Louisville East Post Acute

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' baseline care plan which provided instructions needed to provide effective and person-centered care for each resident was implemented for 1 of 5 (Resident (R) 9) sampled residents reviewed for elopement risk. Resident 9, who had major neurocognitive impairment, was care planned to be monitored frequently for his whereabouts, however, on 07/27/2025, the Resident left the facility by removing his bedroom window and climbing through it without staff knowledge/supervision. The Resident walked approximately 1.3 miles, in the dark. The failure to implement R9's baseline care plan to prevent R9's elopement during 81-degree heat with 90-degree heat index created Immediate Jeopardy with the likelihood for serious harm or death. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remained free of accident hazards and provide adequate supervision for one (Resident (R) 9) of five sampled residents reviewed for elopement risk. Resident 9, who had major neurocognitive impairment, eloped from the facility on 07/27/2025. Facility safety processes and systems used for supervision failed when the resident left the facility by removing the bedroom window and climbing through it without staff knowledge/supervision. The resident walked approximately 1.3 miles, in the dark. The failure to prevent R9's elopement during 81-degree heat with 90-degree heat index created Immediate Jeopardy with the likelihood for serious harm or death. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to serve meals that were palatable and attractive. Interviews with Residents (R)13, R26, R74, R81, R86, revealed concerns related to the foods not being palatable, or attractive with foods running together on the plate, causing the food to be watery and sloppy. Additionally, during the Group Interview, conducted by the State Survey Agency, R22, R12, and R46 all stated the food was not appetizing and did not taste good, partly because the foods were overcooked and watery and plated in a manner in which fluids from one food would run into the others. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure garbage was stored in containers and off the ground to prevent potential spread of insect or rodent activity. This failure affected all 172 facility residents.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. During tours of the facility, on 07/16/2024 and 07/17/2024, live roaches were observed in resident room [ROOM NUMBER] and in the the dry storage area of the kitchen. Additionally, interviews with residents and staff revealed they had seen roaches in the building. All 172 residents had the potential to be affected.

Inspectors wroteBased on interview, and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) that included all required appeal contact information for three (3) of three (3) residents reviewed for beneficiary notices out of a total sample of 39 residents, Resident (R)13, R58, and R219. Additionally, the facility failed to correctly complete the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for R13 and R58, informing residents or their responsible party of information related to a Medicare A; and the facility failed to follow the appropriate instructions for the SNFABN form. This failure could lead to residents or their responsible party not understanding their options when skilled care was ending.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to issue the resident or their representative a written notification of transfer when the resident was transferred to the hospital for three (3) of five (5) sampled residents reviewed for emergency transfers out of a total sample of 39 residents, Resident (R)73, R124, and R150. The facility failed to have a system in place for sending written notifications to residents and/or their representatives. This failure created the potential for the resident and/or the representative to lack the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure a comprehensive person-centered care plan was developed related to falls for one (1) of 39 sampled residents, Resident (R)110. The facility assessed R110 to be at high risk for falls; however, there was no documented evidence a Care Plan was developed in an attempt to prevent falls. This placed the resident at risk for unmet care needs and at an increased risk of sustaining a fall.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide appropriate services to prevent and or treat pressure ulcers for two (2) of four (4) sampled residents reviewed for pressure ulcers out of a total sample of 39 residents, Resident (R)9 and R267. The facility failed to implement pressure ulcer prevention measures and accurately assess a pressure ulcer for R9. This failure had the potential to contribute to development of new pressure ulcers and/or a lack of wound healing or wound deterioration for R9. Additionally, the facility failed to provide pressure ulcer treatments as ordered for R267. This failure had the potential to contribute to a lack of wound healing or wound deterioration for R267.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medications were available for administration per Physician's orders for two (2) of 39 sample residents (R74 and R717). These failures placed the residents at risk of harm or discomfort related to missed medication doses. R74 was ordered Eliquis (apixaban, an anticoagulant medication) five (5) milligrams (mg) twice daily for stroke prevention on 03/23/2023. However, there was no documented evidence the resident received the scheduled doses of medication on 05/21/2024 at 8:00 AM, 06/05/2024 at 8:00 PM and 06/19/2024 at 8:00 AM. The Progress Notes on these dates revealed the medication was re-ordered or the medication was unavailable. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to remove expired hydrogen peroxide and accu-check glucose control solutions from one (1) of two (2) medication storage rooms. This failure could result in the potential of residents being subject to unsafe or ineffective treatment.

Inspectors wroteBased on observation, interview, medical record review, review of facility policy and review of the Centers for Disease Control and Prevention guidance, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The following failures could promote the spread of multi drug resistant organisms (MDROs) throughout the facility: The facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) for one (1) of three (3) residents reviewed for enhanced barrier precautions (EBP) when providing care, Resident (R) 129. [...]

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Observation of the kitchen, on 05/14/19, revealed food stored in the walk-in refrigerator was not dated and food items were not covered. Review of the facility Census and Condition, dated 05/14/19, revealed one-hundred and forty-three (143) of one-hundred and fifty-five (155) residents received their meals from the kitchen.

Inspectors wroteBased on interview, record review, review of Hospital Records, and facility policy review, it was determined the facility failed to implement a comprehensive care plan for one (1) of five (5) sampled residents related to transfers. Resident #20 was care planned for two (2) staff to transfer resident with the use of a mechanical lift, however; on 09/29/18, Certified Nurse Aide (CNA) #1 transferred the resident without the assistance of another staff and without the use of a lift which resulted in the resident sustaining a fractured ankle.

Inspectors wroteBased on interview, record review, facility policy review, and Hospital Medical Record review, it was determined the facility failed to ensure one (1) of three (3) sampled residents received adequate supervision and assistance devices to prevent accidents related to the use of a Hoyer lift (Resident #20). Resident #20 was assessed and care planned for a two (2) person transfer with mechanical lift; however, on 09/29/18 the Certified Nurse Aide (CNA) transferred the resident from bed to wheelchair by himself without assistance of another staff and the use of the lift. The resident sustained a fracture to the right ankle.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observations of a medication pass on 05/15/19, revealed a staff touched medications with their bare hand.