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 altered mental status and moderately impaired cognition fell from a bedside commode after a CNA turned her back to help the roommate with a blanket, despite the care plan requiring supervision while on the commode. The resident sustained a rib contusion, and the CNA stated the fall could have been prevented if she had not turned away or if another staff member had been present.
Unsafe and Unhomelike Resident Room Conditions: Surveyors observed stained, moisture-damaged ceiling tiles in several rooms and a supply closet, along with peeling paint and holes in resident rooms. A resident reported the room condition did not feel homelike, another said paint dust was getting onto belongings, and others said the holes made them feel unsafe or bothered them. The Maintenance Director linked the ceiling damage to a prior roof leak from clogged gutters, and the Administrator said repairs were usually handled promptly when reported.
Delayed Incontinence Care and Brief Changes: The facility failed to provide timely incontinence care for four residents who were unable to manage ADLs. One resident waited about 26 minutes after using the call light for bowel incontinence, another reported waiting over 3 hours in a wet brief, a third said she sat in feces for 2 hours because two CNAs were needed for care, and a fourth waited about 40 minutes after repeated call light requests. Facility policy required perineal care as needed, and the DON stated soiled briefs should be changed within 10 to 15 minutes.
Incomplete PRN Narcotic Pain Documentation: The facility failed to document pain assessments and reevaluations for PRN narcotic pain meds for four residents. MARs and controlled substance records showed multiple Hydrocodone-Acetaminophen and Tramadol doses removed or administered without the required documentation, despite care plans addressing pain and opioid use. Staff interviews confirmed awareness that PRN meds must be documented on the MAR and that missing documentation could allow a narcotic to be given too soon.
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.
Failure to Supervise Resident on Bedside Commode
Penalty
Summary
The facility failed to ensure a resident was adequately assisted to prevent an accident when the resident fell from a bedside commode. The resident was admitted with diagnoses including pneumonia, altered mental status, and need for assistance with personal care, and the Quarterly MDS showed a BIMS score of 8, indicating moderately impaired cognition. The resident's care plan included an intervention that the resident must be supervised while on the bedside commode. According to the fall report, a CNA assisted the resident to the bedside commode, then became distracted by the roommate asking for a blanket and turned her back while the resident was sitting on the commode. The resident fell off the bedside commode and was assessed and returned to bed. Progress notes documented that the resident sustained a rib contusion after the fall. During interviews, the CNA stated the fall would have been prevented if she had not turned her back on the resident and if another staff member had been present to assist her.
Unsafe and Unhomelike Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in multiple rooms. Survey observations identified stained ceiling tiles with apparent moisture damage in rooms 100, 107, 109, and 119, including several tiles that were yellowish-brown, bowed, or stained in areas near windows, corners, and above resident areas. A small supply closet near the nurse's station also had stained and bowed ceiling tiles while storing disposable cups, spoons, isolation gowns, N95 respirator masks, aerosol masks with tubing, oxygen tubing, nasal cannulas, and other oxygen supplies. The Maintenance Director stated the building had experienced heavy rain about 6-8 weeks earlier due to clogged gutters and roof leakage, and that the gutters had since been cleaned and the stained ceiling tiles replaced. Additional observations showed peeling paint and holes in resident rooms affecting R11, R12, R19, and R20. In one room, surveyors observed a 20-inch by 12-inch hole in drywall above R11's bed, along with peeling paint and a hole in the ceiling tile. In another room, there were multiple areas of peeling paint, a hole in the wall near the floor, a scrape behind one bed, and a round spot of missing paint below a clock, with R12's clothes and shoes covered in white dust and particles from crumbling paint. Another room had a 21-inch by 4-inch hole in the wall near the air conditioner. Residents stated the room conditions bothered them, did not feel homelike, and in one case made the resident feel unsafe. The Administrator stated residents were comfortable reporting repairs to the Maintenance Director and that issues would usually be fixed promptly if he knew about them.
Delayed Incontinence Care and Brief Changes
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for four sampled residents who were unable to manage their own activities of daily living. Facility policies stated that residents were entitled to reasonable accommodation of their needs and that incontinent residents were to receive perineal care as needed to maintain cleanliness, comfort, and prevent skin breakdown. The Director of Nursing stated the expectation was for a soiled brief to be changed within 10 minutes, and no longer than 15 minutes after an episode of incontinence. One resident reported using the call light for bowel incontinence and waiting approximately 15 minutes before speaking with staff, then waiting until a CNA entered the room about 26 minutes after the initial request to change the brief. The room smelled of feces when observed, and two staff members were sitting at the nurses' station at the time. Another resident stated she was changed only once per night shift and had waited over 3 hours in a wet brief after asking to be changed. She said this made her miserable because she was always incontinent. A third resident reported sitting in feces for 2 hours because two people were needed for her incontinence care and only two CNAs were working on the floor at the time. A fourth resident stated she waited about 40 minutes in a wet brief the night before the interview, after pressing the call light twice while staff were at the nurses' station. She became tearful and said waiting that long made her feel terrible because she got raw in her perineal area if she sat in a soiled brief too long.
Incomplete PRN Narcotic Pain Documentation
Penalty
Summary
The facility failed to ensure pain assessments were completed before and after the administration of PRN narcotic pain medications for four sampled residents: R4, R8, R16, and R18. Facility policies for Pain Management and PRN Medication required use of a pain assessment tool appropriate to the resident’s cognitive status, documentation of the reason for PRN use, the time of administration, and evaluation of effectiveness. The policies also stated that pain management would be reassessed at established intervals for effectiveness and adverse consequences. R18 was admitted with diagnoses including cerebral infarction, neuralgia, and unspecified pain, and her care plan included pain-related interventions and opioid-related goals. Her MAR showed documented administrations of Hydrocodone-Acetaminophen with pain assessments before and after administration, but the Medication Monitoring/Control Record showed additional tablets removed that were not documented on the MAR. For March 2026, 17 tablets were removed and 13 PRN doses were missing from the MAR, including pain assessment and reevaluation. For April 2026, 10 tablets were removed and 8 PRN doses were missing from the MAR, also without the required pain assessment and reevaluation. R4 was admitted with diagnoses including diastolic heart failure, wedge compression fracture of T11-T12 vertebra, and unspecified pain. Her care plan identified pain related to age, decreased mobility, restless leg syndrome, muscle spasms, and opioid use. Her MAR showed one documented Tramadol administration in March 2026, one in April 2026, and none in May 2026, while the Medication Monitoring/Control Record showed 9 tablets removed in March, 6 in April, and 7 in May. In each month, multiple PRN doses were missing from the MAR, including pain assessments and reevaluations before and after administration. R16 was admitted with cerebrovascular disease, Alzheimer’s disease with late onset, and idiopathic neuropathy. Her care plan addressed pain related to hip fracture history, decreased range of motion, arthritis, weakness, CVA, and muscle weakness. Her MAR showed no documented Hydrocodone-Acetaminophen administrations in April 2026 and one documented administration in May 2026, while the Medication Monitoring/Control Record showed 5 tablets removed in April and 9 in May. In both months, PRN doses were missing from the MAR, including pain assessment and reevaluation. R8 was admitted with Type 2 diabetes mellitus with hyperglycemia, unspecified myalgia, and acquired absence of the left foot and right great toe. Her care plan addressed acute pain related to toe amputation and opioid use. Her MAR showed no documented Hydrocodone-Acetaminophen administrations in March 2026, four documented administrations in April 2026, and none in May 2026, while the Medication Monitoring/Control Record showed 5 tablets removed in March, 16 in April, and 7 in May. In each month, PRN doses were missing from the MAR, including pain assessments and reevaluations before and after administration.
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.
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Compliance trends in Kentucky
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 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): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 July 29, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Kentucky
- Re-educated all nurses on policies requiring physician/nurse practitioner notification for significant weight changes and changes in condition, and prevented nurses from working until education was completed (J - F0684 - KY) (J - F0580 - KY)
- Administered post-tests after nurse education with a required 100% pass rate and provided re-education as needed (J - F0684 - KY) (J - F0580 - KY)
- Added education on notification of significant weight changes/changes in condition to new-hire orientation for nurses (and certified medication technicians where specified) (J - F0684 - KY) (J - F0580 - KY)
- Educated the Director of Nursing Services to review weight reports timely related to the weekly Nutritional At Risk meeting (J - F0580 - KY)
- Implemented ongoing audits to verify weight changes and resident assessments resulted in physician/nurse practitioner notification when warranted, with results forwarded to QAPI for review and presented by the Director of Nursing (J - F0684 - KY) (J - F0580 - KY)
Failure to Recognize and Act on Rapid Weight Gain and Edema as Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to recognize and respond to a significant change in condition for one resident, including substantial weight gain and edema, in accordance with its own policies and the resident’s care plan. The resident was admitted for short-term rehabilitation following a serious illness with sepsis and a spinal abscess, with hospital diagnoses including atrial fibrillation, coronary artery disease, pneumonia, and stable shortness of breath at discharge. On admission, the facility documented diagnoses of pneumonia, nontraumatic subdural hemorrhage, and primary hypertension, and the MDS reflected atrial fibrillation, hypertension, moderate cognitive impairment (BIMS score of 8/15), IV access, and shortness of breath when lying flat. The care plan directed staff to weigh the resident as ordered, notify the physician of significant weight changes, and, after an update, to observe and document signs and symptoms of cardiac dysfunction such as shortness of breath, abnormal lung sounds, decreased urine output, edema, and changes in mental status, and to notify the physician of abnormal findings. The facility’s policies on Change in Condition and Weight Monitoring required staff to notify the physician or nurse practitioner for abnormal weights and significant changes, to re-weigh residents for weight changes of 3 pounds or more in one day or 5 pounds in one week, and to notify the physician, resident, and representative of such changes. Despite these policies, the resident’s weight increased from an admission weight of 252.8 pounds to 259 pounds within four days, then to 267 pounds within nine days, and to 270 pounds within 13 days, for a total gain of 17.2 pounds. The DON entered the 259‑pound weight and acknowledged later that this represented a clinically significant gain per policy but did not assess the resident or notify the APRN. LPN1 entered the 267‑pound weight but did not document any re‑weigh, assessment, or provider notification related to this gain and could not recall taking any such actions, stating that if she had notified a provider she would have charted it. During this period of rapid weight gain, clinical signs consistent with fluid accumulation were present but not consistently recognized or acted upon as a change in condition. A Health Status Note documented that a family member reported the resident’s right hand swelling, increased confusion from baseline, and complaints of shortness of breath; LPN5 documented these findings and notified the APRN, who ordered continued monitoring only, without further specified parameters. Skilled nursing assessments on two dates documented shortness of breath or labored breathing with exertion and when lying flat, need for supplemental O2 and head-of-bed elevation, and edema in both lower extremities, yet the corresponding progress notes from admission through the date of transfer contained no documentation of edema or shortness of breath and no evidence that staff recognized the weight gain as a significant change in status or notified the physician as required. On the thirteenth day, LPN4 documented +3 to +4 pitting edema in all four extremities, marked scrotal swelling, and shortness of breath after the family member again raised concerns, and EMS later assessed the resident as in acute respiratory distress with crackles/wheezing and pitting edema in all extremities. The APRN and Medical Director both stated they relied on nursing staff to notify them of rapid weight gain and changes in assessment findings, and the DON confirmed she could find no evidence that staff identified the resident’s weight gain as a potential change in condition or notified the APRN after the initial report of arm swelling, leading surveyors to cite the facility under F684 for failing to provide care in accordance with policies, care plan, and professional standards.
Removal Plan
- Resident #117 was discharged.
- All current residents were re-weighed and reassessed for change of condition by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager, with weights reviewed for the last 6 months.
- For any significant weight changes identified, a nursing assessment was completed by the Director of Nursing Services, Assistant Director of Nursing Services, or Unit Manager with notification of the physician or nurse practitioner for orders as needed.
- All residents were reassessed and reweighed, and any changes of condition were reported to the Nurse Practitioner with orders given.
- All nurses were re-educated by the Infection Preventionist/Staff Development, Director of Nursing Services, or Assistant Director of Nursing Services regarding the policy to notify the physician or nurse practitioner of all significant weight changes and the policy on changes in condition; no nurse worked before receiving the education.
- A post-test was administered to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
- The Director of Nursing, Assistant Director of Nursing, Infection Preventionist/Staff Development, or Unit Manager will provide education until all nurses complete it.
- Education on notification of significant weight changes and changes in condition will be added to new-hire orientation for nurses and certified medication technicians.
- An ad hoc QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, plan, and education regarding notification of changes.
- The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all weight changes and head-to-toe resident assessments resulted in physician or nurse practitioner notification when warranted.
- Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.
Failure to Notify Physician of Significant Weight Gain and Fluid Overload Signs
Penalty
Summary
The deficiency involves the facility’s failure to recognize and notify a physician of a resident’s significant weight gain and associated symptoms, as required by facility policy and the resident’s care plan. The facility’s Weight Monitoring policy required staff to notify the physician of a weight gain or loss of three pounds within one week. The resident was admitted with diagnoses including pneumonia, nontraumatic subdural hemorrhage, primary hypertension, atrial fibrillation, and hypertension, and had a care plan intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes, documenting abnormal findings and notifying the physician. The physician’s orders included weekly weights. From admission, the resident’s weight increased from 252.8 pounds to 259 pounds within four days, a gain of 6.2 pounds, and then to 267 pounds within nine days, a total gain of 14.2 pounds from admission. These weights were entered by the DON and an LPN, respectively. There was no documentation that the provider was notified of either the 6.2‑pound gain in four days or the 14.2‑pound gain in nine days, despite the facility policy requiring notification for a three‑pound gain in one week. Nursing documentation also showed that the resident had shortness of breath and/or labored breathing with exercise and while lying flat, but there was no documentation that the physician was notified of these abnormal findings, contrary to the resident’s care plan interventions. The resident’s weight continued to increase, reaching 270 pounds 13 days after admission, a total gain of 17.2 pounds. On that date, an LPN documented +3 to +4 pitting edema in all four extremities and shortness of breath, and notified the APRN, obtaining orders for a chest x‑ray, labs, and intramuscular furosemide. The resident was sent to the hospital for evaluation at the request of a family member. Interviews with the family member indicated he observed increasing swelling of the resident’s legs, feet, and scrotum throughout the stay and reported these concerns daily to staff, who told him the edema was not a problem. Interviews with the APRN, Medical Director, DON, and Administrator confirmed that staff were expected to notify a provider of significant weight changes and changes in condition, and that there was no evidence staff had identified the resident’s weight gain as a significant change in condition or notified the APRN or physician of the repeated weight gains prior to the date when the APRN was finally contacted.
Removal Plan
- All current residents were re-weighed and reassessed for change of condition by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager; weights for the last 6 months were reviewed.
- For any significant weight changes identified, nursing assessments were completed by the Director of Nursing Services, Assistant Director of Nursing Services, or Unit Manager with physician or nurse practitioner notification for orders as needed.
- All residents were reassessed and reweighed.
- All residents were reassessed by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager with any changes of condition reported to the Nurse Practitioner and orders obtained.
- Director of Nursing Services was educated by the Regional Nurse Consultant to review weight reports timely related to the weekly Nutritional At Risk meeting.
- All nurses were educated by the Infection Preventionist/Staff Development, Director of Nursing Services, or Assistant Director of Nursing Services regarding the policy on notifying the physician or nurse practitioner of all changes of condition including weight changes; education completion tracked.
- A post-test was administered to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
- Director of Nursing Services, Assistant Director of Nursing Services, Infection Preventionist/Staff Development, or Unit Manager will provide education until all nurses complete it.
- Education on notification of changes in condition including weight changes will be added to new-hire nurse orientation.
- An ad hoc QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, and education regarding notification of changes.
- The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all changes in condition including weight changes resulted in physician or nurse practitioner notification.
- Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.
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