WURTLAND, KY - Wurtland Nursing & Rehabilitation was cited for serious violations including chronic understaffing that forced residents to wait hours for basic care and improper medication storage that rendered insulin ineffective.
Severe Understaffing Creates Care Delays
The February 2025 inspection revealed systematic staffing shortages that left nursing assistants responsible for dangerously high resident caseloads. Documentation showed that on multiple occasions, individual nursing assistants were caring for 27 residents each during day shifts and up to 37 residents each during overnight hours.
The facility's own assessment indicated a need for 12-18 nursing assistants per day to properly care for an average census of 109 residents. However, staffing records revealed significant gaps below these targets. On one documented evening, only three nursing assistants worked from 6:00 PM to 9:00 PM, requiring each to oversee 37 residents before additional staff arrived.
These understaffing conditions created cascading problems throughout the facility. Residents frequently experienced extended waits for assistance with basic needs like toileting and incontinence care. One family member documented waiting over 20 minutes for call light responses on multiple occasions, and another resident's family member timed a one hour and three minute wait for toileting assistance.
During interviews, nursing assistants described the impossible workload. One aide stated: "We need more SRNAs, the workload is horrible and to get everyone changed you sometimes have to miss showers." Another aide explained that with 22 residents to care for, she "felt like she was drowning" and could not complete required two-hour check and change rounds for all residents.
Residents Left in Soiled Conditions for Hours
The staffing crisis directly impacted resident dignity and health. Multiple residents reported being left in wet or soiled briefs for extended periods. One resident described sitting in a wet bed for "a couple hours" after putting her call light on twice, only to be told by staff they were "busy with a new admission." Another resident waited from 6:00 PM until after 10:00 PM for help changing her brief, stating the experience made her feel "humiliated."
These delays in basic hygiene care create serious health risks. Prolonged exposure to moisture and waste can lead to skin breakdown, urinary tract infections, and pressure ulcers. The skin acts as the body's primary barrier against infection, and when compromised by extended contact with urine or feces, it becomes vulnerable to bacterial colonization and tissue damage.
Proper incontinence care protocols require checking and changing residents every two hours maximum. However, nursing assistants consistently reported being unable to meet this standard due to their excessive caseloads. One aide explained that residents would sometimes have to wait "three to three and a half hours" for care when she was responsible for 30-35 residents.
Call Light System Failures
Inspectors documented multiple instances where call lights went unanswered for extended periods while licensed nurses remained at the nurses' station. In one observation, a call light sounded for four minutes continuously while two licensed practical nurses sat within view and hearing of the alert board, but neither responded.
The call light system serves as residents' primary means of requesting assistance for urgent needs. When these systems fail to receive timely responses, residents may attempt to meet their own needs, potentially leading to falls, injuries, or medical emergencies. Industry standards recommend call light response times of five minutes or less, with immediate response for emergency situations.
Multiple nursing assistants reported that licensed nurses rarely assisted with answering call lights or providing basic care, instead remaining focused on medication administration and documentation duties. This created an environment where nursing assistants were solely responsible for responding to resident needs despite being overwhelmed with excessive caseloads.
Dangerous Medication Storage Conditions
The facility also failed to properly store insulin medications, with two of four medication refrigerators operating below the safe temperature range. Inspectors found refrigerators running at 26 degrees Fahrenheit and 30 degrees Fahrenheit, well below the manufacturer-required range of 36-46 degrees Fahrenheit for insulin storage.
The affected refrigerators contained multiple types of insulin including Lantus, NovoLog, Fiasp, Tresiba, Basaglar, and Admelog. All insulin manufacturers specify that their products must not be frozen and should be discarded if exposed to freezing temperatures. Frozen insulin loses its therapeutic effectiveness and can provide inadequate blood sugar control for diabetic residents.
Improper insulin storage poses significant health risks for diabetic residents who depend on these medications to manage their blood glucose levels. Ineffective insulin can lead to hyperglycemia, diabetic ketoacidosis, and other serious complications. For elderly nursing home residents with multiple health conditions, uncontrolled diabetes can be life-threatening.
The facility lacked proper monitoring protocols to ensure medication storage compliance. While nurses were responsible for checking refrigerator temperatures twice daily, the system failed to detect and correct the temperature problems before medications were compromised.
Impact on Resident Care Quality
The combination of staffing shortages and medication storage failures created a perfect storm affecting resident well-being. Nursing assistants reported having no time for basic comfort measures like oral care, nail care, or simply talking with residents. One aide explained that residents would ask her to sit and visit, but she "does not have time to do it."
The facility's own employee engagement survey revealed chronic staff frustrations, with nursing assistants citing the need for more staff 17 times in their comments. High turnover compounded the problem, with experienced staff leaving due to unsustainable workloads and new hires struggling to adapt to the demanding conditions.
Management appeared disconnected from floor-level operations. Multiple nursing assistants reported rarely seeing administrators in resident care areas, with one aide stating he "did not know who the Director of Nursing Services was until the state survey team entered the building."
Additional Issues Identified
Beyond the major staffing and medication violations, inspectors documented several other concerning practices:
- Incomplete personal protective equipment usage due to time pressures - Mechanical lift operations performed by single staff members instead of the required two-person teams - Missed showers and personal care activities when staffing levels dropped - Nursing assistants working through lunch breaks to maintain productivity bonuses - Inadequate support from licensed nursing staff for basic resident care activities
The facility received a One Star Staffing Rating from Medicare, indicating performance significantly below national averages. Weekend staffing data showed particularly low levels, with the facility frequently operating with minimal coverage during these periods.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wurtland Nursing & Rehabilitation from 2025-02-11 including all violations, facility responses, and corrective action plans.
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