Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chestnut Ridge Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of swallowing disorders and a physician-ordered pureed diet was provided a peanut butter sandwich by a CNA, despite clear SLP recommendations and staff awareness of dietary restrictions. The care plan lacked specific interventions to ensure snacks met the resident's prescribed diet, leading to the resident choking and subsequently dying. Staff interviews confirmed the absence of individualized care planning and unclear guidance on acceptable foods for modified diets.
A resident with severe dysphagia and multiple comorbidities was provided a peanut butter sandwich by a CNA, despite a physician order for a pureed diet with nectar-thickened liquids. The CNA, aware of the dietary restriction, gave the sandwich at the resident's request without verifying the current diet order. The resident choked on the sandwich and later died in the hospital. Staff interviews confirmed the failure to follow established protocols for diet verification, and the official cause of death was choking on a food bolus.
Infection control practices were not consistently followed for residents on isolation precautions, including residents with COVID-19 and a resident with C. diff. Staff were observed entering and exiting rooms without the expected PPE, an RN delivered meal trays to a resident and roommate without PPE despite posted precautions, and a maintenance worker entered an isolation room without PPE. Some rooms had missing or inconsistent signage, and one resident with an active C. diff contact isolation order had no sign posted at the door.
The facility did not complete required Kentucky Nurse Aide Abuse Registry checks for a Dietary Aide and an Activities Assistant before hiring, as revealed by personnel file reviews and confirmed by the Administrator. The facility's policy mandates screening all potential employees for abuse history, but the registry check was omitted for non-clinical staff due to a lack of license verification and absence of a dedicated HR staff member.
Failure to Develop and Implement Individualized Care Plan for Dietary Needs Resulting in Resident Death
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan that accurately reflected the nutritional and dietary needs of a resident with a history of swallowing disorders. The resident had previously experienced choking incidents and had been evaluated by a Speech-Language Pathologist (SLP), who recommended a pureed diet with nectar thick liquids and specifically advised against peanut butter sandwiches. Despite these recommendations and physician orders, the resident's care plan did not include specific interventions to ensure that all snacks provided, including those outside of scheduled meals, met the prescribed therapeutic diet. On the day of the incident, a Certified Nurse Aide (CNA) provided the resident with a peanut butter sandwich at the resident's request, despite being aware of the pureed diet order. The CNA had previously observed the resident eating peanut butter sandwiches without difficulty and did not verify the current diet order through available resources such as the KARDEX, electronic medical record, or by consulting a nurse. The resident choked on the sandwich, became unresponsive, and later died at the hospital. The official cause of death was determined to be choking on a food bolus. Interviews with staff revealed a lack of clarity and consistency in care planning and implementation. The care plan did not incorporate the SLP's or dietary manager's recommendations, and there was no policy or standard provided regarding acceptable food items for different therapeutic diets. Staff members were aware of the resident's dietary restrictions, but the absence of clear, individualized interventions in the care plan contributed to the provision of an unsafe snack, resulting in the resident's death.
Removal Plan
- The Dietary Manager labeled all snacks/snack-room foods with correct consistency per residents' diet orders.
- The DON, ADON, and SDC educated all licensed nurses, CMTs, and CNAs regarding: Reviewing the care plan, KARDEX, and diet orders before providing snacks; IDDSI standards for puree and mechanical soft diets; Specific instruction that peanut butter was not allowed for puree diets unless blended with another food to meet puree consistency.
- Staff completed return demonstrations and will not work unsupervised until competency verified.
- Care plans for all residents on modified diets were reviewed and updated by licensed staff to include: Speech therapist and dietary recommendations; Specific snack and supplemental food interventions; Cross-reference to diet order consistency requirements.
- Administrator initiated ongoing daily audits of snacks and care plans to ensure compliance.
- New staff will be educated during orientation and before working independently.
Failure to Follow Therapeutic Diet Order Results in Fatal Choking Incident
Penalty
Summary
A facility failed to ensure that a resident received a therapeutic diet as ordered by the physician, resulting in a fatal choking incident. The resident, who had a history of cerebrovascular disease, anoxic brain damage, dementia, dysphagia, and other significant medical conditions, was prescribed a pureed diet with nectar-thickened liquids due to severe swallowing difficulties. Despite these orders, a Certified Nurse Assistant (CNA) provided the resident with a peanut butter sandwich, which was not permitted on the prescribed diet. The CNA was aware of the resident's dietary restrictions but gave the sandwich at the resident's request, having previously observed the resident eat similar food without apparent difficulty. The incident occurred when the resident began eating the peanut butter sandwich and subsequently choked, leading to a loss of pulse. Staff attempted the Heimlich maneuver and initiated CPR, but the resident was ultimately transferred to a hospital and expired. The official cause of death was listed as choking on a food bolus. Interviews with staff confirmed that the CNA did not verify the resident's current diet order through available resources such as the KARDEX, care plan, or by consulting a nurse, despite being aware of the resident's dietary restrictions and the facility's protocols for verifying diet orders before providing snacks. Further review revealed that the facility's policies required snacks to be compatible with therapeutic diets and that staff were trained to check diet orders before providing food to residents. However, there was no specific policy or standard provided regarding acceptable food items for different therapeutic diets. The resident had a documented history of swallowing disorders and previous choking incidents, including a prior event involving a peanut butter sandwich that led to a change in diet orders and additional speech therapy interventions. Despite these measures, the failure to follow the prescribed diet directly resulted in the resident's death.
Removal Plan
- All mechanical soft and pureed snacks in the snack room and refrigerator were labeled by the Dietary Manager with the appropriate consistency.
- The Administrator reviewed all snacks and supplemental foods available outside of meal service to ensure compliance with current diet orders.
- Education was initiated by the Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator for all licensed nurses, certified medication technicians, and certified nurse aides.
- Staff were instructed on the new process for labeled snacks, the requirement to verify diet orders through the Kardex, care plan, or physicians' order, and the inappropriateness of peanut butter on a pureed diet unless blended to proper consistency under IDDSI standards.
- All staff completed return demonstrations prior to working their next scheduled shifts, and competency validation was confirmed.
- A 100% audit of all resident diet orders and Kardex entries was completed by the DON, MDS nurse, and Regional Nurse.
- The ADON completed a 100% audit of all physician diet orders in Point-Click-Care against tray tickets to ensure accuracy.
- Ongoing monitoring was implemented, including nursing audits of 10 trays per week for four weeks, followed by 10 trays monthly for three months.
- The Administrator audited snacks three times per week for four weeks, then decreased frequency over the following two months.
- All new hires will receive training on therapeutic diets, Kardex review, and snack verification during orientation prior to assuming care responsibilities.
- The QAPI Committee held an ad hoc meeting to review corrective actions, with a monthly follow-up scheduled for three months.
- The Medical Director was notified of all corrective measures and ongoing monitoring efforts and agreed with the plan.
Infection Control and Isolation Precautions Not Consistently Followed
Penalty
Summary
The facility failed to ensure an effective infection prevention and control system for residents on multiple units, including residents with COVID-19 and one resident with C. diff. Facility policy required environmental infection prevention practices, isolation precautions, and universal PPE use when residents had a positive COVID test or symptoms. However, observations on multiple dates showed no signage at the facility entry to indicate residents with COVID, and staff were observed entering and exiting isolation rooms without the expected PPE or with inconsistent PPE use. On Lakeview Hall, Resident 77 had an Enhanced Barrier Precaution sign on the door and a Contact Precaution sign on the room door, but CNA staff were observed exiting the room without PPE, and a Maintenance Assistant entered the room without putting on PPE before checking light switches. CNA staff also removed PPE inside the room and handled items afterward. For Resident 12, both EBP and Contact Precautions signs were posted, but an RN entered the room and delivered meal trays to the resident and roommate without any PPE. The RN stated she was not aware of the Contact Precautions and believed the resident should only have been on EBP. For Residents 41 and 63, both of whom tested positive for COVID-19, staff were observed donning PPE before entering the room, but then exiting without PPE. The MDS Coordinator was also observed carrying a Contact Precaution sign and masks toward the rooms but did not place the sign. For Resident 9, who had an active order for Contact Isolation Precautions related to C. diff, the room had no signage at the entrance. An agency RN later confirmed the C. diff history and noted the active order remained in the record, while the DON stated residents with COVID should be on Droplet Isolation/Contact Precautions with signage posted on the door and PPE available outside the room.
Failure to Complete Pre-Employment Abuse Registry Checks for Non-Clinical Staff
Penalty
Summary
The facility failed to complete all required pre-employment checks for two of eight sampled new employees, specifically a Dietary Aide and an Activities Assistant. According to the facility's abuse prevention policy, all potential employees are to be screened for a history of abuse, neglect, or mistreatment, including checks of multi-state registries and license verifications. However, review of the personnel files revealed that the Kentucky Nurse Aide Abuse Registry check was not completed for either the Dietary Aide or the Activities Assistant prior to their employment. During an interview, the Administrator confirmed that while license verifications were performed for clinical staff such as CNAs and nurses, the registry check was not conducted for non-clinical staff, as they did not possess licenses to verify. The absence of a dedicated Human Resources staff member at the time contributed to this oversight.
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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Oaks Health & Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| Treyton Oak Towers | 1.1 mi | ★★★★★ | 0 | 0 |
| Home Of The Innocents | 2 mi | ★★★★★ | 0 | 0 |
| Kindred Hospital - Louisville | 2.1 mi | ★★★★★ | 3 | 0 |
| Hillcrest Village | 2.5 mi | ★★★★★ | 11 | 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 August 2026) and official state health department websites.