Inspection Reports for
Nazareth Home Clifton
2120 PAYNE STREET, LOUISVILLE, KY, 40206
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 8, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with medication labeling and storage regulations in the nursing home.
Findings
The facility failed to ensure all drugs were labeled and stored according to professional standards. Medication cups were found unlabeled and unattended, and treatment carts were unlocked and unattended during the survey.
Deficiencies (1)
F 0761: The facility failed to ensure drugs and biologicals were labeled and stored in locked compartments as required. Medication cups were unlabeled and unattended, and treatment carts were unlocked with medications left out.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #8 | Interviewed regarding medication cart security and labeling. | |
| Administrator | Interviewed regarding expectations for medication cart security and medication storage. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 22, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident rights violations, abuse, misappropriation of property, care planning deficiencies, supervision failures, nutritional care, and infection control at the nursing home.
Complaint Details
The investigation was complaint-driven, focusing on allegations of resident rights violations, abuse, misappropriation of property, inadequate care planning, supervision failures, nutritional neglect, and infection control deficiencies. The allegations were substantiated in part, with multiple findings of minimal harm or potential for harm.
Findings
The facility was found to have multiple deficiencies including failure to protect resident rights, failure to prevent abuse and ensure a safe environment, failure to protect residents' property, failure to develop and implement comprehensive care plans, failure to provide adequate supervision, failure to provide feeding assistance and monitor nutritional status, and failure to establish an infection control system for Legionnaire's Disease and COVID signage.
Deficiencies (7)
F 0550: The facility failed to protect resident rights when an LPN took a resident's cell phone against their wishes, substantiated by investigation and witness statements.
F 0600: The facility failed to ensure an environment free from abuse when one resident placed his/her arm around another resident's neck and threatened harm, with inadequate care plan updates and supervision.
F 0602: The facility failed to protect residents from misappropriation of property involving missing lottery tickets, cell phone, money, and rings for multiple residents, with incomplete investigations and lack of reimbursement.
F 0656: The facility failed to develop and implement comprehensive care plans with measurable objectives for residents' mental and psychosocial needs, including failure to update care plans after incidents and failure to provide feeding assistance and daily weights as ordered.
F 0689: The facility failed to provide adequate supervision when a resident was left unsupervised in the shower without assistance or instruction on how to call for help.
F 0692: The facility failed to provide feeding assistance and failed to obtain daily weights as ordered for a resident at nutritional risk, resulting in inadequate monitoring of nutritional status.
F 0880: The facility failed to establish an infection control system to monitor for Legionnaire's Disease and failed to provide signage notifying visitors of active COVID presence in the facility.
Report Facts
Facility census: 101
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Resident cognitive scores: 15
Resident cognitive scores: 3
Resident cognitive scores: 10
Value of missing rings: 3765
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Named in resident rights violation for taking cell phone |
| LPN #8 | Licensed Practical Nurse | Witness and responder to resident-to-resident altercation |
| CNA #4 | Certified Nursing Assistant | Provided statements on dementia training and care plan adherence |
| LPN #7 | Licensed Practical Nurse | Involved in care and documentation related to resident altercation |
| Director of Nursing | Director of Nursing | Provided statements on care plan expectations and abuse policy |
| Administrator | Facility Administrator | Provided statements on facility policies and expectations |
| Medical Director | Medical Director | Provided statements on care plan and abuse policy expectations |
| Advanced Practice Registered Nurse | APRN | Provided statements on care plan and resident monitoring |
| Housekeeper #1 | Housekeeper | Interviewed regarding missing lottery tickets |
| Social Services Director | Social Services Director | Involved in investigations and family communications |
| Registered Dietician | Dietician | Provided statements on nutritional documentation importance |
| Maintenance Director | Maintenance Director | Provided statements on Legionnaire's Disease water testing |
Inspection Report
Deficiencies: 0
Date: Jan 16, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Nazareth Home Clifton, representing a regulatory inspection visit.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 9
Date: Nov 21, 2018
Visit Reason
Routine inspection of Nazareth Home Clifton nursing facility to assess compliance with regulatory requirements including resident rights, care planning, safety, medication storage, food safety, and infection control.
Findings
The facility was found deficient in maintaining resident dignity and privacy, accurate resident assessments and care plans, safe environment free from hazards, proper medication storage, sanitary food handling, and effective infection control practices including hand hygiene.
Deficiencies (9)
F 0550: The facility failed to maintain resident dignity and privacy for Resident #8 by displaying a white board with personal ADL care needs visible from the hallway.
F 0583: The facility failed to keep Resident #8's personal and medical care information confidential as the white board with ADL needs was visible to visitors and other residents.
F 0584: The facility failed to maintain a homelike environment for Residents #14 and #23, including a hole in Resident #14's room wall and failure to maintain comfortable water temperature for Resident #23's bathing.
F 0641: The facility failed to complete accurate Minimum Data Set (MDS) assessments for Residents #22 and #54 by omitting Pulmonary Hypertension and cardiac pacemaker diagnoses respectively.
F 0656: The facility failed to develop and implement complete care plans for Residents #22 and #54 that reflected their diagnoses of Pulmonary Hypertension and cardiac pacemaker.
F 0689: The facility failed to provide a safe environment on the 500 Unit by leaving a clean utility room door unlocked with hazardous chemicals accessible to residents and allowing Resident #80 to possess a can of ant spray.
F 0761: The facility failed to ensure controlled medications were stored in separately locked, permanently affixed compartments in the 300 and 500 Unit medication rooms, with controlled meds stored on refrigerator door shelves.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner, including thawing raw chicken in soiled dish sinks, expired milk in refrigerators, and staff failing to maintain hand hygiene during meal service.
F 0880: The facility failed to maintain an effective infection control program related to hand hygiene on the 300 Unit, as a nurse failed to perform hand hygiene and disinfect equipment between residents during medication pass.
Report Facts
Residents sampled: 28
Containers of bleach wipes: 5
Bottles of alcohol hand sanitizer: 15
Bottles of body wash: 30
Bottles of body lotion: 5
Bottles of peri-wash: 35
Deodorants: 15
Razors: 10
Nail polish remover pads: 118
Lactose free milk containers expired: 4
Utility doors in facility: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed failing to perform hand hygiene and disinfect equipment during medication pass |
| LPN #1 | Licensed Practical Nurse | Observed entering unlocked 500 Unit clean utility room |
| Unit Manager #2 | Unit Manager | Reported checking utility doors multiple times daily and concern for resident safety |
| Director of Nursing | DON | Monitored utility doors and infection control practices |
| Administrator | Administrator | Responsible for overall facility compliance and safety |
| AM Cook | Cook | Observed thawing raw chicken in soiled dish sinks and food handling practices |
| PM Cook | Cook | Observed food handling and glove use violations |
| Director of Food Services | DFS | Reported on food safety and staff practices |
| MDS Coordinator #2 | MDS Coordinator | Reported on MDS assessment process and deficiencies |
| MDS Director | MDS Director | Responsible for MDS assessment oversight |
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