Inspection Reports for
Bradford Heights Nursing and Rehabilitation
950 HIGHPOINT DRIVE, HOPKINSVILLE, KY, 42240
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
34% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 2
Date: Sep 12, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations, including food service safety and infection prevention and control programs.
Findings
The facility failed to properly store, prepare, distribute, and serve food according to professional standards, exposing residents to potential food contamination and fire hazards due to unclean kitchen conditions. Additionally, the facility failed to maintain an effective infection prevention and control program, with observed improper wound care practices that increased the risk of infection for residents.
Deficiencies (2)
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including uncovered moldy food, improper food labeling, and unclean kitchen areas with grease buildup posing a fire hazard.
F 0880: The facility failed to implement an infection prevention and control program, with wound care staff not disinfecting bedside tables or performing proper hand hygiene during dressing changes, risking infection spread among residents.
Report Facts
Residents affected: 93
Residents sampled for wound care: 20
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Named in food service safety deficiencies regarding improper food storage and kitchen cleanliness |
| Director of Nursing | Director of Nursing and Infection Preventionist | Named in infection control deficiency related to wound care practices and staff training |
| Wound Care Nurse | Named in infection control deficiency for improper wound care procedures |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 20, 2024
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with healthcare facility regulations, focusing on resident rights, care planning, and pressure ulcer prevention.
Findings
The facility failed to ensure resident self-determination in bathing preferences for one resident, did not develop and implement comprehensive care plans for two residents including psychiatric and skin integrity needs, and failed to prevent a pressure injury in one resident due to lack of timely interventions.
Deficiencies (3)
F 0561: The facility failed to ensure a resident's right to choose activities and personal care, as Resident #6 was not provided showers as preferred due to equipment limitations and staff assumptions.
F 0656: The facility failed to develop and implement comprehensive, measurable care plans for two residents, including addressing psychiatric diagnoses for Resident #23 and pressure injury risk for Resident #99.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers, as Resident #99 developed a facility-acquired deep tissue injury due to lack of timely interventions and inconsistent use of heel boots.
Report Facts
Residents sampled: 30
Residents affected: 1
Residents affected: 2
Residents affected: 1
BIMS score: 14
BIMS score: 0
BIMS score: 15
Pressure injury size: 4.04
Pressure injury size: 3.09
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 8 | CNA | Provided care to Resident #6 and reported bathing refusals and equipment limitations |
| Assistant Director of Nursing | ADON | Interviewed regarding bathing preferences and care plan responsibilities for Residents #6 and #99 |
| Director of Nursing | DON | Interviewed regarding bathing preferences and care plan development for Residents #6 and #99 |
| Administrator | Facility Administrator | Interviewed regarding bathing preference assessments and care plan oversight |
| MDS Nurse 1 | MDS Nurse | Responsible for completing comprehensive care plans and updating care plans as needed |
| MDS Nurse 2 | MDS Nurse | Responsible for residents' care plans and updating care plans upon new concerns |
| Licensed Clinical Social Worker | LCSW | Provided psychosocial assessment and weekly visits for Resident #23 |
| Family Member | Certified Nurse Aide | Reported observations and concerns regarding Resident #99's pressure injury care |
| Wound Care Nurse Practitioner | NP | Provided wound care evaluation and treatment recommendations for Resident #99 |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 20, 2024
Visit Reason
Routine state inspection survey of Bradford Heights Nursing & Rehabilitation to assess compliance with regulatory requirements including resident rights, grievance policies, PASRR screening, care planning, nutrition, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to honor resident self-determination regarding bathing preferences, failure to follow grievance policy and document grievances, failure to complete required Level II PASRR screening, failure to develop comprehensive care plans for residents' medical and psychiatric needs, failure to notify physician and follow dietician recommendations for significant weight loss, failure to maintain food safety standards in the kitchen, and failure to follow infection control procedures during ophthalmic medication administration.
Deficiencies (7)
F 0561: The facility failed to ensure resident choice in bathing for 1 of 30 residents; Resident #6 was not given showers as preferred due to equipment limitations and staff assumptions.
F 0585: The facility failed to follow its grievance policy for 2 residents; grievances were not documented or resolved per policy, including missing clothing complaints.
F 0645: The facility failed to ensure a required Level II PASRR evaluation was completed for 1 of 2 residents with positive Level I PASRR screening (Resident #23).
F 0656: The facility failed to develop and implement comprehensive care plans for 2 residents; Resident #99 lacked a skin integrity care plan prior to developing a pressure injury and Resident #23 lacked psychiatric care plans.
F 0692: The facility failed to notify the physician and obtain orders for weekly weights as recommended by the dietician for Resident #83, who experienced significant weight loss.
F 0812: The facility failed to store, prepare, and serve food in accordance with professional standards; food items were unlabeled and undated, staff failed to wear beard covers, and gloves were improperly used during food service.
F 0880: The facility failed to follow infection control procedures during ophthalmic medication administration; a Certified Medication Aide administered eye drops without gloves, risking cross-contamination.
Report Facts
Residents sampled: 30
Residents affected: 1
Residents affected: 2
Residents sampled for Level II PASRR: 2
Residents affected: 1
Residents affected: 2
Weight loss percentage: 5.98
Weight loss in pounds: 3.8
Residents affected: 90
Facility total residents: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA 2 | Certified Medication Aide | Named in infection control deficiency for administering eye drops without gloves |
| Administrator | Interviewed regarding grievance policy and bathing preferences | |
| Director of Nursing | DON | Interviewed regarding care plans, PASRR, weight loss, and infection control |
| Assistant Director of Nursing | ADON | Interviewed regarding grievance policy, weight loss, and care plans |
| Social Services Director | SSD | Facility grievance official interviewed about grievance process |
| Registered Dietician | RD | Provided recommendations for weekly weights for Resident #83 |
| Licensed Clinical Social Worker | LCSW | Interviewed regarding Resident #23's psychiatric status |
| Head Cook | Interviewed regarding food labeling and storage | |
| Regional Certified Dietary Manager | CDM | Interviewed regarding food safety and staff practices |
| Unit Manager 1 | UM | Interviewed regarding ophthalmic eye drop administration procedures |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 27, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to implement comprehensive person-centered care plans, inadequate activities of daily living assistance, improper catheter care, unsafe respiratory treatment administration, inappropriate psychotropic medication use, improper medication labeling, and food storage violations.
Deficiencies (7)
F 0656: The facility failed to implement a comprehensive person-centered care plan with measurable objectives for two residents, resulting in unmet needs related to activities of daily living and catheter care.
F 0677: The facility failed to provide activities of daily living, including shaving and nail care, to one resident who required assistance and requested care.
F 0690: The facility failed to provide appropriate catheter care to three residents, including improper cleaning, failure to maintain drainage bags properly, and failure to apply drain sponges as ordered.
F 0695: The facility failed to ensure safe and appropriate respiratory care when a resident's nebulizer treatment was left running and unattended for an extended period.
F 0758: The facility administered an antipsychotic medication to a resident without an appropriate diagnosis, specifically prescribing Seroquel for anxiety.
F 0761: The facility failed to ensure medications, specifically insulin vials, were labeled with the date opened as required by professional standards.
F 0812: The facility failed to store food properly by not dating items placed in the freezer, violating food safety standards.
Report Facts
Residents sampled: 18
Doses of Seroquel administered: 22
Residents receiving meals: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #4 | Named in failure to provide shaving and nail care to Resident #74 | |
| Licensed Practical Nurse (LPN) #4 | Named in catheter care deficiencies and grooming expectations | |
| Certified Nurse Aide (CNA) #2 | Named in suprapubic catheter care deficiencies for Resident #189 | |
| Registered Nurse (RN) #1/Unit Manager | Named in expectations for catheter care and ADL assistance | |
| Director of Nursing (DON) | Named in multiple interviews regarding care plan, catheter care, medication, and grooming expectations | |
| Advanced Practitioner Registered Nurse (APRN) | Named in interview regarding inappropriate psychotropic medication use for Resident #87 | |
| Kentucky Medication Aide (KMA) #1 | Named in medication labeling deficiency regarding insulin vials | |
| Licensed Practical Nurse (LPN) #5 | Named in medication labeling deficiency regarding insulin vials | |
| Dietary Manager | Named in food storage and labeling deficiency | |
| Certified Nurse Aide (CNA) #1 | Named in failure to provide complete peri care to Resident #37 | |
| Licensed Practical Nurse (LPN) #3 | Named in failure to provide complete peri care to Resident #37 |
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