Lyndon Crossing
Lyndon Crossing in Louisville, KY — inspection on February 13, 2025.
Found 5 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
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