Lyndon Crossing, Llc
Lyndon Crossing, LLC in Louisville, KY — inspection on February 13, 2025.
Found 17 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
address on file with the facility.
could request to receive their quarterly statements at any time.
She stated she was unaware
statements to the residents violated their rights.
She stated the business office was responsible for sending out quarterly statements to the residents and guardians.
The DON stated the facility had been bought by another company in August 2024.
In interview with the Administrator on 02/13/2025 at 9:38 AM, she stated residents had issues with receiving quarterly statements.
However, residents had been receiving their statements since her hire date, 12/18/2024.
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Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
Shower Room.
She stated Hall C Shower Room was currently being remodeled and was unsure how
On 02/12/2025 at 9:38 AM in an interview with the Director of Nursing (DON), she stated they have had no hot water off and on for the last few weeks.
The DON stated she understood why Hall A Shower Room could not be used due to the cold water.
She stated she did think it was an issue that 72 residents were using the one shower room on the East Unit that worked.
On 02/12/2025 at 10:31 AM in an interview with Social Services (SS), when the pipes burst some residents ran out of hot water due to the high demand for the one shower room and he would have to tell them to wait a half an hour until the water heated back up and try getting a shower again. He stated that for the female residents who were able to walk, the Certified Nursing Assistants (CNA) took them to the locked women's unit for a shower instead.
On 02/13/2025 at 8:18 AM in an interview with the Administrator she stated renovations were ongoing and they were currently working on three of the six shower rooms: [NAME] Unit Shower, East Unit Hall A Shower, and East Unit Hall C Shower.
The reason there was no hot water was due to these renovations, but this issue had been fixed.
She stated she was unaware of the cold water in residents' rooms and in Hall A Shower Room until this past Sunday when they were made aware and since then a plumber had come and fixed the issue.
When asked if she felt one shower was sufficient for 72 residents, she stated the facility had three other showers residents could utilize.
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Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
completed by the previous owner of the facility and anyone hired after 09/01/2024 was processed
185165 02/13/2025
Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
talked to all the staff and no one reported they saw or heard anything (on the day of the alleged
Administrator stated the police officer contacted her on her last day at the facility and stated he did
The IA stated CNA14 delayed her reporting of the incident.
On 02/12/2025 at 9:38 AM in an interview with the Director of Nursing (DON), she said that CNA14 reported she was in the room with another CNA (CNA13) when R79 became combative.
She stated CNA14 reported CNA13 had placed her hands on R79's neck and choked her.
Per the interview, the DON stated her expectation of the staff was for staff to report allegations of abuse immediately.
The DON stated staff should ensure the resident was out of harms way.
Then, after ensuring the safety of the resident, the nurse , DON, or Administrator should be contacted.
Further, she stated the reporting CNA (CNA14) was sent home and CNA13, the alleged perpetrator, was put on leave.
She stated the allegation was not substantiated and CNA13 was brought back on day shift at the recommendation of Human Resources (HR).
On 02/13/2025 at 8:18 AM in an interview with the Administrator she stated that she was not employed at the facility when the incident with CNA13 and R79 occurred.
Her expectation was if there was an allegation of abuse staff should make sure the resident was safe and tell the nurse about the allegation immediately.
Then the nurse would make her aware of the situation.
The staff member that was the alleged perpetrator would be taken off work until the allegations were investigated.
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Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
resident could get out and a lot could happen.
jeopardy to resident health or safety
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Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
resident was care planned for the boot as he had been wearing it for sometime.
been at the facility for almost two years.
The MDSC stated she completes the care plans and that all
admitted she completed the care plan the next day.
The MDS Coordinator stated nurses could complete the care plan under evaluations then select the admission assessment located where they could complete a baseline care plan.
The MDS Coordinator stated the facility's version of baseline consist of basic activities of daily living, support need, and anything a resident may be at risk.
In interview with the Administrator on 02/13/2025 at 9:38 AM, she stated comprehensive care plans should be updated within 24 hours of admission, so the correct care could be provided for the resident.
The Administrator stated baseline and comprehensive care plans were very important for patient care.
She stated the facility provided the best quality of care to all residents and R22's care plan not being developed (to include the AFO) could just possibly be an oversight.
In additional interview with the DON on 02/13/2025 at 10:23 AM, she stated it was very critical any resident's baseline and comprehensive care plans were developed or updated in a timely manner.
The DON stated comprehensive care plans should be completed seven days after the completed comprehensive (MDS) assessment.
Additionally, the DON stated documentation in the progress notes for R22 should have included any occupational and physical therapy notes regarding the use of the SoftPro Ambulating AFO Boot the resident was issued and wearing.
185165 02/13/2025
Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
During the interview a note from PT was reviewed which noted R400 had weight bearing issues and it was that issue that was preventing her from progressing.
The PT said R400's ankle had been injured from the falls she experienced.
The PT stated with the fall that occurred on 01/30/2025, R400 had received an x-ray which showed no fracture, but R400 refused to ambulate on 02/02/2025 due to pain in the ankle.
The PT and OT said on 02/05/2025, they both asked for R400's weight bearing status from the provider.
Per the therapists in interview, on Thursday, 02/06/2025, R400 had been deemed as non-weight bearing by the provider and was awaiting another x-ray per NP 6.
Both OT and PT stated
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Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
assess their competencies, skills, and knowledge and their required training would be met annually.
185165 02/13/2025
Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
During an interview on 02/06/2025 at 2:15 PM with the Director of Nursing (DON), she stated it was her expectation that expired medications were not to be in the carts.
She stated the nurses were expected to look at the dates prior to use and reorder the medication and dispose the expired medications.
She stated that open dates and expiration dates should be written on the medications with either the 30 day after open date or the manufacture's date, whichever comes first.
The DON stated the nurses were to look at the medications in the carts daily for expiration dates and the unit managers were to check once a week.
She stated random pills in the medication carts were expected to dispose the medications.
The DON stated medications were to be in their separate container with a resident identifier.
During an interview on 02/06/2025 at 2:33 PM with the Administrator, she stated it was her expectation that expired medications should not be in the medication or treatment carts.
She stated any nurse could check at least once a week and review the carts.
She stated medications have to have open dates according to policy.
The Administrator stated that loose, random medications in the carts must be destroyed.
She stated medications could not be in medication carts without personal containers with identifiers needed.
She stated a negative outcome could be death, the right medications needed to go to the right resident.
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Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
unlabeled pill found in two separate medication carts. (Refer to F-F761).
facility's POC was a team effort which was overseen by the Administrator and nursing team.
She
carts during the audits being performed.
The ADON reported any loose medications were a definite issue and the breakdown in the process of implementing the facility's POC fell on the managers.
In interview on 04/03/2025 at 4:54 PM, the Administrator stated she was responsible for ensuring all staff were educated and for ensuring all audits were completed as per the facility's POC.
The Administrator said she expected education of staff to be performed, for staff to follow the facility's policies and perform all audits as required in the POC.
She further stated she was ultimately responsible for making sure all sections of the facility's POC were followed.
The facility failed to submit direct care staffing information for the third quarter (July-September) of 2024 which triggered for no RN [registered nurse] Hours, and failure to have Licensed Nursing Coverage 24 Hours/Day Four or More Days Within the Quarter, specifically August and September
- The findings include:
Review of the facility's provided CMS Payroll Based Journal (PBJ) report which was based on the staffing data submitted by the facility revealed excessively low weekend staffing, no RN hours, and a failure to have licensed nursing coverage 24 Hours/Day triggered for August and September 2024.
A request for the facility's staffing data submitted for the third quarter (July, August, September) PBJ was requested but no verification that it had been reported successfully was provided.
The facility provided an Excel spreadsheet for August and September 2024 which included payroll data for all staff; however, no verification the information was submitted or received by CMS system was provided.
Further, the facility could not provide the facility's assessment completed for 2024.
In an interview with the [NAME] President of Regional Clinical Operations (VPRCO), on 02/13/2025 at 3:04 PM, she stated the [NAME] President of Finance (VPF) advised her that the requested PBJ staffing data had not been submitted.
She stated the VPF indicated that she (the VPF) had attempted to submit the data unsuccessfully.
In an interview with the VPF, on 02/13/2025 at 3:30 PM, she stated she was responsible for submitting the payroll data to CMS for the PBJ Staffing Data Report.
She stated during the third quarter there was a change of ownership and the data was entered into a new software program and could only conclude that there was an error in the software.
She stated she submitted the information on 10/14/2024 but received an error message on 10/15/2024 which indicated the data was not submitted.
She stated there was a lot of confusion with the third quarter because the data for July 2024 was submitted by the previous owners, but the new owners would submit the August and September 2024 data.
She stated she had not contacted CMS because the error was realized after the deadline of 10/15/2024.
In an interview with the Administrator, on 02/13/2025 at 4:00 PM, she stated she was new in her position and was still learning her role during the change in ownership.
She stated she was made aware the staffing data had not been submitted due to a software error.
She stated she understood the importance of submitting the payroll data timely to CMS because it had affected the facility's survey outcome and also decreased the facility's star rating.
She stated her expectation was that the facility submitted the required data timely to ensure the facility was in compliance.
185165 02/13/2025
Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
expectation for wound care was for staff to have a clean field on which to do wound care.
She stated
as the bed controls, tube feed pump, or the resident.
She stated staff should change gloves after
changed.
The DON stated that she expected staff to wash their hands and sanitize after any dirty task and change gloves.
In an interview with the Wound Care Nurse/Staff Development Coordinator (WCN/SDC) on 02/12/2025 at 1:17 PM, she stated it was her expectation of staff performing would care to clean the surface they were placing their barrier on with bleach wipes and allow it to dry the specified time before putting down a barrier like a chux.
Then wound care supplies should be put on the clean chux.
She stated staff should hand sanitize and/or hand wash before putting on PPE (gloves and gown) to enter the room for the wound treatment.
Further, she stated staff should also change gloves and wash their hands when touching anything that was not clean or sterile.
The SDC stated her expectation was that the Leptospermum honey would be applied to the wound with an applicator to prevent contaminating the wound and the Leptospermum honey bottle.
She stated if proper hand hygiene and changing of gloves did not occur this could cause contamination of the wound and possible infection.
In an interview on 02/13/2025 at 9:17 AM with the Wound Doctor, she stated she had been seeing R67 weekly for her pressure ulcer since she inherited the facility from the previous wound doctor.
She stated her expectations for wound care was that nurses go into the resident's room with PPE on.
She stated staff should perform hand hygiene and wear gloves for all wound care.
Further, she stated gloves should be changed in between each wound.
The Wound Doctor stated that if staffs' hands were soiled staff should wash their hands, otherwise, they could use hand sanitizer for hand hygiene.
She stated she expected staff to change their PPE between residents.
The Wound Doctor stated she expected staff to use hand sanitizer and put on new gloves after they clean the wound.
Per the interview, she stated if staff touched anything in the room that was not clean or sterile, staff should complete hand hygiene and change gloves.
Further, she stated barriers should be down when completing wound care, to put the supplies on.
She stated if staff did not perform hand hygiene and change gloves appropriately, staff could contaminate the wound and cause an infection.
185165 02/13/2025
Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
Based on observation, interview, and record review, the facility failed to ensure the development and implementation of comprehensive resident centered care plans for three of 23 sampled residents. (Refer to
Review of the facility's policy, Elopements and Wandering Residents, reviewed/revised 03/06/2024, revealed the facility ensured residents at risk for elopement received adequate supervision to prevent accidents and received care in accordance with their person-centered plan of care addressing unique factors contributing to elopement risk.
Per review, elopement occurred when a resident left the premises or safe area without authorization (i.e. an order for discharge or leave of absence) and/or any necessary supervision to do that.
Continued review revealed the facility was to establish and utilize a systematic approach for monitoring and managing residents at risk for elopement.
The systematic approach was to include identification and assessment of risk .implementing interventions to reduce hazards and risks, and monitoring the effectiveness and modifying interventions when necessary.
185165
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185165 B.
Wing 02/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
Based on observation, interview, and record review, the facility failed to ensure all drugs were labeled in
in two separate medication carts. (Refer to
F-F689 at a Scope and Severity (S/S) of a J.
The facility was notified of the IJ on 02/12/2025 at 4:23 PM.
On 02/12/2025 at 4:23 PM, the facility's Executive Director, Regional [NAME] President of Clinical (RVPC), and Regional [NAME] President (RVP) were provided a copy of the IJ Template and notified that the facility's failure to ensure the resident's safety is likely to cause serious injury, impairment, or death.
The facility provided an acceptable IJ Removal Plan, on 02/13/2025 at 2:47 PM, alleging removal of the IJ on 02/13/2025.
The State Survey Agency (SSA) validated the IJ had been removed on 02/13/2025, as alleged, after an acceptable IJ Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections.
Remaining non-compliance continued at a S/S of a D at
The facility failed to submit direct care staffing information for the third quarter (July-September) of 2024 which triggered for no RN [registered nurse] Hours, and failure to have Licensed Nursing Coverage 24 Hours/Day Four or More Days Within the Quarter, specifically August and September 2024.
The findings include:
Review of the facility's provided CMS Payroll Based Journal (PBJ) report which was based on the staffing data submitted by the facility revealed excessively low weekend staffing, no RN hours, and a failure to have licensed nursing coverage 24 Hours/Day triggered for August and September 2024.
A request for the facility's staffing data submitted for the third quarter (July, August, September) PBJ was requested but no verification that it had been reported successfully was provided.
The facility provided an Excel spreadsheet for August and September 2024 which included payroll data for all staff; however, no verification the information was submitted or received by CMS system was provided.
Further, the facility could not provide the facility's assessment completed for 2024.
In an interview with the [NAME] President of Regional Clinical Operations (VPRCO), on 02/13/2025 at 3:04 PM, she stated the [NAME] President of Finance (VPF) advised her that the requested PBJ staffing data had not been submitted.
She stated the VPF indicated that she (the VPF) had attempted to submit the data unsuccessfully.
In an interview with the VPF, on 02/13/2025 at 3:30 PM, she stated she was responsible for submitting the payroll data to CMS for the PBJ Staffing Data Report.
She stated during the third quarter there was a change of ownership and the data was entered into a new software program and could only conclude that there was an error in the software.
She stated she submitted the information on 10/14/2024 but received an error message on 10/15/2024 which indicated the data was not submitted.
She stated there was a lot of confusion with the third quarter because the data for July 2024 was submitted by the previous owners, but the new owners would submit the August and September 2024 data.
She stated she had not contacted CMS because the error was realized after the deadline of 10/15/2024.
In an interview with the Administrator, on 02/13/2025 at 4:00 PM, she stated she was new in her position and was still learning her role during the change in ownership.
She stated she was made aware the staffing data had not been submitted due to a software error.
She stated she understood the importance of submitting the payroll data timely to CMS because it had affected the facility's survey outcome and also decreased the facility's star rating.
She stated her expectation was that the facility submitted the required data timely to ensure the facility was in compliance.
185165
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185165 B.
Wing 02/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lyndon Crossing 1101 Lyndon Lane Louisville, KY 40222
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.