Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highlands Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain a safe, clean, and homelike environment, with surveyors observing unsanitary conditions and disrepair in the 1C Unit, including foul odors, missing toilet seats, and mold. Staff interviews revealed systemic issues in maintenance and housekeeping processes, with a lack of communication and follow-through in addressing concerns. Management acknowledged the importance of maintaining a safe environment but were unaware of the extent of the disrepair.
The facility employed a Cook with a felony burglary conviction and failed to conduct required Nurse Aide Abuse Registry checks for non-clinical staff, contrary to state regulations and facility policies. The Director of Nursing and Administrator acknowledged the oversight, which occurred due to misinterpretation of policies and absence of the HR Director.
The facility failed to notify the Ombudsman of resident transfers to the hospital, as required by policy. Three residents were transferred for various medical reasons, but there was no evidence of notification. Interviews revealed confusion among staff about the responsibility for notifications, and the Ombudsman confirmed not receiving any since May 2021.
A resident with a history of falls and severe cognitive impairment did not receive a perimeter mattress as part of their care plan, despite experiencing multiple falls. The facility's staff, including the LPN, Unit Manager, and DON, failed to ensure the implementation of this intervention, which was only addressed during a survey.
A resident with a history of falls and severe cognitive impairment experienced multiple falls due to the facility's failure to implement a care-planned perimeter mattress. Despite the IDT's decision to use a perimeter mattress for fall prevention, it was not placed on the bed until over a month later during a survey. Observations and staff interviews revealed a lack of awareness and verification of care plan interventions.
The facility failed to provide routine dental care for two residents, both with severe cognitive impairments and dental issues. One resident was last seen by a dentist in April 2023, and the other in August 2023, with no documented annual exams thereafter. Observations noted missing, broken, and decayed teeth, and staff interviews revealed a lack of awareness and follow-through in ensuring annual dental care.
A facility failed to maintain an effective infection control program when an LPN did not change gloves or perform hand hygiene after touching potentially contaminated surfaces before providing catheter care to a resident with a suprapubic catheter. The resident, with severe cognitive impairment and at risk for infection, was not protected by the facility's Enhanced Barrier Precautions. Interviews revealed deficiencies in training and auditing processes for catheter care.
A resident assessed as high risk for wandering and elopement was admitted to a Memory Care Unit but refused to wear a Wanderguard device. Despite this, the facility did not increase supervision or implement alternative safety measures. The resident left the facility unsupervised and returned to their home 85 miles away, highlighting a failure to follow the facility's policy for managing elopement risks.
A resident with vascular dementia and high elopement risk left an LTC facility unsupervised after refusing a Wanderguard. The receptionist, unaware of the resident's status, allowed the exit. The resident was found 85 miles away, having been picked up by a truck driver. Staff interviews revealed a lack of communication and failure to implement alternative interventions, leading to the resident's unsupervised departure and subsequent hospitalization for smoke inhalation.
The facility failed to inform residents of their rights to conduct Resident Council meetings without staff and did not adequately address grievances. Residents were unaware of their rights, and grievances were not resolved or communicated effectively. Staff interviews revealed inconsistencies in handling grievances, contributing to the deficiency.
The facility failed to properly label and store medications, as a vial of Tuberculin PPD was not discarded after 30 days, contrary to policy. Personal items were also found in the medication room. Staff interviews revealed a lack of adherence to medication management policies, with unit managers responsible for audits not effectively enforcing them.
Two residents in the facility were found with call lights out of reach, compromising their ability to alert staff for assistance. One resident, with multiple diagnoses including cerebral infarction, was non-verbal and relied on a communication board, while another resident with Alzheimer's was observed in a wheelchair with the call light inaccessible. Staff interviews confirmed the importance of accessible call systems for resident safety.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of disrepair and unsanitary conditions. During a tour of the 1C Unit, surveyors noted a pervasive foul odor of stale urine throughout the hallway. Specific rooms had issues such as dried urine on the bathroom floor, missing toilet seats, peeling paint, sagging and stained ceiling tiles, and missing baseboards. Additionally, the 1C shower room was found to have fecal matter on the toilet seat and a lawn chair, as well as mold and discoloration on the ceiling tiles. Interviews with staff revealed systemic issues in the maintenance and housekeeping processes. A State Registered Nurse Aide (SRNA) mentioned that maintenance staff were not present during her shift, and work orders were the responsibility of the first shift and management staff. A Licensed Practical Nurse (LPN) noted that while some maintenance had been done, many issues remained unaddressed. The 1C Unit Manager acknowledged the need for more frequent cleaning in certain areas and the importance of addressing maintenance issues to ensure a homelike environment. Further interviews with management, including the Maintenance Director, Admissions Coordinator, Director of Nursing (DON), and Executive Director (ED), highlighted a lack of communication and follow-through in addressing maintenance concerns. The Maintenance Director stated that work orders were being addressed, but the Admissions Coordinator admitted to being distracted during rounds, leading to missed issues. The DON and ED both emphasized the importance of maintaining a safe environment but were unaware of the extent of the disrepair on the 1C Unit. The ED expressed doubt about the duration of the disrepair, despite staff reports indicating long-standing issues.
Failure to Conduct Proper Background and Abuse Registry Checks
Penalty
Summary
The facility failed to comply with Kentucky regulations and its own policies by employing individuals with disqualifying criminal convictions. Specifically, the facility hired a Cook with a felony burglary conviction from 2016, which was flagged during a background check. Despite the facility's policy stating that individuals with such convictions should not be employed, the Cook was hired based on a misinterpretation of the policy regarding a seven-year span for disqualifying criteria. The Director of Nursing Services and the Administrator acknowledged the oversight, with the Administrator admitting that the facility's policy might not align with state regulations. Additionally, the facility did not conduct required Nurse Aide Abuse Registry checks for non-clinical staff, including the Cook, Business Office Manager, and Administrative Assistant, before their employment. This oversight was contrary to the facility's Abuse Prevention Program policy, which mandates such checks to ensure that employees do not have a history of abuse, neglect, or mistreatment. The Director of Nursing and the Regional Vice President of Operations confirmed that these checks were not completed for non-clinical staff, which could potentially allow individuals with a history of abuse to work in the facility. Interviews with facility staff revealed a lack of clarity and adherence to the policies regarding background checks and abuse registry checks. The Director of Nursing and the Administrator both indicated that these checks were the responsibility of the Human Resources department, which was not functioning properly due to the HR Director's absence. This situation led to the Administrator temporarily assuming HR duties, during which the deficiencies occurred. The failure to conduct thorough background and abuse registry checks compromised the facility's ability to ensure a safe environment for residents.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of resident transfers to the hospital, as required by their policy. This deficiency was identified for three residents, each of whom was transferred to the hospital for various medical reasons. Resident R95 was admitted to the facility with Alzheimer's disease and other conditions and was transferred to the hospital after a fall, but there was no evidence that the Ombudsman was notified. Similarly, Resident R107, who had chronic heart and lung conditions, was transferred to the hospital for altered mental status, yet the notification to the Ombudsman was not documented. Resident R23, with a history of diabetes, dementia, and kidney disease, was transferred to the hospital multiple times, but the facility failed to notify the Ombudsman on each occasion. Interviews with facility staff, including the Social Services Director, Regional Nurse Consultant, and Director of Nursing, revealed a lack of clarity and responsibility regarding the notification process. The Executive Director indicated that either social services or medical records were responsible for the notifications, but no evidence of such notifications was found. The Ombudsman confirmed not receiving any notifications since May 2021.
Failure to Implement Comprehensive Care Plan for Fall Prevention
Penalty
Summary
The facility failed to implement the Comprehensive Care Plan (CCP) for a resident identified as at risk for falls. The resident, who was admitted with diagnoses including vascular dementia with agitation, osteoporosis, and a history of falls, experienced a fall from bed on the day of admission. The CCP was updated to include interventions such as keeping the bed in a low position, ensuring the call light was within reach, and utilizing a perimeter mattress. Despite these interventions being documented on the CCP, the perimeter mattress was not implemented until over a month later, during a survey. The resident experienced another fall from bed four days after the initial fall, yet there was no documented evidence that the facility verified the implementation of the care-planned interventions, including the perimeter mattress. Observations made during the survey revealed that the resident's bed did not have a perimeter mattress until the day of the survey. Interviews with facility staff, including the LPN, Unit Manager, DON, and Executive Director, highlighted a lack of awareness and follow-up regarding the implementation of the care plan interventions, which were crucial for preventing further falls and ensuring the resident's safety.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as at risk for falls. The resident, who was admitted with diagnoses including vascular dementia with agitation, osteoporosis, and a history of falls, sustained a fall on the day of admission and was found lying on the floor by her bed. The Interdisciplinary Team (IDT) decided to place a perimeter mattress on the bed to prevent further falls, but this intervention was not implemented. The resident experienced another fall a few days later, again found on the floor beside her bed. Despite the care plan listing a perimeter mattress as an intervention, it was not placed on the bed until over a month later during the survey. Observations during the survey confirmed the absence of the perimeter mattress, and interviews with staff revealed a lack of awareness and verification of the care plan interventions. The Director of Nursing (DON) and Executive Director (ED) described the facility's process for investigating falls, which included assessments and discussions to determine root causes and appropriate interventions. However, there was no documented evidence that the facility verified the implementation of care plan interventions, such as the perimeter mattress, after the resident's falls. The facility's failure to provide the perimeter mattress as care planned contributed to the repeated falls experienced by the resident.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to assist two residents, R87 and R95, in obtaining routine dental care as per their policy. R87, admitted with early onset Alzheimer's disease and other conditions, was last seen by a dentist in April 2023, but there was no documented evidence of an annual dental exam after that date. Despite having a care plan that identified poor dental condition and missing teeth, the facility did not ensure R87 received the necessary routine dental services in 2024. Observations noted R87 was missing teeth but showed no signs of pain while eating. Similarly, R95, who had Alzheimer's disease and other health issues, was last seen by a dentist in August 2023. The resident's care plan noted partial dentition and tooth decay, with a recommendation for routine dental services. However, there was no evidence of an annual dental exam after August 2023. Observations revealed R95 had broken, decayed, and yellowed teeth, and the resident was assessed as having pain in chewing and swallowing. Interviews with facility staff, including the Unit Manager, Social Services Director, Director of Nursing, and Executive Director, revealed a lack of awareness and follow-through in ensuring these residents received their annual dental care in 2024.
Infection Control Breach During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of an LPN during the care of a resident with a suprapubic catheter. The LPN was observed touching potentially contaminated surfaces, such as a privacy curtain and sink faucet handles, while wearing gloves. She then proceeded to perform catheter care on the resident without changing gloves or performing hand hygiene, which is contrary to the facility's infection control policies and CDC guidelines. The resident involved, identified as R75, was admitted with diagnoses including unspecified intellectual disabilities, obstructed and reflux uropathy, and chronic kidney disease. The resident's care plan included Enhanced Barrier Precautions due to the risk of infection related to the suprapubic catheter. Despite these precautions, the LPN did not adhere to proper infection control practices, potentially compromising the resident's safety. Interviews with the facility's Infection Preventionist and Director of Nursing revealed gaps in training and auditing processes for catheter care. The Infection Preventionist acknowledged the lack of annual skills checkoffs and audits for catheter care, while the Director of Nursing noted that ongoing training was conducted via video rather than in-person skills assessments. The Executive Director also emphasized the expectation for staff to follow guidelines, including changing gloves after touching potentially contaminated surfaces.
Failure to Implement Elopement Prevention for High-Risk Resident
Penalty
Summary
The facility failed to develop a baseline care plan for a resident identified as high risk for wandering and elopement. Upon admission, the resident was assessed with a high risk for wandering, scoring 14 on the Wandering/Elopement Risk Scale. Despite this assessment, the facility did not implement a care plan addressing the resident's high risk for elopement, nor did they document interventions to prevent such an event. The resident refused to wear a Wanderguard device, and no alternative interventions were documented or implemented to ensure the resident's safety. The resident, who had diagnoses including alcohol psychosis dementia and vascular dementia with behaviors, was admitted to the facility's Memory Care Unit. The resident expressed a desire to leave the facility and refused the Wanderguard device, yet the facility did not increase supervision or implement other safety measures. The resident eventually exited the facility through the front door and returned to their home, located 85 miles away, without returning to the facility. Interviews with facility staff revealed a lack of communication and action regarding the resident's refusal to wear the Wanderguard device. The MDS Nurse did not increase supervision, and the DNS was not informed of the refusal. The facility's policy required a systematic approach to monitor and manage residents at risk for elopement, which was not followed in this case, leading to the resident's unsupervised departure.
Resident Elopement Due to Inadequate Supervision and Policy Implementation
Penalty
Summary
The facility failed to ensure a safe and supervised environment for Resident #642, who was at high risk for elopement. The resident, admitted on January 5, 2023, with diagnoses including vascular dementia and major depressive disorder, eloped from the facility on January 7, 2023. Despite being assessed as cognitively intact with a BIMS score of 14, the resident was identified as a high risk for elopement with a score of 14 on the Wandering/Elopement Risk Scale. The resident refused to wear a Wanderguard device, and the facility did not implement alternative interventions to address the high risk of elopement. On the day of the incident, the resident exited the facility through the front door when the receptionist, unaware of the resident's status, opened the door. The resident was later found 85 miles away at their home, having been picked up by a truck driver. The facility's investigation revealed that the resident had left the facility without authorization, and the staff failed to monitor and supervise the resident adequately. The receptionist did not refer to the wandering notebook, which contained information about residents at risk for elopement. Interviews with staff indicated a lack of communication and awareness regarding the resident's risk and refusal to wear a Wanderguard. The DNS was not informed of the refusal, and no additional interventions were initiated. The facility's policies on elopement and wandering were not effectively implemented, leading to the resident's unsupervised departure and subsequent admission to an acute care facility for smoke inhalation after starting a fire at their home.
Failure to Inform Residents of Rights and Address Grievances
Penalty
Summary
The facility failed to ensure that residents were informed of their rights to conduct Resident Council meetings without staff presence and that visitors or guests could attend only by invitation. This deficiency was identified through observations, interviews, and record reviews, revealing that seven out of eight residents attending the meetings were not aware of their rights. The residents expressed that they were not informed about their ability to hold meetings independently, and the Resident Council President was also unaware of this right. Additionally, the facility did not adequately address and follow up on grievances raised during Resident Council meetings. Residents reported that their grievances were not resolved, and there was a lack of communication regarding the status or outcome of their concerns. The facility's policies required prompt efforts to resolve grievances and to keep residents informed, but these procedures were not followed, as evidenced by the residents' testimonies and the facility's own admissions. Interviews with facility staff, including the Activities Director, Social Services Director, Director of Nursing Services, and Executive Director, revealed inconsistencies in the grievance handling process. Staff members acknowledged that grievances were not always logged, communicated, or resolved in a timely manner. The facility's failure to utilize a Resident Council response form and to inform residents of their rights contributed to the deficiency, leaving residents without the necessary knowledge to exercise their rights and without resolution to their grievances.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that all drugs and biological agents were properly labeled and stored according to accepted professional principles. During an inspection of the Unit 1B medication room, a vial of Tuberculin Purified Protein Derivative (PPD) was found to have been opened on 02/12/2024 and not discarded after thirty days, as required by both the facility's policy and the manufacturer's guidelines. Additionally, personal items, including a pink jacket and a pink polka-dotted bag, were found on the counter on top of the pharmacy medication return tote, which is against the facility's policy that medication storage areas should be free of clutter and used solely for medication storage. Interviews with staff revealed a lack of awareness and adherence to the facility's medication management policies. The Unit Manager, RN #7, admitted to not knowing the discard timeline for the opened PPD vial and acknowledged that the inventory of the medication room was not regularly checked for expired or discontinued medications. The Director of Nursing Services and the Executive Director confirmed that unit managers were responsible for weekly audits of medication rooms and carts, and that personal items should not be stored in these areas. However, the oversight and enforcement of these responsibilities were lacking, leading to the observed deficiencies.
Inaccessible Call System for Residents
Penalty
Summary
The facility failed to ensure that the call system was accessible to residents while in their bed, chair, or other sleeping accommodations for two of the seventy-five sampled residents. Resident #22, who was admitted with multiple diagnoses including cerebral infarction and vascular dementia, was observed with a call light attached to the wall behind the head of the bed, out of reach. Despite being non-verbal, Resident #22 could communicate using a communication board, indicating the need for accessible call systems to alert staff for assistance. Similarly, Resident #76, admitted with Alzheimer's and severe cognitive impairment, was observed sitting in a wheelchair with the call light also out of reach. During interviews, both a State Registered Nurse Aide and a Licensed Practical Nurse acknowledged the importance of having call lights within reach for resident safety. The Director of Nursing Services and the Executive Director both emphasized the necessity of call lights being accessible to residents to ensure their needs are met and to allow them to alert staff when help is needed.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nazareth Home | 0.6 mi | ★★★★★ | 0 | 0 |
| Eastway Health & Rehabilitation | 0.9 mi | ★★★★★ | 18 | 0 |
| Little Sisters Of The Poor | 1.2 mi | ★★★★★ | 0 | 0 |
| Kindred Hospital - Louisville | 1.4 mi | ★★★★★ | 3 | 0 |
| Cherokee Park Rehabilitation | 1.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.