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 Louisville East Post Acute during CMS and state inspections, most recent first.
A plan to meet a resident's most immediate needs was not created or put into place within 48 hours of admission, as required. The facility did not ensure that a process was followed to assess and address the urgent needs of the newly admitted resident in a timely manner.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
The facility failed to serve meals that were palatable and attractive, as observed during a state survey. Residents reported ongoing issues with food being unappetizing, watery, and poorly plated, with liquids from one dish running into others. Observations during meal service confirmed these complaints, and the Dietary Manager acknowledged the issue, noting a lack of sufficient bowls and staff education on proper plating techniques.
The facility failed to ensure proper disposal of garbage, affecting all 172 residents. A trash compactor was observed with a large pile of dirty and decaying trash underneath it, contrary to the facility's policy requiring food waste to be kept in containers and inaccessible to pests. The Dietary Manager acknowledged the issue, noting the compactor was no longer used and the area was not frequently checked.
The facility's pest control program failed to prevent a roach infestation, with live roaches observed in resident rooms and the kitchen. Residents and staff reported sightings, and the pest issue had worsened over recent months. Despite regular treatments by a pest control company, the cause of the infestation was not identified, and the Administrator minimized the problem, suggesting pests were part of a homelike environment.
The facility failed to provide complete Notices of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) for three residents. The NOMNCs lacked required TTY information, and the SNFABNs were incomplete, missing resident details and explanations for non-coverage. Two residents, one with intact cognition and another severely impaired, opted out of services due to these deficiencies. The Business Office Manager and Administrator were unaware of the correct procedures.
The facility failed to provide written transfer notifications to residents or their representatives for emergency hospital transfers. Three residents, including those with severe cognitive impairment, were transferred without documented evidence of notification. Interviews revealed that the facility staff were unaware of the requirement to send such notifications.
A resident at high risk for falls did not have a comprehensive care plan addressing this risk, despite facility assessments indicating the need. Interviews with the DON and MDSC confirmed the omission, acknowledging the expectation for a care plan to mitigate fall risk.
The facility failed to provide adequate pressure ulcer care for two residents. One resident did not receive heel-lift boots on both feet as ordered, and a pressure ulcer was missed during a skin assessment. Another resident's pressure ulcer treatments were inconsistently documented, with no records of refusals or physician notifications. These deficiencies highlight lapses in following treatment plans and documenting care.
The facility failed to provide timely medication administration for two residents, leading to missed doses of Eliquis for one resident and delayed pain management for another. The issues arose from a lack of communication and procedural adherence, with staff failing to utilize available emergency medication and notify physicians of missed doses.
Expired hydrogen peroxide and glucose control solutions were found in a medication storage room. An LPN confirmed the expiration and removed the items. Interviews revealed inconsistencies in the process of checking for expired medications, with responsibilities unclear between nursing staff and pharmacy audits.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in PPE use, equipment disinfection, and hand hygiene. An LPN did not wear a gown during wound care for a resident under Enhanced Barrier Precautions. Another LPN failed to disinfect a personal blood pressure cuff immediately after use. Additionally, an LPN did not perform hand hygiene between glove changes during wound care. These lapses highlight a lack of adherence to infection control policies.
Failure to Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address a resident's most immediate needs within 48 hours of admission was not created or implemented. The deficiency occurred due to the facility's failure to ensure that a process was in place to assess and meet the immediate needs of newly admitted residents within the required timeframe. This omission resulted in the lack of documented evidence that the resident's urgent needs were identified and addressed promptly after admission.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Deficiency in Meal Presentation and Palatability
Penalty
Summary
The facility failed to serve meals that were palatable and attractive, as observed during a state survey. Multiple residents expressed concerns about the food being unappetizing, watery, and poorly plated, with liquids from one dish running into others. This issue was highlighted during interviews with several residents, who reported that the problem had been ongoing and previously brought to the attention of the staff without resolution. Residents described the food as bland, overcooked, and visually unappealing, with some meals turning soggy due to improper plating. Observations during meal service confirmed these complaints. During lunch and dinner services, cooks were seen serving meals where liquids from vegetables and other dishes spread across the plates, making the food appear soupy and unappetizing. The facility's policy on enhancing the dining experience emphasized the importance of attractive presentation and using separate dishes for foods with liquids, but this was not adhered to during the observed meal services. The Dietary Manager acknowledged the issue, noting that the facility lacked sufficient bowls to properly serve liquid-heavy dishes, although an order for more bowls had been placed and received. Despite this, no education had been provided to dietary staff on proper draining and plating techniques to prevent liquids from running on the plates. The deficiency was further underscored by the lack of a plan of action to address the residents' concerns about food palatability.
Improper Garbage Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, affecting all 172 residents. The facility's policy, dated October 2017, requires all food waste to be kept in containers and stored in a manner inaccessible to pests, with outside dumpsters kept closed and free of surrounding litter. However, during an observation, a trash compactor in the outdoor dumpster area was found with a large pile of dirty and decaying trash underneath it on the ground. The Dietary Manager confirmed the trash was piled on the ground and acknowledged the potential to attract bugs and rodents, stating the compactor was no longer used and she did not often visit the dumpster area.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live roaches in resident rooms and the kitchen's dry storage area. Observations during facility tours revealed roaches in specific resident rooms and the kitchen, with residents and staff confirming sightings. The facility's pest control policy, last revised in 2008, mandates an ongoing program to keep the building free of pests, but the Pest Activity Log showed treatments for various pests without specifying the effectiveness or follow-up actions. Interviews with residents indicated that roaches were a recurring issue, with one resident reporting seeing roaches in his room and another resident witnessing roaches almost every night. Staff interviews revealed that while some had not personally seen roaches, they were aware of the problem through discussions with colleagues. The Assistant Dietary Manager noted that the pest issue had worsened over the past few months, and the Director of Environmental Services acknowledged that roaches had been a persistent problem, particularly in certain resident rooms. The facility had contracted with a pest control company since 1992, with treatments occurring twice monthly and additional treatments as needed. However, the pest control representative could not identify the cause of the infestation. The Director of Nursing was not involved in pest control meetings, and the Administrator downplayed the issue, suggesting that pests were a normal part of a homelike environment. Despite discussions in Morning Meetings, there was no formal education for staff on reporting or preventing roaches, and the Administrator did not recall any family complaints about the issue.
Deficiencies in Issuing Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) with all required appeal contact information for three residents, and did not correctly complete the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for two of these residents. This deficiency was identified during interviews and record reviews. The NOMNCs provided to the residents did not include the required teletypewriters (TTY) information, which is essential for deaf and hard of hearing individuals to use the phone. Additionally, the SNFABNs were incomplete, lacking the residents' names and patient identification numbers, and did not provide the necessary information about why services would not be covered. For Resident 13, the facility issued both the NOMNC and SNFABN on the same day, but the SNFABN was missing critical information such as the resident's name and patient ID. The form also failed to complete the 'Because' section, which should explain why Medicare would not cover the services. Resident 13, who had intact cognition, chose not to receive any skilled nursing or therapy services. Similarly, Resident 58's SNFABN was incomplete, and the resident, who was severely cognitively impaired, also opted out of receiving services. The facility did not follow the correct instructions for the SNFABN form, instead using instructions meant for an ABN form. Resident 219's NOMNC also lacked the TTY number. The Business Office Manager admitted to creating the forms without knowledge of the TTY requirement and was unaware that the ABN instructions were not applicable to the SNFABN. The Administrator claimed to have followed the instructions from the Center for Medicare and Medicaid Services (CMS), but the NOMNC instructions were not provided before the survey exit.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification of transfer to the resident or their representative for three out of five sampled residents who were transferred to the hospital. This deficiency was identified through interviews, record reviews, and a review of the facility's policy. The facility's policy, revised in August 2018, required that a transfer form be prepared and the resident's representative be notified in the event of an emergency transfer. However, the facility did not have a system in place to ensure these notifications were sent, leading to a lack of documented evidence of transfer notices for the residents involved. Resident R124, who had severe cognitive impairment, was transferred to the hospital following a fall, but there was no documented evidence of a transfer notice. Similarly, Resident R73, also with severe cognitive impairment, was sent to the hospital due to a change in condition, yet no transfer notice was documented. Resident R150, who was cognitively intact, was transferred to the hospital for shortness of breath but did not receive any written notification about the transfer or her right to return. Interviews with the Business Office Manager and the Administrator revealed a lack of awareness of the requirement to send written notifications for emergency transfers.
Failure to Develop Comprehensive Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident identified as R110, who was assessed to be at high risk for falls. Despite the facility's policy requiring a care plan with measurable objectives and timetables to meet residents' needs, there was no documented evidence of a care plan addressing R110's fall risk. The resident's admission record indicated diagnoses of muscle weakness, arthritis, morbid obesity, and osteoarthritis of the left knee. The facility's assessments, including the Minimum Data Set (MDS) and Care Area Assessment (CAA), highlighted the resident's fall risk and dependency on staff for transfers, yet these were not reflected in a care plan. Interviews with facility staff, including the Director of Nursing (DON) and the MDS Coordinator (MDSC), confirmed the omission. The DON acknowledged the care plan's deficiency and stated it was expected to address and mitigate the resident's fall risk. The MDSC, responsible for developing the care plan, admitted the oversight and was unsure how the fall risk was omitted. The facility administrator also expressed the expectation that a care plan should have been developed to address the resident's fall risk.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two residents, R9 and R267, leading to deficiencies in their treatment and care. For R9, the facility did not implement the physician's order for heel-lift boots on both feet, which was crucial for preventing pressure ulcers. Observations and interviews revealed that R9 only wore a boot on the left foot, despite the order specifying boots for both feet. This oversight was confirmed by LPN12, who was unaware of the order's specifics until it was clarified with the Nurse Practitioner. Additionally, a comprehensive skin assessment for R9 was not accurately conducted, as a pressure ulcer on the left ankle was missed during the assessment on 07/11/2024, despite being present on other dates. For R267, the facility failed to administer prescribed pressure ulcer treatments consistently. The Treatment Administration Record (TAR) showed multiple instances where treatments for various pressure ulcers were not documented as completed. These omissions included treatments for ulcers on the left heel, right buttock, right hip, left dorsal foot, left hip, right ankle, left calf, left plantar foot, and right buttock. Interviews with LPN10 and the Director of Nursing (DON) indicated that R267 frequently refused care, but there was no documentation to confirm refusals or physician notifications on the TAR or in the Progress Notes for the missed treatments. The deficiencies in care for both residents highlight significant lapses in following physician orders and documenting care refusals or omissions. The lack of adherence to prescribed treatment plans and failure to accurately assess and document skin conditions contributed to the potential for further deterioration of pressure ulcers and inadequate wound healing for both residents.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were available for administration per Physician's orders for two residents, R74 and R717, which placed them at risk of harm or discomfort due to missed medication doses. R74, who was admitted with diagnoses including congestive heart failure and a history of stroke, was prescribed Eliquis (apixaban) for stroke prevention. However, there was no documented evidence that R74 received the scheduled doses on three occasions. Interviews revealed that the medication was either reordered or unavailable, and there was no documentation indicating that the physician was notified or that the medication was obtained from the emergency kit. R717 was admitted to the facility with diagnoses including an open wound and mononeuropathy. Upon admission, R717 had a Physician's order for Oxycodone-acetaminophen for pain management. However, R717 did not receive the medication until more than a day later, after experiencing severe pain. The delay was attributed to the admitting nurse using the resident's discharge summary to enter medication orders, which did not result in a prescription being sent to the pharmacy. The facility's emergency medication system had the medication available, but it was not utilized. Interviews with staff, including the LPN, Unit Manager, Nurse Practitioner, and Director of Nursing, highlighted a lack of communication and procedural adherence regarding medication availability and administration. The facility's failure to ensure timely medication administration and proper notification of missed doses contributed to the deficiencies observed in the care of R74 and R717.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to remove expired hydrogen peroxide and accu-check glucose control solutions from one of the two medication storage rooms. During an observation of the medication room at the nurses' station, two bottles of hydrogen peroxide with an expiration date of February 2023 and three boxes of accu-check glucose control solutions with an expiration date of July 5, 2024, were found. These items were confirmed to be expired by an LPN and subsequently removed from the medication room. Interviews revealed inconsistencies in the process of checking for expired medications and biologicals. The LPN mentioned that a supply person was responsible for checking expiration dates daily, while the ADON stated that unit managers and pharmacy staff performed medication cart audits, but was unsure of the frequency. The DON indicated that pharmacy staff checked the medication rooms monthly, and typically, nursing staff were responsible for checking medication carts for expired items. However, there was no designated supply person for this task.
Infection Control Deficiencies in PPE, Equipment Disinfection, and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the failure to ensure staff wore appropriate Personal Protective Equipment (PPE) for a resident under Enhanced Barrier Precautions (EBP). Specifically, a Licensed Practical Nurse (LPN) was observed providing wound care to a resident with anoxic brain damage without wearing a gown, despite the presence of signage indicating EBP. The LPN admitted to not being fully aware of the requirements for EBP, highlighting a gap in training and understanding among staff. Another deficiency was noted in the cleaning and disinfection of patient equipment. An LPN used a personal blood pressure cuff on a resident with chronic systolic heart failure and chronic kidney disease but failed to disinfect it immediately after use. The LPN claimed to sanitize the equipment later, but this practice did not align with the facility's policy or CDC guidelines, which require disinfection after each use. This lapse in protocol could potentially lead to the spread of infections among residents. Additionally, the facility did not adhere to proper hand hygiene practices during wound care for a resident with a pressure ulcer. An LPN was observed changing gloves without performing hand hygiene in between, due to the sanitizer being inaccessible. This oversight was acknowledged by the LPN and confirmed by the Unit Manager and Director of Nursing, who reiterated the expectation for hand hygiene after glove removal. These incidents collectively demonstrate a lack of adherence to established infection control policies, posing a risk to resident safety.
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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) |
|---|---|---|---|---|
| The Springs At Stony Brook | 1.2 mi | ★★★★★ | 0 | 0 |
| Klondike Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Seneca Place | 1.7 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of East Louisville | 2.1 mi | ★★★★★ | 0 | 0 |
| Westport Place Health Campus | 3 mi | ★★★★★ | 5 | 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.