Christian Heights Nursing And Rehabilitation Cente

F-F586, which includes the right to a safe, clean, comfortable, and homelike environment.

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. Resident R48 and Resident 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 Resident 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. Resident R25 and Resident 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 Resident 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 Resident R40 was cognitively intact, based on a BIMS score of 14/15.

c. Resident R110 and Resident 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. Resident R43 and Resident R10's room had broken tiles in the floor.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 185338 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 f. Resident R19 and Resident R47's room had chipped paint on the wall. There were yellow/brown stains down the wall and onto the floor under the sink. A corner of the door threshold was crumbling and there was a debris pile in the Level of Harm - Minimal harm or floor. potential for actual harm g. The wall in Resident R38's room had paint that was coming off from where a wallpaper boarder had been painted Residents Affected - Many over. The outside environment was visible around the heating/air conditioning unit.

h. Resident R35's room had a wall corner that was crumbling and there was a pile of debris in the floor. The shower for this room was missing six tiles, four of which were stacked to the side. The caulking around the sink was discolored brown and was peeling away from the sink.

i. Resident R7 and Resident R22 had missing tile in the bathroom.

j. The handrail outside of the Director of Nursing's (DON) office had a pile of dust/debris build up. The pile was still present at approximately 3:30pm on 02/21/2025.

k. Food particles on the floor and on the tops of the tables in the dining room.

Additional observations made on 02/21/2025 at approximately 3:15 PM revealed the following:

l. Resident R26's bathroom flooring around the base of the toilet was caked with in a reddish/brown substance.

m. Resident R33's room had chipped paint on the walls. The caulking around the sink was discolored brown and had a substance built up on it.

n. Observation on 02/18/2025 at 11:05 AM revealed the toilet in the bathroom shared by Resident R19, Resident R47, Resident R50, and Resident R46 was not functioning or in good repair. The toilet was filled with a brown/yellow substance, and there was

a strong odor indicative of feces and urine. There was also a yellow dried substance on the toilet seat, indicative of urine. The toilet seat was broken and was hanging sideways from the toilet. A plumber's snake and plunger with duct tape were present. On 02/20/2025 at 10:05 AM, the snake and plunger were gone, but

the toilet was still filled with a brown/yellow substance which continued to smell strongly of feces and urine.

In an interview on 02/20/2025 at 11:00 AM with Housekeeper (H) 1, she stated she is responsible for cleaning resident rooms daily. She cleans bathrooms every day and stated the shared bathroom of Resident R19, Resident R47, Resident R50 and Resident R46 has a problem of stopping up. H1 stated she had reported this to her housekeeping manager and thought she reported it to maintenance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 185338 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 In an interview on 02/20/2025 at 5:00 PM with the Maintenance Director, regarding the bathroom for Resident R19, Resident R47, Resident R50, and Resident R46, he stated, It's a brand-new toilet. We are having an issue with a resident continuously Level of Harm - Minimal harm or stopping up a toilet. The Maintenance Director added that he was trying to get another type of toilet that will potential for actual harm help prevent that from happening, but it had not yet been ordered. The Maintenance Director stated that Currently it must be unstopped one to two times a day. It has gotten to the point that work orders are not Residents Affected - Many being put in because I know I must check it every day. Regarding the condition of the walls, floors, and paint throughout the facility, he stated it was his preference to complete all repairs in one room before moving to another Further interview revealed that at this point, only one room had received all its necessary repairs.

The Maintenance Director indicated that repairs needed to be made relative to the observed gouges in the walls, adding he had plans to place a vinyl material on the walls of the resident rooms to a height of approximately four to five feet from the floor. The Maintenance Director added that once funding was available, he planned to continue renovating room by room. However, until that time, nothing was being done to repair the walls/paint. He stated floor tiles were being purchased a few at a time to place in areas that were missing tile. The Maintenance Director added, They may not match when we get them, but it will be better than nothing.

During an interview with the Environmental Services Director (ESD) on 02/21/2025 at 3:20 PM, she provided

the Project and Deep Clean Calendars, stating that each room was scheduled for a monthly deep clean. Per

the ESD, the monthly deep clean of each room consists of removing the curtains and washing them, cleaning the blinds, removing everything from the walls and cleaning the walls, cleaning under the furniture, and removing bedding and mattress from the bed frame for cleaning.

During an interview on 02/21/2025 at approximately 5:00 PM, the Administrator stated his expectation was for the facility to create a clean, comfortable, and homelike environment for the residents. Per the Administrator, this expectation included cleanliness as well as physical appearance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 185338