Home Of The Innocents

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

room, you could see the resident and what he was doing in his room. She further stated she received a verbal warning and had been re-educated on the facility's abuse/neglect and seclusion policies/procedures.In interview with the Quality Assurance Performance Improvement (QAPI) Manager on 09/13/2025 1:06 PM, she stated all residents were assessed for safety, and the safety monitor was responsible for monitoring, to ensure the safety of all residents. She said those staff were to help during mealtimes by monitoring the alarms. The QAPI Manager stated Resident R14 should have been on 1:1 supervision, when up in his chair. She further stated she had initiated the facility's report and made notifications the same day.In interview on 09/13/2025 at 3:16 PM, the Compliance Officer stated the facility's process, when

it came to allegations of any type of abuse, was to get documentation and video footage, interview the resident if interview able, then interview the team members. The Compliance Officer said the purpose was to identify if there were any gaps in training, identify learning needs or correct procedures, or updating compliance and quality improvement. In further interview the Compliance Officer further stated the purpose was to report it to the external investigators, and it was the responsibility of the external reviewer to determine as to whether occurrences had occurred, or were substantiated.In interview with the Administrator on 09/13/2025 at 4:00 PM, she stated she expected any reports of abuse and neglect to be reported immediately. She said, regarding the incident that occurred on 03/21/2024 involving Resident R14, had been handled appropriately. She reported Resident R14 had been in isolation precautions on the day of the incident, and resident had been care planned to be 1:1 when up in his wheelchair. The Administrator stated the aide blocked Resident R14 in, by re-positioning his bed and that was seclusion, and all staff working on the Maple Unit (Resident R14's unit) had been re-educated. She further stated she had not placed anyone on leave, because she felt like the education they received immediately had been sufficient.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Home of the Innocents

1100 East Market Street Louisville, KY 40206

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

allegation of abuse, adding, there is no confusion about that as far as I know.During interview with the Director of Nursing (DON) on 09/13/2025 at 2:38 PM, she stated her expectation was for staff to immediately notify leadership of any resident allegation of abuse so it can be assessed appropriately. She explained leadership should relay the resident allegation information to her, and then she would notify either the QAPI Manager or the Administrator. The DON said, The QAPI Manager then notifies OIG if it is reportable. She further stated (when asked about the required timeframes for reporting allegations of abuse to OIG), I am not exactly sure. The QAPI Manager handles that, I rely on her to make the determination and to do the reporting.During interview with the Administrator on 09/13/2025 at 4:00 PM, she stated abuse allegations were to be immediately reported to a leader and then we determine our next steps. She said allegations come to me or the QAPI Manager. We get together to discuss it and determine when to report.

The Administrator stated, If it is a report of abuse, we need to report it within 2 hours. She reported if a resident had a history of making false reports and we can't find corroborating evidence; we don't report it (to OIG). The Administrator explained specifically with Resident R77, because of his disease he isn't a reliable reporter, so if we can't find validity, we don't report it. We might wait to see if he perseverates on it. She said (regarding the allegation Resident R77 made against CNA 8), the CNA hadn't worked with Resident R77 recently and there had been inconsistencies in his (Resident R77's) reporting. The Administrator stated there had been no evidence of injury to Resident R77, and nothing had been observed by team members. We do investigate but don't report. So, there are caveats. If there is only a remote possibility it may have happened, we don't report it. She further stated (related to why the facility ultimately reported the allegation), I think we decided to err on the side of caution. The Administrator additionally said if abuse allegations were not reported to OIG in a timely manner, It could potentially delay the investigation, which could put the child (resident) at risk.In interview with the Quality and Compliance Officer (QCO) on 09/13/2025 at 3:15 PM, she reported, I rely heavily on [the QAPI Manager] to determine whether an incident is a 2-hour reportable or 24 hours, reportable incident. She said, Abuse should be reported immediately or at least within 2 hours. The QCO stated continued mistakes, errors, harm to residents could occur if reports were not made as required. She explained Resident R77 can say beautiful, sweet things and then also say that people mistreat him; however, when

the QAPI Manager told her about the allegation, I told her we can't take any chances, even with his diagnosis, so we made a report. The QCO stated (when asked whether the facility's Initial Report had been submitted to OIG within the required timeframe) the allegation should have been reported sooner, saying it had, not been handled appropriately. She further stated, When I heard about it, I said, ‘I know it is constant, but we have to report it because if it is true, it is our job to protect him and if it isn't we will find it out. The QCO additionally said, I am not over there working with him on a regular basis, but I know this is something constant with Resident R77.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Home of the Innocents

1100 East Market Street Louisville, KY 40206

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident. She reported if the facility's investigation was not completed the potential issues included, continued mistakes, errors, or harm. The CQCO said the purpose of reporting to the state agency was to ensure the external reviewers determine abuse/neglect, as the facility did not substantiate abuse internally.

She stated, by the 5-day report, the facility had summarized interviews, did the documentation, performed physician consults, and completed medical chart information.In interview on 09/13/2025 at 3:59PM, the Administrator stated the facility investigation continues to ensure protection, root cause, and training. The Administrator further stated, CPS/APS investigations take precedence; we do not interview when they are involved.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Home of the Innocents

1100 East Market Street Louisville, KY 40206

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

until after Resident R40's hospitalization on 08/15/2025. She further stated Resident R40 received the first dose of Aripiprazole on 08/07/2025, his first day of school, and continued to receive it at school until 08/15/2025 (a total of eight days).During interview with the Resident Education NC on 09/11/2025 at 2:40 PM, she stated

she called and spoke with a nurse at Resident R40's school and verbally discontinued the resident's Aripiprazole order. When questioned regarding the process for communicating medication changes to schools, she stated there was a school form that was to be completed and faxed or emailed. The Resident Education NC acknowledged however, that form had not been completed for the discontinuation of Resident R40's Aripiprazole medication. She further stated the facility sometimes called verbal orders to the schools.During interview with the Director of Support Services (DSS) on 09/11/2025 at 3:15 PM, she stated the process for school medications involved the use of two forms. She reported the two forms were the School Medication Order Form, referred to in the policy as the Monthly School Medication Order Form. and the school Permission Form for Prescribed or Over the Counter Drugs. The DSS said the School Medication Order Form was to be scanned to the pharmacy and the school Permission Form for Prescribed or Over the Counter Drugs, was to be faxed or emailed to the school nurse. She further stated she personally audited residents' medications to ensure accuracy at both the pharmacy and the school.During interview with the Quality Assurance Nurse (QAN) on 09/12/2025 at 9:40 AM, she stated the team reviewed the root cause analysis for the medication error involving Resident R40 in the August QAPI meeting, and identified failures in the facility's process. When asked what types of outcomes could occur when medication changes were not communicated, she stated there could be a negative outcome if a resident continued receiving a discontinued medication, such as an allergic reaction or even a fatal event.During interview with the Director of Nursing (DON) on 09/12/2025 at 2:28 PM, she stated orders were to be checked daily and medication changes should be communicated to the pharmacy and the school within 24 hours of any changes. She further stated the potential for a negative outcome involving a resident receiving a discontinued medication could include overdose, or even death.During interview with the Administrator on 09/13/2025 at 3:59 PM, she stated when a medication order was changed, the expectation was for the Nursing Education Coordinator to receive the order change information, and fill out the correct school forms. The Administrator said the Nursing Education Coordinator was expected to send the order change information via email or fax to the school and the facility's contracted pharmacy. She stated, The breakdown was that when the medication was changed, the double check did not occur, and the form was not filled out and the change was not communicated to the school. The Administrator further stated the potential outcome to not communicating medication order changes could be a serious injury up to death for a client receiving a discontinued medication.

Event ID:

Facility ID:

If continuation sheet