Louisville Gardens Care Center

Inspectors wroteBased on record reviews, observations, interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to maintain infection control practices to prevent the spread of the coronavirus-19 infection (COVID-19 / SA RS-Co Y-2) in the facility and failed to ensure staff performed hand hygiene to prevent cross contamination of germs during Resident #56's incontinence care. This affected four residents (#7, #30, #51, and #45) of 16 residents (#3, #6, #7, #14, #17, #26, #27, #30, #38, #44, #45, #51, #55, #56, #65, and #67) with a positive COVID-19 infection, one resident (#31) out of four residents reviewed for smoking tobacco products, one resident (#56) out of three residents reviewed for incontinence care. This had the potential to affect all the residents in the facility. The facility census was 66.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure staff administered Resident #32's wound treatment as ordered by the physician. This affected one resident (#32) out of three residents reviewed for wounds. The facility census was 66.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure medications were available to administer to Resident #21 and Resident #39 in a timely manner. This affected two residents (#21 and #39) out of five residents reviewed for medication administration. The facility census was 66.

Inspectors wroteBased on record review, review of the facility admission Agreement, interview and facility policy review, the facility failed to ensure Resident #7's admission paperwork was completed in a timely manner and Resident #44's medication administration documentation was accurate. This affected one resident (#7) out of three residents reviewed for admission paperwork and one resident (#44) out of three residents observed during medication administration. The facility census was 66.

Inspectors wroteBased on observations, payroll-based journal review, facility assessment review, policy review and interview, the facility failed to ensure adequate staffing to meet resident needs. This had the potential to affect all residents residing within the facility. The facility census was 53.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure care conferences were completed at least quarterly for Residents #5, #21, and #27, and the facility failed to ensure care plan accuracy regarding incontinence care for Resident #40 and an updated care plan to reflect Resident #51's fall. This finding affected three (Residents #5, #21, #27) of three residents reviewed for care conferences and two (Residents #51 and #40) of 25 residents reviewed for care planning. The facility census was 53.

Inspectors wroteBased on record reviews, interviews and facility policy review, the facility failed to ensure residents received showers as scheduled. This finding affected seven residents (Residents #6, #14, #21, #27, #31, #47 and #48) of seven residents reviewed for activities of daily living (ADL) and had the potential to affect 30 additional residents (Residents #3, #5, #7, #8, #9, #11, #12, #13, #18, #20, #25, #28, #29, #30, #32, #33, #35, #36, #37, #39, #40, #42, #43, #44, #45, #46, #51, #52, #58 and #59) the facility identified as requiring extensive assistance or totally dependent on staff assistance for showers. The facility census was 53.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure meals were served as stated in the dietary menus. This finding had the potential to affect all residents who receive mechanical soft diets and residents who require gravy during meals including Residents #2, #5, #15, #22, #25, #28, #32, #37, #38, #43, #47, #51 and #53. The facility census was 53.

Inspectors wroteBased on review of the medical record, interview, and review of facility policy, the facility failed to ensure resident wishes regarding advanced directives were accurately identified or that the medical record contained the appropriate documentation of these wishes. This affected one resident (Resident #51) of one resident reviewed for advanced directives. The facility census was 53.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was completed as required for Resident #21. This affected one resident (Resident #21) out of one resident sampled for baseline care plans. The facility census was 53.

Inspectors wroteBased on observation, interview, review of the facility nurse signature list and review of facility policy, the facility failed to ensure nurses followed appropriate professional standards when documenting medication administration. This affected one resident (Resident #20) of three residents who were observed for medication administration. The facility census was 53.

Inspectors wroteBased on observation, record review, review of pharmacy invoices, interview and facility policy review, the facility failed to ensure Resident #16's skin treatments were implemented as ordered and Resident #1's dialysis medications were available for resident use. This finding affected one resident (Resident #16) of three residents reviewed for pressure ulcers and general skin conditions and one resident (Resident #1) of one resident reviewed for dialysis services. The facility census was 53.

Inspectors wroteTHIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, witness statement reviews, interview and facility policy review, the facility failed to ensure Resident #45 was provided with adequate supervision to prevent a burn. This finding affected one resident (Resident #45) of six residents reviewed for accidents and hazards. The facility census was 53.

Inspectors wroteBased on review of the medical record, interview and review of the facility policy, the facility failed to ensure appropriate assessments were consistently completed before and after dialysis. This affected one resident (Resident #1) of one resident reviewed for dialysis. The facility census was 53.

Inspectors wroteBased on record review and interview, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 40 residents residing in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to accurately document and put a treatment in place in a timely manner for Resident #34 that was admitted with a pressure ulcer. This affected one (Resident #34) out of three residents reviewed for pressure ulcers. Facility census was 38.

Inspectors wroteBased on observation, record review, including review of the facility payroll records, review of facility billing/financial information, review of email communication, review of the employee handbook, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance of the facility and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. The facility also failed to have an effective system in place to ensure staff were compensated via payroll benefits based on their hire agreement and payroll schedule. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure the use of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 32 residents residing in the facility. Findings Include: Review of the Payroll Based Journal (PBJ) report for Fiscal Year (FY) Quarter 4 2023 (07/01/23 through 09/30/23) revealed the facility triggered for no RN hours. Continued review of the reporting data, as submitted by the facility revealed the facility had no RN hours on 07/06/23, 07/07/23, 07/11/23, 07/12/23, 07/16/23, 07/20/23, 07/21/23, 07/25/23, 07/26/23, 08/30/23 or 08/31/23. Interview on 02/26/24 at 11:23 A.M. with the Administrator revealed she was responsible for submitting PBJ data to Centers for Medicare and Medicaid (CMS). [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure posted nursing staff information was updated in a timely manner. This had the potential to affect all 32 residents residing in the facility.

Inspectors wroteBased on record review, facility policy review, the facility submitted plan of correction to the state agency, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 32 residents in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure staffing information submitted to the Centers for Medicare and Medicaid (CMS) was complete and accurate. This had the potential to affect all 32 residents in the facility. Findings Include: Review of the Payroll Based Journal (PBJ) report for Fiscal Year (FY) Quarter 3 2023 (04/01/23 through 06/30/2023) revealed the facility triggered for a one star staff rating and excessively low weekend staffing. Review of the PBJ report for Fiscal Year (FY) Quarter 4 2023 (07/01/23 through 09/30/23) revealed the facility continued to trigger for a one star rating. Review of the PBJ report for Fiscal Year (FY) Quarter 1 2024 (10/01/23 through 12/30/23) revealed the the facility continued to trigger for a one star rating. This report was the most recent report available for review at the time of the investigation. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 32.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received showers as planned and based on their preference. This affected two residents (#12 and #13) of five residents reviewed for showers.

Inspectors wroteBased on interview and record review, the facility failed to timely notify a physician or nurse practitioner regarding a change in condition for Resident #34. This affected one resident (#34) of three residents reviewed for change in condition. The facility census was 33.

Inspectors wroteBased on observation, review of facility billing/financial information, review of the Facility Assessment, review of the Employee Handbook, facility policy review and interview the facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services and sufficient funds were available to meet payroll demands. This had the potential to affect all 30 residents residing in the facility. Findings Include: 1. On 11/05/23 at 12:20 P.M. an interview related to the facility finances and billing/payment process with the Administrator revealed the facility forwarded all invoices received to the Accounts Payable (AP) department for Epic Healthcare Solutions (the facility corporation). [...]

Inspectors wroteBased on record review, facility policy review, the facility submitted plan of correction to the state agency, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 30 residents in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 30.

Inspectors wroteBased on observation, interview and menu review, the facility failed to ensure food was palatable. This affected 35 residents receiving food from the kitchen as Resident #23 was ordered nothing-by-mouth. The facility census was 36 residents.

Inspectors wroteBased on medical record review, Medscape online medication review, policy review, and staff interview the facility failed to ensure appropriate diagnosis for use of antipsychotic medications for Residents #11 and #32. The facility also failed to ensure appropriate assessments were completed for use of antipsychotic medications for Resident #32. The facility also failed to ensure behavior monitoring was completed for Residents #9, #11, #31 and #32 who were receiving psychotropic medications. In addition, the facility failed to ensure non-pharmacological interventions were attempted for Resident #11 prior to the administration of anti-anxiety medications. This affected four residents (#9, #11, #31 and #32) of five residents reviewed for medication use. The facility census was 36.

Inspectors wroteBased on interview and record review the facility failed to ensure resident funds were disbursed in a timely manner for Resident #35 after death as required. Additionally, the facility failed to provide spend-down letters for Resident #13 each month she was over the resource limit. This affected two residents (#13 and #35) of five residents reviewed for resident funds. The facility census was 36 residents.

Inspectors wroteBased on record review, facility policy review, and interview the facility failed to complete a discharge summary as required. This affected one resident (#34) of one resident reviewed for discharge from the facility. The facility census was 36 residents.

Inspectors wroteBased on medical record review, observation, resident interview, policy review and staff interview, the facility failed to ensure Resident #9 was assisted with Activities of Daily Living (ADL) including hygiene, dressing, and showers. The facility also failed to assist Resident #86 with denture care. This affected two residents (#9 and #86) of two residents reviewed for ADL assistance. The facility census was 36.

Inspectors wroteBased on observation, record review, and interview the facility failed to timely turn and reposition Resident #11 and failed to timely complete a Braden Scale for predicting pressure sore risk assessment. The facility also failed to ensure pressure ulcer wound assessments were timely and thoroughly completed for Resident #12. This affected two residents (#11 and #12) of two residents reviewed for pressure ulcers. The facility census was 36.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure fall interventions were in place for Resident #11. This affected one resident (#11) of one resident reviewed for accidents. The facility census was 36.

Inspectors wroteBased on observation, record review, facility policy review, and interview, the facility failed to ensure Resident #11 received proper incontinence care to decrease the resident's risk of developing a urinary tract infection. The facility also failed to provide timely catheter care to Resident #86. This affected two (Resident #11 and #86) of two residents reviewed for incontinence/urinary tract infection. The facility identified 22 residents who were occasionally or frequently incontinent of bladder and four residents who had urinary catheters. The facility census was 36.

Inspectors wroteBased on observation, interview and menu spreadsheet review, the facility failed to follow the menu's production spreadsheet as written. This affected one resident (Resident #17) of five residents receiving a pureed diet. The facility census was 36 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure meal intake amounts and meal assistance service was completely and accurately documented in the medical records for Resident #9. This affected one resident (Resident #9) of three residents reviewed for nutrition. The facility census was 36.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to provide a pneumococcal immunization. This affected one(Resident #32) of five residents reviewed for immunizations. The facility census was 36.

Inspectors wroteBased on review of the Payroll Based Journal Staffing Data Report and staff interview, the facility failed to ensure staffing information was submitted as required. This had the potential to affect all residents within the facility. The facility census was 36.

Inspectors wroteBased on observation, record review and interview, the facility failed to medicate Resident #10 for complaints of pain during wound care. This resulted in harm to the resident when the resident reported complaints of pain during her wound care and was not medicated to alleviate the resident's pain during or following the wound care. This finding affected one (Resident #10) of two residents (#34) reviewed for pain.

Inspectors wroteBased on interview and document review, the facility failed to ensure the medical director or his designee was present at the quarterly quality assessment and assurance meetings. This had the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased on interviews and review of resident council meeting minutes, the facility failed to keep the resident council informed of actions taken to address ongoing concerns about staffing. This had the potential to affect all current residents with the exception of four residents (Residents #13, #143, #194 and Resident #195) who resided on a unit with one nurse and one nursing assistant scheduled. The facility census was 41.

Inspectors wroteBased on record review and interview the facility failed to ensure the surety bond was purchased for a sufficient amount to ensure the security of all resident funds deposited in the facility resident fund account. This finding had the potential to affect thirty residents (#2, #3, #4, #6, #7, #12, #8, #9, #10, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25, #26, #27, #28, #30, #32, #34, #36, #37, #39, #192 and #197) with funds deposited into the facility resident fund account. The facility census was 41.

Inspectors wroteBased on medical record review, observation, interview and document review the facility failed to provide sufficient nurse staffing levels to meet residents needs. This had the potential to affect all 41 residents currently residing in the facility.

Inspectors wroteBased on observation, review of the Centers for Disease Control hand hygiene guidelines and interview, the facility failed to ensure staff practiced appropriate hand hygiene. This affected one (Resident #28) of one resident observed for incontinence care and had the potential to affect 15 additional residents (Residents #3, #6, #7, #15, #16, #17, #20, #21, #23, #24, #26, #29, #30, #36 and #39) residing on the same unit.

Inspectors wroteBased on review of COVID testing records, review of COVID-19 testing guidance, review of COVID 19 screening, review of employment information and interview, the facility failed to ensure staff testing for COVID 19 was conducted with the required frequency. This had the potential to affect all but six (Residents #10, #93, #143, #193, #194 and #195) of the facility's 41 residents. The six residents either currently had COVID-19 or had it within the prior 90 days (Residents #10, #93, #143, #193, #194 and #195).

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Residents #28 and #36's dignity was maintained during meals and Resident #10's dignity was maintained during the resident's pressure ulcer wound care. This finding affected two residents (Residents #28 and #36) of 16 residents observed eating lunch on the 200 unit and one resident (Resident #10) of one resident reviewed for wound care. The facility census was 41.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #4's right half bedrail was in good repair. This affected one (Resident #4) of forty-one residents reviewed for environmental concerns. The facility census was 41.

Inspectors wroteBased on interview, review of medical records, shower records, and the facility shower policy and CMS 672 review the facility failed to ensure Resident #34, who was dependent on staff for all activities of daily living, received showers as scheduled. This affected one of two residents (#34 and #38) reviewed for activities of daily living. The facility census was 41.

Inspectors wroteBased on observation, medical record review, and interview the facility failed to provide individualized activity programs for two (Residents #7 and #23) of three residents reviewed for activities. The facility census was 41.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure appropriate infection control practices were maintained during Resident #10's pressure ulcer wound care for multiple wounds. This affected one (Resident #10) of one resident reviewed for pressure ulcer wounds. The facility census was 41.

Inspectors wroteBased on observation, medical record review, and interview the facility failed to ensure safety assessments and interventions were implemented for two (Residents #9 and #16) of four residents reviewed for accidents. The facility census was 41.

Inspectors wroteBased on interview, record review and review of Notice to Medicare Provider Non-coverage (NOMNC) letters, the facility failed to provide the residents with claim appeal rights information. This affected three of three residents (#96, #97 and #98) reviewed for liability notices. The facility census was 41.