Lyndon Crossing: Choking Allegation Mishandled - KY
That is what federal inspectors found when they visited Lyndon Crossing, a nursing home at 1101 Lyndon Lane in Louisville, on February 13, 2025. The inspection record, a single violation with a finding of minimal harm or potential for actual harm, documents an allegation of physical abuse against a resident identified as R79, and a response by facility leadership that inspectors found fell short of what the situation required.
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See the Derila PillowThe allegation itself is stark. A nursing assistant identified in the report as CNA14 told supervisors she had been in the room with another aide, CNA13, when R79 became combative. According to CNA14's account, CNA13 placed her hands on R79's neck and choked her.
What happened next is where the inspection record focuses its scrutiny.
CNA14, the witness and reporting party, was sent home. CNA13, the person accused of the choking, was placed on leave while the allegation was investigated. But the investigation did not reach a conclusion before things changed. CNA13 was brought back to work on the day shift, a decision the Director of Nursing told inspectors came at the recommendation of Human Resources after the allegation was deemed unsubstantiated.
The interim administrator who handled the initial response, identified in the report only as the IA, told inspectors she had spoken with all staff members and no one reported seeing or hearing anything on the day of the alleged incident. She said she suspended a couple of CNAs in the immediate aftermath. CNA13 was also placed on suspension.
Then the IA left.
She told inspectors she departed before the investigation into CNA13 was completed. On her last day at the facility, she said, a police officer contacted her and told her he did not believe the abuse had occurred. The officer's view, as she relayed it, was that staff had made up the allegations to get back at CNA13.
The inspection report does not say whether the police conducted a formal investigation, interviewed R79, or reviewed any documentation. It records only what the IA said the officer told her, and that she left the facility with the matter unresolved.
The report also notes that CNA14 delayed her reporting of the incident. The IA flagged this as a problem. How long the delay was, what caused it, and whether CNA14 ever explained it are not detailed in the inspection record.
The Director of Nursing, interviewed by inspectors on February 12, 2025, laid out what she said her expectations were. Staff who witnessed or suspected abuse should report it immediately. They should make sure the resident was out of harm's way first, then contact a nurse, the DON, or the administrator. She confirmed that CNA14 was sent home and CNA13 was put on leave after the report came in. She confirmed that the allegation was not substantiated and that CNA13 was returned to day shift on HR's recommendation.
She did not tell inspectors that the investigation was complete before CNA13 came back. The inspection record does not indicate it was.
The administrator who spoke with inspectors on February 13, 2025, the day the inspection concluded, said she was not employed at the facility when the incident with CNA13 and R79 occurred. She described her own expectations in terms nearly identical to the DON's: make sure the resident is safe, tell the nurse immediately, keep the accused staff member off work until the allegations are investigated. She was describing a standard the facility had already failed to meet before she arrived.
R79 is identified in the inspection record only by that designation. Her age, diagnosis, and condition are not described. Whether she was interviewed by inspectors, whether she was able to communicate what happened to her, whether anyone at the facility sat with her after the incident and asked how she was, none of that appears in what inspectors documented.
What the record does show is a sequence: a resident was allegedly choked by a staff member, the person who reported it was sent home, the person accused was eventually returned to the same shift where the incident occurred, the interim administrator who oversaw the initial response left before the investigation was finished, and the new administrator inherited a closed case she had no part in closing.
The inspection finding carries a designation of minimal harm or potential for actual harm, which is the lower end of CMS's harm scale. That designation reflects the regulatory conclusion about the level of harm to residents, not a judgment about whether the choking occurred or what R79 experienced.
Facilities are required to report allegations of abuse to the state and to investigate them. The inspection record does not detail what Lyndon Crossing submitted to state authorities or when. It does not describe what the internal investigation consisted of beyond the IA's account that she talked to all the staff and no one said they saw or heard anything.
That kind of investigation, one that turns on whether coworkers corroborate an allegation, has a well-documented limitation: people who work alongside each other every day, in a physically demanding and often understaffed environment, do not always tell supervisors what they saw. The inspection report does not say whether anyone interviewed R79 directly.
CNA13 is back on day shift. CNA14 was sent home. The interim administrator is gone. The administrator who answered inspectors' questions on February 13 was not there when it happened.
R79 remains a resident at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lyndon Crossing, LLC from 2025-02-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 14, 2026 · Our methodology
Lyndon Crossing, LLC in Louisville, KY was cited for violations during a health inspection on February 13, 2025.
That is what federal inspectors found when they visited Lyndon Crossing, a nursing home at 1101 Lyndon Lane in Louisville, on February 13, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.