Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Home Of The Innocents during CMS and state inspections, most recent first.
A resident with severe disabilities and requiring 1:1 supervision was placed in isolation for a contagious illness. During this time, staff positioned the resident's bed to block the doorway, preventing the resident from exiting the room while in a wheelchair. Staff interviews confirmed the bed was intentionally placed to restrict movement, contrary to the care plan, resulting in involuntary seclusion.
A resident with severe cognitive impairment and behavioral issues reported being hit by a CNA, but the facility delayed reporting the abuse allegation to OIG, citing the resident's history of making unsubstantiated claims. Staff and leadership were inconsistent in following the policy requiring immediate reporting, resulting in the report being submitted two days after the allegation was made.
A resident with cerebral palsy was admitted with an abdominal bruise, but the facility did not conduct a full internal investigation into the injury of unknown origin. Facility staff paused interviews and investigative steps, believing that CPS involvement required them to stop their own investigation, despite CPS stating otherwise. As a result, necessary interviews and documentation were not completed, and the incident was not discussed in the QAPI meeting.
A resident with autism and cerebral palsy continued to receive a discontinued antipsychotic medication at school due to the facility's failure to properly communicate the medication change to both the school and pharmacy. The required written notifications and forms were not completed or sent, resulting in the school administering the medication for several days after it had been discontinued. The error was discovered only after the resident was hospitalized for a change in mental status.
Failure to Use Beard Guards in Kitchen: The facility did not ensure proper hair restraints were used in the kitchen. The Dietary Director was observed in the kitchen with a full beard uncovered while handling inventory and carrying exposed food, and an employee was later observed preparing lunch and moving uncovered pans of food without a beard guard despite facial hair. Interviews showed staff had been trained on hair restraints, but the Dietary Director did not enforce beard guard use and believed a trimmed beard did not require one.
Resident Subjected to Involuntary Seclusion Due to Bed Placement
Penalty
Summary
A deficiency occurred when a resident with severe intellectual disabilities, spastic quadriplegic cerebral palsy, tracheostomy, and gastrostomy status was subjected to involuntary seclusion. The resident, who required 1:1 supervision when up in his wheelchair due to lack of self-mobility and safety awareness, was placed in isolation for rhinovirus and was not to be left unattended in his room. On the day of the incident, staff positioned the resident's bed in such a way that it blocked the resident from exiting his room freely while he was in his wheelchair. Multiple staff interviews confirmed that the bed was intentionally placed to prevent the resident from leaving the room, with some staff believing this was an acceptable practice during isolation precautions. The resident was visible from the window, but did not have the ability to leave the room independently due to the bed's placement. The care plan specifically required direct supervision and prohibited leaving the resident unattended when up in his wheelchair, but this was not followed. The incident was observed by a nurse manager during rounds, who found the resident blocked in his room and subsequently moved the bed. Staff involved in the incident acknowledged the bed was positioned to restrict the resident's movement, and there was a lack of clarity among some staff regarding the appropriateness of this action. The event was documented and reported, and the facility's investigation confirmed that the resident was involuntarily secluded by staff action.
Failure to Timely Report Allegation of Abuse Due to Staff Judgment on Resident Credibility
Penalty
Summary
The facility failed to ensure that all allegations of abuse and injuries of unknown origin were reported to the State Survey Agency (SSA) within the required two-hour timeframe. Specifically, a resident with severe cognitive impairment and a history of Lesch Nyhan Syndrome, which includes symptoms of uncontrollable self-injury and behavioral issues, reported to staff that a Certified Nursing Assistant (CNA) had been hitting him at night. Although the facility's policy required immediate reporting of such allegations, the initial report to the Office of Inspector General (OIG) was not submitted until two days after the allegation was made. Interviews with facility staff revealed that while staff were trained to report allegations of abuse to leadership immediately, there was confusion and inconsistency among leadership regarding the necessity and timing of reporting, especially when the resident was known to make frequent and sometimes unsubstantiated claims. The QAPI Manager initiated an internal investigation but did not initially plan to report the allegation due to the resident's history of making false accusations. The decision to report was only made after consultation with the Chief Quality and Compliance Officer, who emphasized the importance of reporting regardless of the resident's diagnosis. Further interviews with the DON and Administrator indicated a reliance on the QAPI Manager to determine reportability and a lack of clarity about the required reporting timeframes. The Administrator stated that if a resident was not considered a reliable reporter and there was no corroborating evidence, the incident might not be reported. Ultimately, the delay in reporting the allegation was attributed to the staff's judgment about the credibility of the resident's report, rather than adherence to the facility's policy and federal requirements.
Failure to Investigate Injury of Unknown Origin Due to Misinterpretation of CPS Involvement
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an injury of unknown origin for a resident with cerebral palsy who was admitted with an abdominal bruise. The facility's policy required the QAPI Manager or designee to initiate an investigation for any allegation of abuse, neglect, or misappropriation, and to take immediate action to ensure resident safety. However, there was no documented evidence in the resident's medical record or in the facility's Final Report/5 Day Follow Up that a full internal investigation was initiated regarding the abdominal bruise. The facility paused interviews and other investigative steps, citing their interpretation of state law and guidance from their experience as a childcare agency, believing that interviewing during an active Child Protective Services (CPS) investigation would be considered obstructive. Despite this, the CPS Case Manager clarified that CPS never advised the facility to halt its internal investigation and that most facilities begin their own investigations immediately. Facility leadership, including the QAPI Manager, DON, and Administrator, confirmed that their practice was to stop interviews and internal investigation processes when CPS was involved, based on their understanding of regulatory requirements. As a result, necessary interviews and investigative actions were not completed, and the incident was not discussed in the QAPI meeting. The lack of a thorough internal investigation meant the facility did not fully determine the cause of the injury or whether staff had followed policies and procedures.
Failure to Communicate Discontinued Medication Order Led to Continued Administration
Penalty
Summary
The facility failed to ensure that a resident's discontinued medication order was properly communicated to both the resident's school and the contracted pharmacy, resulting in the administration of a discontinued medication. The process breakdown began when a physician discontinued the resident's Aripiprazole order, but the required school forms and notifications were not completed or sent. The Resident Education Nurse Coordinator verbally communicated the discontinuation to the school but did not follow the established process of completing and faxing or emailing the appropriate forms. As a result, the school and pharmacy were not formally notified of the medication change. The resident, who had diagnoses including autism and spastic quadriplegic cerebral palsy, was admitted with behavioral challenges such as refusals of care and physical behaviors. The resident's Aripiprazole order was initially communicated to the school and pharmacy, and the medication was delivered to the school after the order had already been discontinued. Due to the lack of formal written notification, the school nurse continued to administer Aripiprazole to the resident for eight days after the discontinuation, only becoming aware of the error following the resident's hospitalization for a change in mental status. Interviews with facility staff and the contracted pharmacy confirmed that the pharmacy and school did not receive timely or proper notification of the medication discontinuation. The facility's policy required daily order reviews and written communication of medication changes, but this process was not followed. The deficiency was identified through a root cause analysis, which found that the medication-order double-check process failed and that communication lapses led to the continued administration of a discontinued medication.
Failure to Use Beard Guards in Kitchen
Penalty
Summary
The facility failed to ensure food service safety in accordance with professional standards related to the use of beard guards in the kitchen. The facility’s policy titled Personal Hygiene SOP required staff to wear suitable and effective hair restraints while in the kitchen, and the Infection Control - Kitchen section of the Dietary Rounds checklist stated that all employees were to wear a head covering while in the kitchen. The training orientation packet also required dietary staff to review the Food Safety Plan and sign for acknowledgement of the procedure for wearing effective hair restraints while in the kitchen. On 09/09/2025, the Dietary Director, who had a full beard, was observed in the main kitchen without a beard guard while completing inventory directly in front of food being prepared. On 09/10/2025, he was observed carrying a tray of meat into the walk-in refrigerator without a beard guard, with his beard uncovered and the tray of meat fully exposed. Later that morning, [NAME] 1 was observed preparing lunch and transporting uncovered pans of food from the oven to the warmer without wearing a beard guard, despite facial hair ranging from approximately 1/2 inch to 1-2 inches in length. During interview, the Dietary Director stated beard and hair nets were stored in his office and acknowledged he had not instructed [NAME] 1 to wear a beard guard if his beard was trimmed up. He also stated he knew [NAME] 1 was not wearing a beard guard and noted beard guard use was not in written policy. The Manager of Food Service stated beard guards were part of proper kitchen attire and that she had made both male staff aware of the importance of wearing hair nets and beard guards, but said it was disregarded because the Dietary Director did not enforce it. [NAME] 1 stated he had received training on hair restraints and had been told by the Dietary Director that his beard was short enough that a beard guard was not required.
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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) |
|---|---|---|---|---|
| Kindred Hospital - Louisville | 0.7 mi | ★★★★★ | 3 | 0 |
| Nazareth Home Clifton | 1.3 mi | ★★★★★ | 0 | 0 |
| Sycamore Heights Health And Rehabilitation | 1.4 mi | ★★★★★ | 9 | 0 |
| Clifton Heights | 1.6 mi | ★★★★★ | 11 | 1 |
| River Oaks Health & Rehabilitation | 1.7 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.