Inspection Reports for Home of the Innocents
1100 EAST MARKET STREET, LOUISVILLE, KY, 40206
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 13, 2025
Visit Reason
The inspection was conducted based on complaints alleging abuse, neglect, and medication errors involving residents at the facility.
Complaint Details
The complaint investigation involved allegations of involuntary seclusion, delayed reporting of abuse allegations, incomplete investigations of injuries of unknown origin, and medication errors involving discontinued medications being administered at school.
Findings
The facility was found to have failed in protecting residents from involuntary seclusion, timely reporting of abuse allegations, conducting thorough investigations of injuries of unknown origin, and ensuring proper communication of medication order changes to schools and pharmacies.
Deficiencies (4)
Failed to ensure residents were free from involuntary seclusion for 1 of 3 residents sampled for abuse (Resident R14).
Failed to ensure all allegations of abuse and injuries of unknown origin were reported within 2 hours to the State Survey Agency for 1 of 3 residents sampled for abuse (Resident R77).
Failed to ensure a complete and thorough investigation for an injury of unknown origin for 1 of 3 residents sampled for abuse (Resident R75).
Failed to ensure residents received medications in accordance with professional standards related to a discontinued medication order not being communicated to the resident's school and pharmacy, resulting in administration of a discontinued medication for 1 of 3 residents sampled for medications (Resident R40).
Report Facts
Residents sampled for abuse: 3
Total residents sampled: 20
Days medication continued after discontinuation: 8
Date medication discontinued: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager 3 | Unit Manager | Observed Resident R14 in involuntary seclusion and educated staff on abuse/neglect policies |
| Licensed Practical Nurse 11 | LPN | Nurse on duty during R14 incident, reported residents were in isolation and curtains drawn |
| Licensed Practical Nurse 13 | LPN | Provided notes on R14's condition and involvement in incident |
| Certified Nursing Assistant 3 | Restorative Aide | Reported on supervision needs of R14 and awareness of seclusion |
| Certified Nursing Assistant 8 | CNA | Alleged by Resident R77 of abuse; suspended during investigation |
| Certified Nursing Assistant 10 | CNA | Reported bed positioning incident involving R14 |
| Quality Assurance and Performance Improvement Manager | QAPI Manager | Discussed reporting delays and investigation procedures for abuse allegations |
| Compliance Officer | Compliance Officer | Described facility process for abuse allegation investigations |
| Administrator | Administrator | Oversaw handling of abuse allegations and facility expectations |
| Director of Nursing | DON | Discussed expectations for abuse reporting and investigation |
| Contract Pharmacy Director of Pharmacy Services | Director of Pharmacy Services | Reported pharmacy notification timeline for medication orders |
| Resident Education Nurse Coordinator | Resident Education NC | Responsible for communicating medication orders to school and pharmacy |
| School Nurse | School Nurse | Received medication orders and reported delayed awareness of medication discontinuation |
| Director of Support Services | DSS | Described medication order communication process to schools and pharmacy |
| Quality Assurance Nurse | QAN | Reviewed root cause analysis for medication error |
| Chief Quality and Compliance Officer | CQCO | Discussed purpose of investigations and reporting to state agency |
| Child Protective Services Case Manager | CPS Case Manager | Reported CPS investigation procedures and facility coordination |
| Neighborhood Nurse Manager 2 | NM 2 | Discussed staff training and abuse reporting expectations |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to treat a resident with dignity and respect, failure to prevent abuse, neglect, and theft, failure to implement care plans, and failure to provide adequate supervision to prevent accidents and elopement.
Complaint Details
The complaint investigation was substantiated. The facility failed to treat Resident #102 with dignity and respect, resulting in verbal abuse by an Enrichment Specialist. The facility also failed to prevent elopement of Resident #66 due to inadequate supervision and a malfunctioning fire exit door. Immediate Jeopardy was identified and subsequently removed after corrective actions.
Findings
The facility failed to treat Resident #102 with dignity and respect, resulting in verbal abuse by an Enrichment Specialist. The facility also failed to verify and maintain documentation of abuse screening and training for contract agency employees. Additionally, the facility failed to implement a care plan for Resident #66 to provide continuous line-of-sight monitoring, resulting in an elopement through a malfunctioning fire exit door. Immediate Jeopardy was identified and removed after the facility implemented corrective actions including care plan revisions, staff retraining, door repairs, increased supervision, and monitoring.
Deficiencies (4)
Failure to treat Resident #102 with dignity and respect, including verbal abuse by an Enrichment Specialist.
Failure to ensure abuse prohibition policy was implemented by failing to verify and maintain documentation of screening and training for contract agency employees.
Failure to implement a care plan to provide continuous line-of-sight monitoring for Resident #66, resulting in elopement.
Failure to provide effective monitoring and supervision to prevent elopement for Resident #66, including malfunctioning fire exit door and lack of staff supervision.
Report Facts
Residents affected: 1
Residents affected: 1
Residents at risk for elopement: 16
Duration of Resident #66 outside: 8
Training completion counts: 23
Training completion counts: 92
Training completion counts: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #102 | Resident | Subject of dignity and respect deficiency and verbal abuse incident |
| Enrichment Specialist (ES) | Involved in verbal abuse incident with Resident #102; terminated after investigation | |
| Clinic Nurse #1 | Clinic Nurse | Witnessed verbal abuse incident involving Resident #102 and ES |
| Director of Nursing (DON) | Director of Nursing | Involved in investigation and follow-up of Resident #102 incident |
| Resident #66 | Resident | Subject of elopement and supervision deficiencies |
| Certified Nursing Assistant (CNA) #14 | CNA | Assigned to Resident #66 during elopement incident |
| Certified Nursing Assistant (CNA) #15 | CNA | Assigned to Resident #66 prior to elopement incident |
| Licensed Practical Nurse (LPN) #16 | LPN | Found Resident #66 outside during elopement incident |
| Registered Nurse (RN) #22 | RN | Assigned to Resident #66 during elopement incident |
| Infection Preventionist/Quality Assurance Performance Improvement (IP/QAPI) Specialist | IP/QAPI Specialist | Conducted investigation and follow-up on incidents; involved in staff retraining |
| [NAME] President of Nursing (VPN) | President of Nursing | Involved in investigation and corrective actions for Resident #66 elopement |
| Administrator | Administrator | Oversaw investigation and corrective actions for incidents |
| Manager of Resident Care | Manager of Resident Care | Revised care plans and implemented corrective actions for Resident #66 |
| Agency Cottage Safety Monitor (CSM) #48 | Agency CSM | Received retraining and described role in resident supervision |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 12, 2023
Visit Reason
The inspection was conducted due to complaints and incidents involving failure to implement abuse prevention policies, failure to provide adequate supervision to prevent elopement, and failure to maintain safe food handling practices.
Complaint Details
The complaint investigation was triggered by incidents including failure to implement abuse prevention policies for agency staff and a serious elopement incident involving Resident #66 on 12/14/2022, which resulted in immediate jeopardy. The facility was found to have failed in supervision and door security, and corrective actions were implemented and validated by the State Survey Agency.
Findings
The facility failed to verify and maintain documentation of abuse screening for agency staff, failed to provide continuous line-of-sight supervision for a resident at risk of elopement resulting in an immediate jeopardy event, and failed to consistently monitor and document dishwasher, refrigerator/freezer, and steam table temperatures to ensure food safety.
Deficiencies (6)
Failure to verify and maintain documentation of abuse screening and training for contract agency employees.
Failure to provide continuous line-of-sight supervision for Resident #66, resulting in elopement and immediate jeopardy to resident health or safety.
Failure to provide effective monitoring and supervision to prevent elopement for Resident #66.
Failure to consistently monitor and document dishwasher temperatures and sanitizer levels.
Failure to consistently monitor and document refrigerator/freezer temperatures.
Failure to consistently monitor and document steam table food temperatures.
Report Facts
Deficiencies cited: 6
Residents at risk for elopement: 16
Staff training completion: 23
Staff training completion: 92
Staff training completion: 67
Staff training completion: 27
Staff training completion: 30
Staff training completion: 2
Duration resident outside unsupervised: 8
Door checks frequency: 2
Food temperature log missing dates: 14
Dishwasher log missing dates: 13
Refrigerator/freezer log missing dates: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #14 | Certified Nursing Assistant | Assigned to Resident #66 on 12/14/2022 and provided interview about supervision. |
| LPN #16 | Licensed Practical Nurse | Found Resident #66 outside during elopement and assisted in returning resident inside. |
| RN #22 | Registered Nurse | Assigned to Resident #66 during elopement incident. |
| Infection Preventionist/Quality Assurance Performance Improvement Specialist | Provided information on agency staff monitoring and training. | |
| Manager of Resident Care | Responsible for revising care plans and implementing retraining and supervision plans. | |
| President of Nursing (VPN) | Provided statements on supervision expectations and door repairs. | |
| Administrator | Provided statements on incident, supervision failures, and corrective actions. | |
| Dietary Manager | Provided information on food temperature monitoring and staff training. | |
| CNA #40 | Certified Nursing Assistant | Provided interview about training on supervision responsibilities. |
| Nursing Supervisor #45 | Provided interview about door monitoring and supervision training. | |
| Agency CSM #48 | Provided interview about roles and responsibilities as Cottage Safety Monitor. |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 27, 2019
Visit Reason
The inspection was conducted to assess the facility's compliance with professional standards for food service safety, focusing on food storage, preparation, and labeling practices.
Findings
The facility failed to properly store food according to professional standards, with multiple observations of undated, improperly sealed, expired, and moldy food items in the kitchen and storage areas. Interviews revealed staff were not fully aware of or compliant with food storage policies, posing potential harm to medically fragile residents.
Deficiencies (1)
Food items were not properly dated or sealed; boxes of food were opened and uncovered; refrigerated items were dated past the 72-hour retention period; expired foods were stored in the dry pantry; moldy bread was stored with the bread supply; a scoop was left in an open container of thickener.
Report Facts
Retention period for refrigerated leftover foods: 72
Maximum storage days for prepared foods: 3
Maximum storage days for pre-made items: 7
Number of slices of bread with mold: 2
Number of bags of wheat rolls without expiration date: 3
Number of pieces of white sandwich-style bread undated: 5
Number of bags of unopened marshmallows: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook | Interviewed regarding food storage practices and retention of opened refrigerated items. | |
| Director of Support Services (DSS) | Interviewed about staff rounds for mold and expired foods, and food storage policies. | |
| Assistant Dietary Manager (ADM) | Interviewed about kitchen labeling and dating system and documentation practices. | |
| Administrator | Interviewed regarding awareness of concerns about food labeling and dating. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 30, 2018
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a regulatory inspection of the facility.
Findings
No health deficiencies were found during the inspection.
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