Based on interview, record review, and review of facility's documents, the facility failed to ensure that it was administered in an effective manner to meet the needs of each resident, in the areas of developing/implementing care plans, freedom from abuse, and immediate reporting of alleged incidents of abuse. This failure affected two (Resident (R) 12 and R93) of 13 sampled residents reviewed for abuse. The facility was aware that R12 exhibited escalating behaviors toward staff and other residents, including physical sexual contact and aggression, since at least 08/2025. Despite documented identification of these behaviors, the facility failed to develop and implement a comprehensive care plan to protect residents from the potential for abuse. …
F835 citations in Kentucky
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Kentucky cites F835 more often than its own record predicts
2.85 times the share F835 takes of citations nationally.
Of every deficiency written in Kentucky in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Kentucky surveyors wrote
F835 findings written in Kentucky, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for the management of falls for five of ten sampled residents, (Residents (R)10, R15, R93, R111, and R274). Review of the facility's document titled, Incidents by Incident Type, dated 02/28/2024 through 08/28/2024 revealed the facility noted 44 witnessed falls and 302 unwitnessed falls for a total of 346 fall during that six month time period. …
Based on interview, record review and facility policy review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice had the potential to affect all residents requiring Cardiopulmonary Resuscitation (CPR).The findings include: Review of the facility's document titled, Administrator Job Description, dated 12/2018, revealed the Administrator was to lead and direct the overall operations of the facility in accordance with the customer (resident) needs, government regulations, and company policies. …
The short window
Recent years
| Year | Share of Kentucky citations | vs expected |
|---|---|---|
| 2023 | 2.78% | 9.64× |
| 2024 | 0.90% | 2.75× |
| 2025 | 0.84% | 2.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kentucky surveyors cite →
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