Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Essex Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with cognitive and mental health diagnoses reported suspicious bank charges to the BOM, who then notified the Administrator. Although APS and local police were contacted due to concerns about possible financial exploitation and the resident's ability to manage funds, the facility did not report the suspected misappropriation to the SSA within the required 24-hour timeframe, contrary to policy and regulatory requirements.
A resident with severe cognitive impairment developed a skin tear that was treated by an LPN without physician orders, incident reporting, or proper documentation, contrary to facility policy and professional standards. The wound was not reported to the provider or documented in the medical record until discovered by a surveyor, revealing a breakdown in communication and adherence to wound care protocols.
Staff did not follow established procedures for using a mechanical stand-up lift during a transfer, failing to secure the leg strap behind a resident's legs and not ensuring both feet were flat on the footrest. The resident, who had hemiplegia and moderate cognitive impairment, was not adequately protected from accident hazards due to these deviations from policy and training.
A resident with a low BMI and history of failure to thrive was ordered a nutritional supplement, but frequently received only partial doses due to refusal, with inconsistent documentation and communication among staff. The RD and NP were not promptly informed of the resident's ongoing partial intake, and the issue was not reliably addressed in care planning or interdisciplinary meetings, resulting in inadequate nutritional support.
Three residents experienced misappropriation of their money and personal property by a staff member, including unauthorized use of debit and credit cards and missing cash. The facility failed to promptly investigate missing items, delayed notifying authorities, and did not alert families to potential fraud. The staff member involved had a prior theft conviction, but was still hired and assigned to the affected unit, allowing the misappropriation to occur.
A staff member with a prior guilty finding for theft was hired after facility administrators and HR misinterpreted background check results, leading to the misappropriation of funds from three residents. Facility policies lacked clear guidance on disqualifying crimes and background check procedures, resulting in the employment of an individual with a disqualifying conviction and subsequent harm to residents.
The facility did not promptly investigate or report suspected misappropriation of resident property after a resident reported suspicious financial activity. Despite policy requirements, the Administrator delayed notifying the SSA and did not begin interviewing staff or other residents until additional reports surfaced. Multiple residents were affected before a thorough investigation was initiated, and the facility's actions did not align with regulatory expectations for timely response.
Failure to Timely Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to report a suspected misappropriation of a resident's property to the State Survey Agency (SSA) within 24 hours of forming suspicion, as required by both facility policy and regulatory requirements. The incident involved a resident who, after being admitted with a history of anxiety disorder, mild cognitive impairment, bipolar disorder, and major depressive disorder, reported suspicious charges on their bank statement to the Business Office Manager (BOM). The BOM reviewed the statement and, after discussing with the resident, notified the Administrator due to concerns about possible fraudulent activity and the resident's financial management. The Administrator, upon being informed, contacted Adult Protective Services (APS) and the local police department, expressing concerns about the resident's ability to manage their finances and the potential need for guardianship. However, the Administrator did not report the suspected misappropriation to the SSA, stating that there was no clear evidence of fraud at the time and that the primary concern was the resident's financial mismanagement. Despite the facility's policy and regulatory requirements to report all suspicions of misappropriation within 24 hours, no such report was made to the SSA. Interviews with facility management and legal counsel confirmed that the expectation and policy were to report any concerns of potential fraudulent activity involving resident funds to the SSA, regardless of whether the activity was believed to have occurred inside or outside the facility. Documentation showed that the initial and final report was submitted to APS, but there was no evidence of timely notification to the SSA as required.
Failure to Follow Wound Care Protocol and Documentation for Skin Tear
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident with a skin tear. The resident, who was severely cognitively impaired and at risk for skin integrity issues, sustained a skin tear on the right leg. Despite the facility's policy requiring physician notification, obtaining treatment orders, completing an incident report, and documenting a skin assessment, these steps were not followed. The wound was observed with a transparent bandage in place, but there was no documentation of the injury or treatment in the resident's chart prior to surveyor intervention. Interviews revealed that the skin tear was first noticed by a nursing assistant, who reported it to an LPN. The LPN provided first aid and applied a transparent bandage but did not document the incident, notify the resident's family, obtain physician orders, or complete an incident report, citing being too busy. The treatment nurse and nurse practitioner were unaware of the wound until it was brought to their attention by the surveyor. The facility's wound care protocol and care plan required staff to observe, document, and report skin concerns, and to provide treatment as ordered by a physician, but these procedures were not followed in this case. Multiple staff interviews confirmed that the expected process for new wounds included incident reporting, physician notification, obtaining treatment orders, and documentation in the electronic medical record. However, these steps were not completed for the resident's skin tear. The deficiency was identified when the state surveyor intervened, and it was found that the facility failed to follow its own policies and professional standards of practice regarding wound care and documentation.
Failure to Follow Mechanical Lift Protocols During Resident Transfer
Penalty
Summary
Staff failed to follow established procedures for the use of a mechanical stand-up lift when assisting a resident with hemiplegia and moderate cognitive impairment. During an observed transfer, the staff member did not secure the leg strap around the back of the resident's legs as required by facility policy and manufacturer instructions, instead placing it around the leg rest. Additionally, the resident's feet were not properly positioned on the footrest, with one foot partially out of a slipper and the other heel hanging off the footrest. These actions were inconsistent with the facility's policy and training materials, which specify that the leg strap should be fastened behind the legs and both feet should be flat on the footrest for safety and stability. Interviews with multiple staff members, including nursing assistants, therapy staff, and management, confirmed that the correct procedure for using the stand-up lift involves securing the leg strap behind the resident's legs and ensuring both feet are flat on the footrest. Staff acknowledged that failure to follow these steps could compromise resident safety. Despite this, the staff member involved in the incident believed her method was correct, indicating a lack of understanding or adherence to the established protocol. The resident involved required substantial assistance for transfers due to physical and cognitive limitations, as documented in the care plan and assessment records. The failure to use the assistive device according to policy and training, and to properly position the resident, resulted in a situation where the resident was not adequately protected from accident hazards during the transfer process.
Failure to Ensure Adequate Nutritional Supplementation for Underweight Resident
Penalty
Summary
The facility failed to ensure that a clinically underweight resident, who had a low Body Mass Index (BMI) and diagnoses including adult failure to thrive, received the full amount of a physician-ordered nutritional supplement. The resident was ordered to receive Med Pass 2.0, 120 ml three times daily, but was frequently only given partial doses, with documentation showing that partial amounts were administered on the majority of occasions over several months. Staff interviews revealed that when the resident refused or only partially consumed the supplement, the information was inconsistently reported to nursing staff, and there was no prompt notification to the Registered Dietitian (RD) or medical provider as required by facility policy. Observations confirmed that staff administered only 60 ml of the supplement instead of the ordered 120 ml, citing the resident's refusal to take more. Although staff were expected to document refusals and notify the appropriate clinical team members, interviews with nurses and the unit manager indicated that this process was not reliably followed. The RD and Nurse Practitioner (NP) were not made aware in a timely manner of the resident's ongoing partial consumption of the supplement, and the issue was not consistently discussed in interdisciplinary team meetings or documented in quality assurance records. The resident's weight records showed a significant weight loss over a six-month period, and care plans indicated the need for close monitoring and intervention due to the resident being far below ideal body weight. Despite these indicators and the facility's policies requiring action and communication regarding weight loss and supplement intake, the lack of timely and effective communication among staff, and the failure to follow up on partial supplement administration, resulted in the resident not receiving adequate nutritional support as ordered.
Failure to Protect Residents from Misappropriation of Property by Staff
Penalty
Summary
The facility failed to protect three residents from misappropriation of their property, resulting in the wrongful use of their financial accounts and personal belongings. One resident, who was initially cognitively intact but later became severely impaired, reported a missing wallet and $40.00, and later discovered fraudulent activity on their bank accounts totaling over $2,500. The resident had not given permission for anyone to use their financial information, and the facility's investigation revealed that a staff member was the suspected perpetrator. The facility's documentation showed delays in investigating the missing items and in notifying appropriate authorities, with the administrator leaving the report open for several weeks due to lack of cooperation from the resident and insufficient information. Another resident, with intact cognition, experienced unauthorized transactions on their debit card and missing cash totaling $27.00. The fraudulent activity was identified by the resident's family, who then notified the facility. The family was not alerted by the facility to monitor for suspicious activity, and the facility only began to investigate after being informed by the family. The investigation linked the fraudulent transactions to a staff member who had access to the residents' unit. A third resident, who was moderately cognitively impaired, lost a credit card that was later found, but not before unauthorized charges were made and subsequently reimbursed by the bank. The facility's review of the staff member's personnel file revealed a prior conviction for theft involving a credit/debit card, but this individual was still hired and assigned to the unit where the misappropriations occurred. The facility did not promptly identify or report the pattern of misappropriation, and only initiated a broader investigation after multiple incidents were brought to their attention.
Failure to Prevent Employment of Staff with Disqualifying Criminal Conviction
Penalty
Summary
The facility failed to prevent the employment of an individual with a prior guilty finding for theft, specifically theft-receipt of a stolen credit/debit card, as required by both facility policy and federal regulations. The State Registered Nurse Aide (SRNA) was hired after a preemployment background check, which clearly indicated a guilty disposition for theft. Despite this, the facility's administrative and human resources staff misinterpreted the background check results, believing all charges had been dismissed or amended down, and proceeded with the hiring process without further investigation into the nature of the conviction or the identity of the victim. Following the employment of the SRNA, three residents reported missing personal property and fraudulent charges on their financial accounts. The facility, in conjunction with local law enforcement, identified the SRNA as the suspect in the misappropriation of resident funds, leading to criminal charges and a warrant for arrest. The residents affected included individuals who reported missing debit and credit cards, a wallet, and cash, with subsequent evidence of unauthorized financial transactions. The facility's documentation showed delays in closing investigations into missing property and in recognizing the pattern of misappropriation. Review of facility policies revealed that while there were procedures in place to screen for abuse, neglect, exploitation, or misappropriation, the policies lacked specificity regarding the means of review, such as the use of criminal background checks, and did not clearly define which crimes would prohibit employment. Interviews with facility staff and legal counsel demonstrated a lack of understanding and clarity in interpreting background check results, leading to the employment of an individual with a disqualifying conviction. The failure to accurately review and act upon the background check findings directly contributed to the deficiency and affected the safety and property of multiple residents.
Failure to Timely Investigate and Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure a thorough and timely investigation was completed and submitted to the State Survey Agency (SSA) within five days of forming suspicion that residents' financial information was being used fraudulently. Three residents were affected by this deficiency, each reporting suspicious or fraudulent activity on their financial accounts. The initial report of suspicious charges was made by one resident to facility staff, but the facility did not submit an initial report to the SSA or conduct interviews with other residents or staff to determine the extent of the issue until a second resident's family reported similar concerns nearly two weeks later. Facility policy required the Administrator to direct the investigation process and notify appropriate agencies, but the policy lacked specific instructions on what constituted a thorough investigation or when certain actions should be taken. Documentation showed that missing items and suspicious financial activity were reported by residents over several months, but there was no evidence of a comprehensive investigation or timely reporting to the SSA. The facility did not begin interviewing staff or other residents to assess the scope of the misappropriation until after multiple reports had been made, and the initial report to the SSA was delayed. Interviews with facility staff and the Administrator confirmed that the investigation was not initiated promptly, and that the Administrator did not suspect employee involvement until additional evidence was presented. The Administrator acknowledged that interviews with staff and residents were not started until after the second report, and that the SSA was not notified at the time of the initial suspicion. The facility's management company representatives stated that regulatory requirements call for immediate reporting and investigation, including staff and resident interviews, as soon as an allegation is made.
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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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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Terrace Health Campus | 1.3 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of South Louisville | 2.4 mi | ★★★★★ | 4 | 0 |
| Parkwood Health & Rehabilitation | 4 mi | ★★★★★ | 9 | 0 |
| Signature Healthcare At Rockford Rehab & Wellness | 4.5 mi | ★★★★★ | 2 | 0 |
| Signature Healthcare At Summerfield Rehab & Wellne | 5.3 mi | ★★★★★ | 0 | 0 |
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