Provider Name: FOUNTAIN CIRCLE CARE & REHABILITATION CENTER
Address: 200 GLENWAY ROAD, WINCHESTER, KY 40391
Phone: (859) 744-1800
County: Clark (240)
Ownership Type: For profit - Corporation
Certified Beds: 179
Average Residents Per Day: 130. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: LP WINCHESTER, LLC
First Approved Date: March 1, 1978
Affiliated Entity: SIGNATURE HEALTHCARE (474)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 3 ()
Health Inspection Rating: 3 ()
QM Rating: 2 ()
Long Stay QM Rating: 2 ()
Short Stay QM Rating: 2 ()
Staffing Rating: 3 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.44359, LPN Staff Hours Per Day: 0.7821, RN Staff Hours Per Day: 0.5938, Licensed Staff Hours Per Day: 1.3760
Total Nurse Staff Hours Per Day, per resident: 3.81962
Weekend Nurse Staff Hours: 3.38243, Weekend RN Staff Hours: 0.2908
PT Staff Hours Per Day, per resident: 0.0846
Nurse Staff Turnover: 40.3, Nurse Turnover Note:
RN Turnover: 25.0, RN Turnover Note:
Admin Left Number: 3, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.1391, Case Mix LPN Hours Per Day: 0.8387, Case Mix RN Hours Per Day: 0.4368
Adjusted Nurse Aide Hours Per Day, per resident: 2.32717, Adjusted LPN Hours Per Day: 0.6881, Adjusted RN Hours Per Day: 0.5121
Total Adjusted Nurse Hours Per Day, per resident: 3.52569
Adjusted Weekend Nurse Hours Per Day, per resident: 3.12215
Health Survey Dates and Scores: Cycle 1: 2019-12-19 (Score: 16), Cycle 2: 2018-11-14 (Score: 20), Cycle 3: 2017-11-16 (Score: 68)
Total Weighted Health Score: 26.000
Reported Incidents: 0, Substantiated Complaints: 1
Infection Control Citations: 5
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 3250.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 200 GLENWAY ROAD,WINCHESTER,KY,40391 (38.0155, -84.213)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-08
Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-08
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-08
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-08
Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-12-01
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-12-01
Type: Health, Deficiency: Have a plan that describes the process for conducting QAPI and QAA activities.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-12-01
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-18
Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-18
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-18
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-18
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-18
Type: Health, Deficiency: Provide care by qualified persons according to each resident's written plan of care.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Type: Health, Deficiency: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Type: Health, Deficiency: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Type: Health, Deficiency: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Type: Health, Deficiency: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Type: Health, Deficiency: Have a program that investigates, controls and keeps infection from spreading.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-08
Type: Fire Safety, Tag: 0374, Version: New
Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-08
Type: Fire Safety, Tag: 0741, Version: New
Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-08
Type: Fire Safety, Tag: 0004, Version: New
Description: Develop and maintain an Emergency Preparedness Program (EP).
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-30
Type: Fire Safety, Tag: 0347, Version: New
Description: Properly provide smoke detection systems in areas open to corridors.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-12-17
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-30
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-30
Type: Fire Safety, Tag: 0912, Version: New
Description: Have power receptacles that are properly grounded.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-30
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Type: Fire Safety, Tag: 0355, Version: New
Description: Properly select, install, inspect, or maintain portable fire extinguishes.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-12-24