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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring View Nursing & Rehabilitation during CMS and state inspections, most recent first.
A facility failed to ensure 11 of 11 licensed staff had current CPR certifications, despite policy and job descriptions requiring active CPR for licensed nurses. A resident with Full Code status, a care plan directing CPR, and a physician order for CPR was found unresponsive without pulse or respirations, but an LPN did not initiate CPR. Interviews showed confusion among leadership about CPR certification requirements, and the DON acknowledged CPR was typically indicated for a Full Code resident.
A resident who was full code expired in the facility, and staff failed to initiate CPR and failed to immediately notify the physician or on-call NP. The resident had significant cardiac and cerebrovascular history, was found without pulse or respirations, and the NP was not notified until more than an hour later. Interviews showed staff expected immediate notification, but the DON did not notify the physician and the NP later confirmed the delay.
Failure to Follow Full Code CPR Care Plan: A resident with Full Code status and a care plan directing CPR if found without pulse or respirations was found unresponsive by an LPN, who reported the resident was blue, cold, and had rigor mortis. CPR was not initiated, even though the resident’s code status and care plan were known, and the emergency contact’s request to withhold resuscitation was not consistent with the resident’s documented wishes.
A resident with Full Code status, a living will requesting life-prolonging treatment, and a history of significant cardiac and cerebrovascular disease was found unresponsive, without pulse or respirations. Staff observed the resident was blue, cold, and had signs of death, and CPR was not started even though the resident's care plan and physician orders required it. Interviews showed staff knew the resident was Full Code, but they relied on the resident's emergency contact and the resident's condition rather than initiating CPR as expected.
MDS assessments were inaccurately coded for three residents when current tobacco use was documented in the chart but entered as none on the MDS. Records showed one resident used a vape with nicotine and THC, another was a smoker with repeated sign-outs to smoke, and a third participated in smoking activities with tobacco; however, each MDS coded current tobacco use as 0. The MDS Coordinator said she used nursing, CNA, and therapy documentation to complete assessments, and the MDS Nurse stated incorrect coding could lead to fines, repayment of funds, or affect resident care.
Advance directives were not properly completed for multiple residents. One resident with intact cognition stated she was full code, but her form did not document a directive; another resident with intact cognition had conflicting advance directive forms, one blank and one indicating life-prolonging treatment; a third resident with intact cognition had a DNR status in the EMR but the form had unclear initials and no resident name; and a fourth resident with severe cognitive impairment had a legal representative signature, but the form listed the resident’s name instead of the representative’s and left the legal appointment blank.
A resident with significant cardiac and cerebrovascular history died in the facility, but the provisional death certificate was signed before the death occurred. The facility could not provide a policy for provisional death certificates, and interviews showed blank forms had been pre-signed and kept on the units. The LPN said the resident was already blue, cold, and in rigor mortis with no signs of life, while the SDC said she was not present at the time and had signed blank forms previously. The DON said she should have signed the form, and the Medical Director and Administrator stated the certificate should not be signed until the time of death or soon after.
Missing Annual CNA Performance Evaluations: The facility failed to complete annual performance evaluations for 4 of 6 CNA files reviewed. Record review showed CNA2, CNA16, CNA17, and CNA20 had training documented, but no evidence of a performance evaluation within the required 12-month period; one CNA's last evaluation was in 2022. The DON said she would begin training on performance evaluations because she was new to the position, and the Administrator stated yearly evaluations were beneficial but were not completed.
The facility failed to keep CPR certifications current for licensed and certified staff and did not provide CPR to a resident with Full Code status who was found without pulse or respirations. The CPR policy and job descriptions required active CPR certification for RNs and LPNs, yet most sampled licensed or certified staff were not current. Interviews showed the SDC, DON, and Administrator were aware of CPR certification and code-status expectations, but CPR was not initiated when the resident was found with no signs of life.
Failure to follow Contact Precautions for a resident with a wound infection. A resident with MRSA, necrotizing fasciitis, and severe cognitive impairment was placed on Contact Isolation, and a Contact Precautions sign was posted on the door. However, a CMA entered the room to give medication without a gown or gloves, stating she did not think PPE was needed because she was not doing direct care. The SDC/IP, ADON, DON, and Administrator all stated staff were expected to wear PPE and perform hand hygiene before entering the room.
Expired CPR Certifications and Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The facility failed to ensure that its licensed nursing staff had current CPR certifications, with 11 of 11 licensed personnel records reviewed showing expired or unavailable CPR credentials. The facility policy required CPR-certified staff to always be available, and the RN and LPN job descriptions stated that a current active CPR certification was required for licensed nurses. Review of the personnel files showed no documented evidence of prior CPR certifications for the licensed staff reviewed, including the RN, DON, and multiple LPNs. The deficiency was identified in connection with the death of a resident who had been admitted with diagnoses including TIA/stroke and old MI and who had a Full Code status. The resident’s care plan and physician order both directed CPR if the resident was found without pulse or respirations, and the resident’s living will indicated that life-prolonging treatment was not to be withheld or withdrawn. On the night of the event, an LPN found the resident unresponsive, without pulse, respirations, or signs of life, but did not initiate CPR. Interviews showed that staff were aware CPR certification was expected or required, but the SDC stated she had been told by the Administrator that active CPR certification was not required for licensed staff. The DON stated she did not initiate CPR because of the resident’s condition, though she acknowledged that a Full Code resident typically should have CPR initiated. The Administrator stated he expected proper monitoring of CPR certification, acknowledged that he should have been overseeing staff CPR certifications, and stated he would do so going forward.
Delayed Physician Notification After Resident Death
Penalty
Summary
The facility failed to ensure the physician was immediately notified of a significant change in status for one sampled resident, R71, who was full code and expired at the facility. The deficiency was identified as Immediate Jeopardy after staff did not initiate CPR and did not immediately notify the physician when the resident was found without pulse, respirations, or signs of life. R71’s record showed a history that included atherosclerotic heart disease of native coronary artery without angina pectoris, personal history of TIA, cerebral infarction without residual deficits, and old myocardial infarction. The resident had been admitted to the facility and later expired there. A progress note documented that R71 was in bed with no complaints and vital signs were within normal limits earlier in the night, and later that morning an LPN found the resident with no pulse, respirations, or signs of life. The resident’s emergency contact was at the bedside and stated she did not want attempts at CPR because the resident had passed peacefully in sleep. Interviews showed inconsistent and delayed notification of the physician or NP after the death. The NP initially stated she was made aware of the death shortly after arriving at the facility, but later stated she had actually been notified by text message 1 hour and 36 minutes after the resident’s death and expected immediate notification. The LPN stated staff were supposed to call the physician with any change when it occurred, while the DON stated she did not notify the physician because she was not assigned to the resident. The Medical Director stated he expected to be notified immediately when a resident passed away, and the Administrator stated staff were expected to notify the physician or on-call NP immediately after a resident’s death.
Failure to Follow Full Code CPR Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for Resident 71, who was admitted with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, personal history of transient ischemic attack, cerebral infarction without residual deficits, and old myocardial infarction. The resident’s Advanced Directives Comprehensive Care Plan, initiated and revised before the event, identified the resident as Full Code Status and included an intervention to administer CPR if the resident was found without pulse or respirations. A progress note documented that an LPN found the resident without pulse, respirations, or signs of life, and the resident’s emergency contact stated she did not want any attempts at resuscitation. During interview, the LPN stated the resident was blue, cold, and had rigor mortis, and that CPR was not performed despite awareness that the resident was Full Code. The LPN stated she and the former ADON/current DON believed the resident was too far gone to start CPR. Other interviewed staff, including the Regional Support Nurse, NP, Medical Director, DON, and Administrator, stated they expected CPR to be initiated for a resident with Full Code status and that staff should follow the resident’s care plan and code status.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The facility failed to ensure CPR was initiated for one resident who was found without a pulse, respirations, or signs of life and was documented as Full Code. The resident had diagnoses including atherosclerotic heart disease, prior TIA/stroke, cerebral infarction without residual deficits, and old myocardial infarction. The resident was cognitively intact, had a physician order for Full Code status, and the care plan and advance directives stated CPR was to be administered if the resident was found without pulse or respirations. The resident's Kentucky Living Will Directive indicated wishes for life-prolonging treatment not to be withheld or withdrawn. On the morning the resident was found unresponsive, staff entered the room and observed the resident was blue, cold, and had no chest rise. One staff member reported the resident was too far gone for CPR, and the DON also stated CPR was not initiated because the resident appeared blue, purple, and hard, with rigor mortis starting to set in. The resident's emergency contact was present and reportedly stated she did not want resuscitation attempts and that the resident passed peacefully in sleep. Despite these statements, the resident remained documented as Full Code, and staff interviews confirmed they knew the code status could be found in the EMR, care plan, face sheet, and code binder. Interviews with the Regional Support Nurse, NP, Medical Director, and Administrator reflected that CPR was expected for a resident with Full Code status until EMS arrived, even if an emergency contact objected. The facility also could not provide documentation that the LPN involved had an active CPR certification at the time of the resident's death. The report states the failure to initiate CPR for this resident constituted Immediate Jeopardy and Substandard Quality of Care.
MDS assessments inaccurately coded tobacco use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ status at the time of assessment for three sampled residents. Review of the CMS RAI 3.0 User’s Manual and facility policy showed the assessment process was expected to accurately reflect the resident’s status and include direct observation and communication with the resident and direct care staff. The facility’s documentation policy also required an accurate representation of the resident’s actual experiences through complete, accurate, and timely documentation. For one resident admitted with acute kidney failure, idiopathic aseptic necrosis of unspecified bone, and generalized anxiety disorder, the record documented daily vaping with nicotine and THC, a risk assessment identified e-cigarettes/vape as the smoking product, and the care plan stated the resident participated in smoking activities utilizing a vape; however, the MDS coded current tobacco use as none. For another resident admitted with fusion of the cervical spine, pseudarthrosis after fusion, and cerebral infarction due to embolism, the record documented the resident as a smoker and showed 495 sign-outs to smoke, yet the MDS also coded no current tobacco use. For a third resident admitted with type 2 diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, and depression, the care plan stated the resident participated in smoking activities utilizing smoking tobacco, but the MDS again coded no current tobacco use. The MDS Coordinator stated she gathered information from nursing evaluations, nurses’ notes, CNA point-of-care documentation, and therapy documentation, and the MDS Nurse stated an incorrectly coded MDS could result in fines, repayment of monies dispersed, or affect resident care.
Advance directives were not properly completed for multiple residents
Penalty
Summary
The facility failed to formulate advance directives at the discretion of four sampled residents who had documented cognitive status assessments and, in several cases, expressed code status preferences. Resident 51 was admitted with COPD, bronchopneumonia, generalized anxiety disorder, and bipolar type disorder, and had a BIMS score of 15/15 indicating intact cognition. During interview, Resident 51 stated she was full code and understood CPR, but the Advance Directives/Medical Treatment Decisions form contained no directive documenting her decision to prolong life and receive life-sustaining treatment. Resident 22 was admitted with incomplete paraplegia, obsessive compulsive disorder, and borderline personality disorder, and also had a BIMS score of 15/15. The resident stated she was full code and said she had formulated an advance directive when admitted, but the form in the record had one version signed by the resident with no directive indicated, while a second version indicated she wished efforts made to prolong her life and provide life-sustaining treatment. Resident 55 had COPD, heart disease, and type 2 diabetes mellitus with diabetic polyneuropathy, had a BIMS score of 15/15, and had DNR status documented in the EMR; however, the advance directive form contained an unclear set of initials below the signature line and no resident name. Resident 6 had CVA, paraplegia, and aphasia, with a BIMS score of 6/15 indicating severe cognitive impairment; the advance directive form was signed by the legal representative, but the resident's name was printed on the line for the representative and the type of legal appointment was left blank.
Provisional death certificate signed before resident’s death
Penalty
Summary
The facility failed to ensure services provided or arranged met professional standards of quality when a provisional death certificate for one resident was signed before the resident’s death. Record review showed the facility could not provide a policy related to provisional death certificates. The facility’s documentation policy required accurate, complete, and timely documentation, and its death-of-a-resident policy required appropriate documentation in the clinical record concerning the death of a resident. The resident, who had diagnoses including atherosclerotic heart disease, cerebral infarction without residual deficits, and old myocardial infarction, was discharged due to death in the facility. Review of the provisional death certificate showed it was signed by the Staff Development Coordinator and witnessed by an LPN, even though the staffing schedule showed the SDC was not scheduled to work that shift. During interviews, the LPN stated the resident was blue, cold, and had rigor mortis when she entered the room, and that the resident had no signs of life and was full code. The LPN stated she was not permitted to sign a provisional death certificate, though she had filled one out in the past, and said the SDC had signed blank forms and left them at the nursing desk. The SDC stated she was not working at the time of the death and did not come to the facility to sign the form, but acknowledged she had signed blank provisional death certificates and kept them on each unit. The DON stated she was working that shift and should have signed the certificate, while the Medical Director and Administrator stated the certificate should not be signed until the time of death or soon after.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure performance evaluation reviews were completed for every CNA at least once every 12 months for 4 of 6 CNA personnel records reviewed, including CNA2, CNA6, CNA17, and CNA20. Review of the facility policy titled, Nursing Services and Sufficient Staff, revised 02/03/2025, stated that sufficient staff with appropriate competencies and skill sets were to be provided to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, and that nurse aides must be able to demonstrate competency in skills and techniques necessary to care for residents. The Administrator did not provide a performance evaluation policy, although the Administrator's job description stated duties included communicating policies, evaluating performance, providing feedback, assisting, observing, and coaching. Record review showed CNA2 was hired on 03/19/2024 and had 24.5 hours of training between 07/15/2024 and 12/05/2024, but there was no documentation of a performance evaluation during the 12-month period. CNA16 was hired on 07/27/2022 and had 37.5 hours of training between 01/23/2025 and 07/06/2025, but there was no documentation of a performance evaluation during the 12-month period. CNA17 was hired on 05/13/2024 and had 33.57 hours of training between 03/06/2025 and 07/15/2025, but there was no documentation of a performance evaluation during the 12-month period. CNA20 was hired on 04/21/2022, and the last evaluation in the file was completed in 2022, with no documentation of a performance evaluation during the last 12-month period. During interview, the DON stated she would begin training regarding performance evaluations to start the yearly evaluation process since she was new to the position, and the Administrator stated yearly performance evaluations were beneficial but were not completed on his part.
Failure to Maintain CPR Certification and Initiate CPR for a Full Code Resident
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The report identified that the facility did not ensure staff CPR certifications were current, even though the CPR policy required healthcare providers to maintain current CPR certification and the RN and LPN job descriptions required active CPR certification. Review of personnel records showed 15 of 21 licensed or certified staff sampled were not up to date with CPR certification. The deficiency was tied to the care of a resident who was admitted with a Full Code status. The resident’s advance directives, care plan, and physician order all indicated that CPR was to be administered if the resident was found without pulse or respirations. A progress note documented that an LPN was called to the resident’s room and found the resident with no pulse, respirations, or signs of life, but nursing staff did not provide CPR. The resident expired in the facility. Interviews showed staff and leadership were aware of problems with CPR certification and expectations, but the issue remained unresolved at the time of the resident’s death. The SDC stated she was responsible for ensuring staff were CPR certified and acknowledged some nurses may have had expired CPR. She also stated the Administrator had told her licensed staff were not required to have active CPR certification, even though it was in their job descriptions. The DON stated she had not been CPR certified until later and that CPR was not initiated for the resident despite the Full Code status. The Administrator stated he expected proper monitoring of CPR certification, acknowledged he should have been overseeing it, and stated the facility had not identified the systemic CPR issue before surveyors entered the facility.
Failure to Follow Contact Precautions for a Resident with Wound Infection
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one sampled resident, R73. R73 was admitted with diagnoses including necrotizing fasciitis, MRSA infection, and pressure ulcer of unspecified site, unspecified stage, and had a BIMS score of 5 out of 15, indicating severe cognitive impairment. A physician order dated 06/23/2025 placed R73 on Contact Isolation Precautions related to a wound infection, and a wound culture dated 07/31/2025 identified MRSA, enterococcus faecium, and Escherichia coli with recommendations to establish Contact Isolation. On 08/10/2025 at 10:00 AM, observation showed a Contact Precautions sign on R73's door, but CMA1 entered the room to administer medication without wearing a gown or gloves. During interview, CMA1 stated she did not think PPE was needed because she was not doing direct care, then acknowledged after reading the sign that she should have worn a gown and gloves before entering the room. The SDC/IP, ADON, DON, and Administrator each stated staff were expected to perform hand hygiene and don PPE before entering a resident's room on Contact Precautions, and the DON stated staff may have been confused with Enhanced Barrier Precautions and Contact Precautions.
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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 Leitchfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grayson Nursing And Rehab Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Edmonson Nursing And Rehabilitation Center | 19.8 mi | ★★★★★ | 0 | 0 |
| Hardinsburg Nursing And Rehabilitation Center | 21.9 mi | ★★★★★ | 0 | 0 |
| Breckinridge Memorial Nursing Facility | 23 mi | ★★★★★ | 3 | 0 |
| Fordsville Nursing And Rehabilitation Center | 26.5 mi | ★★★★★ | 0 | 0 |
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