Inspection Reports for Louisville East Post Acute
4200 BROWNS LANE, LOUISVILLE, KY, 40220
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 5, 2025, found no deficiencies in the facility’s compliance with regulatory standards. Earlier inspections also showed no deficiencies, indicating consistent adherence to health care requirements. There were no complaint investigations or enforcement actions listed in the available reports. The facility has maintained a clean record over time. This suggests a stable compliance pattern with no noted issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
161 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 161
Deficiencies: 0
Sep 5, 2025
Visit Reason
A Recertification Survey and Abbreviated Survey was conducted from 09/02/2025 to 09/05/2025 to assess compliance with regulatory standards.
Findings
No health care deficiencies were identified during the survey with respect to 42 CFR 483 Subpart B.
Report Facts
Survey Census: 161
Sample Size: 32
Supplemental Resident: 8
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation triggered by the elopement of Resident 9 from the facility on 07/27/2025, which raised concerns about the facility's failure to implement the resident's baseline care plan and ensure adequate supervision to prevent elopement and accidents.
Findings
The facility failed to implement Resident 9's care plan to prevent elopement, resulting in the resident leaving the facility unsupervised by climbing out a window and walking 1.3 miles in dangerous heat conditions. This failure created Immediate Jeopardy to resident health and safety. The facility also failed to maintain a safe environment free from accident hazards and provide adequate supervision. The Immediate Jeopardy was removed after the facility implemented corrective actions including increased supervision, staff education, environmental safety improvements, and policy updates.
Complaint Details
The complaint investigation was substantiated with Immediate Jeopardy identified on 08/13/2025, determined to have existed since 07/27/2025. The facility was notified and provided an acceptable plan of removal by 08/15/2025, with the Immediate Jeopardy removed on 08/04/2025 prior to the survey team's entrance.
Severity Breakdown
Immediate Jeopardy: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement Resident 9's baseline care plan to prevent elopement, resulting in the resident leaving the facility unsupervised. | Immediate Jeopardy |
| Failure to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents. | Immediate Jeopardy |
Report Facts
Distance walked by resident: 1.3
Temperature: 81
Heat index: 90
Risk score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN4 | Licensed Practical Nurse | Nurse caring for Resident 9 on the day of elopement; described resident behavior and supervision issues. |
| CNA5 | Certified Nursing Assistant | Staff member assigned to Resident 9 on the night of elopement; provided observations about resident behavior and supervision. |
| Director of Nursing | Director of Nursing | Notified of Immediate Jeopardy; stated expectations for staff to increase supervision and follow care plans. |
| Administrator | Administrator | Notified of Immediate Jeopardy; provided statements about staffing and facility response. |
| Director of Maintenance | Director of Maintenance | Investigated window breach used by Resident 9 to elope; secured windows after incident. |
Inspection Report
Routine
Deficiencies: 3
Jul 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care, food service quality, and pest control in the nursing facility.
Findings
The facility failed to provide appropriate pressure ulcer care for two residents, resulting in potential harm due to inadequate prevention and treatment. Additionally, the facility failed to serve palatable and attractive meals, with multiple residents reporting issues with food quality and presentation. The facility also failed to maintain an effective pest control program, with live roaches observed in resident rooms and kitchen areas.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide appropriate pressure ulcer care and prevention for two residents, including failure to implement pressure ulcer prevention measures and to provide ordered treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve meals that were palatable, attractive, and at a safe and appetizing temperature, with foods running together on plates and being watery and sloppy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective pest control program, with live roaches observed in resident rooms and kitchen dry storage area. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sampled residents for pressure ulcers: 4
Residents affected by pressure ulcer deficiency: 2
Residents affected by food service deficiency: Many
Residents affected by pest control deficiency: Many
Pressure ulcers present on R267 admission: 9
BIMS scores: 15
Order receipt for bowls: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN12 | Licensed Practical Nurse | Named in pressure ulcer care deficiency related to Resident R9 |
| LPN9 | Licensed Practical Nurse | Named in pressure ulcer care deficiency related to Resident R9 skin assessment |
| LPN10 | Licensed Practical Nurse | Named in pressure ulcer care deficiency related to Resident R267 wound care refusals |
| Unit Manager 1 | Unit Manager | Named in pressure ulcer care deficiency related to skin assessment standards |
| Director of Nursing | Director of Nursing | Named in pressure ulcer care and pest control deficiencies |
| Dietary Manager | Dietary Manager | Named in food service deficiency related to plating and food presentation |
| Assistant Dietary Manager | Assistant Dietary Manager | Named in pest control deficiency related to insect problem observations |
| Director of Environmental Services | Director of Environmental Services | Named in pest control deficiency related to roach infestation and control efforts |
| Administrator | Administrator | Named in pest control deficiency related to facility management and response |
Inspection Report
Routine
Deficiencies: 10
Jul 19, 2024
Visit Reason
The inspection was conducted to assess compliance with Medicare and Medicaid regulations including resident notices, transfer notifications, care planning, pressure ulcer care, medication administration, infection control, food service, and pest control.
Findings
The facility was found deficient in multiple areas including failure to issue proper Medicare non-coverage notices, failure to notify residents or representatives of hospital transfers, incomplete care plans for fall risk, inadequate pressure ulcer prevention and treatment, missed medication doses, improper infection control practices, unpalatable and poorly presented food, improper garbage disposal, and ineffective pest control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to issue Notice of Medicare Non-Coverage (NOMNC) with all required appeal contact information and failed to correctly complete Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely written notification to residents or representatives before emergency hospital transfers for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a comprehensive person-centered care plan addressing fall risk for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevention for two residents, including failure to wear prescribed pressure boots and failure to provide ordered wound treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were available and administered as ordered for two residents, resulting in missed doses of anticoagulant and pain medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to remove expired hydrogen peroxide and glucose control solutions from medication storage rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve meals that were palatable and attractive; foods were watery, overcooked, and plated in a manner causing liquids to run together. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly dispose of garbage; trash was piled on the ground under a non-functioning trash compactor, creating potential for pest attraction. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement infection prevention and control program adequately including failure to wear gowns during enhanced barrier precautions, failure to disinfect patient equipment between uses, and failure to perform hand hygiene during wound care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective pest control program; live roaches were observed in resident rooms and kitchen dry storage area, and residents and staff reported ongoing roach sightings. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for beneficiary notices: 39
Residents reviewed for emergency transfers: 39
Residents reviewed for pressure ulcers: 4
Residents reviewed for infection control: 8
Residents reviewed for medication administration: 39
Residents affected by pest control deficiency: 172
Number of expired hydrogen peroxide bottles found: 2
Number of expired accu-check glucose control solution boxes found: 3
Number of large bowls ordered: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN12 | Licensed Practical Nurse | Named in wound care and pressure ulcer prevention deficiencies |
| LPN6 | Licensed Practical Nurse | Named in medication administration deficiency for missed apixaban doses |
| LPN4 | Licensed Practical Nurse | Named in infection control deficiency for failure to wear gown during wound care |
| LPN5 | Licensed Practical Nurse | Named in infection control deficiency for failure to disinfect blood pressure cuff |
| LPN10 | Licensed Practical Nurse | Named in pressure ulcer treatment refusal documentation deficiency |
| CNA4 | Certified Nurse Aide | Named in pressure ulcer prevention deficiency |
| CNA2 | Certified Nurse Aide | Reported roach sightings in facility |
| CMT1 | Certified Medication Technician | Named in medication administration deficiency for narcotic pain medication |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including infection control and medication administration |
| Assistant Director of Nursing | Assistant Director of Nursing/Infection Control Preventionist | Interviewed regarding infection control program and PPE use |
| Dietary Manager | Dietary Manager | Interviewed regarding food service and plating deficiencies |
| Administrator | Facility Administrator | Interviewed regarding overall facility operations and pest control |
| Director of Environmental Services | Director of Environmental Services | Interviewed regarding pest control program and roach sightings |
Inspection Report
Annual Inspection
Census: 143
Deficiencies: 4
May 16, 2019
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements related to resident care, safety, food service, and infection control.
Findings
The facility was found deficient in implementing comprehensive care plans for resident transfers, ensuring adequate supervision and use of assistive devices, proper food storage practices, and maintaining an effective infection prevention and control program. Specific incidents included a resident sustaining a fractured ankle due to improper transfer without a mechanical lift, food items in the kitchen not being dated or covered, and a staff member handling medications with bare hands during administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement a comprehensive care plan for resident transfers, resulting in a resident sustaining a fractured ankle due to improper transfer without mechanical lift assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate supervision and use of assistive devices to prevent accidents related to the use of a Hoyer lift. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored in accordance with professional standards; food items in the walk-in refrigerator were not dated and not covered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish and maintain an infection prevention and control program; staff observed handling medications with bare hands during administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents receiving meals from kitchen: 143
Residents affected by deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Transferred Resident #20 without assistance or mechanical lift, resulting in injury. |
| LPN #1 | Licensed Practical Nurse, Unit Manager | Interviewed regarding transfer procedures and staff education. |
| RN #1 | Registered Nurse | Observed removing medication from blister pack with bare hands during medication pass. |
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding staff expectations and infection control policies. |
| Dietary Aide #1 | Dietary Aide | Interviewed about food storage practices. |
| Dietary Manager | Dietary Manager | Interviewed about food storage policies and expectations. |
Inspection Report
Annual Inspection
Deficiencies: 3
Feb 23, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning and provision of necessary care and services, including wheelchair positioning and meal assistance, for sampled residents.
Findings
The facility failed to develop a comprehensive person-centered care plan for wheelchair positioning for Resident #119 and failed to revise and implement an adequate care plan for eating assistance for Resident #60. Observations and interviews revealed inadequate care plan updates, insufficient supervision during meals, and failure to ensure residents received necessary assistance, posing risks for contractures and poor nutrition.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for wheelchair positioning for Resident #119, including leg rests and non-compliance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise the care plan to reflect eating assistance needs for Resident #60, resulting in inadequate supervision and support during meals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary care and services for eating according to the resident's Minimum Data Set (MDS) for Resident #60, including insufficient staff to assist and supervise during meals. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 32
Residents affected: 1
Days to develop care plan: 7
Degrees for wheelchair leg rests: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Occupational Therapist (OT) | Evaluated Resident #119 for wheelchair positioning and recommended leg rests | |
| License Practical Nurse (LPN) #1 | Interviewed regarding wheelchair positioning devices and care plan responsibility | |
| Unit Manager #2 | Interviewed about Resident #119's wheelchair leg rest usage and care plan development | |
| MDS Coordinator | Interviewed about care plan development and refusal of care for Resident #119 and Resident #60 | |
| Director of Nursing (DON) | Interviewed about expectations for care plan development and monitoring | |
| Administrator | Interviewed about Nursing Management Team and Quality Assurance Committee roles in care planning | |
| Licensed Practical Nurse (LPN) #3 | Observed assisting Resident #60 during meals | |
| Certified Nursing Assistant (CNA) #3 | Interviewed about Resident #60's meal supervision and care plan knowledge | |
| Certified Nursing Assistant (CNA) #4 | Interviewed about meal supervision and Resident #60's eating habits | |
| Licensed Practical Nurse (LPN) #4 | Interviewed about care plan updates and meal assistance staffing | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about importance of accurate care plans and resident nutrition | |
| Certified Nursing Assistant (CNA) #2 | Interviewed about meal assistance challenges on memory unit |
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