General Information: BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Nursing home name BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Address2141 SYCAMORE AVENUE
LOUISVILLE, KY 40206
Phone number (502) 895-5417
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesYes
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Resident
Certified number of beds 96
Total number of residents 85
Perc of occupied beds 88
Sprinkler status Yes
Number of Facility Reported Incidents1
Number of Substantiated Complaints4
Number of Fines2
Total Amount of Fines$40787
Total Number of Penalties1
Total Number of Penalties3
Ratings Summary: BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Overall rating 2
2
Nursing Home Staffing 4
4
Registered Nurses only 3
3
Health Inspections 1
1
Quality Measures 3
3
Nursing Home Staffing Info: BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
National AverageKentucky AverageBROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Overall staff rating NA NA 4
4
Registered Nurses only rating NANA 3
3
Total Number of Residents NA NA 85
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.38 hours 4.01 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.85 hours 1.95 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.89 hours 0.64 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.96 hours 1.31 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.53 hours 2.06 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.09 hours 0.07 hours
Health Survey: BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Heath Survey Summary on 2013-08-01
Total Number of Health Deficiencies 14
Scope and Severity of most Severe Health Deficiency Isolated/Actual harm
Heath Survey Summary on 2012-07-12
Total Number of Health Deficiencies 7
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Heath Survey Summary on 2011-07-21
Total Number of Health Deficiencies 5
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Health Survey Details: BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Inspection Results: 08/01/2013
Corrected Deficiency Scope and Severity
09/13/2013 Give residents a notice of rights, rules, services and charges. Isolated/Minimal harm or potential for actual harm
09/13/2013 Provide timely notification to the resident before transfer or discharge. Isolated/Minimal harm or potential for actual harm
09/13/2013 Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated/Minimal harm or potential for actual harm
09/13/2013 Reasonably accommodate the needs and preferences of each resident. Isolated/Minimal harm or potential for actual harm
09/13/2013 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Actual harm
09/13/2013 Allow residents the right to participate in the planning or revision of care and treatment. Isolated/Minimal harm or potential for actual harm
09/13/2013 Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. Pattern/Potential for minimal harm
09/13/2013 Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated/Minimal harm or potential for actual harm
09/13/2013 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated/Actual harm
09/13/2013 Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated/Minimal harm or potential for actual harm
09/13/2013 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern/Minimal harm or potential for actual harm
09/13/2013 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
09/13/2013 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm
09/13/2013 Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated/Actual harm
Inspection Results: 07/12/2012
Corrected Deficiency Scope and Severity
08/24/2012 Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern/Minimal harm or potential for actual harm
10/09/2012 Provide housekeeping and maintenance services. Pattern/Minimal harm or potential for actual harm
08/24/2012 Provide care by qualified persons according to each resident's written plan of care. Isolated/Minimal harm or potential for actual harm
08/24/2012 Dispose of garbage and refuse properly. Widespread /Minimal harm or potential for actual harm
11/21/2012 Have a program that investigates, controls and keeps infection from spreading. Widespread /Minimal harm or potential for actual harm
11/21/2012 Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern/Minimal harm or potential for actual harm
11/21/2012 Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern/Minimal harm or potential for actual harm
Inspection Results: 07/21/2011
Corrected Deficiency Scope and Severity
08/20/2011 Provide housekeeping and maintenance services. Pattern/Minimal harm or potential for actual harm
08/20/2011 Ensure services provided by the nursing facility meet professional standards of quality. Pattern/Minimal harm or potential for actual harm
08/20/2011 Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated/Minimal harm or potential for actual harm
08/20/2011 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
08/20/2011 Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Pattern/Minimal harm or potential for actual harm

Fire Safety Survey: BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Fire Safety Survey Summary on 2013-08-01
Total Number of Fire SafetyDeficiencies 6
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2012-07-11
Total Number of Fire SafetyDeficiencies 16
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2011-07-21
Total Number of Fire SafetyDeficiencies 5
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey: BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Fire Safety Survey Results: 08/01/2013
Corrected Deficiency Severity
09/13/2013 Corridor and hallway doors that block smoke. Isolated/Minimal harm or potential for actual harm
09/13/2013 Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. Isolated/Minimal harm or potential for actual harm
09/13/2013 Record of quarterly fire drills for each shift under varying conditions. Widespread /Minimal harm or potential for actual harm
09/13/2013 Automatic sprinkler systems that have been maintained in working order. Widespread /Minimal harm or potential for actual harm
09/13/2013 Other fire safety features required by fire safety codes. Isolated/Minimal harm or potential for actual harm
09/13/2013 Properly installed electrical wiring and equipment. Widespread /Minimal harm or potential for actual harm
Fire Safety Survey Results: 07/11/2012
Corrected Deficiency Severity
08/24/2012 Record of quarterly fire drills for each shift under varying conditions. Widespread /Minimal harm or potential for actual harm
08/24/2012 Other fire safety features required by fire safety codes. Isolated/Minimal harm or potential for actual harm
08/24/2012 Proper medical gas storage and administration areas. Isolated/Minimal harm or potential for actual harm
08/24/2012 Exits that are free from obstructions and can be used at all times. Isolated/Minimal harm or potential for actual harm
08/24/2012 Portable fire extinguishers. Isolated/Minimal harm or potential for actual harm
08/24/2012 Automatic sprinkler systems that have been maintained in working order. Widespread /Minimal harm or potential for actual harm
08/24/2012 An approved automatic sprinkler system connected to the fire alarm system. Isolated/Minimal harm or potential for actual harm
08/24/2012 Weekly inspections and monthly testing of generators. Widespread /Minimal harm or potential for actual harm
08/24/2012 Emergency lighting that can last at least 1 1/2 hours. Widespread /Minimal harm or potential for actual harm
08/24/2012 Proper backup exit lighting. Isolated/Minimal harm or potential for actual harm
08/24/2012 Properly installed electrical wiring and equipment. Pattern/Minimal harm or potential for actual harm
08/24/2012 Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. Isolated/Minimal harm or potential for actual harm
08/24/2012 Smoke barrier doors that can resist smoke for at least 20 minutes. Widespread /Minimal harm or potential for actual harm
08/24/2012 Walls that prevent smoke from passing through and would resist fire for at least one hour. Pattern/Minimal harm or potential for actual harm
08/24/2012 Corridor and hallway doors that block smoke. Isolated/Minimal harm or potential for actual harm
08/24/2012 Exits that are accessible at all times. Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Results: 07/21/2011
Corrected Deficiency Severity
08/20/2011 Corridor and hallway doors that block smoke. Pattern/Minimal harm or potential for actual harm
08/20/2011 Signs that state that exit doors are to be kept closed. Isolated/Minimal harm or potential for actual harm
08/20/2011 Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. Isolated/Minimal harm or potential for actual harm
08/20/2011 Exits that are accessible at all times. Isolated/Minimal harm or potential for actual harm
08/20/2011 Other fire safety features required by fire safety codes. Pattern/Minimal harm or potential for actual harm

Resident Complaints: BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Date Complaint Substantiated: 01/22/2014
CorrectedCategoryDeficiencySeverity
02/28/2014Try to resolve each resident's complaints quickly. D
02/28/2014Permit residents to remain in the facility and not be transferred or discharged without adequate reason. D
02/28/2014Provide timely notification to the resident before transfer or discharge. D
02/28/2014Tell the resident or the residents representative in writing how long the nursing home will hold the residents bed in cases of transfer to a hospital or therapeutic leave. D
02/28/2014Protect each resident from all abuse, physical punishment, and involuntary separation from others. K
02/28/20141) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. K
02/28/2014Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. K
02/28/2014Provide medically-related social services to help each resident achieve the highest possible quality of life. K
02/28/2014Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. K
02/28/2014Keep accurate, complete and organized clinical records on each resident that meet professional standards. K
02/28/2014Establish 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 K
02/28/2014Allow residents the right to participate in the planning or revision of care and treatment. K
02/28/2014Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. K
02/28/2014Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. D
02/28/2014Provide care by qualified persons according to each resident's written plan of care. K
02/28/2014Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . K
Date Complaint Substantiated: 08/28/2012
CorrectedCategoryDeficiencySeverity
10/18/2012Ensure each resident receives an accurate assessment by a qualified health professional. D
10/18/2012Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D
10/18/2012Allow residents the right to participate in the planning or revision of care and treatment. E
10/18/2012Have enough nurses to care for every resident in a way that maximizes the resident's well being. D
10/18/2012Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. D
Date Complaint Substantiated: 11/17/2011
CorrectedCategoryDeficiencySeverity
12/16/2011Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. D
12/16/2011Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. D
12/16/2011Have a program that investigates, controls and keeps infection from spreading. D

Quality Measures: BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Quality Measures National Average Kentucky Average BROWNSBORO HILLS HEALTH CARE AND REHABILITATION C
Overall quality rating NA NA 3
3
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 17.0% 25.7%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 9.6% 7.7%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 6.6% 12.0%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 8.2% 6.7%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 45.7% 39.3%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 4.1% 2.7%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 7.5% 6.0%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 4.6% 0.0%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 2.7% 0.0%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 4.0% 8.9%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 94.7% 95.7%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 97.1% 95.8%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 22.2% 22.5%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 21.9% 20.4%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 1.4% 0.7%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 88.5% 62.1%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 87.8% 64.1%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 3.1% 2.9%

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