Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Pioneer Trace Group Llc during CMS and state inspections, most recent first.
Failure to Protect Residents from Abuse: A resident with mood, intellectual, anxiety, conduct, and dementia-related diagnoses had repeated verbal and physical outbursts, including threats, cursing, spitting, throwing objects, and striking staff and other residents. Multiple residents reported feeling afraid, unsafe, and forced to avoid common areas or hide in their rooms because of the resident’s behavior, and staff confirmed the resident required frequent intervention and supervision.
A resident with moderate cognitive impairment and a history of wandering/exit-seeking had repeated attempts to leave the facility, including tailgating visitors and later eloping from the building and being found outside near the back entrance roadway. Although the care plan already listed wandering interventions such as a WanderGuard and monitoring, it was not revised to add increased supervision or monitoring after the resident’s exit-seeking behavior was observed, and staff interviews showed the behavior was known on the unit but not consistently communicated or addressed in the care plan.
A resident with moderate cognitive impairment and documented wandering/exit-seeking behaviors eloped from the facility in a wheelchair and was found outside near the back entrance roadway without staff awareness or supervision. The resident had a WanderGuard bracelet, but staff interviews and the facility investigation showed door alarms were not always immediately responded to, the alarm code was known by residents, and a prior exit attempt had occurred earlier the same evening without increased monitoring.
A facility failed to keep food stored at safe temperatures when the walk-in refrigerator repeatedly read above 41 degrees F and reached 48 degrees F during kitchen observation. Food temp logs showed multiple out-of-range readings, and staff did not consistently report the issue to the Dietary Manager or Maintenance despite posted HACCP guidance and job duties requiring temperature monitoring and notification of problems.
Walk-In Refrigerator Not Kept in Safe Operating Condition. The facility failed to maintain the walk-in refrigerator below the required temperature, with logs and surveyor observation showing repeated temperatures above 41 F and an observed temperature of 48 F. Records showed prior service for a warm cooler with clogged coils, and later service found frozen coils and an inconsistent defrost timer. The Dietary Manager knew the door did not close well and had told maintenance staff, but no work order was completed or reported to the current Maintenance Director or Administrator. Staff had to make a concerted effort to close the door, and refrigerated foods were discarded after the high temperature was observed.
A resident with dementia, severe cognitive impairment, malnutrition, and a g-tube was placed on hospice and prescribed lorazepam and morphine for end-of-life care. A hospice RN obtained 15 lorazepam 0.5 mg tablets in a brown pill bottle from the pharmacy, which an LPN and an SRNA/KMA counted, documented, and locked in the narcotic drawer after one dose was given, leaving 14 tablets. During a hectic shift change, the oncoming LPN did not count the lorazepam despite being informed it was in a bottle, and the SRNA/KMA later accepted the cart without performing the required narcotic count with the night nurse. When the same LPN later attempted to administer another dose, only nine tablets were present, confirming five missing tablets after a recount, and the discrepancy was reported to the unit manager. The pharmacist verified that 15 tablets had been dispensed, and leadership stated that all narcotics were expected to be counted at each cart handoff, but this did not occur, resulting in unaccounted-for controlled medication.
A resident receiving off-site dialysis had incomplete coordination and communication between the facility and the dialysis provider. The facility did not maintain an active dialysis contract, and the nursing home section of the dialysis handoff form was left incomplete for multiple treatments even though the dialysis center returned its portion. RN and LPN interviews confirmed staff forgot to complete or send the forms, while the DON and Administrator acknowledged the expected communication process and the missing contract.
The facility failed to ensure residents received mail on Saturdays, violating their rights to privacy in written communications. A resident reported the issue during a council meeting, confirmed by others. The BOM was unaware of the violation, and only department heads, who worked weekdays, had mailbox keys, preventing weekend mail distribution.
The facility lacked a comprehensive water management program to prevent Legionella growth, with key staff unaware of water system details and responsibilities. The Maintenance Director had no training on Legionella, and the Administrator, DON, and ADON did not actively manage the water system, leading to a deficiency in infection prevention.
The facility failed to prevent cross-contamination in food preparation due to a gnat infestation. A Dietary Aide was observed preparing food with gnats around an uncovered blender, and gnats were also present near a trash can in the dining area. Staff interviews confirmed the presence of gnats, but there was a lack of effective communication and action to address the issue, as maintenance had not been informed, and pest control had not targeted gnats.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from mental and verbal abuse involving a resident with a history of aggressive and disruptive behaviors. The cited resident was admitted with diagnoses including mood disorder, intellectual disability, anxiety disorder, developmental disorder, conduct disorder, and mild dementia, and had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The resident’s care plan documented repeated episodes of verbal abuse, physical aggression, yelling, cursing, striking others, throwing objects, and escalating behavioral outbursts over several months. Survey findings showed multiple incidents in which the resident threatened, cursed at, spit at, and physically assaulted other residents and staff. Documentation included a resident-to-resident altercation in which the resident told another resident, “I hate you,” “I’m not going to talk to you,” and “I’m going to kill you,” as well as later episodes of yelling profanities, throwing items, punching walls and bed rails, kicking furniture, and attempting to strike staff and other residents. On one occasion, the resident became combative in the dining room, attempted to spit on residents and staff, threw a water bottle, attempted to throw a wheelchair, and struck multiple staff members. Another incident involved the resident spitting at another resident during a dining room altercation. Other residents reported feeling unsafe because of the resident’s behavior. One resident stated he did not feel safe at the facility due to the resident’s outbursts, another reported not feeling safe because of hitting, kicking, and spitting, and additional residents stated they hid in their rooms, altered their routes, avoided the dining room, or felt they had to walk on eggshells around the resident. Staff interviews also confirmed repeated aggressive episodes, frequent need for staff intervention, and that the resident’s behaviors required significant attention. The report further stated the facility had not attempted to identify or secure an alternative placement despite ongoing concerns and reports from residents that they did not feel safe.
Failure to Revise Care Plan for Exit-Seeking and Elopement
Penalty
Summary
The facility failed to revise a resident’s care plan to include interventions for supervision and monitoring after the resident demonstrated exit-seeking and elopement behaviors. The resident was admitted with diagnoses including Wernicke’s encephalopathy and agitation, and the quarterly MDS showed a BIMS score of 9/15, indicating moderate cognitive impairment. The resident’s MDS ancillary assessments identified the resident as high risk for wandering/elopement, and the care plan documented a focus area for wandering/exit-seeking behaviors with interventions such as monitoring every shift and use of a WanderGuard bracelet. The care plan also documented multiple exit-seeking behaviors over several months, including entries on 11/09/2025, 01/06/2026, 02/16/2026, and 04/10/2026. Additional interventions had been added earlier, including scheduled hydration, assisting the resident to bed if pacing or exit-seeking continued, calm and reassuring care, reorientation, frequent reminders to notify staff, and 15-minute location checks. Several of these interventions were later marked as resolved, but the care plan did not identify dates when they were resolved, and the ongoing interventions remained monitoring every shift and the WanderGuard bracelet. On 05/02/2026, staff observed the resident exiting the facility at approximately 5:55 PM and were able to intervene and return the resident to the unit. Staff interviews indicated the resident had been exhibiting exit-seeking behavior that day, including discussion with another resident about ways to leave and tailgating visitors through the front entrance. Despite these events, the care plan was not revised to add increased supervision or monitoring. Later that evening, the resident eloped again and was found outside near the back facility entrance roadway by a dietary aide, having traveled approximately 286 feet from the facility’s entrance in a wheelchair over an uneven surface without staff awareness or supervision.
Failure to Supervise Resident With Wandering and Exit-Seeking Behaviors
Penalty
Summary
The facility failed to maintain an effective system of supervision and monitoring for a resident with documented wandering and exit-seeking behaviors. The resident was admitted with diagnoses including Wernicke's encephalopathy, lack of coordination, muscle weakness, and age-related physical debility, and had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The care plan identified a focus area for wandering and exit-seeking, noted repeated exit-seeking behaviors, and included interventions such as a WanderGuard bracelet, monitoring every shift, and other measures that were later marked resolved without dates being identified. The resident's elopement/wander risk evaluations identified the resident as a mild elopement risk, while MDS ancillary assessments identified the resident as high risk for wandering/elopement. On the evening of the incident, the resident eloped from the facility and was found outside near the back facility entrance roadway by a dietary aide who was taking out trash. The resident had traveled approximately 286 feet from the facility entrance in a wheelchair over an uneven surface without staff awareness or supervision. The facility's investigation also documented that at least two residents, including one wearing a WanderGuard bracelet, knew the code to silence the door alarms. Staff interviews indicated the WanderGuard alarms frequently sounded during evening hours and were not always immediately responded to when staff were providing resident care. Additional interviews showed that the resident had previously tailgated visitors out the front entrance and had been returned to the unit after traveling about 60 feet from the entrance, but monitoring was not increased afterward. Staff also reported that a door alarm was reset without checking outside, and other staff assumed someone else had already addressed the alarm. The administrator stated the facility knew residents had learned the front door access code before the elopement, but the code was not changed until after the incident and no additional monitoring of the entrance doors or residents was implemented before the elopement occurred.
Walk-In Refrigerator Stored Food Above Safe Temperature
Penalty
Summary
The facility failed to ensure that food was stored in a manner that minimized the risk of foodborne illness for all 78 current residents. Review of the facility’s policy, job descriptions, HACCP poster, and food temperature logs showed that refrigerated food was required to be held below 41 degrees F, and staff were expected to monitor refrigerator temperatures and notify the Dietary Manager immediately if temperatures were out of range. Review of the food temperature logs for 01/01/2026 through 01/06/2026 showed the walk-in refrigerator temperature was above 41 degrees F on 01/01/2026, 01/04/2026, 01/05/2026, and 01/06/2026. During the initial kitchen tour on 01/07/2026, the analog thermometer inside the walk-in refrigerator showed 48 degrees F. The thermometer was then repositioned and replaced, but the temperature remained 48 degrees F. At that time, the Dietary Manager was present in the kitchen, and staff disposed of all refrigerated foods; no food from the refrigerator was used for the midday meal. Interviews showed staff did not consistently report the out-of-range temperatures. The Dietary Manager stated cooks checked refrigerator and freezer temperatures daily and that she notified maintenance after learning of the problem. One cook stated she recorded temperatures on 01/05/2026 and 01/06/2026 but did not inform the Dietary Manager of the readings. Another staff member stated she documented temperatures above 41 degrees F on 01/01/2026 and 01/04/2026 but did not notify the Dietary Manager, Maintenance, or any authority. The Maintenance Director stated a repair company was contacted after the concern was reported, and the Administrator stated the food had to be thrown out after the temperature issue was identified.
Walk-In Refrigerator Not Maintained at Safe Temperature
Penalty
Summary
The facility failed to ensure essential kitchen equipment was maintained and kept in safe operating condition for all 78 current residents. Review of the facility policy showed refrigerated food was to be monitored and stored below 41 degrees F, and staff job descriptions required inspection of equipment for proper functioning and safety and immediate reporting of repair needs. The food temperature logs showed the walk-in refrigerator was above 41 degrees F on multiple days, and the refrigerator was documented as expected to remain between 32 and 41 degrees F. An outside contractor invoice from 06/20/2025 showed the walk-in cooler/refrigerator had been running warm and had clogged condenser coils, with repairs completed at that time. A later invoice from 01/07/2026 showed the walk-in cooler was warm again, the condenser coils were frozen, and the defrost timer was inconsistent. During the initial kitchen tour on 01/07/2026, the internal temperature of the walk-in refrigerator was observed at 48 degrees F, and the thermometer was later repositioned and replaced, but the temperature remained 48 degrees F. The Dietary Manager stated she had told maintenance staff the refrigerator was not staying cool enough and that the door did not close well, but she had not completed a work order or reported the concern to the current Maintenance Director or Administrator. Staff stated they had to make a concerted effort to shut the door, and the Maintenance Director stated he had not previously been made aware of the door issue. Staff discarded all refrigerated foods after the continued high temperature was observed, and no food from the refrigerator was used for the midday meal.
Failure to Account for Controlled Medication Resulting in Missing Lorazepam Tablets
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property by not ensuring proper accountability of controlled medications. Facility policies required that controlled substances be counted at each shift change by two licensed nurses, with any discrepancies reported to the DON, and that a physical inventory of all controlled medications be conducted and documented at each shift change. The Abuse Prevention policy defined misappropriation of resident property as the wrongful use of a resident’s belongings without consent. For one resident with severe cognitive impairment (BIMS score of 0), admitted with moderate protein-calorie malnutrition, dementia, adult failure to thrive, and receiving medications via g-tube, hospice was consulted and lorazepam and morphine were ordered for end-of-life comfort care. According to the record and interviews, a hospice RN obtained 15 lorazepam 0.5 mg tablets from the contracted pharmacy in a brown pill bottle for the resident. An LPN and an SRNA/KMA counted 15 tablets, created a narcotic count sheet, and locked the bottle in the narcotic drawer of the medication cart. The LPN administered one dose of lorazepam via g-tube later that day, leaving 14 tablets. The SRNA/KMA reported that the evening was hectic due to a call-in and stated that at shift change, she informed the oncoming LPN that the lorazepam was in a bottle rather than a blister pack, but the oncoming LPN closed the drawer without counting the pills. The SRNA/KMA further stated that the following morning she failed to count the lorazepam bottle with the night shift nurse before accepting the cart keys, despite knowing facility policy required this. Later that day, when the LPN went to administer another dose of lorazepam to the resident, only nine tablets were found in the bottle instead of the expected 14, indicating five missing tablets. The LPN and SRNA/KMA recounted and confirmed the discrepancy, then attempted to locate the DON and, when unsuccessful, reported the missing tablets to the unit manager RN. The pharmacist confirmed that 15 lorazepam tablets had been dispensed in a brown bottle to the hospice RN. The responding police officer reported being contacted by the Administrator and noted that key staff had been sent home or were unavailable, and that no police report had yet been filed at the time of interview. The DON and Administrator both stated they expected all narcotics to be thoroughly counted at cart acceptance regardless of container type, but the required counts and documentation were not consistently performed, resulting in unaccounted-for controlled medication for the resident.
Dialysis Coordination and Communication Failures
Penalty
Summary
Appropriate dialysis care and services were not provided for one resident who was receiving off-site dialysis. The facility failed to maintain an active contract or written agreement with the dialysis provider for the resident, who had diagnoses including end-stage renal disease, type II diabetes mellitus, hypertension, and dependence on renal dialysis. The resident’s care plan indicated dialysis three days per week and a left upper arm AV fistula, and the resident’s MDS showed a BIMS score of 13 of 15, indicating cognitive intactness. The facility also failed to ensure dialysis communication was completed and exchanged consistently to support continuity of care. Review of the dialysis handoff communication tool showed the nursing home section was incomplete for multiple dialysis treatments, although the dialysis center returned the forms with its section completed. RN and LPN interviews confirmed that staff forgot to complete or send the forms on some occasions, and the DON stated nursing staff were expected to complete the nursing home section and review the dialysis section upon the resident’s return. The Administrator stated the dialysis contract had been misplaced by the nursing facility and the dialysis provider and acknowledged the facility should have an active contract when a resident is receiving dialysis services.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that all residents had the right to send and receive mail on Saturdays, as required by their policy on residents' rights. During a Resident Council meeting, a resident reported that mail was not delivered or sent on Saturdays, although packages were received unopened on the day of delivery. This was confirmed by other residents in attendance. The facility's policy, revised in 2014, states that residents have the right to privacy in written communications, including the right to send and promptly receive mail. Interviews with facility staff revealed a lack of awareness and procedural gaps regarding mail delivery on weekends. The Business Office Manager (BOM) was unaware that not delivering mail on Saturdays violated residents' rights and stated that her work schedule did not include weekends, which prevented her from sorting mail on those days. The Activities Department, which was present seven days a week, was responsible for distributing mail to residents, but only department heads, who worked Monday through Friday, had keys to the mailbox. This resulted in a failure to deliver mail to residents on Saturdays, despite the facility's policy and the expectations set by the Director of Nursing and the Administrator.
Deficiency in Water Management Program for Infection Control
Penalty
Summary
The facility failed to establish a comprehensive water management program to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens. The facility's existing policies, including the Infection Control Policy and the Prevention of Legionella Growth and Exposure policy, lacked detailed documentation and implementation of a water management program. Interviews revealed that key staff members, including the Maintenance Director, Administrator, ADON, and DON, were unaware of the existence of a water management system or schematic of the building's water flow. The Maintenance Director, who had recently assumed the role, had not received training related to Legionella and was unsure about chlorine testing procedures. The Administrator and nursing leadership, including the DON and ADON, shared responsibilities for infection prevention but did not actively manage or monitor the water system. The facility's Quality Assessment and Performance Improvement (QAPI) meetings did not address the water management system, and there was no evidence of tracking or surveillance of potential Legionella outbreaks. Despite the absence of reported Legionella cases, the lack of a documented water management program and the unclear division of responsibilities contributed to the deficiency in infection prevention and control.
Cross-Contamination Risk Due to Gnat Infestation
Penalty
Summary
The facility failed to prepare food safely, leading to a potential cross-contamination issue. On October 1, 2024, a Dietary Aide (DA2) was observed preparing a puree brownie with gnats flying around an uncovered blender. Additionally, a heavy presence of gnats was noted around a trash can in the dining area where residents were present for lunch. The facility's policies on food preparation and pest control were reviewed, revealing that the facility was expected to maintain an effective pest control program and ensure safe food handling practices. Interviews with various staff members, including dietary aides, the Dietary Manager (DM), housekeeping, maintenance, the Director of Nursing (DON), and the Administrator, confirmed the presence of gnats in the facility. Staff members acknowledged being trained on cross-contamination and reported sightings of gnats to their supervisors. However, there was a lack of effective communication and action to address the gnat issue, as maintenance had not received reports of gnats in the kitchen, and the pest control company had not been tasked with addressing gnats specifically. The Administrator acknowledged the presence of gnats and expressed the need for staff to follow policies and treat the facility as the residents' home.
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What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Nursing homes near Flemingsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maysville Nursing And Rehabilitation Facility | 15 mi | ★★★★★ | 0 | 0 |
| Willowbrook Healthcare | 17.4 mi | — | 0 | 0 |
| Robertson County Health Care Facility | 17.8 mi | ★★★★★ | 0 | 0 |
| Ridgeway Nursing & Rehabilitation Facility | 18.6 mi | ★★★★★ | 0 | 0 |
| Ohio Valley Manor Care Center | 23.7 mi | ★★★★★ | 5 | 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.