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Complaint Investigation

Christian Heights Nursing And Rehabilitation Cente

February 21, 2025 · Pembroke, KY · 124 West Nashville Street
Citations 1
CMS Rating 1/5
Beds 60
Provider ID 185338
Healthcare Facility
Christian Heights Nursing And Rehabilitation Cente
Pembroke, KY  ·  View full profile →
Inspection Summary

Christian Heights Nursing and Rehabilitation Cente in Pembroke, KY — inspection on February 21, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF586
Minimal harm or floor. Many over. The outside environment was visible around the heating/air conditioning unit. affected

Review of the facility policy, Homelike Environment Standard of Practice, last reviewed 10/2020, revealed the facility shall maximize, to the extent possible, characteristics of the facility to reflect a personalized, homelike setting.

This shall include cleanliness and order and pleasant, neutral scents.

Observation of the facility during an initial tour on 02/18/2025, beginning at 10:55 AM. revealed the following:

a. R48 and R55's room had chipped paint and gouge marks on the door and doorframe.

The rubber baseboard was pulled away from the wall, and there were yellow/orange stains on the floor.

During an interview with R48 on 02/21/2025 at 4:00 PM, he stated it would be nice if the peeling paint and poor condition of the walls and floor was repaired.

Review of a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/2024 revealed the resident was cognitively intact, based on a Brief Interview for Mental Status (BIMS) score of 15/15.

b. R25 and R40's room had a hole in the bathroom door.

The baseboard was pulled away from the wall.

The walls had a large area of chipping paint. In an interview on 02/21/2025 at 4:05 PM with R40, she stated she would like to see it fixed, referring to the condition of the walls, floors, and paint.

Review of an MDS, with an ARD of 02/15/2025, revealed R40 was cognitively intact, based on a BIMS score of 14/15.

c. R110 and R16's room had a strong odor of urine.

The floor had broken tile and was uneven.

Food particles were noted on the floor.

d. R43 and R10's room had broken tiles in the floor.

e. R42 and R49's room had multiple broken and missing tiles in the floor.

185338

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 185338 B.

Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Christian Heights Nursing and Rehabilitation Cente 124 West Nashville Street Pembroke, KY 42266

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Pembroke, KY, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Christian Heights Nursing and Rehabilitation Cente or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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