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PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.


Level of harm – Immediate Jeopardy

Based on interview, record review, review of the facility’s policy and procedure, review of the Hospital emergency room Note, and review of a Provisional Report of Death, it was determined the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for one (1) of nine (9) sampled residents (Resident #1). The facility failed to provide ongoing assessments and monitoring for Resident #1 when a significant change in condition was identified. On 07/25/14, at approximately 1:50 PM, Resident #1 was found in his/her room by facility staff unresponsive and cyanotic (low oxygen causing bluish discoloration of the skin). The resident’s oxygen saturation was sixty-nine percent (69%) (normal 90-100) on room air, blood pressure was 79/45 (normal 118/68), and heart rate was 136 (normal 60-100) beats per minute (bpm). There was no documented evidence the physician was called to notify her of the resident’s significant change in condition; however, at 2:25 PM, thirty-five (35) minutes later, a text message was sent to the physician. At 3:45 PM, a physician’s orders [REDACTED]. At 5:30 PM, approximately three (3) hours and ten (10) minutes after the resident’s significant change in condition, Resident #1 was noted to be cyanotic, with labored respiration and an oxygen saturation of seventy-four percent (74%). The Physician was notified and a new order was received to send Resident #1 to the emergency room (ER). The resident was transferred to the hospital where he/she was admitted to the Critical Care Unit with the [DIAGNOSES REDACTED]. (Refer to F-157) The facility’s failure to ensure each resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/07/14 and determined to exist on 07/25/14.

Continuing: Interview with the Director of Nursing, (DON) on 08/07/14 at 3:25 PM, revealed that based on the documentation the resident was not capable of determining if he/she was going to the hospital. Further interview revealed the DON stated, I do expect the staff should have sent the resident out to the hospital, absolutely. She stated the facility did not have a policy to address what to do when a resident refused to be sent to the hospital. Additionally, she stated the nurse should have not sent a text message to the physician and should have phoned him immediately. Interview with the Administrator, on 08/07/14 at 4:04 PM, revealed he expected the staff to phone the physician in a crisis situation, rescue the resident, and transfer the resident out to the hospital.


Level of harm – Immediate Jeopardy

Based on interview, record review, review of the facility’s policy and procedure, and review of the Hospital History and Physical, Hospital emergency room Note it was determined the facility failed to provide adequate supervision to prevent accidents for two (2) of nine (9) sampled residents (Resident #1 and Resident #2). 

Continuing: Resident #2 had a fall with injury and was noted at the time of the fall, to have a shuffling gait, which was a side effect of the Haldol. Resident #2 was diagnosed with [REDACTED]. The physician was notified of the shuffling gait; however, was not notified of the Consultant Pharmacist’s recommendation. The physician ordered Cogentin, a medication to help reduce the side effects of the antipsychotic medication, Haldol. Resident #2 had a second fall three (3) days later on [DATE] resulting in three (3) additional fractures (his/her humerus, radius, and ulna). The physician was not made aware of the recommendation until [DATE], after the resident had sustained two (2) falls with injury. On [DATE], the facility assessed Resident #1 as dependent on two (2) staff for transfers; however, review of the care plan revealed an intervention for one (1) to two (2) staff to transfer. On [DATE], Resident #1 was lowered to the floor during a transfer when he/she was being transferred by one (1) Certified Nursing Assistant (CNA). Resident #1 sustained a fracture of the right fibula (leg bone) after the fall. The resident was assessed as having a significant decline in ADLs and expired at the facility on [DATE]. The facility’s failure to provide adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE].

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here or call our toll free hot line number: 1-800-645-5262

You can make a difference even if your loved one has already passed away.

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  1. My Dad was in this facility up until his death. I often wondered about how well he was being taken care of. One time staff dropped him from a hoyer lift. He was a double amputee. And one time I went in and a fan was being used because he was having a hard time breathing. I was never contacted to be informed of this. I went to see him on a weekly basis, until my own health became an issue and I was no longer able.He always had dried food on his mouth. And the electric razor I bought for him was always missing where it was used for other residents. I bough him one because when they used the disposable razors he was always severely razor burned. I want to be kept informed of this facility. And what is discovered. because if I find out he was mistreated someone is going to be punished severely for it. There is no cause for this to happen. If an administrator does their job correctly then this is more unlikely to happen.

  2. Janice says:

    my only question/concern is the measure the nurse/facility did in the time between when the symptoms started and whet the doctor was notified. As this shows you can obviously tell there was a change in vials for the better as far as the oxygen saturation. However, as u read on they do not provide the blood pressure or pulse. The intervention status of this patient was also left out. Was the patient a do not revive or a full intervention? A lot of information is missing from this report. To have a full idea of what occurred you would have to have all the information which is not provided in this “documentation” of the actual event. There are many questions unanswered in this “report”. This documentation reported on this site leads you to what it wants you to believe. The “shuffling gait” of resident 2 has a few details left out as well including the history of the patient other things besides medications cause this “shuffling gait”. How long has the resident been on the meditation? Was it given as the patient needed it or was it given scheduled by the physician? What was the dose of the medication and how long has the resident been on the medication? These are all things left out. This “report” from the nursing home sounds like a lawyer pledding their case. The worst thing about these accusations toward the nursing home is the leading of information. Anyone can read this and think this is terrible I would never have my loved one in this place but what really happened? We will not know based on the evidence in this post. I have little back ground in the medical field but I know that all my questions aren’t answered and I and not satisfied with the information provided being that it is all one sided. How many people have falling in the care of their families and not been on any medications and as a result the family member has not been able to care for themselves and have died? I’m not saying that the nursing home was conplletely in the right or wrong all I’m saying is this article is completely one sided and has left out ALOT of information I would like to know before I could make an educated evaluation of what had occurred during what was described. If you read this article and didn’t think the same then you must believe everything the media and news tells you. They can’t get the weather right half the time and people are suing everyone for things as simple as their coffee being to hot. Before you judge get all the facts there’s always two sides to every story and we have only heard one in this article and you can plainly see who was painting the picture in this one.

  3. Vivian Middleton says:

    This is becoming a Chronic Problem in many of our Kentucky Nursing homes. Henderson, Ky’s one Nursing Home or Rehab Facility was cited for multiple deficiencies. When I inquired why they don’t shut them down, I was told that there was no where else to put the patients. To me that is a very poor excuse. Another problem that is becoming very scary is when a Nursing Home try’s to illegally evict a resident that is on Medicaid in order to fill the bed with a Private Pay patient. This happened to my Mother In Law who is 91 yrs old and has been a resident of the facility for over 9yrs. When I went to the nursing home, her chart was so out dated. They still had her deceased daughter as an Emergency call person. They had also documented false information in regards to her ADL’S saying she could bathe herself. She is in a wheel chair and when we asked her if she took her BATH by herself, she stated with laughter,”Of course I can, I just go to the sink and wash my face and hands like I always do.” That is not a bath!! Poor Hygiene is a big problem as well. I am a Retired Nurse of 30+ years having worked in Nursing Homes in my early career and am well aware of how things are hidden from State Survey when the facility suspects they are due to come in. I so wish that I had gone to work for the State of JACCO prior to retiring. I know exactly what and where to look for those hidden deficiencies and when the charts have been updated and falsified with inadequate entries. I hope that at some point, this abuse will stop. I would love to see more Nursing Homes open that truly care about the residents in their care.

    • You have this down to a Tee!! I wish you would step up and go back to work on this!! You are a good person and we need more like you caring for the elderly!!!!……Signed, Kim Carner

    • David Caudill says:

      I agree on this one my wide was there they did not do what they should have she was there for rehab she had 2 storks she was there for 5 days before they even got her out of bed she’s not with us now and in my heart they did wrong when I asked one of the nurse about my wife’s day she said she didn’t take her med when asked why the nurse said she didn’t want them and I don’t have time to baby set her I’m sorry I can’t go on right I hope this helps someone God bless

  4. vicki says:

    My grandmother has been a resident of a nursing facility for 5 yrs. I have found it is a total waste of time to contact the state ombudsman. If the state really wants to know what is going on they should just walk in—unannounced—to see what is going on. They are way understaffed. CNA’s have way more than they can do—the sad thing is—they are the one’s that get blamed if something goes wrong.

    • Nikki davis says:

      When I worked at a nursing home,there was a code word over the intercom system to let everyone know when state walked in the doors. So they never really could just show up without you having a heads up even I ggb it was just a few minutes.

    • The CNA’s are under-paid and some dont even want to be there…My Grandmother went to work at a nursing home when she was in her 60’s..She has told me all about this. She died in a NH in Madisonsville at age 102. She didnt have to go until she was 99! Signed, Kim Carner

  5. Brenda Johns says:

    This article was very difficult to read because my mother is a patient in this nursing home.I live in another state but my sister is closer and has been upset by, what she feels is a lack of proper care at times.

  6. Pansy Allen says:

    Sounds similiar to the way my husband was treated at Christian Health in Hopkinsville, Ky. They were getting over $4000 a month from Medicare and yet we were forced to have a sitter with him @ $10 per hour, when I complained, they said they were understaffed, shortly after I complained, they sent him off to another state to a behavioral center to get rid of him without first consulting with me. He was at Christian Health from Jan.12 until Jan.21, 2015 and I tried to get them to call the resident Dr. to get his meds straightened out, the Dr. did not see him the whole time he was there and he continually got worse. He is now deceased. I would never recommend this place to anyone.

  7. Lucinda Grace says:

    My grandmother is a resident of this nursing home and she has told me plenty of times that they abuse her but I didn’t know what to believe because she has dementia but I wouldn’t put it pass them because I did training there when I was in high school. If anything does happen to my grandma while she is in their care than they will have a rude awakening and they won’t like me.

  8. shannon says:

    I have sit here and counted how many Nursing homes I have been employed by (6), 1 of which I worked at 4 times, 3 of which I worked at 2 times each. I can honestly say that EVERY ONE of them were ran the same…when they r expecting “STATE” to walk through the door, everything has to be done properly and “by the book”..that’s about 2 wks out of the year that your loved ones r takin care of more of the way they should..Its always sickened me to death what I Have seen and/or heard while trying to do my job to the best of my ability..and YES I’ve also gotten a couple of ignorant, negligant girls fired for their actions that I unfortunetly witnessed (WITH NO REGRETS I might add) OMBUDSMAN?? What good r they? When all they do is call the facility beforehand, and then show up!!! Gives the facility time to cover their tracks (dot their i’s and cross their t’s)..its a shame that people put their trust in someone to take care of their loved one at ungodly rates and then have to be put through this kind of heartache..GOD BLESS YOU ALL, MY HEART IS TRULY HEAVY

  9. renee says:

    This is RIDICULOUS!! Things NEED to change. These are our Mothers and Fathers that raised us, worked their butts off for us, and LOVED us!! I WILL be reporting this and following up on it!

  10. Cindy K says:

    NHC and Brighton Corner are the two worse ones around here. Every nursing home is short staff if you ask me. Our loved ones pay good money to be fed slop and to be ignored. I know for a fact if you bring this up to DON and charge nurses nothing gets done. We over pay nursing homes to care for our loved ones. Its ashame cause thats a last resort for some.And your right. The only time things are good is when states there. Where state screws up is telling them.. Show up unknown. Go as a family member. Really get a good look.

  11. Cherie Burton says:

    If I have to go to a nursing home, just let me die.

  12. ... says:

    I work there and I can promise you I do my absolute best to take care of each one of my residents they way that I would want myself or my family to be taken care of. Not everyone can honestly say that.


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