Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Klondike Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with respiratory issues was not assessed for the ability to self-administer albuterol, as required by facility policy. Despite this, nursing staff left the medication at the resident's bedside multiple times. The ADON confirmed the lack of assessment and the need for staff education, while the DON and Administrator were unaware of the oversight.
The facility failed to transmit quarterly MDS assessments for two residents within the required timeframe. The new MDS Coordinator, unaware of the need for manual transmission, completed the assessments but transmitted them late. The DON and Administrator noted the Coordinator was still adjusting to the facility's procedures.
The facility's IDT failed to review and revise the care plan for a resident, resulting in 22 falls in 2023, including a subdural hematoma and rib fracture. Despite interventions, the care plan was not updated to reflect the resident's changing needs and abilities, leading to inadequate fall prevention measures.
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents. One resident sustained twenty-two falls in 2023, with seventeen being unwitnessed, and suffered a subdural hematoma and a rib fracture. Another resident, who required a mechanical lift for transfers, was not transferred according to the care plan, resulting in a laceration that required emergency treatment. The facility's policies on safety and fall risk management were not adequately followed.
The facility failed to protect residents from sexual abuse, as evidenced by multiple incidents of inappropriate touching among residents with cognitive impairments. Despite being aware of the residents' tendencies, the facility did not implement effective measures to prevent these incidents.
A resident with severe cognitive impairment was injured during a transfer when staff failed to use the required mechanical lift, leading to a laceration that required emergent treatment. The incident highlighted a breakdown in communication and adherence to the resident's care plan.
A medication administration error occurred when a CNA/CMT and an RN simultaneously administered medications, potentially giving one resident another's medication. This led to the resident being sent to the hospital for evaluation. The facility's policy mandates that medications be administered safely and as prescribed, with the individual administering medications verifying the resident's identity, which was not followed in this instance.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R54, was assessed for the ability to self-administer medications, specifically albuterol sulfate inhalation nebulization solution. The facility's policy requires an interdisciplinary team (IDT) assessment to determine if self-administration is clinically appropriate and safe. However, R54, who has a medical history of acute and chronic respiratory failure with hypoxia and COPD, was not assessed by the IDT for self-administration. Despite this, nursing staff left medication at the resident's bedside on multiple occasions without the necessary assessment and documentation in the medical record or care plan. Observations revealed that vials of albuterol were left on R54's over-the-bed table on several dates. The Assistant Director of Nursing (ADON) confirmed that the resident had not been assessed for self-administration and acknowledged the need to educate the nursing staff to prevent leaving medications with the resident. The Director of Nursing (DON) and the Administrator were also unaware of the situation, with the DON stating that an assessment was required to ensure the resident's competence in self-administering medications. The Administrator expected staff to follow the policy and obtain a physician's order for self-administration, which had not been done in this case.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for two residents, R22 and R14. The MDS assessments were not transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required 14 days of the MDS completion date. Specifically, both residents' assessments, with an Assessment Reference Date (ARD) of 11/09/2024, were completed on 11/23/2024 but were not transmitted until 12/09/2024, as revealed by the facility validation report dated 12/18/2024. The deficiency occurred due to the MDS Coordinator's lack of awareness that she needed to manually transmit the MDS assessments, as her previous facility had an automatic transmission system. The MDS Coordinator began her employment on 11/10/2024 and acknowledged the late transmission of the assessments. The Director of Nursing (DON) and the Administrator both noted that the new MDS Coordinator was still acclimating to the facility's policies and procedures, which contributed to the delay in transmission.
Failure to Revise Care Plan Leads to Multiple Falls
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to review and revise the comprehensive care plan for Resident 9 (R9) with each assessment, including both the comprehensive and quarterly review assessments, to prevent falls. R9 sustained twenty-two falls in 2023, one of which resulted in a subdural hematoma and another in a rib fracture. Despite the facility's care plan interventions, such as encouraging the use of a walker and anti-tippers on the wheelchair, these measures were not effectively implemented or updated according to R9's changing needs and abilities. For instance, the Director of Rehabilitation (DOR) noted that R9 did not have the cognitive ability to use a reacher and could not lock the brakes on the wheelchair, yet these interventions remained in the care plan without revision. The facility's policies required a baseline care plan within 48 hours of admission and a comprehensive care plan within 21 days, which should be updated as needed. However, the care plan for R9 was not adequately revised despite multiple falls and changes in the resident's condition. The facility's fall reports indicated that many of R9's falls were unwitnessed and occurred during nighttime hours, often related to toileting needs. Despite these incidents, the care plan interventions were not effectively adjusted to address the root causes of the falls, such as the resident's inability to use certain assistive devices and the need for more frequent monitoring. Interviews with staff, including the Assistant Director of Nursing (ADON), Registered Nurse (RN) 8, and the Director of Nursing (DON), revealed a lack of communication and coordination in updating and following the care plan. The DOR admitted that some interventions were no longer appropriate for R9, and the MDS Coordinator emphasized the importance of updating care plans to prevent incidents. The DON acknowledged that the facility had tried various interventions but failed to revise the care plan adequately. The Administrator also highlighted the need for more frequent rounds and checks for residents at high risk of falls, which were not consistently implemented for R9.
Failure to Prevent Accidents and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents. One resident, who had a history of dementia and severe cognitive impairment, sustained twenty-two falls in 2023, with seventeen of these falls being unwitnessed or having unidentified witnesses. Despite the resident's frequent falls, the facility only initiated one intervention related to the resident's falls and toileting issues nearly nine months after the resident had already sustained seventeen falls. The resident suffered a subdural hematoma and a rib fracture as a result of these falls, indicating a lack of timely and effective interventions to prevent further incidents. Another resident, who required a mechanical stand-alone transfer lift for transfers, was not transferred according to the care plan on one occasion. Instead, the staff used a different method, resulting in the resident sustaining a laceration to the lower right leg that required emergency treatment. The facility's failure to follow the care plan for this resident led to an avoidable injury, highlighting a lapse in adherence to established safety protocols. The facility's policies on safety and supervision, as well as fall risk management, emphasize the importance of creating a safe environment and implementing resident-centered fall prevention plans. However, the facility did not adequately follow these policies, as evidenced by the incomplete documentation and lack of timely interventions for the residents involved. Interviews with staff revealed a lack of consistent and effective strategies to prevent falls and ensure resident safety, further contributing to the deficiencies observed.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by multiple incidents involving inappropriate touching among residents. Resident 4 (R4) was involved in two separate incidents where he/she touched other residents inappropriately. On one occasion, R4 touched Resident 3's (R3) knee and made a sexually suggestive comment. Despite R4's history of sexually inappropriate behavior, the facility did not have a care plan addressing these behaviors. In another incident, R4 was observed rubbing Resident 5's (R5) buttock during breakfast. R5, who had severe cognitive impairment, was unable to consent to such contact. The facility's response included starting R4 on a Climara patch and implementing one-on-one supervision, but these measures were not in place at the time of the incidents. Resident 6 (R6) was also involved in an incident of inappropriate touching. R6, who had a history of physical behaviors and severe cognitive impairment, was observed with his/her hand under R5's shirt, touching R5's breast. Despite R6's known history of touching others and R5's severe cognitive impairment, the facility's care plans did not adequately address these behaviors. Staff interventions were limited to encouraging R5 to keep his/her hands to himself/herself, which was insufficient given R5's cognitive state. Interviews with staff and family members revealed that the facility was aware of the residents' tendencies to touch others inappropriately but failed to implement effective measures to prevent such incidents. The Director of Nursing (DON) and the facility's Administrator acknowledged the need for frequent rounding and keeping residents engaged in activities to prevent inappropriate touching. However, these measures were not consistently applied, leading to repeated incidents of sexual abuse among residents.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for a resident who required the use of a mechanical stand-alone lift for transfers. On one occasion, staff transferred the resident from the bed to the wheelchair without using the mechanical lift, resulting in a laceration to the resident's lower right leg that required emergent treatment. The resident had severe cognitive impairment and was assessed to need extensive physical assistance for transfers, which was not followed by the staff during the incident. The facility's policies on care plans and safety and supervision of residents were not adhered to, as the staff did not use the mechanical lift as care planned. The incident occurred when a CNA performed a stand-pivot-sit transfer instead of using the mechanical lift, leading to the resident's injury. The LPN present during the transfer was unaware that the mechanical lift was required for the resident, indicating a communication breakdown regarding the resident's care plan. Interviews with facility staff, including the Director of Rehab, MDS Coordinator, DON, and Administrator, revealed that the care plan was not effectively communicated or followed. The Director of Rehab and the LPN were not aware of the requirement for a mechanical lift, and the MDS Coordinator emphasized the importance of care plans as communication tools. The DON and Administrator acknowledged that not following care plans could lead to potential incidents and unmet resident needs.
Medication Administration Error
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with accepted standards of clinical practice for one of twenty-six sampled residents, Resident #6. On the morning of 10/04/2023, a CNA/CMT and an RN were administering medications simultaneously and might have administered Resident #19's medication to Resident #6. This led to Resident #6 being transferred to the hospital Emergency Department for evaluation and observation of possible adverse effects. The facility's policy on administering medications, revised in 04/2019, mandates that medications be administered in a safe and timely manner, and as prescribed, with the individual administering medications verifying the resident's identity before giving the medications. However, this protocol was not followed in this instance, leading to a potential medication error. Resident #6, who was admitted to the facility on 11/29/2021, has diagnoses including unspecified Dementia, Altered Mental Status, and unspecified Psychosis not due to a substance or known physiological condition. On 10/04/2023, a change in condition was noted after the nurse notified the ADON that Resident #6 was administered the wrong medications. The on-call provider was notified, and a new order was received from the Physician to send Resident #6 to the ED for closer monitoring. Resident #19, who was admitted on 12/06/2022, has diagnoses including Cerebral infarction due to unspecified occlusion, Type 2 Diabetes Mellitus, and Unspecified Convulsions. Resident #19's scheduled medications for the morning of 10/04/2023 included several medications, some of which were potentially harmful to Resident #6. Interviews with staff and residents revealed that the CNA/CMT had prepared medications for both Resident #6 and Resident #19, which were then administered by the RN. This practice is against the facility's policy and accepted standards of clinical practice, which require that medications be prepared and administered by the same individual, one resident at a time, to minimize the risk of errors. The RN admitted to not following protocol and administering medications that were prepared by the CNA/CMT. Resident #6 was sent to the hospital for evaluation and returned to the facility the same afternoon after exhibiting no symptoms from receiving the wrong medications.
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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) |
|---|---|---|---|---|
| Louisville East Post Acute | 1.3 mi | ★★★★★ | 12 | 2 |
| Seneca Place | 1.4 mi | ★★★★★ | 0 | 0 |
| The Springs At Stony Brook | 2 mi | ★★★★★ | 0 | 0 |
| Cherokee Park Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of East Louisville | 2.8 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.