Average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Willows At Springhurst during CMS and state inspections, most recent first.
Uncovered Hair in Food Service Area: A Cook was observed in the kitchen with a hair net that did not cover the side or back of her hair, leaving about eight inches of hair exposed while around food. The facility policy required all dining service employees to wear hair restraints, and the DFS and ED stated staff were expected to follow the policy.
A resident with bipolar disorder, dementia, depression, anxiety, and paranoid personality disorder developed new psychiatric concerns, including delusions, mania, psychosis, and paranoia, but the facility did not submit the new qualifying diagnoses for PASRR Level II review. Staff stated the diagnoses should have been entered into KLOCS, yet the MDS Coordinator found they were not submitted, and the DON confirmed the resident should have been referred when the new diagnoses were identified.
A resident with type II DM and CHF had insulin lispro ordered before meals, but RN 2 administered 6 units after lunch rather than at the ordered time. The eMAR documented the dose in the lunch timeframe, while surveyor observation showed the insulin was actually given later in the afternoon. Staff stated insulin should be given before meals and at the right time based on blood glucose readings, and the DHS expected staff to follow the five rights of medication administration.
An RN administered insulin to a resident with DM without wearing gloves, and the resident did not sanitize hands while in the room. Facility policy required hand hygiene and glove use for injectable medication administration, and staff interviews confirmed the expectation that these infection control steps be followed.
Uncovered Hair in Food Service Area
Penalty
Summary
The facility failed to prepare, store, and serve food under sanitary conditions for 51 of 52 residents who received food from the kitchen. During observation, the Cook was seen with a hair net that did not cover the side or back of her hair, with approximately eight inches of hair left uncovered while in the kitchen and around food. The facility's Hair Restraint Policy, revised 07/09/2025, required all dining service employees to wear hair restraints as required by the Federal Food Code, which states food employees shall wear hair restraints such as hats, hair coverings, or nets designed and worn to keep hair from contacting exposed food. During interview, the Cook stated employees were to wear a hair net that covered all hair when in the kitchen and around food, and said she had a lot of hair. The DFS stated staff should wear hairnets or hats that covered the hair and that he had just seen the Cook's hair out of the hair net. The Executive Director stated she expected staff to follow the policies and that she rounded periodically to assure policies were followed.
Failure to Refer Resident With New Psychiatric Diagnoses for PASRR Level II Review
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorder for Level II PASRR evaluation. Resident 5 was originally admitted with diagnoses including acute and chronic respiratory failure, bipolar disorder, dementia, major depressive disorder, generalized anxiety disorder, and paranoid personality disorder, and the initial PASRR completed on 07/01/2022 did not indicate a Level II referral. The resident’s comprehensive care plan later documented altered behaviors including delusions and medication for bipolar disorder, and the quarterly MDS with an ARD of 07/18/2025 coded bipolar disorder as an active diagnosis while also scoring the resident 15/15 on the BIMS. Record review showed the resident was sent to an outside hospital for psychiatric evaluation after exhibiting psychiatric concerns, and the hospital discharge summary documented hospitalization for bipolar disorder with recent mania and psychosis. When the resident returned to the facility, the diagnoses included bipolar I, psychosis, and paranoia. During interviews, staff stated that new qualifying diagnoses should have been submitted through KLOCS for PASRR review, but the MDS Coordinator found that the resident’s new diagnoses had not been submitted. The Director of Health Services stated the resident should have been referred for a Level II evaluation when the new qualifying diagnoses were received, and the Executive Director stated the facility did not have a specific PASRR policy and followed CMS and state guidelines.
Medication Given Outside Ordered Time
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors and received medications at the right time. The resident had a history of type II diabetes and congestive heart failure and was identified as having a risk for hypoglycemia and hyperglycemia in the care plan. On 09/17/2025, the resident’s blood glucose readings were 123 at 9:37 AM, 255 at 10:27 AM, and 124 at 4:17 PM. The resident’s order for insulin lispro required administration before meals within specified timeframes, including 10:00 AM - 12:30 PM for the lunch dose. The eMAR showed RN 2 documented 6 units of lispro insulin during the 10:00 AM - 12:30 PM timeframe, but surveyor observation later that day showed RN 2 administering 6 units of lispro insulin at 2:27 PM, after the resident had finished lunch. During interview, RN 2 stated that was when he got to the resident to administer the insulin. Staff interviews indicated insulin was expected to be given before meals and at the right time based on blood glucose readings, and the DHS stated staff were expected to follow the medication administration policies and the five rights of medication administration.
Failure to Follow Hand Hygiene and Glove Use During Insulin Injection
Penalty
Summary
The facility failed to follow infection prevention and control practices during subcutaneous insulin administration for one resident. The resident was admitted with diagnoses including type II diabetes and CHF, and the care plan identified a risk for hypoglycemia/hyperglycemia related to diabetes mellitus. During observation, an RN entered the resident’s room and administered insulin subcutaneously, but the resident did not sanitize hands while in the room and the injection was given without gloves. Facility policies reviewed required hand hygiene before and after direct resident contact and specified that gloves were part of the equipment for injectable medication administration, including subcutaneous injections. During interviews, the RN stated he performed hand hygiene before entering the room but administered the insulin without gloves. Other staff, including an LPN, the Infection Preventionist, the DHS, and the Executive Director, stated they expected staff to perform hand hygiene and wear gloves before giving injections and that this was part of the facility’s infection prevention and control practices.
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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) |
|---|---|---|---|---|
| Signature Healthcare At Jefferson Manor Rehab & We | 2.5 mi | ★★★★★ | 0 | 0 |
| The Episcopal Church Home | 2.5 mi | ★★★★★ | 13 | 1 |
| Lyndon Crossing | 2.5 mi | — | 3 | 2 |
| Signature Healthcare At Jefferson Place Rehab & We | 2.7 mi | ★★★★★ | 0 | 0 |
| Forest Springs Health Campus | 3.6 mi | ★★★★★ | 3 | 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.