Inspection Reports for
Christian Heights Nursing and Rehabilitation Center
124 WEST NASHVILLE ST, PEMBROKE, KY, 42266
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
93% occupied
Based on a November 2025 inspection.
Occupancy rate over time
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 0
Date: Nov 25, 2025
Visit Reason
An Abbreviated Survey was conducted to assess compliance with 42 CFR 483 subpart B at Christian Heights Nursing and Rehabilitation Center.
Findings
The facility was found to be in substantial compliance with no deficiencies issued related to KY2673655 and KY2609335.
Report Facts
Sample Size: 3
Supplemental Residents: 2
Inspection Report
Abbreviated Survey
Census: 57
Deficiencies: 2
Date: Feb 21, 2025
Visit Reason
A Standard Recertification and an Abbreviated Survey was conducted on 02/21/2025 to assess the facility's compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with federal regulations, with deficiencies issued related to food safety and environmental conditions. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, and failed to provide a safe, functional, sanitary, and comfortable environment for residents.
Deficiencies (2)
Food items were not sealed and/or covered to prevent contamination; opened food items were not dated; food maintained on ice exceeded the required 41-degree Fahrenheit limit, potentially affecting 56 residents.
Facility failed to provide a safe, functional, sanitary, and comfortable environment for 20 of 57 residents; issues included broken/missing floor tiles, peeling paint, unsanitary commodes, and malfunctioning toilets.
Report Facts
Survey Census: 57
Sample Size: 16
Supplemental Residents: 1
Temperature limit: 41
Residents potentially affected: 56
Temperature of hot foods: 186
Temperature of cold foods: 41
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook 1 | Interviewed regarding food safety practices and labeling | |
| Cook 2 | Interviewed regarding food safety practices and labeling | |
| Dietary Manager | Interviewed and provided education on food safety and storage | |
| District Dietary Manager | Interviewed regarding food safety expectations and monitoring | |
| Administrator | Interviewed regarding food safety and environmental maintenance expectations | |
| Maintenance Director | Interviewed regarding bathroom repairs and maintenance issues | |
| Housekeeping Supervisor | Provided education on housekeeping and maintenance issues | |
| Housekeeper (H1) | Interviewed regarding cleaning responsibilities and bathroom issues | |
| Environmental Services Director | Interviewed regarding cleaning schedules and deep cleaning |
Inspection Report
Routine
Census: 57
Deficiencies: 2
Date: Feb 21, 2025
Visit Reason
The inspection was conducted to assess compliance with food safety standards and the overall safety, cleanliness, and comfort of the nursing home environment.
Findings
The facility failed to properly store, prepare, and serve food according to professional standards, with uncovered and improperly dated food items and cold foods held above safe temperatures. Additionally, multiple resident rooms and bathrooms had broken floor tiles, peeling paint, unsanitary conditions, and maintenance issues, compromising a safe and homelike environment.
Deficiencies (2)
F0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Food items were uncovered, not sealed, and not dated as required. Cold food items exceeded the required 41-degree Fahrenheit temperature limit during lunch service.
F0921: The facility failed to provide a safe, clean, and comfortable environment for residents. Resident rooms had broken or missing floor tiles, peeling paint, holes in walls, and unsanitary commodes in poor repair.
Report Facts
Residents affected: 56
Residents affected: 20
Census: 57
Inspection Report
Routine
Census: 57
Deficiencies: 2
Date: Feb 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with food safety standards and the overall safety, cleanliness, and comfort of the nursing home environment.
Findings
The facility failed to properly store, prepare, and serve food according to professional standards, with uncovered food items, improper labeling, and cold foods held above safe temperatures, potentially affecting 56 residents. Additionally, multiple resident rooms and shared bathrooms were found to have broken floor tiles, peeling paint, unsanitary conditions, and maintenance issues, impacting 20 residents.
Deficiencies (2)
F0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Food items were uncovered, unlabeled, and cold foods exceeded the required 41-degree Fahrenheit temperature limit, risking contamination for 56 residents.
F0921: The facility failed to provide a safe, clean, and comfortable environment for 20 residents. Resident rooms had broken or missing floor tiles, peeling paint, holes in walls, and unsanitary commodes in poor repair.
Report Facts
Residents affected: 56
Residents affected: 20
Resident census: 57
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 9, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident where Resident #1 exited the facility without staff knowledge, posing immediate jeopardy to resident health or safety.
Complaint Details
The complaint investigation was triggered by an elopement incident on 12/31/19 where Resident #1 exited the facility unnoticed and was found across the road. Immediate Jeopardy was determined to exist on 12/31/19 and was removed on 01/07/2020 after corrective actions and monitoring were implemented.
Findings
The facility failed to have an effective system to provide adequate supervision to prevent elopement of a high-risk resident, resulting in the resident leaving the facility unnoticed and walking across a busy highway. Immediate Jeopardy was identified but later removed after corrective actions were implemented and verified.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent elopement of Resident #1, who exited the facility without staff knowledge and walked across a busy highway. This failure caused immediate jeopardy to resident health or safety.
Report Facts
Elopement Risk Assessment score: 50
Elopement drills: 10
Temperature: 48
Speed limit: 35
Dates of corrective actions: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Conducted head to toe assessment of Resident #1 after elopement and checked wanderguard function. |
| DON | Director of Nursing | Led interviews, updated care plans, and participated in corrective action implementation and audits. |
| Administrator | Oversaw corrective actions, verified alarm system functionality, and participated in QAPI meetings. | |
| MDS Coordinator | Completed Elopement Risk Assessments for Resident #1 and other residents. | |
| Social Services Director | Participated in audits, care plan reviews, and corrective action implementation. | |
| Maintenance Director | Checked door alarms and wanderguard system functionality. | |
| ADON | Assistant Director of Nursing | Provided assessment and care after Resident #1 returned from elopement. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 1, 2018
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan development and implementation requirements, specifically regarding the failure to revise a resident's comprehensive care plan to address medical conditions.
Findings
The facility failed to develop and implement a person-centered comprehensive care plan for one resident to address diagnoses of Pneumonia, COPD, and CHF. Interviews revealed that care plans were not updated as required, though staff stated physician orders were followed.
Deficiencies (1)
F 0657: The facility failed to revise the comprehensive care plan to address Resident #26's Pneumonia, COPD, and CHF diagnoses with measurable objectives and timeframes. The care plan was not updated to reflect individualized interventions to minimize re-hospitalization risk.
Report Facts
Residents sampled: 14
Residents affected: 1
MDS BIMS score: 10
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