumanized by the lack of outdoor access. Resident #53, who was severely cognitively impaired, also reported staff not allowing her to go outside, leading her to feel imprisoned by the restriction. During interviews with staff members, it was revealed that the facility did not offer many activities for residents and rarely took them outside. The Activities Director mentioned occasional outdoor trips but cited delays in repairing wheelchair ramps and decks as hindrances to outdoor access. State Registered Nurse Aide #3 recalled a previous Administrator preventing Resident #52 from going outside, though the reason for this restriction was unknown. Other staff members, including SRNA #11 and LPN #1, confirmed the lack of outdoor activities and expressed uncertainty about safe outdoor spaces for residents. The Director of Nursing stated she was unaware of residents' complaints about outdoor access, while the Administrator, who had been at the facility for only three weeks, expressed a desire for a more robust activity program with outdoor opportunities.
Failure to Provide Dignity Cover for Catheter Bag
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not providing a dignity cover for the resident's catheter bag. The resident, who was cognitively intact and interviewable, was observed with an uncovered catheter bag anchored to the bed frame facing the door. This lack of a dignity cover was confirmed through multiple observations and interviews with the resident and staff members, who all acknowledged that the catheter bag should have been covered to maintain the resident's dignity. The facility's policy on dignity, revised in February 2021, mandates that each resident be cared for in a manner that promotes their sense of well-being and self-esteem. Despite this policy, the resident's catheter bag was left uncovered, causing embarrassment to the resident. Interviews with various staff members, including State Registered Nurse Aides (SRNAs), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the Administrator, all confirmed that the catheter bag should have had a dignity cover to prevent a dignity issue for the resident.
Failure to Ensure Active Advance Directive Orders for Residents
Penalty
Summary
The facility failed to ensure that each resident had an active Advance Directive order in place for five of the 25 sampled residents. Specifically, Residents #8, #9, #22, #28, and #61 did not have documented evidence of a Physician's Order indicating their Do Not Resuscitate (DNR) or Full Code status. This deficiency was identified through a review of admission records, Minimum Data Set (MDS) assessments, and comprehensive care plans, which revealed inconsistencies and missing orders regarding the residents' code statuses. For instance, Resident #8's care plan noted a full code status, but there was no corresponding Physician's Order, and Resident #9's care plan indicated a DNR status without a supporting Physician's Order in the records. Similar issues were found for Residents #22, #28, and #61, where their care plans indicated a specific code status, but the necessary Physician's Orders were absent from their records. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed that a signed Physician's Order is required to document a resident's code status. The staff stated that the code status should be noted in both the electronic record and the physical chart. However, the review revealed that this protocol was not consistently followed, leading to discrepancies between the residents' care plans and their documented code statuses. The DON and the Administrator both acknowledged that the residents' code statuses should be obtained upon admission and properly documented in the electronic and physical records. The facility's policies on Advance Directives and Do Not Resuscitate Orders were reviewed and found to require that DNR orders be signed by the attending physician and maintained in the resident's medical record. Despite these policies, the facility did not ensure compliance, resulting in the identified deficiencies. The lack of proper documentation and adherence to the facility's policies on advance directives and code statuses for the sampled residents highlights a significant gap in the facility's processes for managing and recording critical medical decisions.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to implement procedures that addressed and monitored the safe storage and handling of medications. Specifically, the facility did not record temperatures for one of the two medication storage refrigerators for three consecutive days. The facility's policy required daily temperature monitoring to ensure medications were stored at appropriate temperatures. However, the temperature log for the refrigerator was incomplete and incorrectly dated, indicating a lapse in adherence to the policy. The refrigerator contained various diabetes medications and different types of insulins, which require specific temperature ranges to maintain their efficacy. Interviews with staff revealed a lack of clarity and adherence to the protocol for checking refrigerator temperatures. An agency LPN was unaware of the protocol, and both the ADON and DON confirmed that the responsibility for checking temperatures could fall on any shift but was primarily assigned to the nightshift nurse. The ADON and DON acknowledged that failure to monitor temperatures could ruin medications. The Administrator also confirmed that staff were expected to monitor and record refrigerator temperatures per the facility's policy, highlighting a clear deficiency in the facility's medication storage practices.
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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 Madisonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madisonville Health And Rehabilitation, Llc | 0.9 mi | ★★★★★ | 1 | 0 |
| Brighton Cornerstone Group, Llc | 0.9 mi | ★★★★★ | 9 | 0 |
| Ridgewood Terrace Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Joseph Eddie Ballard Western Kentucky Veterans Cen | 5.1 mi | ★★★★★ | 4 | 0 |
| Tradewater Pointe | 16.2 mi | ★★★★★ | 8 | 0 |
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