Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harrison Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure residents received mail on Saturdays, affecting all 49 residents. The SSD took over mail delivery from the Activities Director due to complaints but did not work weekends, resulting in undelivered mail. Staff interviews revealed confusion over mail delivery responsibilities, with the DON unaware of the issue and the Administrator expecting timely delivery.
The facility failed to label and store medications properly, with observations revealing undated, opened, and expired medications in multiple carts. Medications such as inhalers, insulin, and antifungal creams were improperly labeled or stored, and unwasted narcotics were found for a deceased resident. Staff interviews indicated a lack of awareness and adherence to policies, contributing to the deficiencies.
The facility failed to maintain an effective QAPI process, as evidenced by the repeated use of expired insulin, affecting all 49 residents. Despite plans for regular audits, expired and undated medications were found over several months. The DON was responsible for monitoring compliance but was unavailable for an interview during the survey.
The facility failed to maintain an effective infection prevention and control program, as evidenced by an LPN not using PPE in an EBP room and improperly cleaning a glucometer, and an RN cleaning a stethoscope with dirty gloves. Additionally, the facility did not adequately monitor its water system for Legionella, lacking documentation and a process flow diagram to identify risk areas.
The facility failed to document vaccine education for five residents, using outdated Vaccine Information Sheets and not providing updated information to residents or their representatives. Interviews with staff revealed a lack of adherence to facility policy and CDC guidelines, affecting residents with varying cognitive abilities.
The facility failed to document COVID-19 vaccination education and status for four staff members, including two LPNs and a CNA. Employee files lacked evidence of vaccine offering and education, despite interviews confirming some education was provided. Key staff emphasized the importance of following CDC guidelines and maintaining documentation for infection control.
A resident with severe cognitive impairment was observed multiple times without a privacy cover for their catheter bag, which was visible from the hallway. Despite the facility's policy to provide dignity covers, staff were unaware of the oversight, indicating a gap between policy and practice.
A facility failed to include Hospice services in a resident's baseline care plan upon admission, despite a physician's order. The resident, admitted with conditions such as Alzheimer's dementia and major depression, did not have a focus area for Hospice care in the care plan until five days later. Interviews with staff revealed inconsistencies in the understanding and implementation of the baseline care plan policy.
The facility failed to develop timely and comprehensive care plans for two residents, one admitted to Hospice care and another with respiratory needs. The Hospice care plan was delayed by four days, and the respiratory care plan did not address non-compliance with oxygen therapy. Staff interviews revealed a lack of awareness and implementation of individualized care plans, contrary to facility policy.
A resident with chronic respiratory failure did not receive oxygen therapy as per the physician's order, with the oxygen concentrator set higher than the prescribed 3 LPM. Despite the resident's awareness of the correct setting, staff failed to regularly check and adjust the concentrator. The facility's policy on oxygen usage was not followed, and the resident's care plan and records lacked documentation of the oxygen orders.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that all residents had the right to send and receive mail on Saturdays, affecting all 49 current residents. The facility's policy, revised in December 2024, stated that residents had the right to privacy in written communications, including the right to send and promptly receive mail. During a Resident Council meeting, it was reported by 12 residents that they did not receive or send mail on Saturdays, and packages were not received unopened on the day they were delivered. The Social Services Director (SSD) acknowledged that mail was not delivered on Saturdays and stated that the Activities Director was initially responsible for mail delivery on weekends. However, due to complaints, the SSD took over the responsibility but did not work on weekends, resulting in mail not being delivered on Saturdays. Interviews with staff revealed a lack of clarity and communication regarding mail delivery responsibilities. The Activities Director confirmed she did not work on weekends and was informed by the Business Office Manager that the SSD would handle mail delivery. The Director of Nursing (DON) was unaware of the mail delivery issues and stated that not receiving mail or packages on delivery days was a violation of residents' rights. The Administrator expected residents to receive their mail upon delivery to the facility, indicating a disconnect between expectations and actual practices regarding mail distribution.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs used were labeled in accordance with professional standards, as observed in multiple medication and treatment carts. During observations, undated, opened, and expired medications were found in three out of four medication carts and one treatment cart. These included inhalers, insulin vials, insulin pens, laxatives, antifungal powder, and topical creams. Specific instances included a Trelegy Ellipta inhaler with an expired date, an opened and undated bottle of Acid Gone, and albuterol packets without an opened date. Additionally, medications such as tiotropium bromide and Robafen DM Cough Syrup were not in their original packaging and lacked proper labeling. Further observations revealed expired and undated medications in the medication cart for rooms 206-212, including an expired insulin lispro vial, a lactulose bottle, and several inhalers and insulin pens that were opened and unbagged. Unwasted narcotics were also found in the narcotic box for a resident who had expired. Interviews with LPNs and staff indicated a lack of awareness regarding the expiration and proper labeling of medications, with LPNs acknowledging that expiration dates should be checked before administration and that undated medications should be discarded. The treatment cart was also found to contain unlabeled and unbagged medications, including nystatin powder and various antifungal creams. Interviews with staff, including the DON and the Administrator, highlighted expectations for medications to be dated upon opening and checked regularly. The DON admitted to forgetting about narcotics for an expired resident, and the Administrator emphasized the importance of proper packaging and dating to prevent medication errors. Despite weekly audits, the facility's practices did not align with its policies, leading to the observed deficiencies.
Repeated Use of Expired Insulin Highlights QAPI Failures
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process, as evidenced by the repeated issue of expired insulin being used. During an observation, insulin lispro was found opened, in use, and dated with an expiration date that had already passed. This issue was not new, as a previous survey had already identified the use of expired insulin, indicating a failure to address the problem effectively. The deficiency affected all 49 residents in the facility, highlighting a systemic issue in medication management. The Director of Nursing (DON) was responsible for monitoring compliance regarding the labeling and storage of medications, as outlined in the facility's job descriptions and plan of correction. However, audits performed by the pharmacy technician revealed multiple instances of expired and undated medications over several months. Despite the facility's plan to conduct regular audits, the problem persisted, and the DON was unavailable for an interview regarding the QAPI process during the survey. The Nursing Home Administrator acknowledged that it was the DON's responsibility to monitor QAPI audits to ensure compliance.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several observations and interviews. One incident involved a Licensed Practical Nurse (LPN) who did not don personal protective equipment (PPE) in an enhanced-barrier precaution (EBP) room before providing direct care to a resident with a wound dressing. The LPN also failed to clean the glucometer according to the manufacturer's instructions, using a disinfectant wipe for only 24 seconds instead of the required two-minute dwell time. This oversight occurred despite the LPN's acknowledgment of the correct dwell time and the importance of following infection control protocols. Another deficiency was observed when a Registered Nurse (RN) cleaned a stethoscope with an alcohol wipe while still wearing dirty gloves after administering medication to a resident. The Director of Nursing (DON) later stated that staff were expected to remove dirty gloves, perform proper hand hygiene, and re-glove before cleaning equipment. However, there was no documentation of staff infection prevention and control practice (IPCP) audits, which the DON acknowledged as necessary to ensure compliance with guidelines. Additionally, the facility failed to assess and monitor the building's water system for Legionella and other opportunistic waterborne pathogens. There was no documentation of control measures such as visible inspections, disinfection, and temperature controls. The facility also lacked a process flow diagram to identify areas where Legionella could grow and spread. Interviews with the Maintenance Director and Administrator revealed a lack of awareness and documentation regarding the water management program, further highlighting the facility's failure to adhere to CDC guidelines and recommendations.
Failure to Document Vaccine Education for Residents
Penalty
Summary
The facility failed to ensure that the medical records of five residents included documentation of education regarding the benefits and potential side effects of immunizations. The facility's policy required that residents be educated and offered available immunizations to minimize the risk of disease transmission. However, the facility did not provide current Vaccine Information Sheets (VIS) for the 2024-2025 vaccines, instead offering outdated sheets from 2023. This lack of updated information and documentation was evident in the records of residents with varying levels of cognitive impairment, as well as those who were cognitively intact. For residents with severe cognitive impairment, such as those with a Brief Interview for Mental Status (BIMS) score of 5 out of 15, there was no documentation that their resident representatives were contacted or provided with updated vaccine information. In the case of residents who were cognitively intact, they reported not receiving any VIS to read or sign before the administration of their vaccines. This lack of education and documentation was consistent across all sampled residents, regardless of their cognitive status. Interviews with facility staff, including the Infection Preventionist (IP), Director of Nursing (DON), Administrator, and Medical Director, revealed a lack of awareness and adherence to the facility's policy and CDC guidelines. The IP and DON acknowledged the importance of providing vaccine education and maintaining proper documentation but could not explain why the sampled resident files lacked this information. The Administrator emphasized the need for compliance with CDC recommendations and facility policies, while the Medical Director expected the facility to follow all policies and procedures.
Failure to Document COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination education, offering, and status for four sampled staff members, including two LPNs, a CNA, and the Business Office Manager. The review of employee files revealed no documented evidence that these staff members were offered the COVID-19 vaccination or received education regarding its benefits, risks, and potential side effects. Interviews with some staff members confirmed that while they received education, they did not sign any documentation acknowledging it or the offering of the vaccine. Interviews with the Infection Preventionist, Director of Nursing, Administrator, and Medical Director highlighted the importance of following CDC guidelines and maintaining documentation of staff immunizations or declinations as part of the facility's infection control program. Despite the facility's policy to educate and offer vaccinations to staff, the lack of documentation in employee files indicates a failure to adhere to these guidelines, which is essential for ensuring the safety of both staff and residents.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect by not providing a privacy cover for an indwelling urinary catheter bag. Over several days, observations revealed that the resident's catheter bag was visible from the hallway, as the privacy curtain was not pulled, and the bag was not covered. This lack of privacy was noted during multiple observations, indicating a consistent oversight in maintaining the resident's dignity. Interviews with staff, including CNAs, an LPN/Unit Manager, the Director of Nursing, and the Administrator, confirmed that it was the facility's policy and expectation to provide privacy covers for catheter bags to protect residents' privacy and dignity. Despite this policy, the staff interviewed were unaware of why the resident did not have a dignity cover, highlighting a gap between policy and practice. The resident involved had severe cognitive impairment, as indicated by a low BIMS score, and was admitted with diagnoses including obstructive uropathy and protein calorie malnutrition.
Failure to Include Hospice Services in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included necessary instructions for providing effective, person-centered care for a resident admitted with Hospice services. The resident was admitted with diagnoses including senile degeneration of the brain, Alzheimer's dementia, anxiety, and major depression. Despite the physician's order to admit the resident with Hospice services, the baseline care plan did not include a focus area for Hospice care until five days after admission. Interviews with facility staff, including an LPN, the MDS Coordinator, the DON, and the Administrator, revealed discrepancies in the understanding and execution of the baseline care plan policy. The LPN and MDS Coordinator indicated that the baseline care plan should be initiated upon admission and completed within 48 hours, including any necessary changes. However, the DON stated that Hospice services were not included in the baseline care plan because it would not alter the level of care provided. The Administrator acknowledged that basic information, including Hospice services, should be included in the baseline care plan at admission.
Deficiencies in Care Planning for Hospice and Respiratory Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in meeting their medical, nursing, and psychosocial needs. Resident 9 was admitted to Hospice care, but the care plan for Hospice services was not developed until four days after admission. This delay in care planning was acknowledged by the MDS Coordinator, who stated that the care plan should have been developed immediately upon admission to Hospice services. Resident 16, who was admitted with acute on chronic respiratory failure and other conditions, did not have a care plan addressing non-compliance with medical treatments and oxygen therapy. Despite being cognitively intact, the resident was observed adjusting the oxygen concentrator settings, which were not consistent with the physician's orders. Interviews with staff, including the LPN and Infection Preventionist, revealed a lack of awareness regarding the specific focus of the care plan related to the resident's non-compliance and respiratory care needs. The facility's policy emphasized a patient-focused approach, yet the care plans for both residents did not reflect their current status or provide adequate direction for individualized care. The MDS Coordinator and other staff members acknowledged the importance of care plans in ensuring appropriate, resident-specific care, but the deficiencies highlighted a failure to implement timely and comprehensive care plans for these residents.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide oxygen therapy according to the Physician's Order for a resident, identified as R16, who was admitted with acute on chronic respiratory failure and encephalopathy. Observations over several days revealed that the oxygen concentrator's flow rate was consistently set higher than the prescribed 3 liters per minute (LPM), with settings observed at 4.5 LPM, 5 LPM, and 4 LPM on different occasions. The resident, who was cognitively intact, confirmed that the oxygen flow rate should be set at 3 LPM and mentioned that the concentrator was old and unable to hold the setting. Despite this, no staff had checked the concentrator to ensure it was functioning correctly. Interviews with facility staff, including the Infection Preventionist (IP) Nurse and the Director of Nursing (DON), revealed a lack of adherence to the facility's policy on oxygen usage, which required regular assessments and documentation of oxygen flow rates. The IP Nurse indicated that the medication nurse was responsible for ensuring correct oxygen settings, but acknowledged that the resident was not care planned for oxygen therapy and that the orders were not included in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The DON and the Administrator both expressed expectations that staff should follow physician orders to ensure proper care delivery, but were unaware of why the orders were missing from the records.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cynthiana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgemont Healthcare | 0.9 mi | — | 0 | 0 |
| Cedar Ridge Health Campus | 2.6 mi | — | 2 | 0 |
| Bourbon Heights Nursing Home | 13.5 mi | — | 0 | 0 |
| Willowbrook Healthcare | 14.1 mi | — | 0 | 0 |
| Robertson County Health Care Facility | 15.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.