CMS · Kentucky Office of Inspector General publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity GHarm
Care planningRecords
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-09-25Record 185122-20250827-F656
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-09-25Record 185122-20250827-F689
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity FStandard
Dignity & rights
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-09-25Record 185122-20250827-F584
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-25Record 185122-20250827-F628
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-25Record 185122-20250827-F761
F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-09-25Record 185122-20250827-F800
F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-09-25Record 185122-20250827-F803
F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-09-25Record 185122-20250827-F809
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-09-25Record 185122-20250827-F812
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-25Record 185122-20250827-F880
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2021-09-21Record 185122-20210703-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2021-09-21Record 185122-20210703-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2021-09-21Record 185122-20210703-F609
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity JHarm
Care planningRecords
Isolated; immediate jeopardy to resident health or safety.Corrected 2021-11-24Record 185122-20210703-F657
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2021-11-24Record 185122-20210703-F689
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2021-09-21Record 185122-20210703-F697
F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2021-09-21Record 185122-20210703-F745
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity JHarm
Records
Isolated; immediate jeopardy to resident health or safety.Corrected 2021-12-17Record 185122-20210703-F835
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F550
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F561
F565Honor the resident's right to organize and participate in resident/family groups in the facility.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F565
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-11-24Record 185122-20210703-F580
F583Keep residents' personal and medical records private and confidential.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F583
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F584
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F610
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F641
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F656
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F684
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F726
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F755
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F759
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F761
F791Provide or obtain dental services for each resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F791
F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F802
F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F803
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F812
F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F837
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2021-12-17Record 185122-20210703-F867
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-09-21Record 185122-20210703-F880