Inspection Reports for
Highlands Nursing and Rehabilitation
1705 STEVENS AVENUE, LOUISVILLE, KY, 40205
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than Kentucky average
Kentucky average: 4.7 deficiencies/year
Deficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 7
Date: Feb 28, 2025
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including environment safety, employee background checks, resident care plans, dental services, and infection control.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, ensuring proper employee background checks, providing timely notification of resident transfers to the Ombudsman, implementing comprehensive care plans and fall prevention interventions, assisting residents with routine dental care, and maintaining infection prevention and control practices.
Deficiencies (7)
F 0584: The facility failed to maintain a safe, clean, and homelike environment with issues including foul odors, dried urine, peeling paint, sagging and stained ceiling tiles, missing toilet seats and paper holders, mold, and exposed damaged walls in multiple bathrooms and common areas.
F 0606: The facility employed individuals with disqualifying criminal convictions and failed to complete Nurse Aide Abuse Registry checks for certain employees prior to employment.
F 0623: The facility failed to provide timely notification to the resident, resident representative, and Ombudsman before transfer or discharge for 3 sampled residents.
F 0656: The facility failed to implement the care plan intervention of a perimeter mattress for a resident at risk for falls, resulting in repeated falls without the intervention in place.
F 0689: The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident at risk for falls, as the perimeter mattress was not in place after two falls.
F 0791: The facility failed to assist residents in obtaining routine dental care for 2 sampled residents, with no documented annual dental exams in 2024.
F 0880: The facility failed to maintain an infection prevention and control program by not following proper glove use and hand hygiene during suprapubic catheter care, risking infection transmission.
Report Facts
Residents sampled: 29
Employees with disqualifying convictions: 3
Residents affected: 3
Residents with dental care deficiencies: 2
Residents with catheter infection risk: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Registered Nurse Aide (SRNA)16 | Interviewed regarding maintenance issues and work order responsibilities | |
| Licensed Practical Nurse (LPN)4 | Interviewed regarding maintenance work orders and resident care | |
| 1C Unit Manager | Interviewed regarding maintenance issues and resident care plan implementation | |
| Maintenance Director | Interviewed regarding building upkeep and maintenance work orders | |
| Admissions Coordinator | Interviewed regarding daily rounds and maintenance observations | |
| Director of Nursing (DON) | Interviewed regarding care plan implementation, employee background checks, and infection control expectations | |
| Executive Director (ED) | Interviewed regarding facility oversight, maintenance, employee hiring, and infection control | |
| Social Services Director (SSD) | Interviewed regarding dental care coordination and Ombudsman notifications | |
| Infection Preventionist (IP) | Interviewed regarding infection control policies and catheter care education | |
| Licensed Practical Nurse (LPN)1 | Observed providing catheter care with improper glove use |
Inspection Report
Abbreviated Survey
Census: 143
Deficiencies: 7
Date: 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.
Deficiencies (7)
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.
Failure to ensure employment of individuals with adverse actions or disqualifying criminal convictions.
Failure to provide proper notice requirements before transfer or discharge of residents.
Failure to develop and implement comprehensive, person-centered care plans for residents.
Failure to provide routine and emergency dental services to residents.
Failure to establish and maintain an infection prevention and control program.
Failure to ensure free of accident hazards and adequate supervision and assistive devices to prevent accidents.
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 |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 23, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding residents' rights to organize and participate in Resident Council meetings without staff present, and to assess the facility's handling of resident grievances and elopement risks.
Complaint Details
The complaint investigation focused on residents' rights to conduct Resident Council meetings without staff presence and the facility's response to resident grievances. It also investigated the care and supervision of a resident at high risk for elopement who left the facility without authorization and was not returned. The investigation included interviews with residents, staff, and family members, and review of policies and records.
Findings
The facility failed to inform residents of their rights to conduct Resident Council meetings without staff present and did not adequately address or communicate resolutions of resident grievances. Additionally, the facility failed to develop a baseline care plan and increase supervision for a high-risk resident who eloped and did not return. Medication storage and call light accessibility issues were also identified.
Deficiencies (5)
F 0565: The facility failed to inform residents of their right to hold Resident Council meetings without staff present and did not address or communicate resolutions of grievances for seven of eight sampled residents.
F 0655: The facility failed to develop a baseline care plan for a high-risk resident related to elopement and did not increase supervision after the resident refused a Wanderguard device, resulting in the resident eloping and not returning.
F 0689: The facility failed to ensure a safe and supervised environment to prevent elopement for a high-risk resident who eloped and was found 85 miles away, with inadequate implementation of elopement prevention policies.
F 0761: The facility failed to ensure all drugs and biologicals were properly labeled and stored; an opened vial of Tuberculin PPD was not discarded after 30 days and personal items were found in the medication room.
F 0919: The facility failed to ensure call lights were accessible to residents in bed or chair for two sampled residents, with call lights attached out of reach behind the beds.
Report Facts
Residents attending Resident Council meeting: 8
Residents with unresolved grievances: 7
Resident elopement distance: 85
Opened vial expiration days: 30
Residents at risk for elopement: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #101 | Resident Council President | Interviewed regarding Resident Council meetings and grievances |
| Activities Director | Activities Director | Interviewed about Resident Council meetings and grievance follow-up |
| Social Services Director | Social Services Director | Interviewed about grievance process and communication |
| Director of Nursing Services | Director of Nursing Services | Interviewed about Resident Council grievance process and expectations |
| Executive Director | Executive Director | Interviewed about Resident Council rights and grievance resolution expectations |
| Registered Nurse #4 | Registered Nurse | Interviewed about Resident #642 supervision and elopement |
| Director of Nursing Services | Director of Nursing Services | Interviewed about Resident #642 elopement and supervision |
| Executive Director | Executive Director | Interviewed about expectations for resident care and supervision |
| Registered Nurse #7 | Unit Manager | Interviewed about medication storage and expired medication removal |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about personal items in medication room |
| Registered Nurse #2 | Unit Manager | Interviewed about medication room audits and expired medication removal |
| Director of Nursing Services | Director of Nursing Services | Interviewed about medication room maintenance and expired medication removal |
| Executive Director | Executive Director | Interviewed about medication storage policies |
| Medical Director | Medical Director | Interviewed about elopement incident and staff education |
| Receptionist #1 | Receptionist | Interviewed about allowing Resident #642 to exit facility |
| State Registered Nurse Aide #4 | State Registered Nurse Aide | Interviewed about Resident #642 behavior and elopement |
| State Registered Nurse Aide #6 | State Registered Nurse Aide | Interviewed about call light importance |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about call light importance |
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Jan 11, 2020
Visit Reason
Annual recertification survey and complaint investigation of Highlands Nursing and Rehabilitation.
Complaint Details
Resident #57 filed complaints regarding lack of timely incontinent care, missed showers, and failure to use BIPAP machine as ordered. Resident #493 complained of delayed medication administration causing anxiety.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, grievance resolution, environment cleanliness and maintenance, resident transfer notifications, care planning, medication administration, infection control, staff training, food safety, and respiratory care.
Deficiencies (17)
F 0550: Facility failed to treat residents with dignity by serving beverages in disposable plastic cups instead of regular cups on four nursing units.
F 0565: Facility failed to promptly address and resolve grievances of resident groups concerning care issues including call light response, medication availability, and staff responsiveness.
F 0584: Facility failed to maintain a safe, clean, and homelike environment with observations of stained ceiling tiles, broken furniture, soiled shower rooms, and dirty dining areas.
F 0623: Facility failed to notify the Ombudsman and resident or responsible party timely of resident transfers and discharges, and failed to document transfer information.
F 0625: Facility failed to provide written notice of bed-hold policy to residents and representatives upon hospital transfers for two residents.
F 0656: Facility failed to develop and implement complete care plans for six residents, including failure to administer pain medication as ordered, implement fall prevention interventions, and provide respiratory services as planned.
F 0677: Facility failed to provide timely assistance with activities of daily living for Resident #57, resulting in resident being left in soiled briefs and not receiving scheduled showers.
F 0684: Facility failed to provide medications in a timely manner for Resident #493, resulting in delayed administration of critical medications for over 22 hours.
F 0692: Facility failed to monitor weight loss and provide dietary supplements as recommended for Resident #107, with inconsistent weight monitoring and supplement administration.
F 0695: Facility failed to provide respiratory services as ordered for Resident #57 by not applying BIPAP machine during daytime naps and night sleep times.
F 0697: Facility failed to ensure effective pain management for Residents #34 and #101, with multiple missed doses of pain medication and lack of pain assessments.
F 0700: Facility failed to ensure safe use and maintenance of Resident #91's bed rails, which were broken and partially resting on the floor, creating a fall hazard.
F 0730: Facility failed to ensure seven Certified Nurse Aides completed required annual 12 hours of continuing education and annual evaluations.
F 0760: Facility failed to ensure nursing staff obtained physician orders before administering medications, including Heparin flush without order for Resident #110.
F 0761: Facility failed to ensure medications were stored securely in medication rooms and carts, with unlocked medication rooms and unattended medication carts observed.
F 0812: Facility failed to ensure food safety including improper storage of open and undated food, failure to calibrate thermometers, dish machine not reaching sanitizing temperature, and uncovered food served on meal trays.
F 0880: Facility failed to implement an effective infection control program related to staff not washing hands between glove changes during medication administration.
Report Facts
Missed pain medication doses: 9
Missed pain medication doses: 20
Weight loss (pounds): 14
Scheduled showers missed: 6
CNA continuing education hours missing: 7
Medication cart unlocked observations: 3
Dish machine temperature: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Administered Heparin flush without order, failed to flush PICC with saline |
| LPN #4 | Licensed Practical Nurse | Noted broken bed rail, failed to report immediately |
| CNA #2 | Certified Nursing Assistant | Notified about broken bed rail but did not submit work order |
| CNA #4 | Certified Nursing Assistant | Reported broken bed rail for 4 months |
| CMT #2 | Certified Medication Technician | Left controlled meds unattended on medication cart |
| LPN #15 | Licensed Practical Nurse | Discussed medication storage and CE requirements |
| Dietary Manager | Dietary Manager | Responsible for food safety and dish machine monitoring |
| Administrator | Facility Administrator | New administrator aware of deficiencies and expectations |
| Director of Nursing | Director of Nursing | New DON, identified medication and care plan issues |
| Staff Development Coordinator | Staff Development Coordinator | Newly hired, no prior CE tracking available |
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