Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Altercare Of Louisville Ctr For Rehab & Nsg Care during CMS and state inspections, most recent first.
Staff failed to follow hand hygiene policies during medication administration and incontinence care. An LPN administered medications to several residents in sequence, moved between resident rooms and the medication storage room, and assisted a resident with a nasal cannula without performing hand hygiene between contacts, only washing hands after adjusting the oxygen device. In a separate incident, a cognitively intact, frequently incontinent resident who depended on staff for toileting and turning received perineal care from a nurse aide in training and an LPN; both removed soiled gloves and immediately donned new gloves without hand hygiene, and there was no hand sanitizer dispenser in the resident’s bathroom, contrary to facility policies requiring hand hygiene before handling meds, before and after resident contact, and after glove removal.
A resident with multiple medical conditions, including hemiplegia and chronic heart failure, received wound care for a right lower arm skin tear without a corresponding physician order. Staff confirmed that treatment was provided and documented, but the required physician order was not present in the medical record, contrary to facility policy and the resident's care plan.
A resident with multiple chronic conditions did not receive physician-ordered wound care for pressure ulcers when the facility failed to administer treatments as prescribed, including not applying betadine to the heels due to lack of supply. Documentation and observations confirmed that wound care was missed or altered without physician authorization, and the DON acknowledged the treatments were not provided as ordered.
A resident with diabetes did not receive prescribed weekly Mounjaro injections on multiple occasions due to a nurse's documentation error and a lack of medication supply from the pharmacy, which went unnoticed by facility management. The resident missed several doses before the issue was identified and the medication was delivered.
Call Light Not Kept Within Reach: A resident with dementia, Alzheimer's disease, impaired cognition, and a history of repeated falls was observed sitting in a Broda chair while the call light was tucked under the blanket on the bed and out of reach. A CNA and later the DON both verified the call light was not within reach.
Failure to immediately notify the physician and responsible party after a resident fall. A resident with MS, unsteadiness on feet, and diabetes fell while transferring to the toilet, with inconsistent documentation about the time of the incident and no record that the nightshift agency nurse reported the fall or completed the required notifications. RN documentation later noted left knee pain and NP notification, but staff interviews confirmed the physician and responsible party were not promptly informed.
Failure to maintain resident privacy and confidentiality: two residents were affected when an EMR was left open on an unattended med cart in a hallway, showing a resident’s picture, demographic information, and medical orders, and when the DON provided wound care to another resident without closing the door or drawing the blinds. The facility policy stated that health information would be monitored and protected.
Failure to Maintain Ordered Fall Interventions: A resident with dementia, severe cognitive impairment, and repeated falls had ordered fall precautions including a low bed, a defined perimeter mattress, and a call light within reach. Surveyors observed the call light tucked out of reach, the bed not in the lowest position until a CNA lowered it, and the resident out of bed without gripper socks or shoes, with CNA and DON verification of the missed interventions.
PEG tube dressing care was not provided as ordered for a resident with aphasia, gastrostomy status, and moderate cognitive impairment. Although the MAR/TAR showed an LPN documented the care as completed, observation found the PEG site without a dressing, and a CNA confirmed the site was undressed.
Respiratory care was not provided and stored as ordered for three residents. One resident with COPD and CHF had ordered continuous O2, but the nasal cannula was found wrapped up and not being used, and an LPN confirmed it was not administered as ordered. Two other residents with significant respiratory diagnoses had aerosol masks left directly on bedside surfaces without a protective barrier, and an LPN was observed using one contaminated mask without cleaning it or getting a new one.
Missing Pre and Post Dialysis Assessments: A resident with ESRD, sepsis, diabetes, and chronic pain was ordered hemodialysis three times weekly, but required pre and post dialysis assessments were not completed on multiple occasions. An LPN stated agency nurses did not complete the assessments as required, and the DON and Regional Nurse verified the missing documentation.
Pharmacy identified a GDR issue for a resident receiving PRN Ativan for anxiety, but there was no evidence the physician reviewed or addressed the recommendation. The resident had dementia, depression, anxiety, and severe cognitive impairment, and the facility policy required medication irregularities to be reported to the physician and reviewed for continued need, dosage, side effects, and risks or benefits.
An RN failed to perform hand hygiene while administering medications to a resident. She pushed the med cart to the resident's room, obtained the resident's BP, prepared the medications, and administered them without washing her hands before entering the room, before the BP check, before giving the meds, or after leaving the room. The RN confirmed the lapse, and the facility policy required proper hand hygiene to help prevent transmission of infectious diseases.
A resident with malignant neoplasm and other conditions did not receive scheduled doses of Gabapentin due to the facility's failure to reorder the medication timely. The resident's Medication Administration Record showed missed doses, and the physician was not informed. Interviews confirmed the deficiency, highlighting delays in medication delivery.
A resident with severe cognitive impairment bit an STNA during care, leading the STNA to slap the resident, leaving a red mark. The incident was initially unsubstantiated, but further investigation revealed conflicting staff accounts. The facility's policy requires immediate reporting and investigation of abuse incidents.
A resident with severe cognitive impairment and incontinence did not receive timely incontinence care as per facility policy, which requires care every two hours. The resident was only provided care at 9:30 A.M. and 2:00 P.M., despite being dependent on staff for all personal care activities. Family concerns about care quality were also noted, including the use of a surveillance camera to monitor the resident's care.
Failure to Perform Hand Hygiene During Med Pass and Incontinence Care
Penalty
Summary
The deficiency involves failures in hand hygiene practices during medication administration and incontinence care, contrary to the facility’s own infection control and hand hygiene policies. During a morning medication pass, an LPN dispensed and administered medications to multiple residents in succession without performing hand hygiene upon exiting resident rooms or after returning from the medication storage room. Hand hygiene was not performed before handling medications or after direct resident contact, including when the LPN assisted a resident with inserting and adjusting a nasal cannula for oxygen, and handwashing only occurred after this assistance. These actions conflicted with the facility’s Medication Administration-General Guidelines and Hand Washing-Hygiene policies, which required hand hygiene before handling medications, before direct resident contact, and after direct resident contact and contact with objects near the resident. The deficiency also includes improper hand hygiene during incontinence care for a resident with epilepsy, physical debility, Type 2 diabetes, muscle weakness, major depressive disorder, urinary incontinence, and dependence on staff for toileting hygiene and turning. During observed perineal care, a nurse aide in training removed soiled gloves and immediately donned new gloves without performing hand hygiene, then continued drying and repositioning the resident. An LPN assisting with the same incontinence care removed gloves when obtaining an incontinence brief from the bathroom, then returned, handed the brief to the aide, and immediately applied new gloves without hand hygiene before continuing to assist with positioning. There was no hand sanitizer dispenser in the resident’s bathroom. These practices were inconsistent with the facility’s Perineal Care and Hand Washing-Hygiene policies, which required hand hygiene after removing gloves and before applying new gloves, and after contact with contaminated objects and intact resident skin.
Failure to Obtain Physician Order for Skin Tear Treatment
Penalty
Summary
A deficiency occurred when the facility failed to obtain a physician order for the treatment of a right lower arm skin tear for a resident with diagnoses including hemiplegia, aphasia, and chronic systolic congestive heart failure. The resident's care plan included an intervention to perform treatments as per physician orders, and the resident was assessed as having moderate cognitive impairment. Documentation showed the skin tear was first identified and measured, and wound care was provided, but there was no corresponding physician order for the treatment in the resident's medical record for the relevant period. Observations confirmed the resident had a dressing on the right arm, and interviews with staff, including a CNA and the DON, verified that wound care was being provided without an active physician order. The DON acknowledged that although a treatment plan was obtained, it was not written as a physician order. Facility policy required wound care to be provided using professional standards of practice, which was not followed in this instance.
Failure to Administer Ordered Pressure Ulcer Care Due to Lack of Supplies
Penalty
Summary
A deficiency occurred when a resident with diagnoses including end stage renal disease, cellulitis of both lower limbs, and chronic pain did not receive pressure ulcer care as ordered by the physician. The resident's care plan required wound treatments to the left medial ankle, posterior Achilles, and bilateral heels, including the use of normal saline, iodoform, betadine, and xeroform dressings. Documentation revealed that on specific dates, wound care was not administered as ordered: the wound care was placed on hold without physician authorization, and betadine was not available for use on the resident's heels. Observations confirmed that dressings were not changed as scheduled, and betadine was not applied during wound care treatments. Further review and interviews established that the facility had run out of betadine, and the DON confirmed that the resident had not received the prescribed wound care. There was no evidence in the medical record that the physician had ordered wound care to be held. The facility's policy required identification of residents at risk for pressure injuries and provision of care for existing wounds, but these interventions were not followed for this resident, resulting in a failure to provide pressure ulcer care as ordered.
Failure to Administer Diabetic Medication as Ordered
Penalty
Summary
Resident #81, who had a diagnosis of type two diabetes mellitus and was at risk for pressure injuries, was not administered his prescribed diabetic medication, Mounjaro, according to physician orders. The resident was admitted with intact cognition and required substantial assistance with mobility. Physician orders specified a weekly subcutaneous injection of Mounjaro, but review of the Medication Administration Record (MAR) showed missed doses on three separate occasions. The MAR comments incorrectly indicated the medication was discontinued or on hold, and the resident only received one dose during the period in question. Further review and interviews revealed that a nurse erroneously documented the discontinuation of Mounjaro when only the resident's Lantus insulin had been discontinued. Additionally, after the initial dose was administered, the pharmacy did not send further doses, and facility management was unaware of the missing medication until several weeks later. As a result, the resident missed multiple scheduled doses because the medication was not available in the facility, and the issue was not identified or addressed in a timely manner.
Call Light Not Kept Within Reach
Penalty
Summary
The facility did not ensure the call light was kept within reach for Resident #27. The resident was admitted with diagnoses including senile degeneration of the brain, dementia, chronic kidney disease, depression, Alzheimer's disease, impulsiveness, repeated falls, generalized anxiety disorder, psychotic disorder, insomnia, and sundowning. The quarterly MDS 3.0 assessment showed severely impaired cognition and two or more falls with no injuries. During observation on 07/22/25 at 10:42 A.M., Resident #27 was up in a Broda chair in the middle of the room, and the call light was tucked under the blanket on the bed and out of reach; a CNA verified it was not within reach. A second observation on 07/23/25 at 9:55 A.M. again found the resident in the Broda chair with the call light tucked under the blanket on the bed and out of reach, and the DON verified it was not within reach.
Failure to Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to immediately notify the physician and responsible parties after a fall involving Resident #8. Resident #8 was admitted with diagnoses including acute and chronic respiratory failure, multiple sclerosis, unsteadiness on feet, and diabetes, and the admission MDS indicated no cognitive impairment and extensive assistance with toileting. The incident log showed a fall on 07/06/25, and the resident later stated she fell around 5:00 A.M. while transferring to the toilet in her bathroom and that an agency nurse was assigned to her that shift. Documentation related to the fall was inconsistent and incomplete. The STNA witness statement did not identify the CNA who reported the fall or the exact time it occurred, and the fall investigation listed two different incident times, 5:00 A.M. and 8:30 A.M. RN #205 documented at 8:45 A.M. that the resident reported left knee pain and that the NP was notified, but there was no documentation from the agency nurse about the fall or any record that the physician and responsible party were notified at the time of the incident. Staff interviews confirmed the nightshift agency nurse did not report the fall, and the DON and Regional Nurse stated the nurse was expected to complete the investigation, notify the physician and responsible party, chart the event, and relay it in report, but did not.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential for two residents. For one resident, the electronic medical record was left open on a medication cart on the 100 hall, and the screen displayed the resident’s picture, personal demographic information, and list of medical orders while the cart was unattended and visible to anyone passing by. An LPN verified that the resident’s EMR was open in the hallway and that the private information was in view of passersby. The facility policy stated that it would monitor and protect health information, including care plans, nursing information, dietary, social service, activity, therapy, and progress notes. For another resident, wound care was provided to the right heel while privacy was not maintained. The resident was in bed during the treatment, but the DON did not close the door or draw the blinds, leaving the resident exposed to anyone outside the room or in the hallway. The resident’s record showed diagnoses including malignant neoplasm of the bone and breast, CHF, radiculopathy, diabetes, atrial fibrillation, glaucoma, and chronic kidney failure, and the physician order directed daily cleansing and dressing of the right heel wound.
Failure to Maintain Ordered Fall Interventions
Penalty
Summary
The facility failed to ensure fall interventions were in place for a resident with severe cognitive impairment and a history of repeated falls. The resident had diagnoses including senile degeneration of the brain, dementia, Alzheimer's disease, impulsiveness, generalized anxiety disorder, psychotic disorder, insomnia, sundowning, chronic kidney disease, depression, and repeated falls. The medical record showed orders for a defined perimeter mattress, keeping the bed in the lowest position when occupied, and identifying the resident as high risk for falls. The care plan identified fall risk related to behavior, confusion, antidepressants, antihypertensives, and an unsteady gait, and included interventions such as a defined perimeter mattress, low bed position, gripper socks/shoes when out of bed, and a call light for assistance sign in the room. Observations showed the resident’s call light was tucked under the blanket on the bed and out of reach while he was up in a Broda chair, and a CNA verified it was not within reach. Another observation showed the resident in bed with the bed not in the lowest position until a CNA entered the room and lowered it. A later observation showed the resident in the Broda chair in the dining room wearing regular nonslip socks instead of gripper socks or shoes, and an agency CNA verified the resident did not have gripper socks or shoes on. The DON also verified the call light was not within the resident’s reach.
PEG Tube Dressing Care Not Provided as Ordered
Penalty
Summary
The facility failed to ensure Resident #7's PEG tube dressing was administered as ordered. Resident #7 was admitted with diagnoses including aphasia following a cerebral infarction, gastrostomy status, and chronic pain syndrome, and the MDS assessment indicated moderate cognitive impairment. A physician order dated 03/26/25 directed staff to cleanse the PEG tube site with normal saline and apply a t-sponge dressing daily, and the care plan included an intervention dated 04/01/25 to administer the skin treatment to the PEG tube site as ordered. Review of the MAR and TAR from 07/01/25 to 07/21/25 showed LPN #213 documented that the PEG tube dressing care was completed. However, on 07/21/25 at 9:07 A.M., an observation found Resident #7 lying in bed with the PEG tube site visible and no dressing present on the site. During a follow-up observation at 9:18 A.M., CNA #223 confirmed that Resident #7 did not have a dressing on the PEG tube site. The facility's Enteral Feeding Site Care policy, updated 05/01/25, stated that ostomy site care for residents with enteral tubes was to be provided in accordance with professional standards.
Respiratory Equipment Not Administered and Stored Properly
Penalty
Summary
The facility failed to ensure Resident #17’s oxygen therapy was administered as ordered. Resident #17 was readmitted with diagnoses including chronic diastolic congestive heart failure, muscle weakness, and COPD, and had a care plan intervention to administer oxygen as ordered. The physician ordered continuous oxygen at 2 liters per nasal cannula with placement checks every shift for shortness of breath, and the MAR/TAR showed the therapy was implemented as ordered from 07/01/25 through 07/22/25. However, an observation on 07/21/25 at 9:39 A.M. showed the resident’s oxygen tubing via nasal cannula wrapped up and placed in a protective plastic bag hanging on the bedside dresser drawer knob, with the tubing dated 07/18/25. An LPN confirmed the oxygen therapy was not being administered as ordered and stated it was hard to keep the oxygen on the resident. The facility also failed to store aerosol masks for Residents #55 and #87 in a protective barrier to prevent contamination. Resident #55 had diagnoses including COPD, chronic respiratory failure, dysphagia, dementia, and Alzheimer’s disease, and had an order for ipratropium-albuterol nebulization twice daily; Resident #87 had diagnoses including acute respiratory failure with hypoxia, pneumonia due to COVID-19, COPD, obstructive sleep apnea, and shortness of breath, with an order for albuterol sulfate nebulization every four hours as needed. Observations showed Resident #55’s aerosol mask lying directly on the bedside table and Resident #87’s aerosol mask lying directly on the bedside stand. An LPN verified the masks were not stored in a protective barrier, and further observed the LPN pick up Resident #87’s aerosol mask from the bedside stand, place medication in the reservoir, and apply it to the resident’s face without obtaining a new mask or cleaning the contaminated one. The facility policy stated professional standards were to be followed to reduce the risk of transmission of infection when utilizing respiratory equipment.
Missing Pre and Post Dialysis Assessments
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met when pre and post dialysis assessments were not completed as required for Resident #5. The resident was admitted on 05/05/25 with diagnoses including end stage renal disease, sepsis, diabetes, and chronic pain, and the MDS identified the resident as cognitively intact. Orders showed hemodialysis scheduled for Tuesday, Thursday, and Saturday at 5:00 A.M. Review of the Pre/Post Dialysis Assessments from 06/01/25 through 07/01/25 showed missing at least one of the two required assessments on 06/05/25, 06/07/25, 06/14/25, 06/17/25, 06/21/25, 06/24/25, 06/28/25, and 07/01/25. An LPN stated that when agency nurses worked at the facility, the pre and post dialysis assessments did not get done as required for Resident #5, and verified multiple dialysis assessments were not completed. The DON and Regional Nurse stated there was no other place staff documented pre/post dialysis assessments except on the assessment form and verified the missing assessments.
Pharmacy GDR Recommendation for PRN Ativan Not Addressed
Penalty
Summary
The facility did not ensure that a licensed pharmacist’s monthly drug regimen review, including review of the medical chart and irregularity reporting, was completed in a way that addressed a gradual dose reduction recommendation for anti-anxiety medication for Resident #58. Resident #58 was admitted on 04/28/23 and had diagnoses including senile degeneration of the brain, difficulty walking, muscle weakness, dementia, depression, and anxiety. The MDS assessment showed the resident was severely cognitively impaired and required extensive assistance with activities of daily living, including supervision for eating and total dependence for toileting and showering. Physician orders for September 2024 included Ativan 1 mg every 2 hours as needed for anxiety, with the order beginning on 09/02/24 and stopping on 01/28/25. A facility GDR recommendation dated 09/09/24 showed pharmacy requested the physician address the use of as-needed Ativan for longer than 14 days, but there was no evidence the form had been reviewed by the physician. During an interview on 07/23/25 at 9:16 A.M., the Administrator confirmed the September 2024 GDR recommendation for Resident #58 was not addressed by the physician. The facility policy on Psychoactive Medication stated irregularities with medications would be reported to the physician and that the facility would comply with regulations regarding regular review of continued need, dosage, side effects, and risks or benefits.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure staff performed hand hygiene during medication administration for Resident #21. During observation of medication administration, RN #205 pushed the medication cart from the nurses station to Resident #21's room, entered the room, obtained the resident's blood pressure, returned to the medication cart to prepare medications, and then took the medications back to the resident and administered them without performing hand hygiene. After administering the medications, RN #205 returned to the medication cart and continued medication administration in the hallway. During interview, RN #205 confirmed she had not washed her hands before entering the room, before obtaining the resident's blood pressure, before administering the medication, or after leaving the room. Review of the facility's undated Hand Hygiene policy stated that employees were to conduct proper hand hygiene to aid in the prevention and transmission of infectious diseases.
Failure to Timely Reorder Pain Medication
Penalty
Summary
The facility failed to ensure timely reordering of pain medication for Resident #29, who was diagnosed with malignant neoplasm of the head, face, neck, and tongue, as well as dysphagia and gastrostomy status. The resident, who was mildly impaired with a BIMS score of 12, had a physician's order for Gabapentin 600 mg to be administered orally twice daily. However, the Medication Administration Record indicated that the resident did not receive the scheduled doses on February 10 and February 11, 2025, due to the medication being on hold while awaiting pharmacy delivery. There was no documentation in the nurse progress notes indicating that the physician was informed of the missed doses. Interviews conducted with the Director of Nursing and Resident #29 confirmed the deficiency. The Director of Nursing acknowledged that the facility nurses did not reorder the Gabapentin in a timely manner, resulting in the missed doses. Resident #29 reported experiencing delays in receiving his pain medication and missing doses because the facility failed to order the medications promptly. This deficiency was identified during an investigation of Complaint OH00162436.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from staff-to-resident physical abuse. The incident involved a resident with severe cognitive impairment who was admitted with diagnoses including vascular dementia and muscle weakness. During an attempt to provide personal care, the resident became agitated and bit a State tested Nursing Assistant (STNA) on the forearm, drawing blood. In response, the STNA slapped the resident, leaving a red handprint on the resident's face. The incident was initially unsubstantiated, but further investigation revealed conflicting accounts from the staff involved. The resident's medical record and Minimum Data Set (MDS) assessment indicated severe cognitive impairment, which may have contributed to the resident's behavioral response during care. The incident occurred when two STNAs attempted to provide incontinence care, leading to the resident's agitation and subsequent biting of the STNA. The STNA's reaction to the bite was to slap the resident, which was later confirmed by the facility's Administrator during an interview. The facility's policy on abuse, neglect, and misappropriation requires immediate reporting and investigation of such incidents, which was not fully adhered to in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident with severe cognitive impairment and incontinence of bowel and bladder. The resident, who was dependent on staff for all activities of daily living, including toileting hygiene, was observed to have received incontinence care at 9:30 A.M. and again at 2:00 P.M., despite the facility's policy requiring care every two hours. This lapse in care was confirmed by a State Tested Nursing Assistant (STNA) who acknowledged that the resident was not checked and changed every two hours as required. The resident's medical record indicated a history of Alzheimer's disease with early onset, altered mental status, and adult failure to thrive. The resident was also dependent on a Hoyer mechanical lift for transfers and required assistance with all personal care activities. Despite these needs, the facility did not adhere to its policy of routine resident checks every two hours, which was intended to ensure the safety and well-being of residents. Interviews with staff and family members revealed additional concerns, including the use of a surveillance camera by the resident's family to monitor care. The family expressed worries about the adequacy of care, including the frequency of showers and nail care, and the proper use of the Hoyer lift. The facility's failure to provide timely incontinence care was documented as a deficiency under a complaint investigation.
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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) |
|---|---|---|---|---|
| Saint Joseph Care Center | 2.1 mi | ★★★★★ | 17 | 0 |
| Green Meadows Skilled Nursing And Rehab | 2.5 mi | ★★★★★ | 0 | 0 |
| Louisville Gardens Care Center | 5.2 mi | ★★★★★ | 17 | 0 |
| Canterbury Villa Of Alliance | 5.9 mi | ★★★★★ | 3 | 0 |
| Windsor Medical Center Inc | 6.1 mi | ★★★★★ | 1 | 0 |
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