The Pavilion At Kenton
The Pavilion at Kenton in Covington, KY — inspection on March 26, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation on 03/22/2026 at 5:44 PM of the floor in room [ROOM NUMBER] appeared to be
In an interview with the Maintenance Director on 03/24/2026 3:30 PM, he stated a water leak in the wall coil assist located in the ceiling caused the floor to buckle.
The facility had plans to repair the flooring in rooms [ROOM NUMBERS].
In an Interview with the Director of Nursing (DON) on 03/26/2026 at 9:58 AM, she stated her expectation was the facility, as it was the resident's home, should be kept clean, and should be made as nice as possible for residents.
She stated she was unaware of the current status of the small dining room but acknowledged it needed to be repaired.
She stated she wanted all spaces utilized for the benefit of residents.
She stated her expectation was for all facility floors to be even, clean, dry, and free from clutter for resident safety and use In an interview with the Administrator on 03/26/2026 at 1:42 PM, she stated the facility was in the final process of getting a quote approved for repairing the floor in the small dining room.
She stated the floor in the Honor shower room needed to be redone, and the facility had already started replacing holes in the floor.
She stated it was her expectation that it was the resident's home, and it should be a homelike environment, with simple concerns addressed in the moment, and major repairs addressed as the facility was able to find appropriate contractors.
185038 03/26/2026
The Pavilion at Kenton 401 East 20th Street Covington, KY 41014
Review of R32's Care
the admission Record for R67 revealed the facility admitted the resident with an initial admission date
Disorder (PTSD).
Review of the Care Plan Report for R67, most recently updated 02/23/2025 revealed no focus for the PTSD diagnosis.
Review of R67's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2026, revealed a mood severity score of 18, indicating the resident was affected by difficulty sleeping, little interest in participating in activities, and feeling depressed or hopeless nearly every day. It also included the diagnosis of PTSD.Review of R67's Psychiatry Progress Note, dated 03/03/2023, revealed R67 was seen for a consult/medication management for a history of multiple mental health diagnoses, including PTSD and Schizoaffective Disorder, both due to the onset of trauma in her teen years.
Additionally, R67 continued to have nightmares related to abuse.6.
Review of R10's admission Record revealed the facility admitted the resident on 03/16/2016 with diagnoses including post-traumatic stress disorder (PTSD) and borderline personality disorder.Review of R10's quarterly MDS, with an ARD of 01/01/2026 revealed an active diagnosis of PTSD.Review of R10's Comprehensive Care Plan, undated, revealed no evidence that the facility had addressed the resident's PTSD diagnosis, including identification of triggers, symptoms, or interventions to support trauma-informed care and prevent re-traumatization.In an interview on 03/26/2026 at 10:22 AM, the Social Services Director (SSD) stated a care plan addressing R10's PTSD, including triggers, symptoms, and interventions, had not been completed.
The SSD further stated it was important that staff was aware of a resident's PTSD diagnosis and triggers to provide resident-centered care and avoid re-traumatization.
During an interview on 03/25/2026 at 11:17 AM with the MDS Nurse, who was also Licensed Practical Nurse (LPN) 7, she stated she was unaware the PTSD focus had been missed.
She stated the plan of care did include some behavioral concerns, just not specific to the PTSD diagnosis.
She stated it was important to include this because the resident could be retraumatized if it was not identified, with or without potential triggers.
During an interview on 03/25/2026 at 2:15 PM with the Director of Nursing (DON), she stated since the MDS Nurse was an LPN, it was her job as the RN/DON to sign off on her work.
She stated the diagnosis for PTSD had been overlooked on the care plan and not having it there could cause the residents unnecessary harm by unknowingly re-traumatizing them.
During additional interview on 03/25/2026 at 3:31 PM with the DON, she stated it was her expectation that care plans were fully developed and communicated so staff knew how to properly take care of residents.During an interview on 03/26/2026 at 1:33 PM with the Administrator, she stated she expected an accurate assessment and plan of care for the residents.
She stated failure to do this could result in a resident not receiving the appropriate care and could result in unnecessary adverse outcomes.
She stated the MDS Nurse was responsible for fully developing care plans, and it was important for them to be accurate and followed to meet the needs of the residents.
185038 03/26/2026
The Pavilion at Kenton 401 East 20th Street Covington, KY 41014
During an interview with the Director of Nursing (DON) on 03/26/2026 at 2:00 PM, she stated feeding tube connectors should be covered to prevent contamination and reduce the risk of infection.
She further stated enteral feeding was to be administered according to physician orders and should not be hung longer than the recommended timeframes.
The DON stated that if a resident has more than minimal leakage at the G-tube site, nursing staff are expected to notify the physician for further evaluation and management.During additional interview on 03/25/2026 at 3:31 PM with the Director of Nursing (DON), she stated it was her expectation that tube feedings should never be uncapped when not in use, and a new system should be set up if it is found undated, untimed, or uncapped.
She stated they should always be dated and timed, and they were normally good for 24 hours, depending on the tube feeding and manufacturer.
She stated it was important to make sure the residents were getting fresh tube feedings to help prevent infection.
During an interview with the Administrator on 03/26/2026 at 11:00 AM, she stated she had not been made aware of concerns related to uncovered feeding tube connectors, prolonged hanging of enteral feeding, or excessive leakage at a resident's G-tube site.
She stated staff was expected to report care concerns so they could be addressed.
The Administrator further stated that enteral feedings should be administered according to physician orders, and equipment should be maintained in a clean and sanitary manner.
185038 03/26/2026
The Pavilion at Kenton 401 East 20th Street Covington, KY 41014
03/24/2026 at 1:04 PM, she stated department heads always passed out trays.
She stated more
because administration wanted department heads to pass trays. In an interview with the Director of
the proper temperature. In an interview with the Administrator on 03/26/2026 at 1:40 PM, she stated her expectation was for food temperatures to be adequate when served to residents.
She stated the hot food should be hot, and the cold food should be cold.
185038 03/26/2026
The Pavilion at Kenton 401 East 20th Street Covington, KY 41014
Review of the facility's policy titled, Food Receiving and Storage, dated 2001, revealed all foods stored in the refrigerator or freezer were covered, labeled, and dated with use by date.
Observation of the main dining room Honor Unit refrigerator on 03/22/2026 at 1:18 PM revealed the refrigerator and freezer were soiled with dry food products throughout each side and on the shelves.
Further observation revealed an opened grape jelly container sitting on top of the refrigerator, not dated and not stored in the refrigerator.
The label stated to store in the refrigerator after opening.
Observation of the Pavilion Unit refrigerator and freezer on 03/22/2026 at 1:20 PM revealed soiled shelves with dried food in both sides of the shelves.
Observation of the Purpose Unit dining room refrigerator and freezer on 03/22/2026 at 5:28 PM revealed the refrigerator was soiled with dried food. In an interview with State Trained Nurse Aide (STNA) 7 on 03/22/2026 at 4:54 PM, she stated Dietary was responsible to clean the unit nourishment refrigerators.
Observation of the kitchen on 03/24/2026 at 11:58 AM revealed two opened and undated grape jelly containers found out of the refrigerator. In an interview with the Dietary Manager on 03/25/2026 at 10:05 AM, she stated the nourishment refrigerators were cleaned twice weekly and any spills should be cleaned up by staff.
She stated they kept the jelly out to make peanut and butter jelly sandwiches.
She stated the grape jelly should be dated when opened and kept in the refrigerator. In an interview with the Director of Nursing on 03/25/2026 at 12:39 PM, she stated her expectation for the nourishment refrigerators was for them to be clean. In an interview with the Administrator on 03/26/2026 at 1:40 PM, she stated her expectation was for staff to wipe up any spills in the nourishment refrigerators and maintain the cleanliness of the nourishment and resident refrigerators.
185038 03/26/2026
The Pavilion at Kenton 401 East 20th Street Covington, KY 41014
During an interview with Registered Nurse (RN) 1 on 03/22/2026 at the time of the observation, she stated she forgot to disinfect the medication cart surface before placing supplies for another resident. RN1 further acknowledged she should have cleaned the cart surface between residents to prevent cross-contamination. 4.
Observation on 03/23/2026 at 8:42 AM, revealed RN5 failed to clean the blood pressure (BP) cuff between its use on R3 and R66.During an immediate interview, RN5 stated she normally would clean the cuff with Sani-wipes but forgot.
She stated she did not have any wipes in her cart, but they were usually in the cart.
She stated not cleaning the equipment between residents could expose residents to germs and increase the risk of making them sick. 5.
Observation on 03/24/2026 at 3:14 PM revealed STNA4 and LPN3 used the mechanical lift to place R1 back to bed.
They then placed the mechanical lift in the hall after it was used but did not clean it after use.
During an interview on 03/24/2026 at 3:35 PM with STNA4, she stated the mechanical lift should be cleaned after it was used to prevent the spread of germs.
During an interview with the Director of Nursing (DON) on 03/23/2026 at 2:30 PM, she stated staff should follow infection control practices, including disinfecting shared surfaces and equipment between resident use to prevent cross-contamination.
During an interview on 03/26/2026 at 1:19 PM with the Administrator, she stated it was her expectation that staff would follow policies, CDC guidance, and clean shared equipment between each use.
She stated it was her expectation that the appropriate signage and precautions be in place to keep the residents and the staff safe from developing any new issues.
185038 03/26/2026
The Pavilion at Kenton 401 East 20th Street Covington, KY 41014
well as some residents, had complained of seeing mice.
She stated pest control came to the facility
mice.
She stated she had seen gnats flying around, and they had been a problem since late last year,
and the exterminator came to the facility and sprayed, which helped for a little while. In an interview with the Director of Maintenance on 03/24/2026 at 3:30 PM, he stated residents had too much opened food in their rooms. He stated one resident collected cups from trays daily and kept them in her room.
He stated he expected the kitchen door to be kept closed. He stated he expected the side door to be kept closed except when in use for deliveries, for an emergency exit, and when taking trash out of the building. He stated the doors should not be left opened, which allowed pests to enter. In an interview with the Dietary Manager on 03/25/2026 at 10:05 AM, she stated the doors should be shut unless staff was taking trash out.
She stated keeping the door opened would allow pests to enter and possibly cross-contaminate the food.In additional interview with the DON on 03/25/2026 at 12:39 PM, she stated the door to the kitchen should remain closed for safety and to prevent pests from entering.In continued interview with the DON on 03/26/2026 at 9:58 AM, she stated the facility should be kept clean and as nice as possible for residents. In an interview with the Administrator on 03/26/2026 at 1:40 PM, she stated she expected staff to provide residents with a homelike environment.