Based on interview, record review, and facility policy/document review, the facility's Governing Body failed to provide effective oversight to the Administrator to ensure the facility implemented policies, including identifying and reporting an allegation of sexual abuse of one (Resident (R) 2) of nine sampled residents reviewed for abuse. On 11/21/2024, staff observed R3, who was naked from the waist down, in bed on top of R2. R3 was observed pulling at R2's brief and stated, We are fucking. The Administrator and Director of Nursing (DON), who were both members of the Governing Body, reported this incident to additional members of the Governing Body, including the Regional Director of Operations (RDO) and Regional Director of Clinical Services (RDCS). on the same night it occurred. …
F837 citations in Kentucky
Administration Deficiencies
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Kentucky cites F837 more often than its own record predicts
2.57 times the share F837 takes of citations nationally.
Of every deficiency written in Kentucky in 2025, this is the portion that was F837.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Kentucky surveyors wrote
F837 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, record review, review of job descriptions, and review of the facility's policy, it was determined the facility failed to ensure the Governing Body, or designated persons functioning as a Governing Body, that was legally responsible for establishing and implementing policies regarding the management and operation of the facility, was responsible and accountable for the QAPI program, related to the facility's Acceptable Plan of Correction (POC), provided on 09/22/2020. The facility submitted a Plan of Correction for deficiencies, cited on 06/26/2020, alleging compliance on 09/25/2020. …
Based on interview, record review, and facility policy/document review, the facility's Governing Body failed to provide effective oversight to ensure the facility implemented policies to prevent the misappropriation of resident funds. This had the potential to affect all the facility's residents. The findings include:Review of the facility's policy titled, Patients' Rights and Responsibilities, undated, revealed upon written authorization of a resident, the facility must hold, safeguard, manage and account for the personal funds of the resident.Review of the facility's document, titled Nursing Home Administrator Job Description, last edited 07/12/2023, revealed the primary purpose of the Administrator is to manage the facility in accordance with current applicable federal, state, and local… …
The short window
Recent years
| Year | Share of Kentucky citations | vs expected |
|---|---|---|
| 2023 | 0.93% | 12.53× |
| 2024 | 0.45% | 4.93× |
| 2025 | 0.14% | 2.57× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kentucky surveyors cite →
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