Louisville Gardens Care Center

In the surveyor’s words

From the most serious findings on record at Louisville Gardens Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Mar 11, 2024

  Based 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. […]

• Actual harm, isolatedF697Apr 27, 2021

  Based 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. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF686Jan 11, 2021

  Based on medical record review, staff interview and facility policy, the facility failed to identify resident skin impairment, failed to seek treatment options in a timely manner and failed to implement pressure relieving intervention for Resident #44, (who required total assistance with all activities of daily living) and failed to perform thorough weekly wound assessments on Resident #44 and Resident #6. This resulted in actual harm on 11/29/20 when a coccyx wound for Resident #44 declined to a Stage Four pressure ulcer and she developed deep tissue injuries to both of her heels. This affected two residents (Resident #45 and #6) of three residents reviewed for pressure ulcers. Findings include: 1. […]

• Actual harm, isolatedF760Jan 11, 2021

  Based on record review and interview the facility failed to prevent significant medication errors for Resident #44. Actual harm occurred on 06/03/20 when Resident #44 was administered the incorrect medications causing a change in her condition requiring medical testing/evaluation and additional medication changes. This affected one of three residents reviewed for medications errors. Findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home with family on 11/30/20. Review of the medication error report dated 06/03/20 at 7:40 A.M. […]

• No harm, potential for more than minimal, widespreadF725Sep 4, 2025

  Based 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. Findings include: 1. Review of the Facility Assessment Tool updated 08/11/25 revealed the staffing included seven nurses per day; ten certified nursing assistants (CNAs) per day; two other nursing personnel; one dietitian, seven food and nutrition services staff, and one respiratory care services staff. […]