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Home › KY › Manchester › Paces Creek Child Development Center
390 East Couch Road, Manchester KY 40962 · License #L355805 · Center · Licensed
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Generated from this facility's specific inspection record
Data synced from Kentucky Cabinet for Health and Family Services, Division of Child Care on Jul 11, 2026 · Source records · Report an error
922 KAR 2:090 · 922 KAR 2:090. Section 8. General.
General: Based on multiple interviews and review of video footage, the surveyor found that a four-year-old child was inappropriately and roughly handled by staff in the Paces Creek Classroom on multiple occasions. The surveyor found that during nap time multiple staff members roughly picked up the child by her arms, aggressively held the child by her arms and/or wrist and forced the child to sit in a chair for time-out for a prolonged period of time. On multiple occasions in the video, a staff person can be seen placing the child’s chair in between the staff person's legs and the staff person holding the child's arms or legs down while the child sat in the chair. During review of the video footage of several of the incidents, the child can be seen screaming and crying while she was trying to get away from the staff. Based on the incidents mentioned, the health, safety and comfort of the child was compromised. The date(s) of the incidents were unknown as the video footage did not have a date or time stamp; however, the video footage did confirm that the incidents occurred during naptime. Employee Records Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, the surveyor found that a staff’s (DOH: 10/18/23) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Programming Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.
General: Based on multiple interviews and review of video footage, the surveyor found that a four-year-old child was roughly handled by multiple staff in the Paces Creek Classroom on multiple occasions. In addition, the surveyor found that during nap time a staff person would place the child in a chair at the table for a prolonged period of time. Several staff stated that the child care center staff were not supposed to use “time-out” on children; however, the child was required to sit in a chair at the table due to misbehaving or refusing to nap. Based on review of video, the surveyor found that the chair/table that the child sat in for time-out was also used for eating; therefore, the child-care center failed to ensure that discipline was not associated with rest or food. The date(s) of the incidents were unknown as the video footage did not have a date or time stamp; however, the video footage did confirm that the incidents occurred during naptime.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 6. Sleeping and Napping Requirements.
General: Based on review of documentation, the surveyor found that the child-care center failed to offer an alternate activity to a four-year-old child on multiple occasions during rest time. Through review of video footage, the surveyor found that a child would be placed in a chair at a table and would be required to sit for a prolong period of time before being allowed to go back to the cot for nap time. Through multiple interviews, the surveyor learned that the child-care center does not offer an alternate activity for children who do not nap during rest time. Hygienic Practices Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on observation, the surveyor found through video footage that six (6) children were sent to a table after rest time to be given their afternoon snack. The surveyor observed all six (6) children to sit down at the table and to begin to eat their snack without washing their hands; therefore, the child-care center failed to ensure that the children washed their hands prior to handling food.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:280 · 922 KAR 2:280. Section 3. Implementation and Enforcement.
General: Based on review of documentation, the surveyor found a staff member’s (DOH: 05/26/23) file did not contain documentation of background checks submitted through the Kentucky Applicant Registry and Employment System (KARES). The staff member's file did not contain a completed Child Abuse/Neglect Background Check dated or a completed Criminal Records Background Check. After a review of KARES, the surveyor found that the staff member had not been entered into KARES; therefore, the staff member was hired prior to clearance for employment. During interview with staff-in-charge, she stated the staff member was a substitute for the child-care center and could possibly be located on a different head start’s KARES report. Staff-in-charge stated the staff member has not worked alone with children. The surveyor did not observe the staff member working at the child-care center on the day of the surveyor’s visit. The surveyor reviewed the staff member's individual report in KARES and confirmed that the staff member did not have a completed background check and was not listed on another child-care center’s KARES report.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:280 · 922 KAR 2:280. Section 11. Status of Employment.
General: Based on review of documentation, the surveyor found a staff member's (DOH: 01/06/23) file contained documentation from the Kentucky Applicant Registry and Employment System (KARES) that the staff person was eligible for hire on 12/08/22. On the day of the surveyor's visit, the surveyor printed the child-care center’s KARES report to review the names listed and found the staff member was not listed under the child-care center’s roster; therefore, the child-care center failed to update the staff member’s employment status. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 6 Inspection Report Director Requirements In Compliance Employee Records Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, the surveyor found the following: 1. A staff member’s (DOH: 03/12/97) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. During interview, staff-in-charge stated that the staff person did have a current TB skin test; however, the staff member works at the Head Start Central Office location and was out of the office. The staff member could not obtain the documentation during the surveyor's visit. 2. A staff member’s (DOH: 07/31/17) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. During interview, staff-in-charge confirmed that the staff member did not have a current TB skin test. 3. A staff member’s (DOH: 08/16/21) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. During interview, staff-in-charge stated that the staff member did have a current TB skin test; however, a copy not available for the surveyor to review. 4. A staff member’s (DOH: 05/03/23) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. During interview, staff-in-charge confirmed that the staff member did not have a TB skin test. 5. A staff member’s (DOH: 10/10/23) file contained documentation of a TB skin test; however, the surveyor was unable to read the documentation that was provided and could not see the date that the TB skin test was given or read for the staff member. During interview with staff-in-charge, she stated she would have the staff member obtain a new TB skin test. 6. A staff member’s (DOH: 10/18/23) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. During interview, staff-in-charge confirmed that the staff member did not have a current TB skin test.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.
General: Based on review of documentation and ECE-TRIS, the surveyor found that one (1) staff member (DOH: 05/26/23) did not complete the required cabinet approved training in first aid and cardiopulmonary resuscitation (CPR).
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, the surveyor found the following: 1. Based on review of ECE-TRIS, one (1) staff member (DOH: 01/01/2021) completed (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training completed between 01/01/23 - 06/30/23. 2. Based on review of ECE-TRIS, one (1) staff member (DOH: 01/05/22) completed (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training completed between 01/05/23 - 06/30/23. 3. Based on review of ECE-TRIS, one (1) staff member (DOH: 05/26/23) did not have documentation that Orientation was completed within the first three (3) months of hire. The surveyor reviewed ECE-TRIS and confirmed that the staff person had not completed the Orientation training by the date of the surveyor's visit. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 6 Inspection Report Premises Not In Compliance
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation, the surveyor found the following: Early Head Start #1: 1. The faucet on the tall sink in the classroom was not secured to the counter and moved easily when touched by the surveyor; therefore the faucet was not kept in good repair. Horse Creek: 1. The faucet on the sink in the classroom was not secured to the counter and moved easily when touched by the surveyor; therefore the faucet was not kept in good repair. 2. There was a thick build-up of dirt around the faucet on the classroom sink; therefore, the sink was not kept clean. Paces Creek: 1. There was a dead bug in the windowsill located near the library corner; therefore, the windowsill was not kept clean.
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation, the surveyor found the following: Horse Creek: 1. A large blue rug with colorful circles contained debris; therefore, the rug was not kept clean. 2. In the boys' restroom, a ceiling tile located over the toilet had water discoloration; therefore the ceiling was not kept in good repair. During interview with staff-in-charge, she stated that she was not aware of a leak in the ceiling in the boys' restroom.
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation, the surveyor found the following: Early Head Start #1: 1. The hot water temperature in the restroom had a temperature reading of approximately one hundred thirty (130) degrees Fahrenheit; therefore, the hot water was not a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of one hundred twenty (120) degrees Fahrenheit. 2. The hot water temperature in the small sink located in the classroom had a temperature reading of approximately one hundred thirty (130) degrees Fahrenheit; therefore, the hot water was not a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of one hundred twenty (120) degrees Fahrenheit. 3. The hot water temperature in the tall sink located in the classroom had a temperature reading of approximately one hundred thirty (130) degrees Fahrenheit; therefore, the hot water was not a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of one hundred twenty (120) degrees Fahrenheit. Early Head Start #2: 1. The hot water temperature in the tall sink located in the classroom had a temperature reading of approximately one hundred twenty four (124) degrees Fahrenheit; therefore, the hot water was not a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of one hundred twenty (120) degrees Fahrenheit. 2. The hot water temperature in the restroom had a temperature reading of approximately one hundred twenty six (126) degrees Fahrenheit; therefore, the hot water was not a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of one hundred twenty (120) degrees Fahrenheit. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 6 Inspection Report
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation, the surveyor found the following: Early Head Start #1: 1. The toilet seat moved easily and was not tightly secured to the toilet in the restroom. Early Head Start #2: 1. The toilet seat moved easily and was not tightly secured to the toilet in the restroom. Horse Creek: 1. The toilet seat moved easily and was not tightly secured to the toilet in the girls' restroom. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation, the surveyor found that the mulch underneath the swing set was depleted; therefore, the child-care center failed to have an adequate protective surface underneath the swing set.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation, the surveyor found the following: 1. On the far left side of the Head Start Playground, there was a piece of the fence broken that contained a piece of metal sticking out onto the playground area; therefore, the fence was not kept in good condition. 2. On the far left side of the Head Start Playground, there was a large gap at the bottom of the fence row that measured approximately eleven and one-half (11 1/2) inches wide; therefore, the fence was not kept in good condition. 3. On the back side of the Head Start Playground, the surveyor observed the fence to wobble and not be secured to the ground; therefore, the fence was not stable and not kept in good repair. Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 5 of 6 Inspection Report Written Documentation Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.
General: Based on review of documentation, the surveyor found a staff member’s (DOH: 03/12/97) file contained a professional development plan dated for 08/16/21; therefore, the plan was not completed annually. During interview with staff-in-charge, she stated that the staff member works in the Head Start's central office and was currently out of the office. Posted Documentation In Compliance Animals In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.
General: Based on review of documentation and ECE-TRIS, the surveyor found that a staff (DOH: 11/08/18) had not completed the required CPR/First-Aid training.
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation and ECE-TRIS, the surveyor found the following: 1. A staff’s (DOH:08/16/21) file did not contain documentation of one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma training; therefore, the training was not completed within one (1) year of employment. 2. A staff (DOH: 08/15/21) obtained zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 07/01/21 – 06/30/22. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Premises Not In Compliance
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation, the surveyor found that the water from the sinks in all the classrooms and restrooms has a temperature reading of seventy (70) degrees Fahrenheit; therefore the sinks did not have a hot water temperature reading ranging from ninety (90) degrees Fahrenheit to one hundred-twenty (120) degrees Fahrenheit. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation, the surveyor found that the fence on the Head Start Playground had a broken wooden plank sticking out with a sharp edge; therefore, the fence was not kept in good condition. Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, the surveyor found that two (2) staff’s (DOH: 8/16/21) files did not contain a high school diploma, GED, or a Commonwealth Child Care Credential. Staff reported the documentation for the staff’s proof of education could be at the child care center’s central office location. The staff from central office were out-of-state at a training and were not available to check for the staff’s education documentation. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, the surveyor found the following: (1.) Two (2) staff’s (DOH: 8/16/21) files did not contain a statement from a health professional that the individuals were free of active tuberculosis or a copies of negative tuberculin results. (2.) Staff’s (DOH: 7/27/17) file contained a negative tuberculin result that was dated 10/12/19; therefore, the staff’s tuberculin result was no longer current. (3.) Staff’s (DOH: 12/6/19) file contained a negative tuberculin result that was dated 3/13/19; therefore, the staff’s tuberculin result was no longer current. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:280 · 922 KAR 2:280. Section 3. Implementation and Enforcement.
General: Based on interview and review of documentation, the surveyor was not presented with a completed Child Abuse/Neglect background check or a Criminal Records background check for a staff member (DOH: 10/15/20). Staff-in-charge identified the staff member as a substitute teacher and reported the staff member has not worked alone with children. The surveyor did not observe the staff member working alone with children. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements In Compliance Employee Records In Compliance Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Outdoor Play Area Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation, the surveyor found the following: 1.) A large piece of plywood was propped against a building located on the Head Start playground that poses a safety risk to the children. 2.) A wooden sandbox was located on the Head Start playground that had decayed wood and was accessible to the children. Staff-in-charge reported that the Head Start playground has not been in use due to the center operating virtually. Staff-in-charge stated that they would have the plywood and sandbox removed from the playground. Equipment In Compliance Transportation In Compliance Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation Not In Compliance
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.
General: Based on review of documentation, the surveyor was not presented with an updated annual professional development plan for a staff member (DOH: 07/29/16). The last professional development plan on file was dated for 07/29/19. Posted Documentation In Compliance Animals Not Applicable Emergency Regulation In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.
General: Based on interview, the surveyor learned that a child was left on the school bus with no supervision. The morning bus had two (2) staff and ten (10) children on the bus. Staff confirmed through interview that staff entered their classroom to wash the children's hands and get ready to eat breakfast when staff discovered that one (1) of the ten (10) children was missing. One (1) staff left the classroom to find the child was still sitting on the bus unsupervised. Staffing Requirements In Compliance
Open Not marked corrected in the state record
Category: supervision. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 10. Director Requirements and Responsibilities.
General: Based on observation during a tour of the Garrard Classroom, the surveyor found the following: 1. During naptime, sheets of plastic, used for the hygienic storage of the children’s mats, were placed within the reach of the children. 2. A toilet plunger was stored beside the door in the girls' restroom. The plunger was within reach of the children. Employee Records Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation and ECE-TRIS, the surveyor found no verification that a staff (DOH: 7/30/18) completed six (6) hours of cabinet-approved orientation training. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Premises Not In Compliance
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation during a tour of the Garrard Classroom, the surveyor found the following: 1. Dark stains were present on the interior toilet bowl located in the girls’ restroom. 2. Yellow stains, indicative of urine, were on the base of the toilet located in the boys’ restroom. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 6. Sleeping and Napping Requirements.
General: Based on observation during a tour of the Garrard Classroom, the surveyor found that six (6) children were napping on mats that were placed less than twelve (12) inches apart. Transportation Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 12. Transportation.
General: Based on review of documentation, the surveyor found that the the children’s morning arrival times at the childcare center and their afternoon departure times from the childcare center were not recorded. Food Service/Food Program In Compliance Food Service Not In Compliance
Open Not marked corrected in the state record
Category: transportation. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Meal Requirements.
General: Based on observation during a tour of the kitchen, the surveyor observed that a large can of cranberry sauce was being used to prop open a door. The cranberry sauce was not stored at least six (6) inches off the floor. Children's Records Not In Compliance
Open Not marked corrected in the state record
Category: nutrition. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.
General: Based on review of documentation, the surveyor found that a child’s (DOE: 7/10/18) file contained an immunization certificate that was no longer current as of 9/20/18. Written Documentation In Compliance Posted Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Animals Not Applicable
Open Not marked corrected in the state record
Category: health medication. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 6. Reports.
General: Based on interview, the surveyor found that a child (DOE: 8/22/17) was taken to the emergency room on 10/31/17 after receiving an injury from a fall at the childcare center. Staff completed an incident report on 10/31/17. The center did not report the incident to the Division of Regulated Child Care until 11/6/17; therefore, the incident was not reported within the twenty - four (24) hour time frame.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 6. License Issuance.
General: Based on review of documentation and interview, the surveyor found that the proof of liability insurance presented for review documented that the policy expired as of 8/1/16. Upon interview, staff-in-charge reported that the updated insurance policy statement had not yet been recieved from central office. Director Requirements Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 4. Director Requirements and Responsibilities.
General: Based on review of documentation and interview, the following was found: 1. A staff file (DOH: 03/12/97) presented for review contained an annual evaluation that was completed in April of 2016; therefore, the evaluation had not been updated annually as required. 2. A staff file (DOH: 11/20/84) presented for review contained an annual evaluation that was completed in May of 2014; therefore, the evaluation had not been updated annually as required. Staff-in-charge reported that when some staff transferred to the center from other centers their updated evaluations were not sent with their file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report Employee Records Not In Compliance
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on review of documentation and interview, the surveyor found that a staff file (DOH: 11/20/84) presented for review contained a negative tuberculin skin test which had been read on 9/13/13; therefore, the staff had not completd a negative turberculin skin test every two (2) years as required. Staff-in-charge explained that the staff member had transferred in from another center.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on review of documentation, review of ECE-TRIS, and interview, the following was found: 1. A staff file (DOH: 1/26/10) contained documentation of having completed Pediatric Abusive Head Trauma (PAHT) on 4/20/12. Review of ECE-TRIS confirmed that the staff member had completed PAHT training on 4/20/12; therefore, the staff did not meet the requirement of completing PAHT training every five (5) years. 2. A staff file (DOH: 8/30/99) contained documentation of having completed Pediatric Abusive Head Trauma (PAHT) on 4/20/12. Review of ECE-TRIS confirmed that the staff member had completed PAHT training on 4/20/12; therefore, the staff did not meet the requirement of completing PAHT training every five (5) years. 3. A staff file (DOH: 6/2/08) contained documentation of having completed Pediatric Abusive Head Trauma (PAHT) on 4/20/12. Review of ECE-TRIS confirmed that the staff member had completed PAHT training on 4/20/12; therefore, the staff did not meet the requirement of completing PAHT training every five (5) years. 4. A staff file (DOH: 9/17/02) contained documentation of having completed Pediatric Abusive Head Trauma (PAHT) on 4/20/12. Review of ECE-TRIS confirmed that the staff member had completed PAHT training on 4/20/12; therefore, the staff did not meet the requirement of completing PAHT training every five (5) years. 5. A staff file (DOH: 7/10/00) contained documentation of having completed Pediatric Abusive Head Trauma (PAHT) on 4/20/12. Review of ECE-TRIS confirmed that the staff member had completed PAHT training on 4/20/12; therefore, the staff did not meet the requirement of completing PAHT training every five (5) years. 6. A staff file (DOH: 8/21/97) contained documentation of having completed Pediatric Abusive Head Trauma (PAHT) on 4/20/12. Review of ECE-TRIS confirmed that the staff member had completed PAHT training on 4/20/12; therefore, the staff did not meet the requirement of completing PAHT training every five (5) years. 7. A staff file (DOH: 3/23/84) contained documentation of having completed Pediatric Abusive Head Trauma (PAHT) on 4/20/12. Review of ECE-TRIS confirmed that the staff member had completed PAHT training on 4/20/12; therefore, the staff did not meet the requirement of completing PAHT training every five (5) years. 8. A staff file (DOH: 12/14/07) contained documentation of having completed Pediatric Abusive Head Trauma (PAHT) on 4/20/12. Review of ECE-TRIS confirmed that the staff member had completed PAHT training on 4/20/12; therefore, the staff did not meet the requirement of completing PAHT training every five (5) years. 9. A staff file (DOH: 7/29/16) did not contain documentation of having completed Pediatric Abusive Head Trauma (PAHT) within the first year of employment. Review of ECE-TRIS, revealed that the staff member has not yet completed PAHT. 10. A staff file (DOH: 8/1/16) did not contain documentation of having completed Pediatric Abusive Head Trauma (PAHT) within the first year of employment. Review of ECE-TRIS, revealed that the staff member has not yet completed PAHT. Staff-in-charge was not aware of the PAHT training requirements. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report
922 KAR 2:120 · 922 KAR 2:120. Section 12. Transportation.
General: Based on review of documentation and interview, the following was found: 1. The most recent driver history report submitted for staff (DOH: 12/12/13) was completed on 8/9/16; therefore, the driver history record was not completed annually as required. 2. The most recent driver history report submitted for staff (DOH: 03/23/84) was completed on 8/9/16; therefore, the driver history record was not completed annually as required. 3. The most recent driver history report submitted for staff (DOH: 12/14/07) was completed on 8/9/16; therefore, the driver history record was not completed annually as required. Upon interview, staff-in-charge was not aware that the driver history report was supposed to be completed annually. Programming In Compliance Premises Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on observation and interview, the surveyor found that a closet located in the Garrard Classroom was left unlocked. The closet contained a gallon of Clorox Bleach and container of Pinesol. These items were accessible to the children due to the closet being left unlocked. Staff stated that they had been in and out of the closet through out the morning.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation and interview, the surveyor found that the wall located behind the toilet in the boys' restroom off of the Garrard Classroom had sustained some water damage. The water damage had cause the rubber trim at the base of the wall to peel away from the wall. Upon interview, staff were not aware of the water damage to the wall.
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation and interview, the surveyor found the following: 1. The toilet located in the girls' restroom off of the Garrard Classroom contained black and yellow stains inside the toilet bowl. Staff reported that the toilets and restrooms are cleaned daily. 2. The toilet in the girls' restroom located off of the Horsecreek Classroom containe a chip in the toilet seat exposing the absorbent wood beneath the paint. The toilet was not in good repair and could not be properly sanitized. Staff stated they were not aware of the condition of the toilet. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report Hygienic Practices Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation and interview, the surveyor found that the surface below the diaper changing mat in the restroom off of the Early Head Start Classroom was soiled with dirt and debri. Staff stated that the surfaced is cleaned daily. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Food Service Not In Compliance
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 8. Kitchen Requirements.
General: Based on observation and interview, the surveyor found that the white freezer located in the kitchen contained a thermometor which was reading at ten (10) degrees Fahrenheit rather than the required zero (0) degrees Fahrenheit or less. Kitchen staff were not aware that the thermometor was not reading correctly. Children's Records In Compliance Written Documentation Not In Compliance
Open Not marked corrected in the state record
Category: nutrition. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on review of documentation and interview, the following was found: 1. A staff file (DOH:06/16/16) presented for review did not contain an annual professional development plan. 2. A staff file (DOH: 03/12/97) contained an annual professional development plan that was last updated on 8/1/16. 3. A staff file (DOH: 06/16/16) presented for review contained an annual professional development plan that was last updated on 8/1/16. 4. A staff file (DOH: 11/20/84) presented for review contained an annual professional development plan that was last updated on 8/7/14. The annual professional development plans have not been updated annually as required. Staff-in-charge reported that some of the staff have transferred from other centers and she has not yet received their updated professional development plans.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on review of documentation and interview, the surveyor found that a monthly fire drill had not been documented for September of 2016. Staff stated they were not sure if a drill had been conducted. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on review of documentation and interview, it was found that a monthly fire drill was not completed for September of 2016. Upon interview, staff were not sure if a drill had been completed and did not locate documentation for the drill. Posted Documentation In Compliance Animals In Compliance
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on review of documentation, the surveyor found the following: 1. A staff members (DOH: 2/28/06) file contained a copy of a tuberculin skin test result that is no longer current as of 8/20/16. 2. A staff members (DOH: 11/20/84) file contained a copy of a tuberculin skin test result that is no longer current as of 9/13/15. In an interview with the staff person in charge the surveyor was informed that the staff member does have a current tuberculin skin test result; however, the verification could not be located at the time of the inspection.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on review of documentation, and ECE-TRIS, the surveyor found the following: 1. A staff member (DOH: 01/26/10) has not completed fifteen (15) hours of cabinet approved training. 2. A staff member (DOH: 12/15/14) has not completed the one and a half (1 ½) hours of pediatric abusive head trauma (PAHT) training. 3. A staff member (DOH: 08/27/15) has not completed the one and a half (1 ½) hours of pediatric abusive head trauma (PAHT) training.
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation during a tour of the facility, the surveyor found the following: 1. The sinks in both the boys’ and girls’ restrooms located in the Paces Creek Classroom had a water temperature reading of seventy-(70)-degrees Fahrenheit. 2. The sinks in both the boys’ and girls’ restrooms located in the Garrad Classroom had a water temperature reading of seventy-(70)-degrees Fahrenheit. 3. The sinks in both the boys’ and girls’ restrooms located in the Manchester Classroom had a water temperature reading of sixty-five (65) degrees Fahrenheit. 4. The sinks in both the boys’ and girls’ restrooms located in the Horse Creek Classroom had a water temperature reading of seventy-one (71) degrees Fahrenheit.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on review of documentation, the surveyor found the following: 1. A child’s (DOE: 05/19/15) file contained an immunization certificate no longer current as of 12/09/15. 2. A child’s (DOE: 05/12/15) file contained an immunization certificate no longer current as of 04/04/16. 3. A child’s (DOE: 08/12/15) file contained an immunization certificate no longer current as of 04/10/16. 4. A child’s (DOE: 02/26/16) file did not contain a current immunization certificate. 5. A child’s (DOE: 08/12/15) file did not contain a current immunization certificate. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 23 of 26 Web site: http://chfs.ky.gov/ Inspection Report
Open Not marked corrected in the state record
Category: health medication. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on review of documentation and a review of ECE-TRIS, the file presented for review for a staff member (DOH: 07/31/14) did not contain one and one-half (1 1/2) hours of pediatric abusive head trauma (PAHT) training.
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on review of documentation, the file presented for review for a staff person (DOH 6/2/11) contained a tuberculin test that was no longer current as of 4/8/13.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on observation, the children did not wash their hands after eating breakfast in the Garrard classroom.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on review of documentation, the preferred hospital name and number was not included in the children's files.
Open Not marked corrected in the state record
Open / not marked corrected.
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.