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 Salyersville Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a seizure disorder and significant respiratory and neurologic conditions had an order for Vimpat twice daily and another anti-seizure medication. Over several days, multiple doses of Vimpat were documented as not available and not administered, with no evidence the physician was notified. Later, an LPN administered double the ordered Vimpat dose, and the resident experienced a change in condition and was sent to the hospital. Documentation claimed that the physician and responsible party were notified promptly, but the medical providers and responsible party reported they were not informed of the missed doses, the overdose, or the transfer by facility staff. Other staff interviews indicated the LPN realized the error during shift change and told the weekend supervisor, who expected the LPN to notify the provider and responsible party but did not verify that this occurred, contrary to facility expectations and policy.
A resident with respiratory failure, anoxic brain damage, severe intellectual disabilities, and a seizure disorder had an order for Vimpat 100 mg twice daily and Zonisamide 200 mg daily, but Vimpat was repeatedly not administered because it was unavailable, and the physician was not notified of the missed doses. After a stat delivery, an LPN administered 200 mg of Vimpat instead of the ordered 100 mg by pulling a tablet from another resident’s supply, and staff became aware of the error that evening. The resident then became lethargic with increased secretions and low oxygen saturation, and was sent to the ED, where the visit was documented as related to an overdose of antiseizure medication.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital for breathing issues, but the responsible party was not notified by facility staff as required by policy. The RN believed the unit manager was handling notifications, but the responsible party only learned of the transfer from the hospital. Facility leadership confirmed that staff are expected to notify responsible parties of transfers.
The facility did not develop or implement individualized, proactive care plans for several residents with severe cognitive and behavioral issues. Instead, care plans were either missing, not updated, or contained only reactive interventions after incidents occurred. Facility leadership acknowledged a lack of awareness and oversight in care planning, resulting in behavioral issues not being addressed in a timely or resident-specific manner.
A failure to provide adequate supervision during a meal resulted in a physical altercation between two residents when only one staff member was present instead of the required three. Staff interviews revealed confusion about dining room assignments, lack of communication, and no designated person to ensure scheduled coverage, leading to insufficient supervision and a resident being struck by another.
The facility did not ensure that all staff received required annual TB testing, with incomplete or missing records for a significant number of employees and no system in place to monitor compliance during the Infection Preventionist's absence. The facility also lacked facility-specific TB testing policies and failed to provide documentation for many staff members.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents with severe cognitive impairments and a history of behavioral issues were involved in an altercation during an unsupervised smoke break, where one threw an ashtray at the other after being subjected to a racial slur. Although both had updated care plans addressing general behaviors, neither plan included specific interventions for increased supervision or monitoring of their interactions, and staff were not present at the time of the incident.
Two residents with severe cognitive impairment and high risk for skin breakdown did not receive required weekly skin assessments, consistent repositioning, or timely wound care. Nursing staff failed to identify and document new or worsening pressure ulcers, and preventive treatments were inconsistently provided. Incomplete documentation, lack of communication, and failure to replace the wound care nurse during her absence contributed to unrecognized and untreated wounds, with one resident requiring hospitalization for multiple advanced pressure ulcers.
A resident with severe cognitive impairment and multiple medical conditions did not receive the weekly head-to-toe skin assessments required by their care plan. Nursing staff did not perform comprehensive skin checks, as this task was delegated to wound care staff, and preventive treatments were not consistently documented. The resident was later hospitalized with multiple, previously unidentified pressure ulcers and skin breakdown requiring surgical intervention.
Failure to Notify Physician and Responsible Party of Missed Seizure Medications, Overdose, and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and responsible party (RP) when required, in connection with missed and incorrect doses of an anti-seizure medication and a subsequent transfer to the hospital. The facility’s Medication Error Standard of Practice, dated 04/2025, required that upon a suspected or identified medication administration error, the administering nurse or medication aide immediately alert the DON and/or charge nurse for physician notification. The resident, admitted on 01/29/2026 with diagnoses including acute and chronic respiratory failure with hypoxia, anoxic brain damage, severe intellectual disabilities, and a seizure disorder, had a physician order for Vimpat 100 mg twice daily and Zonisamide 200 mg daily. Review of the MAR showed that Vimpat was documented as not available and not administered for multiple consecutive doses from 01/29/2026 through the morning dose on 02/01/2026, with no evidence that the physician was notified that the ordered anti-seizure medication was unavailable and not being given. On 02/01/2026, the resident received an incorrect dose of Vimpat. A Medication Variance Form dated 02/02/2026 and the facility’s investigation indicated that LPN1 administered 200 mg of Vimpat instead of the ordered 100 mg. A late entry progress note, the investigation, and a hospital report dated 02/02/2026 documented that the resident was transferred to the hospital for evaluation of a medication overdose after a significant change in condition. The Medication Variance Form reflected that the physician was notified of the error on 02/01/2026 with no new orders and that the RP was notified on 02/02/2026. However, interviews with the medical director and PA1 established that they were not informed of the missed anti-seizure doses from 01/29/2026 through 02/01/2026, and PA1 stated she was not immediately informed of the medication error that occurred around 6:00 PM on 02/01/2026, only learning of concerns later that night when called about the resident’s low oxygen level, drowsiness, and increased secretions. Interviews also showed discrepancies between documented notifications and what actually occurred. The RP reported that she first learned of the situation from the hospital, which called her at 1:56 AM to report that the resident had been sent there for a medication error; she stated no one from the facility had notified her of the transfer, the missed medications, or the overdose. LPN1 told surveyors she was unaware of the medication error until she was called on 02/02/2026 to complete a report, despite having documented physician and RP notification on 02/01/2026. Other staff interviews contradicted LPN1’s account: LPN2 stated that during shift change at 7:00 PM on 02/01/2026, LPN1 realized she had given the wrong dose, and the weekend supervisor stated that at the end of his 7:00 AM–7:00 PM shift on 02/01/2026, LPN1 informed him of the medication error. Both LPN2 and the weekend supervisor indicated they expected LPN1 to notify the provider and RP, but the supervisor did not follow up to ensure this occurred. The DON stated it was her expectation that any nurse who identified a medication error would immediately notify the physician and responsible party.
Failure to Provide and Correctly Administer Ordered Anti-Seizure Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the anti-seizure medication Vimpat. The resident was admitted with acute and chronic respiratory failure with hypoxia, anoxic brain damage, severe intellectual disabilities, and a seizure disorder, and had an order for Vimpat 100 mg twice daily along with Zonisamide 200 mg daily. From the date of admission through several subsequent days, the Medication Administration Record showed that Vimpat was repeatedly marked as not available and was not administered for multiple scheduled morning and evening doses. There was no evidence that the facility notified the physician that this ordered anti-seizure medication was unavailable and not being given during this period. When the weekend supervisor obtained a stat delivery of Vimpat from the pharmacy, the first available dose was administered in the evening. At that time, the nurse administering medications gave 200 mg of Vimpat instead of the ordered 100 mg dose. Documentation and interviews revealed that the nurse pulled a 200 mg Vimpat tablet from another resident’s supply and administered it, resulting in the resident receiving twice the prescribed dose. The facility’s own Medication Administration and Medication Error policies required medications to be administered in accordance with orders and required immediate notification of the DON and/or charge nurse, physician notification, resident assessment, and completion of a Medication Variance Form when a medication error was suspected or identified. Interviews and records showed discrepancies in staff accounts of when the error was recognized, but confirmed that staff were aware of the error on the same evening it occurred. The resident subsequently became lethargic, with increased mucous and an increased need for suctioning, and respiratory staff noted oxygen saturation levels of 88%–92%. A late entry nursing note documented that the resident was not herself and appeared almost sedated after receiving the 200 mg dose. The on-call provider was contacted about the resident’s drowsiness, increased secretions, and difficulty maintaining oxygen levels, and the resident was sent to the emergency department, where the visit was documented as related to an overdose of antiseizure medication before the resident was returned to the facility with no new orders.
Failure to Notify Responsible Party of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible party (RP) when a decision was made to transfer a resident to the hospital. According to the facility's policy, both the resident and their representative must be informed prior to any transfer, including the reason for the transfer, in a manner they understand. In this case, a resident with severe cognitive impairment, as indicated by a BIMS score of 3 out of 15 and diagnoses including diastolic heart failure, severe vascular dementia, and diabetes, was transferred to the hospital due to breathing issues. The RP was not informed of the transfer by the facility and only became aware when contacted by the hospital. Interviews with staff revealed that the RN assigned to the resident on the day of transfer was under the impression that the unit manager (UM) was responsible for notifying the RP and handling the required paperwork. The UM, who is no longer employed at the facility, could not be reached for clarification. Both the interim DON and the administrator stated that their expectation was for staff to follow the policy and notify the RP with any transfer, but this did not occur in this instance.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four of fourteen sampled residents, as required by its own policy and federal regulations. For one resident with a history of stroke, difficulty walking, and severe cognitive impairment, there was no documented evidence of a resident-specific care plan, and the existing plan included unachievable interventions such as instructing the resident not to yell at others. Additionally, the care plan was not updated quarterly as required. Interviews with the MDS Coordinator and DON confirmed that a comprehensive care plan should have been implemented upon admission and reviewed regularly. For another resident with dementia and delirium, the behavior care plan addressed incidents such as smearing feces and resident-to-resident altercations only after they occurred, with interventions that were reactive rather than proactive or individualized. Similarly, a resident with depression and anxiety had a care plan listing multiple behavioral concerns, but interventions were implemented only after incidents, such as altercations, had already taken place. Another resident with Alzheimer's disease and severe mental impairment had a care plan that included interventions like redirection and reassurance, but these were also reactive and did not include proactive strategies to prevent recurring behaviors. Interviews with facility leadership, including the DON and Social Services Director, revealed a lack of awareness regarding recurring behaviors and an admission that care plans were not resident-specific or proactively updated. The Social Services Director acknowledged that behavioral issues were previously overlooked and not addressed in care planning, and could not explain why preventive interventions were not included. The DON admitted to not reviewing any resident care plans for a period of time, further contributing to the deficiency.
Inadequate Supervision During Mealtime Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents during a mealtime in the dining room, resulting in a physical altercation between two residents. On the specified date, only one staff member was present in the dining room, despite the facility's policy and staffing sheet requiring three staff members to be present for each mealtime. The sole staff member, a Kentucky Medication Aide, was unable to leave the dining room to seek additional help when a resident began a verbal altercation with another resident, which escalated to physical contact. The staff member separated the residents but could not maintain supervision of both while also performing other duties, leading to one resident hitting the other with a sandwich and causing emotional distress. Interviews with staff revealed confusion and lack of communication regarding dining room assignments, with some staff unaware of their scheduled responsibilities and others leaving their shifts without coverage. The Activities Director admitted to forgetting to schedule a replacement for an absent staff member, and the Director of Nursing stated there was no designated person responsible for ensuring staff were present according to the schedule. The Administrator and other staff acknowledged that having only one staff member present was insufficient to ensure resident safety and prevent altercations, confirming a failure to follow established supervision protocols.
Noncompliance with TB Testing Requirements for Staff
Penalty
Summary
The facility failed to comply with federal, state, and local regulations regarding tuberculosis (TB) testing for healthcare workers. Record review showed that out of 131 active employees, TB testing records were only provided for 70 employees. Of those, only 23 were in compliance with state and local TB testing guidelines, while 47 had either lapsed TB testing or inconsistent annual testing documentation. The facility was unable to provide TB testing records for the remaining 61 employees. Additionally, the facility did not have facility-specific policies for TB testing available when requested. Interviews revealed that the Infection Preventionist (IP), responsible for ensuring timely TB testing, was on medical leave, and there was no system in place to ensure staff received required TB testing. The DON confirmed the absence of an acting IP and acknowledged the lack of oversight for TB testing compliance. The local health department RN stated that annual TB testing should occur in the same month as the employee's hire date. The Administrator expressed the expectation that all staff follow applicable regulations, but multiple attempts to contact the IP were unsuccessful.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents with severe cognitive impairments, resulting in an altercation during an unsupervised smoke break. One resident, diagnosed with aphasia following cerebral infarction and assessed with a BIMS score of 0/15, threw an ashtray at another resident after being called a racial slur. The care plan for this resident had been updated for previous behavioral incidents, including emotional outbursts and altercations, and included interventions such as psychiatric evaluation and 1:1 supervision for limited periods. However, there were no interventions specifically addressing increased supervision or monitoring between these two residents, despite their history of conflict. The second resident involved, diagnosed with epilepsy and cerebral palsy and assessed with severe to moderate cognitive impairment, had a care plan updated for verbally abusive behavior and a prior altercation. Interventions included encouraging respectful behavior, 15-minute checks, and 1:1 supervision, but did not include measures to monitor interactions with the other resident involved in the incident. Staff interviews confirmed that no staff were present during the smoke break when the altercation occurred, and that the care plans lacked targeted interventions to prevent further incidents between these two residents.
Failure to Prevent and Manage Pressure Ulcers Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents, resulting in an Immediate Jeopardy situation. For one resident with severe cognitive impairment and multiple comorbidities, the facility did not conduct comprehensive weekly head-to-toe skin assessments as required by policy. Nursing staff reported that skin assessments were delegated solely to wound care staff, and there was no evidence of regular or thorough assessments by other nurses. Preventive treatments ordered for the resident's heels were not consistently documented as provided, and significant skin breakdown, including multiple unrecognized pressure ulcers, was only identified after the resident was hospitalized for sepsis and other acute conditions. The hospital documented several advanced pressure ulcers that had not been previously identified or treated by the facility, necessitating surgical intervention. Another resident, also with severe cognitive impairment and high risk for skin breakdown, was admitted with an existing stage II pressure ulcer. The care plan required frequent repositioning and weekly skin assessments, but the facility failed to consistently implement these interventions. Turn and repositioning logs showed multiple missed intervals, especially during overnight hours, and weekly skin assessments were not completed as required. Wound documentation was incomplete, lacking essential details such as wound measurements, staging, and progress notes. The resident developed additional wounds, including a deep tissue injury that progressed to necrosis, and experienced a decline in nutritional intake without timely reassessment or intervention. Staff interviews revealed confusion and lack of communication regarding responsibility for physician notification and care plan updates, particularly during the absence of the wound care nurse, who was not replaced during her leave. Facility leadership and clinical staff interviews confirmed systemic failures in communication, documentation, and oversight of wound care and prevention practices. Wounds were not routinely discussed in clinical meetings, and there was a lack of leadership in ensuring that assessments, interventions, and documentation were completed according to policy. The newly appointed wound care physician and nurse identified widespread deficiencies in skin care practices, including lack of preventive measures, inadequate staff education, and insufficient monitoring. These failures resulted in multiple residents developing or experiencing worsening pressure ulcers that were not promptly identified or treated.
Failure to Implement Comprehensive Skin Assessment and Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including Alzheimer's disease, chronic kidney disease, COPD, dementia, and cancer. The care plan for impaired skin integrity specified that weekly skin assessments were to be performed, but there was no evidence that these assessments were consistently completed. Documentation showed that while showers and bed baths were recorded, no new skin issues were identified, and there was a lack of head-to-toe skin assessments by nursing staff. The wound care physician assistant only assessed the resident's head wound and did not perform a full skin assessment, as she was directed by the DON to focus on specific areas or residents. Interviews with various nursing staff, including LPNs and RNs, revealed that they did not conduct comprehensive weekly skin assessments, as this responsibility had been delegated to the wound care staff by the DON. Review of the Treatment Administration Record indicated that preventive treatments for the resident's heels were not documented as provided on certain dates. This lack of thorough and regular skin assessments led to unrecognized and untreated skin breakdown. The deficiency became evident when the resident was admitted to a hospital with multiple, previously unidentified areas of skin breakdown, including eschar on both heels, stage III pressure ulcers on the buttocks, a non-pressure chronic ulcer of the heel and midfoot, and an unstageable pressure ulcer of the sacral area. The hospital records indicated that these wounds required surgical intervention. The facility's own policy required ongoing assessments and timely revisions to care plans, but these were not followed, resulting in the failure to prevent or identify significant skin integrity issues.
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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 Salyersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain Manor Of Paintsville | 16 mi | — | 0 | 0 |
| West Liberty Nursing And Rehabilitation | 16.3 mi | — | 0 | 0 |
| Prestonsburg Health Care Center | 17 mi | — | 0 | 0 |
| Riverview Health Care Center | 18.3 mi | — | 0 | 0 |
| Breathitt Health & Rehabilitation | 21 mi | — | 0 | 0 |
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