Nicholasville Nursing And Rehabilitation
Nicholasville Nursing and Rehabilitation in Nicholasville, KY — inspection on August 22, 2025.
Found 2 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
Federal health inspectors cited Nicholasville Nursing and Rehabilitation in Nicholasville, KY for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-22.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure 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 Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of Nicholasville Nursing and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-18.
During an interview with SRNA9 on 08/21/2025 at 1:29 PM, she stated she was trained not to double mask when using an N-95 because it interfered with proper sealing, increasing chances of cross contamination and spreading germs.
In an interview with SRNA16 on 08/22/2025 at 9:06 AM, she stated she did wear a surgical mask under her N-95 for extra protection, and no one had told her otherwise.
During a brief interview with the Director of Nursing Services (DNS) on 08/19/2025 at 11:25 AM, she stated the staff was not trained to wear a surgical mask under an N-95, adding it interfered with the seal of the N-95, which could possibly spread Covid throughout the facility.4.
Observation on 08/20/2025 at 3:10 PM revealed therapy staff exited the room where R34 resided, a Covid positive designated room, still wearing an N-95 mask.
Continued observation revealed therapy staff walked to the end of A Hall, through B Hall, and then to the therapy department with the same N-95 mask on and disposed of the mask in the garbage can in the therapy department.
Further observation revealed the N-95 mask in the therapy garbage can.
During an interview with therapy staff at 3:15 PM on 08/20/2025 after observation, she stated she was an Occupational Therapist (OT) and had worked at facility for nine months.
When asked if she had received infection control training since working at the facility, especially pertaining to Covid positive rooms and proper donning and doffing (removing) PPE, she stated she was sure she had but could not remember.
When ask if the N95 mask she wore in R34's room was the same that she disposed in the therapy garbage, she stated it was the same mask.
She stated the concern was if proper donning and doffing was not practiced upon entering and exiting a Covid positive room, the infection could be spread throughout the facility.
During an additional interview with the DNS on 08/22/2025 at 3:05 PM, she stated she had been at the facility one month.
She stated prior to her coming to the facility, she could not say what the infection prevention and control procedure was.
However, she stated she had now provided infection control in-services over two to three days to make sure she covered all shifts and all staff.
She stated, after the first resident tested positive for Covid, each staff person received a packet of information.
She stated she reviewed the kinds of precautions, what PPE to wear, and observed return demonstrations of DNSning and doffing PPE.
The DNS stated her expectation was for staff to follow the education and posted signage on resident room doors to protect all residents and staff.
She stated, if staff did not follow infection control precautions, infections could spread to the residents, staff, and the community.
During an interview with the Executive Director who was also the Infection Preventionist (IP) on 08/22/2025 at 8:32 AM, she stated she had been at the facility as the Executive Director since February 2025 and had served as IP since August 2025.
She stated her expectations of staff members, as both the IP and ED, were they should know and follow the policy for infection control and proper DNSning/doffing of personal protective equipment (PPE) to prevent spreading germs.
She stated staff was trained upon hire in infection control and then yearly and as needed.
She stated each time there was a resident placed in isolation, the facility performed additional training as needed.
She stated staff was trained on all the different types of isolation and should know the procedure and refer to the door signage.
She stated further, if a resident was on contact isolation, staff should be putting on PPE each and every time they entered the room.
She stated all PPE would be taken off prior to exiting the room.
She stated proper signage should be on each isolation room door to explain what PPE was needed and when to remove it to prevent spreading the virus of Covid positive rooms.
She stated, if proper signage was not on the room door, staff would not have guidance to follow, and there would be a risk of spreading germs.
The Executive Director also stated staff was trained not to double mask and should not be doing that.
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