Bourbon Heights Nursing Home

Inspectors wroteBased on observation, interview, record review, review of Droplet Precautions signage, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions to protect facility residents. Observations on 02/17/2026 and 02/18/2026 revealed staff cleaned a glucometer without donning (putting on) gloves; staff failed to sanitize blood pressure cuffs before using on residents and failed to place them on barriers while contaminated; staff failed to wear appropriate personal protective equipment (PPE) in a resident room designated with Droplet Precautions signage; [...]

Inspectors wroteBased on review of the facility's document and interview, the facility failed to ensure its binding arbitration agreement contained appropriate verbiage granting residents the right to rescind the agreement within 30 days of signing it. This deficient practice had the potential to affect 56 of the facility's current census of 76 residents. Review of a facility provided list of residents who had signed binding arbitration agreements revealed 56 residents had signed binding arbitration agreements. Review of the facility's document Agreement to Resolve Disputes by Mediation and Binding Arbitration, not dated, did not include the explicit verbiage granting residents or representatives the right to rescind the agreement within 30 calendar days of signing it. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple occupancy rooms. Observation of eight dual-occupancy rooms (two residents per room) for Rooms 127, 128, 129, 130, 132, 133, 135 and 138, revealed each room measured less than the required square footage, with rooms measuring anywhere from approximately 17 square feet short (Rooms 127, 128, 129, 130) to approximately 26 square feet short (room [ROOM NUMBER]).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 15 residents sampled. The resident preferred to remain anonymous. Interview with 1 of 15 sampled residents who wished to remain anonymous stated their room was too small.

Inspectors wroteBased on interview, record review, review of the Director of Nursing Services (DON) and Administrator's Job Descriptions, review of the facility's employee agreement for the Administrator, review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, and review of the facility's policies, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the total census of 74 residents. On 05/28/2024, Legionella pneumophila Serogroup 1 Strain (SG1) and Legionella pneumophila Serogroup 2 Strain (SG2-15) were identified at uncontrolled growth levels in the Unit 3 shower. [...]

Inspectors wroteBased on interview, record review, review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, review of the facility's Bylaws, and review of the facility's policies, it was determined the facility's Governing Body failed to ensure the facility's policies were implemented regarding the management and operation of the facility for the total census of 74 residents. On 04/04/2024, Immediate Jeopardy (IJ) was identified in the area of F880 (Infection Control) during an Abbreviated Partial Extended Survey with an exit date of 04/05/2024. The facility submitted a Plan of Correction (POC) for deficiencies, cited on 04/05/2024, alleging substantial compliance on 05/20/2024. However, during the Recertification/Abbreviated Survey concluded on 11/22/2024, it was determined the facility failed to maintain substantial compliance. [...]

Inspectors wroteBased on interview, record review, review of the facility's plan of correction from the 04/05/2024 survey, and review of the facility's policy, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program that developed and implemented appropriate plans of action to correct quality deficiencies. Quality deficiencies were evidenced by the facility's failure to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility was cited for infection control related to legionellosis and their water management system during the 04/05/2024 survey, and the facility submitted a plan of correction to address the deficiency. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's documentation and policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the total census of 74 residents. During the Abbreviated/Partial Extended Survey that concluded on 04/05/2024, Immediate Jeopardy was identified in the area of F880 (Infection Control), with the highest scope and severity (S/S) of an L. The facility alleged substantial compliance on 05/20/2024, however; failed to maintain substantial compliance. Legionella pneumophila SG1 and Legionella pneumophila SG2-15 were identified at uncontrolled growth levels in the Unit 3 shower on 05/28/2024. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the resident's physician of a significant change in the resident's physical status for one of 26 sampled residents, (Resident (R)76). R76 sustained an unwitnessed fall on 05/16/2024 at 1:15 PM, and Registered Nurse (RN) 2 (an agency nurse) notified the Nurse Practitioner (NP), who advised monitoring the resident, with no new orders given. RN2 noted R76 had prolonged elevated blood pressure readings, with systolic readings between 180 and 190 until 7:00 PM. However, RN2 failed to inform the NP of R76's continued elevated blood pressure readings. On 05/17/2024, R76's blood pressure continued to remain elevated, and the resident presented a mental status change which included: lethargy, confusion, and incoherent speech. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to have an effective system in place to ensure residents' Comprehensive Care Plans (CCP's) interventions were implemented when a change of condition occurred for one of 26 sampled residents, (Resident (R)76). Review of the facility's CCP developed for R76 revealed the resident was care planned for hypertension to include interventions to monitor, document, and report to the medical provider any signs and symptoms of headache, confusion, and lethargy. R76 sustained an unwitnessed fall on 05/16/2024 at 1:15 PM, and Registered Nurse (RN) 2 notified the Nurse Practitioner (NP) who advised monitoring the resident. RN2 documented normal neurological (neuro) checks for R76. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to promptly identify and intervene for a change in the resident's condition and ensure the resident received prompt assessment and emergency care for one of 26 sampled residents, (Resident (R)76). R76 sustained an unwitnessed fall on 05/16/2024 at 1:15 PM and Registered Nurse (RN) 2 (an agency nurse) notified the Nurse Practitioner (NP) who ordered continued monitoring of the resident, with no additional orders. RN2's assessments noted R76's neurological (neuro) checks were within normal limits (WNL) and the resident was experiencing prolonged elevated blood pressure (B/P), with systolic readings consistently between 180 and 190 until 7:00 PM. However, RN2 failed to notify the NP about R76's elevated B/P. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and implement a baseline care plan for new residents that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of 26 sampled residents (Resident (R)425). R425 required hemodialysis treatments that included parameters for the resident's vital signs and had a known history of falls. However, the facility failed to implement a baseline care plan upon R425's admission to address his hemodialysis needs and risk for falls.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to review and revise the comprehensive care plan (CCP) for one of 26 sampled residents (Resident (R)76). R76 fell on [DATE], and after having a change in mental status was transferred to the hospital on [DATE], where she was diagnosed with a transient ischemic attack (a brief stroke-like attack). R76 returned to the facility on [DATE]. R76's family requested the resident remain in her room to rest after her hospitalization. However, staff on duty failed to update the CCP to include interventions aimed at preventing future falls or to incorporate the family's request for the resident to rest in her room. R76 sustained another fall on 05/19/2024, resulting in a fracture of the intertrochanteric region of her hip.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one of 26 sampled residents (Resident (R)76). 1. R76 sustained an unwitnessed fall on 05/16/2024 while ambulating from the bathroom to the bed. The resident had a change in mental status and was taken to the local hospital where she was admitted with dysarthria (a speech disorder caused by weak or hard-to-control muscles in the mouth, face or upper respiratory system), prolonged elevated blood pressure, and was also diagnosed with a transient ischemic attack (TIA) (a brief stroke-like attack). The resident returned to the facility from the hospital on [DATE]. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and environment that promoted maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for the total census of 74 residents, which included (Resident (R)3, R6, R9, R21, R41, R55, and R67). On 08/29/2024, and 09/04/2024, the sample result for the Unit 2 shower showed legionella non-pneumophila at poorly controlled growth levels. Staff interviews revealed the facility failed to provide showers for residents starting in early September 2024, due to the showers on Unit 1, Unit 2, and Unit 3 being closed. During that timeframe residents were only offered bed baths. [...]

Inspectors wroteBased on observation, interview, poilcy review, and the facility assessment the facility failed to ensure the licensed nurses and other nursing personnel had the knowledge, competencies and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan. In interview agency staff stated they had not received training or education prior to being assigned to residents' care.

Inspectors wroteBased on observation, interview, and review of facility documentation and it 2024 Facility Assessment, it was determined the facility failed to conduct and document a facility-wide assessment to determine the necessary resources for addressing the the ongoing legionella bacterial contamination in the facility's water system. Additionally, the facility failed to address the volume of agency staffing in its assessment to evaluate its resident population and identify resources essential for provision of the necessary care and services of those residents during day-to-day operations and emergencies.

Inspectors wroteBased on interview and review of facility policy, the facility failed to have systems in place to ensure there were an adequate number of staff always present who were properly trained and/or certified in Cardiopulmonary Resuscitation (CPR) for Healthcare Providers to be able to provide CPR until emergency medical services arrived. The deficient practice had the potential to affect all facility residents who required CPR.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure each resident received food and drinks which were palatable, attractive, and at a safe and appetizing temperature for five of nine sampled residents reviewed for food temperatures (Residents (R)68, R29, R9, R65, and R58). During resident council, residents expressed concerns of their food being served cold when the aides passed their trays. Observation of the lunch meal on 11/20/2024, revealed the beef and noodle entree and vegetable medley were not at an appetizing and acceptable temperature.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure residents were notified of changes to services covered by Medicare and/or Medicaid as soon as possible for one of three sampled residents reviewed for appeal writes (Resident (R)38). R38 received therapeutic services; however, the facility failed to inform the resident in writing of the end date to services or of their right to appeal.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents requiring dialysis services, received those services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of one residents sampled for dialysis services, out of the total sample of 26 residents, (Resident (R)425). The facility failed to ensure there was documented evidence of ongoing assessments of R425's condition and monitoring for complications before and after dialysis treatments was done. The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding R425's dialysis care and services was completed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards. Observation revealed undated, opened medications, found in one of four medication carts, which included laxatives, cough medication, and nasal sprays.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility's census was 76. The facility failed to implement the state's Division of Epidemiology and Health Planning's (DEHP) recommendation as communicated by the Local Health Department (LHD) on 03/21/2024, to use faucet filters (or bottled water) until the facility completed further testing to prevent and control the spread of a water-borne infection with legionella. [...]

Inspectors wroteBased on interview, record review, and review of facility's policy, it was determined the facility failed to ensure residents were free from abuse for four of 24 sampled residents (Residents (R) 3, 4, 5, and 6). 1) On 06/04/2023, staff witnessed R3 strike R4 on the right side while shouting, I told you to move. 2) On 09/05/2023, R4 struck R5 on the cheek while sitting in the lobby, having a conversation. 3) On 10/24/2023, R6 struck R3 on the neck while trying to enter through the door to his room.

Inspectors wroteBased on interview, record review, review of the facility's initial report of abuse and review of the facility's policy, it was determined the facility failed to immediately report alleged abuse to the Administrator and State Agencies within specified timeframes for one of 24 sampled residents (Resident 1 (R1)). R1 reported sexual abuse to staff on 03/19/2024 at 2:48 AM. Staff failed to report the allegation to Administration. Resident #1 again reported sexual abuse to staff on 03/20/2024 at 1:15 PM, and Administration was notified on 03/20/2024 at 2:00 PM.

Inspectors wroteBased on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or staff convenience and that are not required to treat resident's medical symptoms for three (3) of three (3) sampled residents reviewed for physical restraints out of a total of twenty (20) sampled residents (Resident #39, Resident #70 and Resident #85). 1. Resident #39 had current Monthly January 2020 Physician's Orders, for a Lap Buddy when in the wheelchair, which was ordered 12/26/19. However, there was no documented evidence the order included the presence of a medical symptom and how the chair alarm would treat the medical symptom and protect the resident. [...]

Inspectors wroteBased on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for one (1) of three (3) sampled residents for restraints out of a total of twenty (20) sampled residents, (Resident # 70). Review of the Quarterly Minimum Data Set (MDS) Assessment, Section P, dated 12/11/19, revealed the facility assessed Resident #70 as not requiring the daily use of a restraint. However, observations of Resident #70 throughout the survey process revealed daily use of a lap tray/lap buddy that Resident #70 was unable to release/remove without staff intervention.

Inspectors wroteThe facility failed to ensure each resident had a person-centered Comprehensive Care Plan (CCP) developed and implemented to address the resident's medical, physical, mental and psychosocial needs related to use of restraints for two (2) residents of twenty (20); (Resident #19 and Residents # 70). Resident #19's Comprehensive Care Plan was not developed to include the use of Buspar (anti-anxiety medication). Resident #70 Comprehensive Care Plans were not developed to include interventions for restraint potential negative outcomes, potential benefits of restraint use, or assess/attempt reduction or removal of restraints when no longer required to treat the resident's medical symptoms.

Inspectors wroteBased on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for five (05) of twenty (20) residents. (Resident #9 and Resident#10). Resident #9 had fall events on 06/04/19 and 08/15/19; however the CCP was not revised to include interventions status post fall to prevent falls of the same nature based on the facility's investigation. Resident #10, had current Monthly January 2020 Physician's Orders, for Celexa (anti-depressant), dated 10/30/19. [...]