Safety Report: Bourbon Heights Nursing Home
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
8Immediate jeopardy citations (severity J–L)
3Actual harm citations (severity G–I)
4Requirements cited on more than one inspection
L
Government finding: Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F880
L
Government finding: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Tag F867
L
Government finding: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Administration Deficiencies · Tag F837
L
Government finding: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · Tag F835
J
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
J
Government finding: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Tag F656
J
Government finding: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F580
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · Tag F657
G
Government finding: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · Tag F655
L
Government finding: Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F880
Citations by topic
3Abuse, neglect & exploitation
3Infection control
1Medications & pharmacy
1Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (4) than in the cycle before (18).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide and implement an infection prevention and control program. (F880) | 3 | February 19, 2026; November 22, 2024; April 5, 2024 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | February 19, 2026; November 22, 2024 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 2 | November 22, 2024; January 10, 2020 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 2 | November 22, 2024; January 10, 2020 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| November 22, 2024 | Payment Denial | Payment denial for 31 days, starting December 25, 2024 |
| November 22, 2024 | Fine | $41,040 |
| April 5, 2024 | Payment Denial | Payment denial for 16 days, starting May 4, 2024 |
| April 5, 2024 | Fine | $16,801 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
February 19, 2026 — 4 citations
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected June 26, 2026
E
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F912
E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F847 · corrected June 26, 2026
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected April 17, 2026
November 22, 2024 — 18 citations (includes serious)
L
Provide and implement an infection prevention and control program.
Immediate jeopardy to resident health or safety · Widespread · Infection Control Deficiencies · F880 · complaint · corrected January 25, 2025
L
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Immediate jeopardy to resident health or safety · Widespread · Administration Deficiencies · F867 · complaint · corrected January 25, 2025
L
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Immediate jeopardy to resident health or safety · Widespread · Administration Deficiencies · F837 · complaint · corrected January 25, 2025
L
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Immediate jeopardy to resident health or safety · Widespread · Administration Deficiencies · F835 · complaint · corrected January 25, 2025
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected January 25, 2025
J
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Immediate jeopardy to resident health or safety · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected January 25, 2025
J
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Immediate jeopardy to resident health or safety · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected January 25, 2025
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected January 25, 2025
G
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected January 25, 2025
G
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Actual harm to a resident (not immediate jeopardy) · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · corrected January 25, 2025
F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F838 · complaint · corrected January 25, 2025
F
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F726 · corrected January 25, 2025
F
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Widespread · Resident Rights Deficiencies · F550 · complaint · corrected January 25, 2025
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · corrected January 25, 2025
E
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F678 · corrected January 25, 2025
D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected January 25, 2025
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected January 25, 2025
D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F582 · corrected January 25, 2025
April 5, 2024 — 3 citations (includes serious) · complaint investigation
L
Provide and implement an infection prevention and control program.
Immediate jeopardy to resident health or safety · Widespread · Infection Control Deficiencies · F880 · complaint · corrected May 20, 2024
D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected May 20, 2024
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected May 20, 2024
January 10, 2020 — 4 citations
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected February 22, 2020
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected February 22, 2020
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected February 22, 2020
D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · corrected February 22, 2020
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare