Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Pioneer Trace Group Llc during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, malnutrition, and a g-tube was placed on hospice and prescribed lorazepam and morphine for end-of-life care. A hospice RN obtained 15 lorazepam 0.5 mg tablets in a brown pill bottle from the pharmacy, which an LPN and an SRNA/KMA counted, documented, and locked in the narcotic drawer after one dose was given, leaving 14 tablets. During a hectic shift change, the oncoming LPN did not count the lorazepam despite being informed it was in a bottle, and the SRNA/KMA later accepted the cart without performing the required narcotic count with the night nurse. When the same LPN later attempted to administer another dose, only nine tablets were present, confirming five missing tablets after a recount, and the discrepancy was reported to the unit manager. The pharmacist verified that 15 tablets had been dispensed, and leadership stated that all narcotics were expected to be counted at each cart handoff, but this did not occur, resulting in unaccounted-for controlled medication.
The facility failed to ensure residents received mail on Saturdays, violating their rights to privacy in written communications. A resident reported the issue during a council meeting, confirmed by others. The BOM was unaware of the violation, and only department heads, who worked weekdays, had mailbox keys, preventing weekend mail distribution.
The facility lacked a comprehensive water management program to prevent Legionella growth, with key staff unaware of water system details and responsibilities. The Maintenance Director had no training on Legionella, and the Administrator, DON, and ADON did not actively manage the water system, leading to a deficiency in infection prevention.
The facility failed to prevent cross-contamination in food preparation due to a gnat infestation. A Dietary Aide was observed preparing food with gnats around an uncovered blender, and gnats were also present near a trash can in the dining area. Staff interviews confirmed the presence of gnats, but there was a lack of effective communication and action to address the issue, as maintenance had not been informed, and pest control had not targeted gnats.
Failure to Account for Controlled Medication Resulting in Missing Lorazepam Tablets
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property by not ensuring proper accountability of controlled medications. Facility policies required that controlled substances be counted at each shift change by two licensed nurses, with any discrepancies reported to the DON, and that a physical inventory of all controlled medications be conducted and documented at each shift change. The Abuse Prevention policy defined misappropriation of resident property as the wrongful use of a resident’s belongings without consent. For one resident with severe cognitive impairment (BIMS score of 0), admitted with moderate protein-calorie malnutrition, dementia, adult failure to thrive, and receiving medications via g-tube, hospice was consulted and lorazepam and morphine were ordered for end-of-life comfort care. According to the record and interviews, a hospice RN obtained 15 lorazepam 0.5 mg tablets from the contracted pharmacy in a brown pill bottle for the resident. An LPN and an SRNA/KMA counted 15 tablets, created a narcotic count sheet, and locked the bottle in the narcotic drawer of the medication cart. The LPN administered one dose of lorazepam via g-tube later that day, leaving 14 tablets. The SRNA/KMA reported that the evening was hectic due to a call-in and stated that at shift change, she informed the oncoming LPN that the lorazepam was in a bottle rather than a blister pack, but the oncoming LPN closed the drawer without counting the pills. The SRNA/KMA further stated that the following morning she failed to count the lorazepam bottle with the night shift nurse before accepting the cart keys, despite knowing facility policy required this. Later that day, when the LPN went to administer another dose of lorazepam to the resident, only nine tablets were found in the bottle instead of the expected 14, indicating five missing tablets. The LPN and SRNA/KMA recounted and confirmed the discrepancy, then attempted to locate the DON and, when unsuccessful, reported the missing tablets to the unit manager RN. The pharmacist confirmed that 15 lorazepam tablets had been dispensed in a brown bottle to the hospice RN. The responding police officer reported being contacted by the Administrator and noted that key staff had been sent home or were unavailable, and that no police report had yet been filed at the time of interview. The DON and Administrator both stated they expected all narcotics to be thoroughly counted at cart acceptance regardless of container type, but the required counts and documentation were not consistently performed, resulting in unaccounted-for controlled medication for the resident.
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, as required by their policy on residents' rights. During a Resident Council meeting, a resident reported that mail was not delivered or sent on Saturdays, although packages were received unopened on the day of delivery. This was confirmed by other residents in attendance. The facility's policy, revised in 2014, states that residents have the right to privacy in written communications, including the right to send and promptly receive mail. Interviews with facility staff revealed a lack of awareness and procedural gaps regarding mail delivery on weekends. The Business Office Manager (BOM) was unaware that not delivering mail on Saturdays violated residents' rights and stated that her work schedule did not include weekends, which prevented her from sorting mail on those days. The Activities Department, which was present seven days a week, was responsible for distributing mail to residents, but only department heads, who worked Monday through Friday, had keys to the mailbox. This resulted in a failure to deliver mail to residents on Saturdays, despite the facility's policy and the expectations set by the Director of Nursing and the Administrator.
Deficiency in Water Management Program for Infection Control
Penalty
Summary
The facility failed to establish a comprehensive water management program to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens. The facility's existing policies, including the Infection Control Policy and the Prevention of Legionella Growth and Exposure policy, lacked detailed documentation and implementation of a water management program. Interviews revealed that key staff members, including the Maintenance Director, Administrator, ADON, and DON, were unaware of the existence of a water management system or schematic of the building's water flow. The Maintenance Director, who had recently assumed the role, had not received training related to Legionella and was unsure about chlorine testing procedures. The Administrator and nursing leadership, including the DON and ADON, shared responsibilities for infection prevention but did not actively manage or monitor the water system. The facility's Quality Assessment and Performance Improvement (QAPI) meetings did not address the water management system, and there was no evidence of tracking or surveillance of potential Legionella outbreaks. Despite the absence of reported Legionella cases, the lack of a documented water management program and the unclear division of responsibilities contributed to the deficiency in infection prevention and control.
Cross-Contamination Risk Due to Gnat Infestation
Penalty
Summary
The facility failed to prepare food safely, leading to a potential cross-contamination issue. On October 1, 2024, a Dietary Aide (DA2) was observed preparing a puree brownie with gnats flying around an uncovered blender. Additionally, a heavy presence of gnats was noted around a trash can in the dining area where residents were present for lunch. The facility's policies on food preparation and pest control were reviewed, revealing that the facility was expected to maintain an effective pest control program and ensure safe food handling practices. Interviews with various staff members, including dietary aides, the Dietary Manager (DM), housekeeping, maintenance, the Director of Nursing (DON), and the Administrator, confirmed the presence of gnats in the facility. Staff members acknowledged being trained on cross-contamination and reported sightings of gnats to their supervisors. However, there was a lack of effective communication and action to address the gnat issue, as maintenance had not received reports of gnats in the kitchen, and the pest control company had not been tasked with addressing gnats specifically. The Administrator acknowledged the presence of gnats and expressed the need for staff to follow policies and treat the facility as the residents' home.
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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 Flemingsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maysville Nursing And Rehabilitation Facility | 15 mi | — | 0 | 0 |
| Willowbrook Healthcare | 17.4 mi | — | 0 | 0 |
| Robertson County Health Care Facility | 17.8 mi | — | 0 | 0 |
| Ridgeway Nursing & Rehabilitation Facility | 18.6 mi | — | 0 | 0 |
| Ohio Valley Manor Care Center | 23.7 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.