The Pavilion at Kenton

Inspectors wroteBased on interview, record review, review of the Facility Assessment, and review of the facility's documents and policy, the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population. Review of the facility's staffing for the past 30 days revealed the facility consistently failed to provide sufficient staff as determined in the Facility Assessment to ensure resident needs were met. The deficient practice had the potential to affect all 80 current residents. [...]

Inspectors wroteBased on observation, interview, and review of the facility's documents and policy, the facility failed to provide food and drink served at a safe and appetizing temperature to residents. The lunch test tray on 03/24/2026 revealed food items that were in the temperature danger zone range for both hot and cold foods. Resident attendees in the Resident Council meeting on 03/23/2026 stated they received cold food at mealtimes. Also, on 03/23/2026, Resident (R) 45 stated she received cold food all the time. This deficient practice had the potential to affect all 78 current residents that received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety. Observations revealed the nourishment refrigerators on the Purpose, Providence, and Honor Unit were not clean. In addition, opened but not dated food containers were observed on the Honor Unit and the kitchen, and the kitchen contained an item that was unrefrigerated which should have been refrigerated. The deficient practice had the potential to affect all 80 current residents.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 9 of 15 residents participating in the Resident Council meeting, Resident (R) 3, R8, R9, R18, R43, R56, R68, R71, and R75.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to have a system in place for residents to send and receive mail, and to receive letters, packages, and other materials delivered to the facility on Saturdays for 15 of 15 residents participating in the Resident Council meeting, Resident (R) 3, R8, R9, R13, R15, R18, R37, R39, R43, R56, R66, R68, R71, R75, and R106.

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined the facility failed to provide a safe, clean, comfortable and homelike environment.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to have information on how to file a grievance or complaint available to residents. In addition, the facility failed to establish a grievance system to ensure the prompt resolution of all grievances.

Inspectors wroteBased on observation, interview, record review, review of the facility's job description, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 25 sampled residents, Resident (R) 10, R11, R23, R32, R47, and R67. The care plans for R10, R11, R47, and R67 were not fully developed at admission to reflect their diagnoses. For R23 and R32, their care plans were fully developed, but staff did not implement the interventions in their care plans.

Inspectors wroteBased on observation, interview, record review, review of the manufacturer's guidance, and review of the facility's policies, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 6 of 6 residents sampled for enteral feeding, Resident (R) 32, R36, R38, R46, R50, and R78. Observations on 03/22/2026 and 03/23/2026 included tube feedings hanging that were not timed or dated with the connector tips without end caps; medications administered via the feeding tube without checking for placement prior to administration; and a tube feeding that was started two hours late and continued past the ordered stop time. [...]

Inspectors wroteBased on interview, record review, review of the facility's job description, and review of the facility's policy, the facility failed to perform a trauma-informed care assessment for 5 of 5 residents sampled for trauma-informed care, Resident (R) 4, R10, R21, R67, and R75.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure that medications were stored securely and remained inaccessible to unauthorized individuals for 3 of 4 medication carts observed that were unlocked and unattended.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) signage, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 12 of 25 sampled residents, Resident (R) 1, R3, R11, R18, R23, R32, R38, R47, R50, R66, R68, and R78. [...]

Inspectors wroteBased on observation, interview, and review of the facility's documents and policy, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents. Observations on 03/22/2026 and 03/23/2026 revealed gnats in multiple areas of the facility. In addition, in interviews with residents and staff on 03/22/2026, 03/23/2026, and 03/24/2026, they reported seeing pests in the facility, including gnats, roaches, and mice. The deficient practice had the potential to affect all 80 current residents in the facility.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to provide reasonable accommodation of resident needs and preferences for 1 of 25 sampled residents, Resident (R) 9.

Inspectors wroteBased on interview, record review, and review of the facility's document and policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 25 sampled residents, Resident (R) 46. During an interview on 03/25/2026 at 9:15 AM with the Regional Nurse, she stated the facility did not provide the representative with a reason for transfer in writing. She stated they made them aware verbally.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, the facility failed to provide individualized and group activities that reflect the schedules, choices, and rights of the residents and to offer at the hours of convenience to the residents, including evenings, holidays, and weekends for 3 of 25 sampled residents, Resident (R) 36, R38, and R50. Observations on 03/22/2026, 03/23/2026, 03/24/2026, 03/25/2026, and 03/26/2026 revealed R36, R38, and R50 were either out of the facility to attend a school for the entirety of the day until approximately 4:30 PM or lying in bed. No observation of one-to-one activities was made, nor were these individuals observed out of bed or in group activity areas for socialization or participation.

Inspectors wroteBased on interview, record review, review of the facility's transfer agreement with the dialysis clinic, and review of the facility's policy, the facility failed to ensure residents who requires dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 sampled resident, Resident (R) 47. The facility was unable to provide evidence of communication with the dialysis center.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide assistive devices that facilitated residents' independence during meals in a manner that met the residents' individual needs for 1 of 25 sampled residents, Resident (R) 4. Observation on 03/22/2026 revealed R4 had his meal served on a glass plate instead of bowls to facilitate the resident's independence with his meal.

Inspectors wroteBased on observation, interview, review of the Food and Drug Administration article, and review of the facility's policy, the facility failed to ensure appropriate storage of residents' oral and topical medications, with multiple medications that were in use but exceeded the labeled expiration date. This occurred in 5 of 6 medication and treatment carts.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies and isolation signage, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 18 sampled residents, Residents (R) 43, R58, R64, R68, and R78. Observation also revealed State Trained Nurse Aide (STNA) 1, STNA2, and STNA3 gave out lunch trays to residents without performing appropriate hand hygiene.

Inspectors wroteBased on observation, interview, review of the facility's documents, and review of the facility's policy, the facility failed to store food safely as determined by observations in the kitchen on 02/25/2025 at 10:30 AM and 02/27/2025 at 10:30 AM. The lunch tray carts contained pre-plated foods and drinks, which were not under refrigeration. Further, during the lunch meal service on 02/25/2025 at 12:12 PM Dietary staff touched different surfaces, but did not change gloves or wash hands.

Inspectors wroteBased on observation, interview, review of the facility's hand hygiene training program, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations, between 07/07/2021 and 07/15/2021, revealed multiple staff members not wearing personal protective equipment (PPE) appropriately while in the facility in patient care areas. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to have safeguards and systems in place to provide pharmaceutical services, to include procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for one (1) of eighteen (18) sampled residents (Resident #273). Review of Resident #273's hospital After Visit Summary (AVS) discharge orders, dated 06/02/2021, revealed four (4) medications were not transcribed from the AVS to Resident #273's Medication Order Summary, or acquired from the pharmacy. These four (4) medications were 1) Albuterol Sulfate HFA Aerosol Solution Inhaler as needed (PRN) (a bronchodilator used to treat wheezing and shortness of breath); Amitriptyline HCL (an antidepressant that could be used for insomnia); [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to adhere to accepted professional standards and practices, by maintaining complete and accurately documented resident records, for one (1) of eighteen (18) sampled residents (Resident #273). Review of Resident #273's hospital After Visit Summary (AVS) discharge orders, dated 06/02/2021, revealed the resident was ordered oxygen therapy at two (2) liters per minute to maintain an oxygen saturation (SpO2) between eighty-eight (88) and ninety-two (92) percent. Further review revealed the physician ordered SpO2 monitoring every shift. Review of Resident #273's medical record revealed the facility failed to transcribe a physician's order for oxygen therapy and document its administration on the Medication Administration Record (MAR). [...]