Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Glen Ridge Health Campus during CMS and state inspections, most recent first.
The facility failed to ensure the medication error rate remained below 5%, with errors identified in the administration of medications to two residents. An LPN did not properly measure a powdered laxative for a resident with gastrointestinal issues, and another resident with hypokalemia and hypothyroidism received multiple medications together and without food, contrary to orders and manufacturer instructions. Staff interviews confirmed that medications were not administered according to policy and best practices.
A resident with severe cognitive impairment and multiple medical conditions was subjected to mental abuse when a Certified Resident Care Aide made an inappropriate hand gesture toward the resident. The aide admitted to the action, and staff interviews confirmed the incident, which was determined to be mental abuse under facility policy.
A resident with severe cognitive impairment alleged that a staff member made an inappropriate hand gesture towards them. Although internal notifications were made promptly, the facility failed to submit the required initial abuse report to the State Survey Agency within the mandated two-hour timeframe due to an unsuccessful fax attempt and lack of follow-up, resulting in delayed external reporting.
A resident with multiple respiratory conditions requiring supplemental oxygen was not accurately assessed on the MDS, as the use of oxygen therapy was omitted from Section O0110. Nursing and physician documentation, as well as interviews with the resident and several LPNs, confirmed ongoing nighttime oxygen use since admission, but this was not reflected in the assessment. The MDS Coordinator acknowledged the error, which was not identified during routine audits.
A resident with multiple respiratory conditions was provided supplemental oxygen nightly without a physician's order specifying administration parameters, despite facility policy requiring such an order. Nursing and physician notes referenced oxygen use, and several LPNs and the Director of Health Services confirmed the absence of a formal order for the ongoing oxygen therapy.
A resident with multiple chronic conditions and dementia was found with dry, flaky skin and a buildup of black, dry skin on their feet, indicating a failure to follow the facility's hygiene policies. Staff confirmed the resident's feet had not been washed for an extended period, and the care plan lacked specific interventions for bathing or hygiene.
A resident with severe cognitive impairment fell in the shower due to a loose metal ring on the grab bar, which was not reported or repaired. The fall resulted in a skin tear and hematoma. Staff involved noted the loose grab bar contributed to the fall, and the Director of Plant Operations confirmed the hazard upon inspection.
A resident missed ten doses of routine medications due to the facility's failure to order medications timely after admission. Staff interviews revealed inconsistencies in the process of ordering and receiving medications, and the issue was not escalated to the Director of Health Services or Executive Director in a timely manner.
A resident with severe cognitive impairment and type 2 diabetes had their blood glucose level checked and insulin administered in a common area, violating privacy policies. Both the LPN involved and facility leadership acknowledged that the procedure should have been conducted in a private area.
A resident's grievance about their roommate's disruptive behavior at night was not resolved by the facility. Despite multiple staff members being aware of the issue, the grievance was not documented or addressed effectively, leading to ongoing sleep disturbances for the resident.
The facility failed to implement the bowel protocol for a resident who exceeded 72 hours without a bowel movement on two occasions. Despite the resident's severe cognitive impairment and dependency on staff for toilet use, the required assessments and interventions were not documented or performed. Staff interviews revealed that the EMR system did not flag the issue, and the bowel protocol was not followed as per the facility's policy.
A resident with multiple chronic conditions had excessively long toenails due to the facility's failure to provide necessary foot care. Despite being dependent on staff for personal hygiene, the resident's care plan did not address toenail care, and the facility lacked a policy for it. Observations and interviews revealed that the issue was not reported or addressed, and the resident had not received podiatry services since admission.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, resulting in a calculated error rate of 15.38% with 4 errors out of 26 opportunities. This deficiency was identified through observation, interviews, and record reviews, and involved two residents during the medication administration task. The facility's policy required medications to be administered as prescribed, following the five rights of medication administration, and within specified timeframes. For one resident with a history of gastrointestinal hemorrhage and constipation, a medication error occurred when an LPN administered polyethylene glycol 3350 powder without properly measuring the dose using the provided measurement lines in the bottle cap, as required by manufacturer instructions and facility policy. The LPN admitted to not knowing the correct method for measuring the medication, and interviews with other nursing staff and the Director of Health Services confirmed that the medication should be measured accurately using the cap's internal lines and checked at eye level. Another resident, admitted with hypokalemia and hypothyroidism, received multiple medications, including levothyroxine, calcium carbonate, ferrous gluconate, and potassium chloride, all administered together in one cup and without food, despite specific orders and manufacturer instructions. Levothyroxine was supposed to be given on an empty stomach and separately from calcium and iron supplements, while potassium chloride was to be given with food. The LPN confirmed that the medications were not administered according to these requirements, and this was corroborated by interviews with other nursing staff, the Director of Health Services, and the facility pharmacist.
Failure to Protect Resident from Mental Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of seven out of 15, was admitted with multiple diagnoses including emphysema, acute respiratory failure with hypoxia, acute kidney failure, and acute on chronic diastolic heart failure. The facility's policy defined mental/emotional abuse as conduct that could cause humiliation, intimidation, fear, shame, agitation, or degradation. Despite this policy, a Certified Resident Care Aide (CRCA) directed an inappropriate hand gesture (middle finger) toward the resident in response to the resident's behaviors. The incident was reported by the resident to the nurse on duty, and the CRCA admitted to making the gesture. Witness statements and interviews with staff confirmed the CRCA's actions and acknowledgment that the gesture could be perceived as abuse. The Director of Health Services classified the gesture as mental abuse, consistent with facility policy. The deficiency centers on the failure to protect the resident from mental abuse perpetrated by a staff member.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to submit an initial report of an allegation of staff-to-resident abuse to the State Survey Agency (SSA) within the required two-hour timeframe for one resident. According to facility policy, all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made if the event involves abuse or results in serious bodily injury. In this case, a resident with severe cognitive impairment, as indicated by a BIMS score of 7 out of 15, reported that a Certified Resident Care Aide (CRCA) made an inappropriate hand gesture towards them. The incident was reported to the Assistant Director of Health Services (ADHS), who then notified the Director of Health Services (DHS) and the Executive Director (ED) in a timely manner. Despite prompt internal notification, the facility did not submit the initial report to the SSA within the required two-hour window. The report was first attempted via fax, but the transmission failed because it was sent to a telephone number instead of a fax line. The ED was unaware that the fax had not been successfully transmitted. The report was eventually submitted via email, but this occurred more than two hours after the initial allegation was made. Interviews with staff confirmed awareness of the reporting requirements, but the delay was due to the unsuccessful fax attempt and lack of follow-up to ensure receipt by the SSA.
Inaccurate MDS Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident with multiple respiratory diagnoses, including pulmonary embolism, acute respiratory failure with hypoxia, pulmonary fibrosis, pulmonary hypertension, and atelectasis. The resident was admitted with a history of hypoxia and required supplemental oxygen, as documented in both nursing and physician progress notes, as well as through interviews with the resident and multiple LPNs who confirmed the use of nighttime oxygen since admission. Despite this, the MDS assessment did not reflect the use of supplemental oxygen under Section O0110, Special Treatments, Procedures, and Programs. Review of the resident's active orders showed a directive for nursing to manage oxygen administration in coordination with the physician, but there was no specific physician order detailing when or at what flow rate the oxygen should be administered. The MDS Coordinator acknowledged that the omission of oxygen therapy on the MDS was an error that should have been identified during routine audits. The Director of Health Services and the Executive Director both stated their expectations for accurate and thorough completion of MDS assessments, but the deficiency was not detected prior to the survey.
Failure to Obtain Physician's Order for Supplemental Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen use for one resident who was admitted with multiple respiratory diagnoses, including pulmonary embolism, acute respiratory failure with hypoxia, atelectasis, pulmonary fibrosis, and pulmonary hypertension. The facility's standard operating procedure required verification of a physician's order prior to administering oxygen. Despite this, the resident was provided with supplemental oxygen nightly since admission, as documented in nursing progress notes and confirmed by staff interviews. The care plan directed staff to administer oxygen per physician's order, but no specific order for oxygen administration or flow rate was found in the resident's active orders. Multiple staff members, including LPNs and the Director of Health Services, acknowledged that a physician's order was necessary for supplemental oxygen administration and confirmed that the resident had been using oxygen at night without such an order. Nursing and physician progress notes referenced the resident's use of oxygen, but did not specify the required parameters or provide a formal order. The deficiency was identified through interviews, record reviews, and review of facility procedures, all of which confirmed the lack of a required physician's order for the ongoing administration of supplemental oxygen to the resident.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to assist a resident with activities of daily living (ADL) care, specifically in maintaining proper hygiene for their feet. Observation revealed that the resident's feet were dry with a buildup of black, dry, and flaky skin between and under the toes, as well as callused skin on the right heel. The facility's policy on pressure prevention, which includes moisturizing the skin and keeping it clean and dry, was not followed. The resident, who had chronic kidney disease, heart failure, chronic respiratory failure, COPD, and dementia, was dependent on staff for personal hygiene and bathing. However, the care plan did not include specific interventions for bathing or hygiene, despite the resident being at risk for skin breakdown due to reduced mobility. During multiple observations and interviews, it was confirmed that the resident's feet had not been washed for an extended period. Certified Resident Care Assistants and a Registered Nurse noted the buildup of dried skin and the lack of cleanliness. The Director of Health Services and the Medical Director both acknowledged that the resident's feet should not have been left in such a condition. The Executive Director also stated that residents should be presentable at all times and expected their feet to be washed and kept clean.
Failure to Address Maintenance Issue Leads to Resident Fall
Penalty
Summary
The facility failed to identify and implement appropriate safety interventions for a resident with severe cognitive impairment, leading to a fall in the shower. The resident, who was dependent on staff for bathing, slipped while being assisted by a Certified Occupational Therapy Assistant (COTA) and a Certified Resident Care Associate (CRCA). The fall was attributed to a loose metal ring on the grab bar in the shower, which startled the resident and caused a loss of balance, resulting in a skin tear and hematoma. Interviews with the staff involved revealed that the loose grab bar cover was not reported prior to the incident. The COTA and CRCA assisting the resident during the fall both noted that the loose part of the grab bar contributed to the resident's fall. The Director of Plant Operations confirmed that no work orders had been submitted for the grab bar, and upon inspection, found the circular screw cover to be improperly applied and sharp, posing a hazard. The Director of Health Services and the Executive Director were unaware of the loose grab bar cover until after the incident. The DHS acknowledged that the grab bar fitting was not properly applied and agreed that it posed a safety risk. The Executive Director emphasized the expectation that maintenance issues should be reported and repaired promptly to ensure resident safety.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #209, who was admitted on 09/25/2023. The resident's medications were not ordered from the pharmacy until the following day, resulting in the resident missing ten doses of routine medications on 09/26/2023. The facility's policy required that emergency or stat medications be available within four hours, but this was not adhered to in this case. Resident #209 had multiple diagnoses, including pneumonia, acute and chronic respiratory failure with hypoxia, sarcoidosis of the lung, acute pulmonary edema, diabetes, hypercholesterolemia, nonrheumatic aortic stenosis, and asthma. The resident was assessed to be cognitively intact with a BIMS score of 14 out of 15. The missed medications included atorvastatin, furosemide, hydrocodone-acetaminophen, ipratropium-albuterol, levothyroxine, losartan, metformin, and potassium chloride. Interviews with various staff members, including RNs and LPNs, revealed inconsistencies in the process of ordering and receiving medications. Some staff members mentioned that medications should arrive within a few hours if ordered stat, while others noted that medications could be pulled from the facility's emergency drug kit. However, in this case, the medications were not available, and the Director of Health Services and Executive Director were not aware of the issue until after the fact.
Failure to Ensure Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to ensure personal privacy for a resident with severe cognitive impairment and type 2 diabetes. The resident's blood glucose level was checked, and insulin was administered in the resident's abdomen while seated at a table in a common area with five other residents. This action was observed by surveyors and confirmed by the Licensed Practical Nurse (LPN) involved, who acknowledged that the procedure should have been conducted in the resident's room to ensure privacy. The Director of Health Services and the Executive Director both stated that they expected staff to provide treatments such as insulin injections in a private area to respect residents' dignity and privacy. The facility's policy on Resident Rights Guidelines, which emphasizes the importance of treating residents with dignity and respect, was not followed in this instance, leading to the deficiency noted in the report.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to ensure the resolution of a grievance for a resident who was unable to sleep at night due to their roommate's yelling and screaming. Despite the resident's repeated complaints to various staff members, including the Executive Director (ED), no effective measures were taken to address the issue. The resident's concerns were not documented in the facility's complaint log, and the grievance process was not completed as required by the facility's policy. Staff members, including Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), acknowledged being aware of the resident's complaints but did not take appropriate action to resolve the issue or follow the grievance process. The ED attempted to address the problem by providing earplugs, which were ineffective, and no further interventions were attempted. The Director of Health Services (DHS) and other staff members failed to document or escalate the resident's concerns properly, resulting in the resident continuing to experience sleep disturbances. The facility's failure to follow its grievance policy and ensure prompt resolution of the resident's complaint led to the deficiency identified in the report.
Failure to Implement Bowel Protocol for Resident
Penalty
Summary
The facility failed to implement the bowel protocol in accordance with physician's orders for Resident #213, who exceeded 72 hours without a bowel movement (BM) on two separate occasions. The facility's policy required the initiation of an Ineffective Bowel Pattern Event and specific interventions, including the administration of natural laxatives, Milk of Magnesia (MOM), Dulcolax suppository, and Fleets enema, if no BM occurred within specified timeframes. However, there was no documented evidence that these steps were taken during the periods from 01/05/2024 to 01/10/2024 and from 01/19/2024 to 01/26/2024, when Resident #213 went without a BM for five and seven days, respectively. Resident #213, who had severe cognitive impairment and was dependent on staff for toilet use, was admitted to the facility with diagnoses including unspecified constipation, chronic pancreatitis, severe dementia, and gastroesophageal reflux disease (GERD). The resident's care plan included monitoring for signs of constipation and notifying the physician as needed. Despite these measures, the facility did not follow the bowel protocol when the resident exceeded 72 hours without a BM, and there was no documentation of the required assessments or interventions. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and the Medical Director, revealed that the facility's electronic medical record (EMR) system did not flag when a resident had no BM for three days, requiring nurses to manually check the vital sign section. Staff acknowledged that the bowel protocol should have been initiated and the Medical Director notified when Resident #213 went without a BM for extended periods. The Director of Health Services (DHS) also confirmed that the bowel protocol was not followed and that the BM report, which was previously posted for staff review, had not been posted for about a year.
Failure to Provide Necessary Foot Care
Penalty
Summary
The facility failed to provide necessary foot care for a resident, leading to a deficiency. The resident, who had diagnoses including unspecified dementia, chronic respiratory failure with hypoxia, chronic kidney disease with heart failure, and COPD, was observed with toenails extending half an inch to one inch beyond the tips of their toes. The resident was dependent on staff for personal hygiene and had not expressed any rejection of care. Despite this, there were no documented interventions addressing toenail care in the resident's care plan, and the facility did not have a policy for toenail care. Multiple observations and interviews revealed that the resident's toenails were excessively long and had not been trimmed. Certified Resident Care Assistants (CRCAs) and a Registered Nurse (RN) confirmed the need for toenail care but stated that the issue had not been reported or addressed. The Director of Health Services (DHS) and the Director of Social Services (DSS) were responsible for coordinating podiatry services, but the resident had not received any podiatry care since admission. The podiatrist's visits were infrequent, and recent cancellations had further delayed care. The Medical Director stated that the facility should have arranged for the resident's toenails to be trimmed by an outside source. The DSS confirmed that podiatry services had not been discussed with the resident, and the podiatry provider confirmed that the resident had never been seen. This lack of coordination and communication led to the resident's toenails becoming excessively long, resulting in the deficiency noted in the report.
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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) |
|---|---|---|---|---|
| Jeffersontown Rehabilitation | 3.2 mi | ★★★★★ | 3 | 0 |
| Signature Healthcare Of East Louisville | 4.5 mi | ★★★★★ | 0 | 0 |
| The Springs At Stony Brook | 5.2 mi | ★★★★★ | 0 | 0 |
| Klondike Nursing And Rehabilitation Center | 6.1 mi | ★★★★★ | 2 | 0 |
| Louisville East Post Acute | 6.2 mi | ★★★★★ | 12 | 2 |
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