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.
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-07-16Record 185237-20240614-F676
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-07-16Record 185237-20240614-F695
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-16Record 185237-20240614-F558
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-16Record 185237-20240614-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 2024-07-16Record 185237-20240614-F565
F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-16Record 185237-20240614-F577
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-16Record 185237-20240614-F641
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 2024-07-16Record 185237-20240614-F761
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-16Record 185237-20240614-F804
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-16Record 185237-20240614-F842
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 2024-07-16Record 185237-20240614-F880
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 2019-04-09Record 185237-20190228-F656
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 GHarm
Care planningRecords
Isolated; actual harm that is not immediate jeopardy.Corrected 2019-04-09Record 185237-20190228-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 2019-04-09Record 185237-20190228-F689
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 2019-04-09Record 185237-20190228-F550
F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F559
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 2019-04-09Record 185237-20190228-F580
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F583
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F585
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F641
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F677
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F679
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-04-20Record 185237-20190228-F690
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F695
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F698
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F744
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F758
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 2019-04-09Record 185237-20190228-F761
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 2019-04-09Record 185237-20190228-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F842
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-09Record 185237-20190228-F849
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-20Record 185237-20190228-F867