Citations in Kentucky
Statistics, citations and compliance trends for long-term care facilities in Kentucky.
Statistics for Kentucky (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Kentucky
A resident with cerebrovascular disease, schizophrenia, and bipolar disorder received multiple scheduled meds by rectum even though the MAR ordered them by mouth and there was no documented change in route. Staff interviews and the facility investigation showed the nurse complied with the resident’s request to change the route instead of obtaining a provider order, and the event was documented as a medication error.
Staff failed to follow infection control practices during resident care and medication administration. An LPN gave insulin to a resident on EBP without a gown, another LPN picked up a glove from the floor and used it during eye drop administration, and staff used shared and resident-specific equipment, including BP cuffs and a glucometer, without cleaning or disinfecting between uses. A resident’s Foley catheter bag was also observed touching the floor.
Failure to perform hand hygiene during medication administration. An KMA did not sanitize hands after each resident medication pass, picked up a dropped Risperidone tablet with bare hands instead of discarding it, and administered medications to a resident without hand washing or hand sanitizing before or after. Facility policy required hand hygiene and infection control procedures during medication administration, and leadership stated staff were expected to clean hands between residents.
Failure to notify physician and guardian of missed antipsychotic injection and behavior changes. A resident with schizoaffective disorder, dementia with behavioral disturbance, and severe cognitive impairment missed a scheduled monthly Invega Sustenna injection, and the dose was not given until weeks later. The MAR and EMR showed no documented notification to the MD or guardian when the medication was missed, and progress notes later documented refusal of oral meds and increased anxiety and agitation without notification. The resident then had escalating psychotic and aggressive behaviors, multiple hospital transfers, and admission to a behavioral unit.
A resident with schizoaffective disorder, dementia, and severe cognitive impairment missed his scheduled monthly Invega Sustenna injection when the dose was documented as unavailable on the MAR. The injection was not given until 17 days later, and there was no evidence the restart dosing sequence was followed after the prolonged gap. After the missed dose, the resident developed increased anxiety, agitation, delusions, and aggressive behavior, requiring transfer to a hospital, then a state psychiatric facility, and later another hospital behavioral admission. Staff and the pharmacy director confirmed the facility did not promptly notify the pharmacy that the medication was unavailable.
Food storage and staff attire standards were not followed in the kitchen. Dry goods were found on the floor, dented cans remained on the active shelf for resident use, a refrigerator holding residents' drinks was above the required temp, and freezer items were uncovered and exposed to ice particles. The DM also prepared meal plates with his beard net below his mustache, despite knowing facial hair was supposed to be fully covered.
Medication Given by Wrong Route After Resident Requested Rectal Administration
Penalty
Summary
The facility failed to administer medications in accordance with provider orders and established nursing practice for one resident. The resident had diagnoses including unspecified cerebrovascular disease, paranoid schizophrenia, and bipolar disorder, and the record showed he was cognitively intact with a BIMS score of 12 out of 15. His orders indicated a controlled carbohydrate diet with regular texture and thin liquids, and that he took medications whole by mouth. On the evening of the incident, the resident received multiple scheduled medications that were ordered by mouth, including atorvastatin, finasteride, trazodone, Amitiza, benztropine, celecoxib, haloperidol, metoprolol, Mucinex, baclofen, Depakote Sprinkles, gabapentin, polyethylene glycol, and sucralfate. The medical record did not document any change in the route of administration. Facility investigation and staff interviews showed that the resident requested medications be given rectally rather than orally, and the nurse complied with that request by crushing medications and administering them per rectum. The investigation also showed that the nurse did not contact the provider for an order to change the route of administration before giving the medications rectally. Staff interviews confirmed that the resident had refused oral medication and that the route was changed based on the resident’s request rather than a provider order. The resident was assessed afterward and was documented as alert, oriented, and without injury or distress, and the incident was identified by the facility as a medication error.
Infection Control Failures During PPE Use, Medication Administration, Equipment Cleaning, and Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 7 of 40 sampled residents, including residents with diabetes, dementia, Parkinson’s disease, wounds, and a urinary catheter. The report cited failures related to enhanced barrier precautions, medication administration practices, cleaning and disinfection of shared and resident-specific equipment, and catheter care. Facility policies and manufacturer instructions required appropriate PPE use, hand hygiene, and cleaning or disinfection of equipment after use, but survey observations showed staff did not consistently follow those requirements. For one resident admitted with type 2 diabetes and Parkinson’s disease, an LPN entered the room while the resident was on enhanced barrier precautions and administered an insulin injection without donning a gown. The resident’s care plan included enhanced barrier precautions related to a wound, and signage was posted on the door. During interview, the LPN stated PPE should be worn for direct resident contact and acknowledged she did not gown up before giving the insulin injection. The IP, DON, and Administrator each stated they expected staff to wear appropriate PPE during medication administration for residents on enhanced barrier precautions. For another resident with type 2 diabetes and dementia, an LPN dropped a glove on the floor while preparing to administer eye drops, then picked up the glove and donned it before giving the medication. The LPN later stated the glove should have been discarded, hand hygiene performed, and clean gloves donned. In separate observations, staff used a shared blood pressure cuff on two residents without cleaning or disinfecting it between uses, used a resident’s glucometer and placed it on the medication cart without cleaning or disinfecting it, and used a personal wrist blood pressure cuff on two residents without cleaning it between residents. The IP, DON, and Administrator stated equipment and glucometers were expected to be cleaned and disinfected between resident uses. The report also identified catheter care concerns for a resident with a Foley catheter. The resident’s catheter bag was observed touching the floor while the bed was lowered and the bag hung from the side of the bed frame. Staff stated the bag should not be on the floor, and the IP, DON, and Administrator each stated the catheter bag should not touch the floor. The facility’s policy also required proper catheter technique, secure placement, and keeping the collection bag and tubing off the floor.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 1 of 6 sampled residents, Resident 79. During observation on 06/03/2026 at 10:19 AM, KMA 2 did not sanitize her hands after each resident medication administration. She also dropped Risperidone 0.5 mg on top of medication cart 1, picked up the pill with bare hands instead of discarding it, and administered it to Resident 79. KMA 2 was also observed administering Flonase to Resident 79 without performing hand washing or hand sanitizing before or after the medication pass. Facility policies reviewed stated that medication administration staff were to follow infection control procedures, hand hygiene was to be performed using handwashing or hand sanitizer, and gloves and hand hygiene were to be used when moving from contaminated to clean body sites during resident care. During interview, KMA 2 stated she sanitized after every third resident and acknowledged she should have sanitized after each medication administration. The Infection Preventionist Nurse stated KMA staff were to hand wash after each resident when passing out medications, if possible, or use hand sanitizer at the very least. The Administrator stated staff were expected to sanitize hands between residents at the very least if unable to wash with soap and water, and the DON stated her expectation was for staff to wash their hands after each medication pass.
Failure to Notify Physician and Guardian of Missed Antipsychotic Injection and Behavioral Change
Penalty
Summary
The facility failed to immediately consult the resident’s physician and notify the resident’s representative when there was a significant change in condition for one resident with schizoaffective disorder, dementia with behavioral disturbance, and severe cognitive impairment. The resident was ordered monthly Invega Sustenna 234 mg, but the scheduled dose for 04/19/2026 was not administered, and the MAR showed no documented evidence that the injection was given during April 2026. The facility’s investigation later determined the dose was not administered as ordered, and the medication was not given until 05/06/2026. The record showed no documented evidence that the resident’s guardian or physician was notified when the injection was missed. Progress notes also documented the resident refused oral medications on 04/20/2026 and 04/21/2026, and later had increased anxiety and agitation on 05/03/2026, but there was no documented evidence that the physician or guardian was notified at those times. The facility’s policy required informing the resident, consulting the physician, and notifying the resident’s representative when there was a significant change in physical, mental, or psychosocial status or a need to alter treatment significantly. After the missed injection, the resident had escalating behavioral issues, including attempts to leave the unit, physical aggression toward staff, transfer to the hospital, return to the facility on 05/21/2026, and another emergency transfer on 05/31/2026 after pushing a staff member and exiting the secure unit. The resident was admitted to the local hospital’s behavioral unit for psychotic behaviors and psychosis. The state guardian stated she was not notified when the injection was missed or when behaviors increased, and the medical director stated he was not notified of the missed medication.
Missed antipsychotic injection and delayed pharmacy notification
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering his scheduled monthly Invega Sustenna injection as ordered and by not promptly notifying the pharmacy that the medication was unavailable. The resident had diagnoses including schizoaffective disorder, dementia with behavioral disturbance, and cognitive communication disorder, and his MDS showed severe cognitive impairment with a BIMS score of 5 out of 15. His care plan identified hallucinations, paranoia, and delusional behaviors, and included administering and monitoring medications as ordered. The resident’s physician ordered Invega Sustenna 234 mg once monthly, and the MAR showed he received the injection on 03/19/2026. The next scheduled dose was due on 04/19/2026, but the MAR documented the medication was unavailable and there was no evidence it was administered during April 2026. The resident did not receive the injection until 05/06/2026, 17 days late, and the package insert indicated that when a maintenance dose of 234 mg is missed by more than six weeks, the injection should be restarted with a different dosing sequence. The record showed there was no documented evidence that this restart dosing occurred, even though more than six weeks had passed between injections. After the missed dose, the resident had increased anxiety, agitation, delusions, and aggressive behavior. He was transferred to the local hospital, returned briefly, and then was sent to a state psychiatric facility after escalating behaviors and physical aggression toward staff. The psychiatric facility’s discharge summary stated he had been admitted on a court order for increasingly violent behavior and threatening to kill and assault staff, and it noted the missed Invega injection and return of symptom burden. Later, the resident again became behaviorally escalated, pushed a staff member through a secure unit exit, and was transported to the hospital’s behavioral unit for psychotic behaviors and psychosis. Interviews with facility staff and the pharmacy director confirmed the medication was not available on the scheduled date and that the facility did not notify the pharmacy that the dose was missing.
Food Storage and Staff Attire Standards Not Followed
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Review of facility policy showed dry goods were to be stored six inches above the floor and cold foods were to be stored in accordance with FDA Food Code guidance, with food kept covered, labeled, dated, and arranged to prevent cross-contamination. During kitchen observation, two cases of boxed juices were stored directly on the floor in the dry pantry, and several dented cans of marinara sauce, 3-bean salad, and banana pudding remained on the active storage shelf to be served to residents. The Dietary Manager stated the items on the floor had come in with a delivery and should have been placed on shelves immediately, and that the dented cans should have been removed and discarded but were overlooked. Further observation showed the 3-door refrigerator was above the required 41 degrees F, measuring 45 degrees F and later 49 degrees F, while residents' drinks remained stored inside even though the temperature was out of range. In the outdoor freezer, a box of sausage patties had uncovered interior plastic, and a box of croissants with uncovered plastic wrapping was stored under the condenser and covered with ice particles. The Dietary Manager stated he did not believe there was concern for storing residents' drinks at 49 degrees F, despite knowing cold items were required to be stored at 41 degrees F, and said food containers were expected to be covered securely to prevent contamination. The facility also failed to follow its staff attire policy when the Dietary Manager was observed preparing meal plates with his beard net below his mustache; he acknowledged the beard net was not covering all facial hair and stated this could allow hair to fall into residents' food.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
Get alerted when Immediate Jeopardy citations hit in Kentucky — free
You're all set
Compliance trends in Kentucky
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.
