Inspection Reports for Little Sisters of the Poor

15 AUDUBON PLAZA DRIVE, LOUISVILLE, KY, 40217

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Inspection Report Summary

The most recent inspection on May 16, 2025, identified deficiencies related to the discharge process, medication labeling and storage, medication administration, and infection prevention and control. Earlier inspections, including the January 30, 2025 renewal survey, found the facility to be in substantial compliance with no deficiencies. The main issues noted involved communication about resident transfers, proper handling and disposal of medications, and maintaining infection control practices. No complaint investigations or enforcement actions were listed in the available reports. This pattern suggests some recent challenges after a period of compliance, indicating a need for focused improvements in medication management and infection control.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

15% better than Kentucky average
Kentucky average: 4.7 deficiencies/year

Deficiencies per year

4 3 2 1 0
2025

Census

Latest occupancy rate 32 residents

Based on a May 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

0 9 18 27 36 45 Jan 2025 May 2025

Inspection Report

Re-Inspection
Census: 32 Deficiencies: 4 Date: May 16, 2025

Visit Reason
This document is a recertification and abbreviated survey investigating multiple CMS identifiers for the facility Little Sisters of the Poor, conducted to determine compliance with federal regulations.

Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to discharge process, labeling and storage of drugs and biologicals, medication administration, and infection prevention and control.

Deficiencies (4)
Failure to notify resident and representative of transfer or discharge and reasons for move in writing for 1 of 1 residents sampled.
Failure to ensure drugs and biologicals were labeled in accordance with accepted professional principles and disposed of by expiration date for 3 of 6 medication and treatment carts.
Failure to discard medications before expiration dates and failure to check expiration dates before administration.
Failure to establish and maintain an infection prevention and control program including hand hygiene and food service hygiene.
Report Facts
Survey Census: 32 Sample Size: 14 Medication and treatment carts reviewed: 6 Expired medications found: 3

Inspection Report

Renewal
Census: 8 Deficiencies: 0 Date: Jan 30, 2025

Visit Reason
A Re-licensure Survey was initiated on 01/28/2025 and concluded on 01/30/2025 to assess compliance for license renewal.

Findings
The facility was found to be in substantial compliance with 902 KAR 20:031. No deficiencies were issued related to the survey.

Report Facts
Survey Size: 4

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