Inspection Reports for Highlands Nursing and Rehabilitation
1705 STEVENS AVENUE, LOUISVILLE, KY, 40205
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 28, 2025, found deficiencies related to the facility’s environment, staffing, care planning, dental services, infection control, and resident safety. Earlier inspections were not provided for comparison, so broader patterns cannot be determined from the available information. Inspectors cited issues including maintenance problems, employment of staff with disqualifying backgrounds, inadequate notice before resident transfers, incomplete care plans, lack of dental care, and insufficient infection prevention measures. There were no complaint investigations or enforcement actions listed in the available reports. Without prior inspection data, it is unclear whether these findings represent a new or ongoing situation.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Abbreviated Survey
Census: 143
Deficiencies: 7
Feb 28, 2025
Visit Reason
A Recertification and Abbreviated Survey was conducted to investigate multiple facility IDs from 02/24/2025 to 02/28/2025.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 Subpart B, with deficiencies cited at the highest Scope and Severity of an 'E'. Issues included failure to provide a safe, clean, comfortable, and homelike environment, failure to ensure employment of staff without adverse actions, failure to provide notice requirements before transfer or discharge, failure to develop and implement comprehensive care plans, failure to provide routine dental services, and failure to maintain infection prevention and control.
Severity Breakdown
E: 1
D: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide a safe, clean, comfortable, and homelike environment including maintenance and housekeeping issues such as foul odors, peeling paint, missing toilet seats, mold, and damaged baseboards. | E |
| Failure to ensure employment of individuals with adverse actions or disqualifying criminal convictions. | D |
| Failure to provide proper notice requirements before transfer or discharge of residents. | D |
| Failure to develop and implement comprehensive, person-centered care plans for residents. | D |
| Failure to provide routine and emergency dental services to residents. | D |
| Failure to establish and maintain an infection prevention and control program. | D |
| Failure to ensure free of accident hazards and adequate supervision and assistive devices to prevent accidents. | D |
Report Facts
Survey Census: 143
Sample Size: 29
Supplemental Resident: 65
Employees with disqualifying background: 3
Residents reviewed for falls: 29
Residents reviewed for accident hazards: 29
Residents reviewed for dental care: 7
Residents reviewed for comprehensive care plan: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)4 | Stated maintenance issues and care plan importance during interviews | |
| State Registered Nurse Aide (SRNA)16 | Reported missing baseboard and maintenance issues during interview | |
| Maintenance Director | Addressed maintenance issues and participated in corrective actions | |
| Housekeeping Supervisor | Involved in cleaning and sanitizing deficient areas and education | |
| Admissions Coordinator | Reported daily rounds and maintenance observations | |
| IC Unit Manager | Reported on maintenance and environmental issues | |
| Director of Nursing (DON) | Director of Nursing | Provided interviews on rounds, maintenance, and education |
| Executive Director (ED) | Reported on management rounds and maintenance follow-up | |
| Cook | Found to have disqualifying felony conviction and no abuse registry checks | |
| Human Resource Director | Handled abuse registry checks and employee audits | |
| Medical Records Nurse | Notified State Long-Term Care Ombudsman of transfers | |
| Social Services Director | Responsible for notifying Ombudsman of resident transfers | |
| Regional Nurse Consultant | Reported lack of notification to Ombudsman | |
| Director of Nursing Services | Provided education and audits related to care plans and dental services | |
| Licensed Practical Nurse (LPN)1 | Observed infection control deficiencies | |
| Infection Preventionist (IP) | Provided education and oversight of infection prevention program | |
| Social Services Director (SSD) | Responsible for dental care orders and consents | |
| Executive Director (ED) | Reported on dental care referrals and audits |
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