Lyndon Crossing: Infection Control Failures - KY
The nurse, identified as LPN6, placed wound care supplies directly on uncleaned bedside tables without barriers, retrieved items that fell on the floor and returned them to the sterile field, and touched contaminated surfaces before opening clean dressings. The violations occurred during wound treatments for two residents with serious injuries requiring enhanced infection control precautions.
During one treatment on February 7, 2025, LPN6 raised a resident's bed and moved items around the bedside table without washing her hands or changing gloves. She removed an old wound dressing, then immediately opened sterile bandages with the same contaminated gloves. After cleaning the wound, she used her gloved fingers to apply honey directly to the injury without performing hand hygiene.
"If staff did not perform hand hygiene and change gloves appropriately, staff could contaminate the wound and cause an infection," the facility's wound doctor told inspectors.
The first resident, identified as Resident 20, had developed an abscess on her left hip that required daily wound care with calcium alginate and silver dressing. The facility had placed her on Enhanced Barrier Precautions specifically because of her wound, requiring staff to wear gowns and gloves during all high-contact care activities.
Inspectors observed LPN6 treating the resident's wound, which was smaller than a dime but had yellow drainage. The nurse sanitized her hands and put on protective equipment before entering the room, but immediately contaminated herself by moving items on the bedside table without cleaning it or placing a barrier.
She removed the wound dressing without changing gloves, then reached into her pocket for a bottle of normal saline. Her gown repeatedly touched the open dressings on the table during the procedure. She touched the resident's bed controls and bedside table before removing her gloves.
The second case involved Resident 67, who had a stage 4 pressure ulcer on her sacrum measuring 0.8 centimeters by 0.3 centimeters. The deep wound had moderate drainage and required specialized treatment with alginate rope and honey.
During this treatment, LPN6 forgot to bring normal saline and had to leave the room. When she returned, she put on new gloves inside the room, then lowered the resident's bed and removed bed covers without changing gloves afterward. She opened sterile supplies with the contaminated gloves.
After cleaning the wound with gauze, she applied honey directly with her gloved fingers without performing hand hygiene. She then pressed a button on the resident's feeding tube pump with the same gloves before packing the wound with alginate rope.
"LPN6 stated she typically placed a barrier before placing supplies on a table and that she should have performed hand hygiene and donned fresh gloves after touching resident equipment and before opening clean wound care supplies," according to the inspection report.
The facility's own policies required hand hygiene before and after glove changes, and specified that gloves did not replace proper hand washing. Staff were required to perform hand hygiene when moving from dirty to clean tasks during wound care procedures.
The Director of Nursing told inspectors she expected staff to maintain "a clean field" during wound care, with barriers placed on cleaned surfaces. Staff should change gloves after touching any contaminated items and perform hand hygiene each time gloves were changed.
The facility's Wound Care Nurse explained that surfaces should be cleaned with bleach wipes and allowed to dry before placing barriers. Honey should be applied with applicators rather than fingers to prevent contamination of both the wound and the honey bottle.
Both residents required Enhanced Barrier Precautions due to their wounds and risk of transmitting resistant organisms. Resident 20 was cognitively intact with a perfect score on mental status testing. Resident 67 had dementia following a stroke and also suffered from diabetes and heart failure.
The wound doctor, who saw Resident 67 weekly, told inspectors she expected nurses to change gloves between each wound and perform hand hygiene after cleaning wounds. Staff should change protective equipment between residents and use barriers when completing wound care.
"If proper hand hygiene and changing of gloves did not occur this could cause contamination of the wound and possible infection," the Staff Development Coordinator told inspectors.
The facility also failed to submit required staffing data to federal regulators for the third quarter of 2024, triggering alerts for having no registered nurse hours and failing to maintain licensed nursing coverage 24 hours a day for multiple days in August and September.
The Vice President of Finance, responsible for submitting payroll data to the Centers for Medicare and Medicaid Services, said she attempted to enter information into new software following a change in facility ownership but received an error message indicating the data was not successfully submitted. She realized the error after the October 15, 2024 deadline and had not contacted CMS.
The Administrator said the reporting failure affected the facility's federal survey outcome and decreased its star rating. She understood the importance of timely data submission but was still learning her role during the ownership transition.
The infection control violations affected residents requiring the most careful wound management, with one resident's injury showing signs of improvement despite the contaminated care practices observed by inspectors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lyndon Crossing from 2025-02-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Lyndon Crossing in Louisville, KY was cited for violations during a health inspection on February 13, 2025.
The violations occurred during wound treatments for two residents with serious injuries requiring enhanced infection control precautions.
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.