Inspection Reports for
Bourbon Heights Nursing Home
2000 SOUTH MAIN STREET, PARIS, KY, 40361
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Kentucky average
Kentucky average: 4.7 deficiencies/year
Deficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
41% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Date: Feb 13, 2025
Visit Reason
An abbreviated survey was conducted to investigate complaints KY00044477 and KY00044571.
Complaint Details
Complaints KY00044477 and KY00044571 were investigated and found to be without deficiencies.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B. No deficiencies were issued related to the investigated complaints.
Report Facts
Sample Size: 4
Supplemental Residents: 41
Inspection Report
Immediate Jeopardy
Census: 74
Deficiencies: 9
Date: Nov 22, 2024
Visit Reason
The inspection was conducted due to ongoing regulatory oversight related to infection control deficiencies, resident care concerns including falls and change in condition, and facility administration issues.
Findings
The facility failed to maintain infection control to prevent legionellosis outbreaks, failed to promptly identify and intervene for resident changes in condition, failed to update care plans after falls, and failed to ensure adequate staffing and training. The facility also failed to implement recommendations from the Division of Epidemiology and Health Planning and Local Health Department regarding legionella contamination. Immediate Jeopardy was identified but later removed with remaining non-compliance.
Deficiencies (9)
F550: The facility failed to treat residents with dignity and respect by not providing showers for over a month due to legionella contamination, only offering bed baths, and failing to communicate the water issues to residents and families.
F580: The facility failed to notify the physician of a significant change in Resident 76's condition after a fall, including prolonged elevated blood pressure and altered mental status, resulting in delayed hospital transfer and diagnosis of transient ischemic attack.
F656: The facility failed to implement Resident 76's care plan interventions after a fall, including monitoring and reporting changes in condition, increasing fall prevention measures, and updating the care plan.
F684: The facility failed to provide adequate supervision and prevent accidents, resulting in Resident 76 sustaining a hip fracture after falling from a wheelchair while unsupervised, and Resident 425 sustaining multiple falls with injuries.
F835: The facility failed to administer the facility in a manner that uses resources effectively and efficiently to maintain resident well-being, including failure to implement recommendations to prevent legionellosis outbreaks.
F837: The facility's governing body failed to ensure policies were implemented regarding management and operation of the facility, including failure to act on legionella outbreak recommendations and inadequate oversight of administration.
F838: The facility failed to conduct and document a facility-wide assessment to determine necessary resources for resident care, including failure to address agency staffing volume and its impact on continuity of care.
F867: The facility failed to maintain an effective Quality Assurance Performance Improvement program to correct quality deficiencies, including failure to implement a Water Management Plan and address legionella contamination.
F880: The facility failed to establish and maintain an infection prevention and control program to provide a safe environment and prevent communicable diseases, including legionella contamination, inadequate flushing logs, incomplete staff training, and failure to notify residents and staff of ongoing contamination.
Report Facts
Resident census: 74
Agency staffing percentage: 68
Legionella CFU/ml: 11
Fall risk score: 7
Fall risk score: 13
Fall risk score: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Named in failure to notify physician of Resident 76's condition and failure to update care plan |
| F4 | State Registered Nurse Aide | Witnessed Resident 76 fall and reported resident's complaints |
| Director of Nursing | Director of Nursing | Named in oversight failures and infection control program |
| Administrator | Facility Administrator | Named in failure to implement DEHP recommendations and communication failures |
| CLWSE | Certified Legionella Water Safety Expert | Consultant providing water management plan and legionella control recommendations |
| IWSC Representative | Independent Water Systems Company Representative | Provided water testing and treatment services |
| BD1 | Board Director | Named in lack of awareness of DEHP recommendations and oversight failures |
| BD6 | Board Director | Named in lack of awareness of DEHP recommendations and oversight failures |
Inspection Report
Deficiencies: 10
Date: Nov 22, 2024
Visit Reason
The inspection was conducted to investigate multiple quality and safety concerns including infection control, water contamination with legionella, care planning deficiencies, medication management, staff competencies, and food safety at Bourbon Heights Nursing Home.
Findings
The facility was found to have multiple deficiencies including failure to notify residents of Medicare/Medicaid coverage changes, incomplete baseline and comprehensive care plans, expired CPR certifications among staff, inadequate dialysis care and communication, improper medication labeling, cold food service, and a deficient infection prevention and control program with ongoing legionella contamination in the water system. Immediate Jeopardy was identified related to infection control and water management but was removed prior to exit with remaining non-compliance.
Deficiencies (10)
F0582: The facility failed to notify one resident in writing of the end date of Medicare-covered skilled services and their right to appeal.
F0655: The facility failed to develop and implement a baseline care plan addressing hemodialysis needs and fall risk for one resident upon admission.
F0657: The facility failed to review and revise the comprehensive care plan after a resident's fall and hospitalization, resulting in a subsequent fall with major injury.
F0678: The facility failed to ensure all licensed nurses and Kentucky Medication Aides maintained current CPR certification, with some staff working with expired certifications.
F0698: The facility failed to provide safe and appropriate dialysis care, including consistent assessments, monitoring, and communication with the dialysis facility for one resident.
F0726: The facility failed to ensure licensed nurses and nursing assistants had appropriate competencies and training to provide care, especially agency staff who lacked orientation and competency assessments.
F0761: The facility failed to label opened medications with the date opened to ensure proper use before expiration.
F0804: The facility failed to ensure food was served at a safe and appetizing temperature, with residents repeatedly complaining of cold food.
F0867: The facility failed to maintain an effective Quality Assurance Performance Improvement program to address legionella contamination and water management deficiencies, resulting in delayed implementation of corrective actions.
F0880: The facility failed to establish and maintain an infection prevention and control program, including failure to implement legionella water management plans, inadequate flushing and water testing documentation, and failure to protect residents from legionella exposure.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Nurses with expired CPR certifications: 8
Agency staffing percentage: 68
Residents affected: 1
Facility census: 74
Water testing legionella CFU/ml: 11
Water testing legionella CFU/ml: 11
Water management plan score: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Agency nurse reporting lack of orientation and support for resident care |
| LPN1 | Licensed Practical Nurse | Reported use of faucet water for ADLs and lack of education on legionella |
| DOM | Director of Maintenance | Reported water system flushing practices and delays in monochloramine treatment |
| IP | Infection Preventionist | Responsible for infection control program and communication of legionella risks |
| CLWSE | Certified Legionella Water Safety Expert | Consultant providing water management recommendations |
| QA Nurse | Quality Assurance Nurse | Member of QAPI committee involved in legionella response |
| SC | Schedule Coordinator | Reported agency staff training and orientation processes |
| DM | Dietary Manager | Member of QAPI committee and involved in legionella response |
| HSKD | Housekeeping Director | Responsible for water line flushing and member of QAPI committee |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 3
Date: Apr 5, 2024
Visit Reason
Investigation of multiple resident-to-resident abuse incidents and failure to immediately report alleged sexual abuse, as well as infection control concerns related to legionella contamination in the facility's water system.
Complaint Details
The complaint investigation was substantiated with findings of resident-to-resident abuse involving four residents, failure to timely report sexual abuse allegations for one resident, and failure to implement infection control measures to prevent legionella exposure. Immediate Jeopardy was identified related to infection control and was removed after corrective actions.
Findings
The facility failed to protect residents from abuse, including resident-to-resident physical abuse and delayed reporting of sexual abuse allegations. Additionally, the facility failed to implement infection control measures to prevent legionella exposure, including not providing bottled water or faucet filters despite positive legionella test results. Immediate Jeopardy was identified and later removed after corrective actions.
Deficiencies (3)
F0600: The facility failed to protect residents from physical abuse, with documented resident-to-resident altercations involving four residents. Staff did not prevent or adequately monitor these incidents.
F0607: The facility failed to immediately report alleged sexual abuse of one resident to the Administrator and State Agencies, delaying notification beyond the required timeframe.
F0880: The facility failed to establish and maintain an infection prevention and control program to prevent legionella exposure. Despite positive legionella tests, the facility did not provide bottled water or install faucet filters as recommended, exposing residents and staff to potential harm.
Report Facts
Residents affected by abuse: 4
Residents affected by delayed abuse reporting: 1
Facility census: 76
Staff educated on Legionnaires' Disease: 55
Facility full-time staff: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Named in failure to report sexual abuse allegation and documentation of progress notes |
| SRNA12 | State Registered Nurse Aide | Witnessed resident-to-resident abuse incident on 06/04/2023 |
| SRNA14 | State Registered Nurse Aide | Witnessed resident-to-resident abuse incident on 10/24/2023 and provided statements about resident behaviors |
| Social Services Director (SSD) | Social Services Director | Conducted investigations and interviews related to abuse incidents |
| Director of Nursing (DON) | Director of Nursing | Provided statements on abuse policy, infection control, and staff education |
| Administrator | Facility Administrator | Provided statements on abuse policy, infection control, and communication of legionella contamination |
| Infection Preventionist (IP) | Infection Preventionist | Responsible for infection control program and communication with health departments |
| Director of Maintenance (DOM) | Director of Maintenance | Responsible for water system maintenance and legionella remediation |
| Medical Director | Medical Director | Provided statements on infection control and facility meetings |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 10, 2020
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to physical restraints, resident assessments, and care planning in a nursing home setting.
Findings
The facility failed to ensure residents were free from physical restraints without proper medical justification and consent for three sampled residents. The Minimum Data Set (MDS) assessments were inaccurate for one resident regarding restraint use. Additionally, the facility failed to develop and implement comprehensive care plans addressing residents' needs related to restraints and medication for two residents, and failed to revise care plans after fall events for two residents.
Deficiencies (4)
F0604: The facility failed to ensure residents were free from physical restraints imposed for discipline or convenience without medical justification and proper consent for three residents. Physician orders lacked documentation of medical symptoms and duration of restraint use, and care plans did not include medical symptoms treated or monitoring requirements.
F0641: The facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for one resident who was restrained with a lap tray/lap buddy but was coded as not restrained.
F0656: The facility failed to develop and implement a person-centered Comprehensive Care Plan (CCP) addressing medical, physical, mental, and psychosocial needs related to restraints and medication for two residents. Care plans lacked documentation of medication use and restraint interventions.
F0657: The facility failed to ensure the Comprehensive Care Plan was reviewed and revised by an interdisciplinary team for five residents. Care plans were not updated after fall events or medication changes to include appropriate interventions.
Report Facts
Residents sampled for physical restraints: 3
Residents sampled for MDS accuracy: 1
Residents sampled for care plan development: 2
Residents sampled for care plan review: 5
BIMS score: 3
BIMS score: 2
BIMS score: 4
BIMS score: 10
Days of anti-depressant medication: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | Registered Nurse/MDS Coordinator | Responsible for MDS assessments and care plan revisions; interviewed regarding restraint coding and care plan accuracy |
| Director of Nursing | Director of Nursing | Interviewed regarding MDS assessment accuracy and care plan development responsibility |
| SRNA #1 | State Registered Nursing Assistant | Interviewed regarding use and monitoring of restraints for Resident #39 and Resident #89 |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding restraint use for Resident #39 and Resident #89 |
| SRNA #5 | State Registered Nurse Aide | Interviewed regarding care and restraint use for Resident #70 |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding restraint assessments and care planning for Resident #70 |
| Quality Assurance Registered Nurse #1 | Quality Assurance Registered Nurse | Interviewed regarding care plan updates and restraint policy compliance |
| Quality Assurance Director | Quality Assurance Director | Interviewed regarding fall investigations and care plan revisions for Resident #9 |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Oct 25, 2018
Visit Reason
The inspection was conducted as a comprehensive annual survey of Bourbon Heights Nursing Home to assess compliance with regulatory requirements related to resident care, activities, and medication management.
Findings
The facility failed to develop and implement comprehensive person-centered care plans and activities for multiple residents, resulting in lack of participation in meaningful activities. Additionally, the facility did not limit PRN psychotropic medication orders to fourteen days as required, leading to administration beyond the recommended duration.
Deficiencies (4)
F 0656: The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for residents #33 and #71, resulting in unmet medical, nursing, and psychosocial needs related to activities.
F 0659: The facility failed to provide care by qualified persons according to each resident's written plan of care for residents #14, #16, and #27, as activities were not provided per their comprehensive care plans.
F 0679: The facility failed to provide an ongoing program of activities to meet the needs and preferences of residents #14, #16, #27, #33, and #71, resulting in lack of documented participation in meaningful group or individual activities.
F 0758: The facility failed to ensure PRN psychotropic medication orders were limited to fourteen days for residents #16 and #83, resulting in administration beyond the recommended duration without documented rationale.
Report Facts
Days of activity report period: 54
BIMS scores: 14
BIMS scores: 3
BIMS scores: 13
BIMS scores: 11
PRN psychotropic medication limit: 14
PRN doses administered beyond stop date: 1
PRN doses administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Activity Director | Interviewed regarding lack of activity documentation and efforts to improve activity programming | |
| Minimum Data Set (MDS) Coordinator | Interviewed regarding MDS assessments and coordination of care plans | |
| Administrator | Interviewed regarding expectations for activity programming and medication management | |
| Consultant Pharmacist | Interviewed regarding recommendations for limiting PRN psychotropic medication use | |
| Director of Nursing (DON) | Interviewed regarding medication administration and PRN psychotropic medication policies | |
| Attending Physician | Interviewed regarding PRN psychotropic medication orders and regulatory compliance |
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