Citations in Kentucky
Comprehensive analysis of citations, statistics, 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
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple medical conditions and moderate cognitive impairment, who was dependent on staff for ADLs, did not receive needed fingernail care. Over several days, observations showed the resident's nails remained long and unclean, despite facility policy and staff expectations. Interviews revealed confusion among CNAs and nursing staff about responsibility for nail care, especially for residents with diabetes, resulting in the resident not receiving appropriate hygiene assistance.
A resident with multiple chronic conditions was given Zofran for nausea by a KMA after an LPN mistakenly believed it was a standing order, despite no such order existing. The medication was administered without prior physician authorization, and the Medical Director was not notified or consulted before the order was entered. Facility leadership confirmed that staff are expected to follow protocols requiring physician orders for all medications not on the standing order list.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with observations of mold in shower rooms, dirty linens, and inadequate cleaning. Housekeeping and maintenance staff confirmed the presence of mold and cited short staffing and lack of reporting as reasons for inaction. Two residents reported seeing mold but did not report it, believing staff were already aware or would not address it. The DON and Administrator were unaware of the extent of the issue, and the deficiency had the potential to affect all residents.
The facility did not ensure that meals were prepared according to standardized recipes, resulting in food that was bland, lacked required ingredients, and was served at improper temperatures. Several residents and staff reported dissatisfaction with the taste and appearance of the food, and surveyors confirmed that the meals were not palatable or attractive.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as identified by surveyors.
Staff did not promptly report two separate abuse allegations: one involving a resident's report of mistreatment during a hospital stay, and another involving a witnessed resident-to-resident altercation. In both cases, required notifications to the DON, Administrator, and state agency were delayed, despite staff being trained on immediate reporting protocols.
Two residents with cognitive and behavioral impairments were physically assaulted by other residents, resulting in injuries and emotional distress. In both cases, staff and documentation confirmed that the aggressors had histories of confusion or aggression, and the incidents occurred despite care plans noting these risks.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Needed Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary personal hygiene services to a resident who was dependent on staff for assistance with activities of daily living (ADLs), specifically in maintaining clean and trimmed fingernails. The resident, who had a history of type 2 diabetes mellitus, muscle weakness, osteoarthritis, and cancer, was assessed as having moderate cognitive impairment and required substantial to maximal staff assistance for personal hygiene. Despite facility policy requiring staff to assist residents unable to perform their own ADLs, multiple observations over several days showed the resident's fingernails remained long, jagged, and unclean. Family members confirmed that the resident's nails needed trimming and expressed that they expected the facility to provide this care. Interviews with CNAs and nursing staff revealed confusion regarding responsibility for nail care, particularly for residents with diabetes. CNAs stated they were responsible for nail care on shower days unless the resident had diabetes, in which case the nurse was to be notified. However, the resident's assigned CNA had not noticed the condition of the nails and had not provided the necessary care, while the nurse had not been alerted to the need. The DON and Administrator both stated their expectation that residents' nails be kept clean and trimmed as allowed, but the resident continued to have untrimmed and unclean nails throughout the period of observation.
Medication Administered Without Valid Physician Order
Penalty
Summary
A deficiency occurred when a resident with dementia, diabetes, and congestive heart failure was administered a Zofran tablet for nausea without a valid physician's order. The resident, who was severely cognitively impaired, requested something for nausea. A Kentucky Medication Aide (KMA) checked the electronic health record and found no order for Zofran, then informed an LPN, who incorrectly stated that Zofran was available as a standing order. However, review of the facility's standing orders confirmed that Zofran was not included. Despite this, the KMA administered Zofran to the resident after the LPN entered an order under the Medical Director's name, but without prior authorization or notification to the Medical Director. Interviews revealed that the Medical Director was not contacted about the new medication and was unaware of the order, expressing that she would have needed more information before approving Zofran for the resident. The LPN later acknowledged the mistake, stating she should have obtained a proper order before administration. The Director of Nursing and the Administrator both confirmed that staff are expected to know the standing orders and obtain physician orders for all medications not on the list, emphasizing the importance of following these protocols for resident safety. The facility was unable to generate a Pyxis report to verify the medication dispensing process.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Clean and Homelike Environment Due to Mold and Poor Housekeeping
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as required by its own policies and federal regulations. Observations revealed a dirty adult brief on a shower chair, a pile of dirty linens on the floor, a toilet full of feces, and a mold-like substance on the ceiling and wall tiles in the shower room. Housekeeping staff confirmed the presence of mold throughout the facility and stated that they had not reported it, citing short staffing and limited time to complete cleaning tasks. The housekeeping supervisor acknowledged awareness of the mold issue but indicated that no action had been taken to address it, also attributing the problem to staffing shortages and time constraints. Interviews with residents confirmed that mold was present in the shower rooms, with one resident stating it was all over the walls, ceiling, and floors, but residents had not reported it because they believed staff were already aware or would not address it. The Maintenance Director admitted to noticing the mold recently and had attempted to address it superficially but had not investigated the cause due to time constraints and lack of reports from staff. The DON was unaware of the mold issue and acknowledged the potential health risks, while the Administrator stated that maintenance was responsible for identifying and addressing such issues, expecting staff to follow policy and guidelines. The failure to maintain cleanliness and address environmental hazards had the potential to affect all 81 residents in the facility.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that food and drinks served to residents were palatable, attractive, and at a safe and appetizing temperature, as required by their policy. During a dinner service, the kitchen ran out of regular ground beef for the last six trays, prompting the Dietary Manager to use frozen hamburger patties, which were quickly cooked and seasoned without following the standardized recipe. The Regional Dietary Manager admitted that the meat was not weighed, seasoning was estimated, and the recipe was not followed. The resulting meal lacked required ingredients such as cumin, salt, onion, and toppings like shredded cheddar cheese and salsa. Food temperatures were measured and found to be below recommended serving temperatures for hot foods and above for cold items. State surveyors found the food bland and lacking in flavor during their taste test. Multiple residents reported dissatisfaction with the food, describing it as lacking variety, not tasting good, and being difficult to chew. Staff interviews confirmed that some residents routinely disliked the main entrée, particularly when chicken was served, and noted that the chicken did not look appetizing. The facility's policy and staff expectations were that menus and recipes should be followed as written to ensure consistent palatability, but this was not adhered to during the observed meal service.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified by surveyors based on observations or events that indicated the environment posed risks for accidents and that supervision was insufficient to prevent such incidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or accidents were provided in the report.
Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or theft, and did not report the results of investigations to the proper authorities as required by policy. In one instance, a cognitively intact resident reported to a nurse aide that they had been mistreated during a recent hospital stay and expressed fear for their safety, showing a bruise on their hand. The aide reported this to the nurse on duty, who then contacted the on-call nurse. However, the incident was not reported to the Director of Nursing (DON) or the Administrator within the required timeframe. The DON and Administrator only became aware of the allegation days later during a morning meeting, well beyond the policy's two-hour reporting requirement for abuse allegations. In another case, a resident-to-resident altercation was witnessed by a nurse aide, where one resident struck another, resulting in minor redness to the face. The incident was reported to the assigned nurse, who checked the injured resident and later reported the event to the DON. However, the report to the DON was delayed by over an hour, and the subsequent report to the state agency was not made within the mandated two-hour window. Staff interviews confirmed that although they had received abuse training and were aware of the immediate reporting requirements, the delay occurred due to being occupied with other duties and a breakdown in communication. Both incidents demonstrate that staff did not follow the facility's policy, which requires immediate reporting of all allegations of abuse, neglect, or misappropriation to the DON or Administrator, and timely notification to state and federal agencies. The failure to report these incidents promptly resulted in non-compliance with regulatory requirements and facility policy, as confirmed by staff and administrative interviews and documentation review.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse by other residents in two separate incidents. In the first incident, a resident with moderate cognitive impairment and a history of insomnia was physically assaulted by another resident with severe cognitive impairment and a history of physical altercations. The assault occurred when the resident with severe cognitive impairment became confused in an adjoining bathroom, exited into the wrong room, and struck the sleeping resident, resulting in a laceration above the victim's right eyelid. Staff interviews confirmed the confusion and physical altercation, and documentation indicated that the aggressor had a prior history of similar behavior. In the second incident, a resident with severe cognitive impairment and a history of physical aggression became upset when their wheelchair was blocked by another resident with moderate cognitive impairment. The agitated resident slapped the other resident in the face, knocking off their glasses and causing redness to the jaw. The incident was witnessed by a nurse aide, and the aggressor was immediately removed from the area. The victim later reported feeling unsafe in the facility as a result of the incident. Both incidents involved residents with documented behavioral and cognitive issues, and the facility's care plans noted the potential for aggression and confusion. Despite these known risks, the facility did not prevent the occurrences of resident-to-resident physical abuse, resulting in physical harm and emotional distress to the affected residents.
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