Lyndon Woods Care & Rehab, Llc

F-F607).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0835 2. 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 Level of Harm - Minimal harm or

F-F655

The findings include:

1. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 Further review of the facility's policy, Elopements and Wandering Residents, reviewed/revised 03/06/2024, revealed residents were to be assessed for risk of elopement upon admission by the interdisciplinary team Level of Harm - Immediate (IDT). The policy review revealed the IDT was to evaluate unique factors contributing to the risk and to jeopardy to resident health or develop a person-centered care plan, with adequate supervision provided to help prevent elopements. In safety addition, charge nurses and unit managers were to monitor implementation of interventions, response to interventions, and document accordingly. Review further revealed if a resident was not located in the building Residents Affected - Few or on the grounds, the Administrator or designee were to notify the police department, along with appropriate reporting to the State Survey Agency (SSA). Per the policy, documentation in the medical record was to include physician/family notification, care plan discussion, and consultant notes as applicable.

Review of the facility's policy, Baseline Care Plan, reviewed/ revised 12/23/2023, revealed the facility was to develop and implement a baseline care plan (CP) for each resident. Per review, the baseline care plan was to include interventions to address the resident's current needs, including any safety concerns to prevent injury, such as elopement, and any identified needs for supervision.

Review of the clinical record for Resident R401 revealed the facility admitted the resident on 01/21/2025 with diagnoses of aphasia following cerebral infarction, epilepsy, hemiplegia and hemiparesis following cerebral infarction, and congestive heart failure (CHF).

Review of the facility's, Wandering/ Elopement Risk Evaluation dated 01/21/2025 at 11:46 PM, revealed Resident R401 was At Risk for Elopement. Review of Resident R401's Progress Notes dated 01/21/2025, revealed Resident R401 was noted as alert and oriented times one (x1).

Review of the Care Plan (CP) dated 01/22/2025, for Resident R401 revealed the facility identified the resident to require assistance with Activities of Daily Living (ADLs) related to impaired decision making and impaired cognition. Continued review of the CP revealed the facility also identified on 01/22/2025, the resident as a risk for falls, related to diminished safety awareness, cognitive impairment and wandering. However, further

review of Resident R401's CP revealed no documented evidence the facility addressed the resident's assessed risk for elopement.

Review of the Speech Therapy SLP Evaluation and Plan of Treatment dated 01/22/2025, revealed Resident R401's short term goals included to increase orientation to person, place, time, purpose, and caregivers. Per review, Resident R401's previous level of functioning (PLOF) was 100%, and the baseline (on 01/22/2025) was 25%. Review revealed Resident R401 had a diagnosis of stroke and increased confusion and cognitive decline. Continued review revealed the reasons Resident R401 was referred to Speech Therapy (ST) included confusion and decreased cognition. Review revealed the resident's BIMS was noted as 12 out of 15, and the St. Louis University of Mental Status (SLUMS) score was noted as 6 out of 30, indicating severe cognitive impairment. Further

review revealed Resident R401 demonstrated severe cognitive deficits for short term memory, delayed recall, orientation, problem solving, and safety awareness.

Review of the Speech Therapy Treatment Encounter Note dated 01/24/2025 at 12:48 PM, revealed Resident R401 answered orientation questions with 25% accuracy with moderate visual cues. Continued review revealed

the resident recalled information from a read story with 20% accuracy with moderate cues, and answered problem solving questions with 30% accuracy with moderate cues.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 Review of the undated facility, Timeline of Events Starting 8:30 PM 01/24/2025, revealed Resident R401 had been observed at 8:30 PM, during the scheduled smoking session. Review of the Timeline revealed at 9:00 PM, Level of Harm - Immediate staff observed Resident R401 wearing a shirt, sweatshirt, jacket, pants, and shoes, and telling staff he was going out jeopardy to resident health or for cigarettes and waving his debit card to show he was going to buy smoking supplies. (However, the facility safety investigation summary noted Resident R401 left the facility at approximately 8:45 PM.) Per review, at 10:00 PM the Unit Manager, was notified upon her arrival to the facility, Resident R401 had not returned from getting smoking Residents Affected - Few materials. Per review, the facility was immediately searched and a head count completed. Continued review revealed on 01/25/2025 at 12:25 AM, the Administrator was notified Resident R401 had not returned from shopping and the DNS notified at 12:32 AM. Review revealed at 2:00 AM, the ED, DNS, Maintenance Director, and Staff Development Coordinator (SDC) arrived at the facility to assist in locating Resident R401.

Continued review of the undated facility, Timeline of Events Starting 8:30 PM 01/24/2025, revealed at 3:00 AM, the Maintenance Director audited 100% of the facility doors, door alarms, and windows to ensure proper functioning, and the door codes were changed. In addition, review revealed at 6:30 AM, the local hospital called the facility to notify them Resident R401 was under their care and supervision. Further review revealed the EMS

record noted Resident R401 called 911 while out shopping and had been picked up by EMS at 2:00 AM.

Review of the website www.wunderground.com temperature for the city Resident R401 was picked up in by EMS on 01/25/2025 at 1:56 AM, revealed the temperature was 26 degrees Fahrenheit.

Review of the local Emergency Medical Services (EMS) [Resident] Patient Care Record for Resident R401 dated 01/25/2025, revealed EMS received a call on 01/25/2025 at 2:03 AM, for seizures. Per review, at 2:21 AM, EMS arrived to Resident R401's location, an intersection approximately 7.79 straight line miles from the facility. Continued review revealed EMS personnel noted Resident R401 had altered mental status and the primary impression was stroke. Further review revealed EMS transported Resident R401 to the local hospital, approximately two to three blocks away. Review of the EMS record additionally revealed Resident R401 told EMS, he had been discharged from a hospital, and described an area that did not have a hospital located there. The EMS

Record further revealed Resident R401 did not know what the year was.

Review of the hospital's, ED Physician Notes Final Report for Resident R401 dated 01/25/2025 at 11:14 AM, revealed

the ED Physician Note documented Resident R401 arrived at the hospital for upper extremity weakness, and had been previously seen for a stroke. Further review of the ED Physician Note revealed it documented stroke as most likely chronic, with a discharge diagnosis of History of Ischemic Stroke.

In interview on 02/07/2025 at 1:47 PM, Resident R401 stated he had not been to the hospital since being admitted to

the facility. (He did not recall the incident on 01/24/2025). Resident R401 stated he slipped on the ice before he was admitted to the hospital and that was why his left arm did not move. (However, he was admitted to the facility

on [DATE REDACTED], with a diagnosis of a stroke with hemiplegia and hemaparesis). Resident R401 reported he was able to leave the facility whenever he liked and had done so about a week ago. He stated he went out with family once and left a second time by himself.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 In interview on 02/07/2025 at 2:34 PM, Resident R401's family member (F)10 stated the resident got out of the facility one weekend and got lost. She stated he almost froze to death and ended up at a local hospital. F10 said Level of Harm - Immediate she did not know how Resident R401 got out of the facility, and he had not had a coat on at the time. She stated Resident R401 jeopardy to resident health or got disoriented and she thought he had fallen in a ditch and someone called EMS for him. F10 reported the safety facility had called her, but she had her phone ringer turned down, but finally answered her phone at 4:00 AM.

She further stated the facility asked her if Resident R401 was with her and asked where he could be. F10 reported Residents Affected - Few Resident R401 ended up in the emergency room ; however, he did not remember what happened.

In interview on 02/08/2025 at 8:17 AM, Licensed Practical Nurse (LPN) 7 stated he was told in report from

the third shift nurse, Resident R401 left the facility between 9:00 PM and 10:00 PM (on 01/24/2025). The LPN stated

he did not receive in report what Resident R401 went to the hospital for; however was told the resident eloped from

the facility. Per LPN 7 in interview, when Resident R401 returned from the hospital, the resident told him (the nurse)

he went out the double door up the ramp (toward the front lobby) and went to a gas station or store. The LPN said Resident R401 told him someone called 911 and the ambulance took him to the hospital. He reported Resident R401 was placed on one to one (1:1) supervision upon return to the facility, although it was stopped prior to the next shift he (LPN) was back to work. The nurse further stated Resident R401 had some cognitive impairment due to the stroke he suffered before he was admitted to the facility.

In interview on 02/09/2025 at 1:42 PM, Certified Nurse Aide (CNA) 27 revealed she knew Resident R401 went out once and returned from the hospital. She stated she did not think Resident R401 was able to go out on his own, both physically and mentally. CNA 27 stated she had not received in report any information saying the resident could not go out on his own.

In interview on 02/09/2025 at 1:57 PM, LPN 6 stated Resident R401 was very impaired (cognitively). The LPN stated

she could talk to the resident and thought he was cognitive (intact); however, as time went by she would begin to notice a change in his conversation. She said Resident R401 would begin saying things that made no sense.

She stated Resident R401 was not able to come and go as he pleased.

Observation of facility's exit doors on 02/09/2025 at 3:30 PM, revealed the exit doors on A hall, B hall (to the facility parking lot at the end of the driveway), C hall, the double doors to go up the ramp (toward the front lobby area) all had keypads.

In interview on 02/10/2025 at 1:51 PM, the East Unit Manager (UM) stated the nurse completed multiple assessments of the resident, which included the risk assessment. She stated the Interdisciplinary Team (IDT) went over the new admission the next day and ensured everything had been completed. The East UM said she would expect to see a detailed note documented in Resident R401's chart of the completed notifications (after he eloped), if the doctor gave any orders, how the resident was acting, and any details that made the nurse come to the assumption the resident had stroke-like symptoms. She reported whether a resident could come and go as they pleased or needed supervision was determined by the resident's BIMS score. She stated Resident R401 was not safe to go out by himself without supervision based on his low BIMS scores and cognition. She further stated he could get hit by a car or kidnapped.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 In interview with LPN 12 on 02/11/2025 at 2:20 PM, she stated she did not know how Resident R401 got out of the facility. LPN 12 said (on 01/24/2025) she had given Resident R401 his medications at 8:30 PM, and she finished that Level of Harm - Immediate hallway around 9:32 PM. She stated when she came back up the hallway around 10:30 PM, staff said they jeopardy to resident health or could not find Resident R401. The nurse stated they looked everywhere for Resident R401 and nobody had seen the resident. safety LPN 12 said we called the nurse that left late that night to see if Resident R401 walked out behind her. The next morning, she stated she received a call from a local hospital saying Resident R401 was in the emergency room (ER) Residents Affected - Few for a stroke, and she informed the hospital the resident had walked away from the facility. LPN 12 said the facility tried to call Resident R401's family member when they realized he was not there and tried several times with no answer. The nurse said from the time she got to work that night, Resident R401 was asking about buying cigarettes.

She reported she did not think any of the residents had gone out to smoke after 8:00 PM that night, due to

the temperature being too cold. LPN 12 said she did not see the police the night Resident R401 went missing. She stated she did not know where Resident R401 had been located before he went to the hospital (after his elopement).

In interview on 02/11/2025 at 3:08 PM, CNA 28 stated she was at the facility when Resident R401 was admitted and

he had been overly anxious and confused as it was a new place. She said he was there for a couple of days with no idea of the facility he was in. CNA 28 said Resident R401 had been asking about leaving when she cared for him the first night and talked about his family member living in an apartment next door and about getting cigarettes. The CNA stated she had been working the night when Resident R401 left the facility and she last saw him by the nurse's station. She reported the last time any staff saw Resident R401 (on 01/24/2025) was around 11:30ish PM or 11:45 PM. CNA 28 said Resident R401 went missing between that time and 1:00 AM, when he was discovered missing. Per the CNA in interview, we had no idea how long Resident R401 had been missing. She stated when Resident R401 returned, he said he left the facility behind someone as they exited out the door at the large parking lot end of

the driveway. CNA 28 stated she was told Resident R401 was a flight risk, but was also told by management that even though the resident scored at risk for elopement, he took care of his own affairs. She said the police were never called (when the resident went missing).

In interview on 02/11/2025 at 3:49 PM, CNA 30 stated she worked the night Resident R401 disappeared from the facility. She stated we did not know where he was. She stated before Resident R401 went missing, she was not told

he was at risk for elopement. The CNA said around 6:00 AM (the next morning) the nurse received a call from the local hospital saying the resident was there. CNA 30 reported she did not remember hearing a door alarm sound that night.

In interview on 02/12/2025 at 9:53 AM, the Night Shift Manager stated her shift started at 10:00 PM the night Resident R401 was missing, and she did not recall hearing any door alarms. She stated the CNAs reported to her when they were doing rounds around 11:30 PM, they had not seen Resident R401. The Night Shift Manager said she checked the whole building, and then drove to apartment buildings nearby as the buildings had doors you could go into to get warm. She stated after they checked the building, she called the DNS and continued looking for Resident R401. The Night Shift Manager said per hearsay, someone asked Resident R401 how he left the building and he said he went out as a staff nurse left. She stated she did not know if the police were notified that night as that was the responsibility of the ED and DNS to determine. She reported Resident R401's elopement risk assessment noted him as at risk; and he was considered at risk for elopement when he returned. The Night Shift Manager reported she was not asked to write a statement about that night. She further stated she had not heard how Resident R401 ended up where he was when he was picked up or how he exited the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 In interview on 02/12/2025 at 10:37 AM, the MDS Coordinator stated she and the other facility MDS Coordinator talked about if Resident R401 was at risk for elopement when he first came to the facility. She stated Level of Harm - Immediate however, she did not know Resident R401 was assessed at risk by the admission nurse (on 01/21/2025). The MDS jeopardy to resident health or Coordinator stated she participated in the clinical meeting (the next morning after Resident R401's admission) and did safety not recall if Resident R401's risk for elopement was discussed. She reported she was called at 2:00 AM, (when Resident R401 was missing) by the DNS and was told the resident had left the facility. The MDS Coordinator said when she Residents Affected - Few got to the facility she called and spoke to Resident R401's family member, who said she did not know where Resident R401 was, and gave them some places to look. She stated she spoke to the nurse at the local hospital when the resident was located. The MDS Coordinator reported after Resident R401 left the facility it was brought up in the clinical meeting; however, there was not a huge discussion about it. She further stated if a resident left the facility without staffs' knowledge the resident might not be safe.

In interview on 02/12/2025 at 1:14 PM, the Staff Development Coordinator (SDC) stated she participated in

the clinical meetings every morning. and there had been no discussion of Resident R401's risk of leaving the facility when admitted . The SDC said however, the meeting did review Resident R401's elopement risk assessment. She stated at risk meant the facility needed to keep an eye on him, pay special attention, and needed to have processes in place so the resident stayed in the facility for his safety.

In interview on 02/12/2025 at 1:59 PM, the DNS stated when a resident triggered as at risk, the resident may or may not actually be an elopement risk, which varied from resident to resident, and was based on their diagnoses. The DNS said she could not remember what the facility policy said about that though. She stated

she was first made aware Resident R401 leaving the facility around midnight by the ED, and had been told the resident left to get cigarettes and had not returned.

In continued interview on 02/12/2025 at 1:59 PM, the DNS stated she conducted the facility investigation which was a collaborative effort. She stated she asked Resident R401 how he got out of the building and the resident told her a young fell ow let him out. The DNS said she did not know when Resident R401 left the facility. She stated

we verbally asked staff and no one saw him leave. The DNS reported however, she could not remember the names of the staff questioned and there were no written statements. She said she was not sure which door Resident R401 went out. She stated if a resident was identified as at risk for elopement her expectation was for a care plan on elopement be implemented within 48 hours. The DNS reported she had not been able to determine who let the resident out the back door at the parking lot. She further stated Resident R401 had last been seen by staff around 7:30 PM and 7:45 PM when he received his medicine.

In interview on 02/12/2025 at 2:38 PM, the Interim Nurse Practitioner (NP) stated he supervised the former NP who reported to him no one at the facility notified her (the former NP) of Resident R401 leaving the facility. He stated the former NP told him she had seen a sitter with Resident R401 a couple of days later and when she asked why he had a sitter she was told he had gotten out.

In interview on 02/12/2025 at 3:03 PM, the Administrator stated she had been notified by the Night Shift Manager, the night of 01/24/2025 or 01/25/2025, that Resident R401 left the facility. She stated she called the DNS

after being notified by the Night Shift Manager. The Administrator said the DNS, MDS Nurse, SDC, Maintenance Director, and herself, all came to the facility, where a thorough search for Resident R401 was conducted.

The Administrator stated facility staff called Resident R401's family member who did not answer. She said the facility reached the family member at 4:00 AM, who said Resident R401 was not with her, and gave staff ideas of where he could be.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 In continued interview on 02/12/2025 at 3:03 PM, the Administrator stated she had been informed by the DNS on 01/25/2025, the local hospital called to ask if the facility had a resident by the name of [Resident R401]. The Level of Harm - Immediate Administrator stated Resident R401 also said he went out the back (of the facility) at the double doors (at the parking jeopardy to resident health or lot at the end of the driveway). safety

Review of the facility's policy titled, Protocol: Smoking, date implemented and revised 11/01/2024, revealed Residents Affected - Few the policy stated Smoking Safety Screens would be completed upon admission, re-admission, quarterly, annually, with a significant change, and as needed.

Review of the facility's policy titled, Fall Prevention Program, date implemented and reviewed 02/01/2024, revealed that upon admission the nurse was to complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk.

2. Review of Resident R400's EMR revealed the facility admitted the resident on 01/24/2025, with diagnoses of cerebral infarction with hemiplegia and hemiparesis, seizures, and diabetes type II.

Review of Resident R400's Admission Minimum Data Set (MDS) Assessment with an ARD of 01/30/2025, revealed

the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. Further MDS review revealed the facility assessed the resident to require partial assistance for all transfers (bed to chair and bed to toilet).

Continued review of Resident R400's EMR revealed no documented evidence of a smoking assessment or fall risk assessment completed for Resident R400 on her admission on 01/24/2025.

Review of the CP for Resident R400 revealed the facility developed a focus area for the resident liked to smoke, with a goal stating the resident would not suffer injury from unsafe smoking practices. Per review, the interventions included instructing Resident R400 about smoking risks and hazards and about smoking cessation aids that were available. Continued CP review revealed the facility also developed a focus area for the resident as at risk for falls or falls related injuries related to decreased mobility and psychotropic medication use. Per review, the goal for the falls CP was for Resident R400 to not sustain serious injury. Further review of the falls CP revealed interventions which included: making sure Resident R400's call light was within reach and encourage the resident to use it to ask for assistance dated 01/25/2025. Additional review of the fall CP revealed other interventions included: Resident R400 needed prompt response to all requests for assistance dated 02/04/2025; encourage use of non-skid footwear when out of bed dated 01/30/2025; encourage her to use the restroom in her own room dated 01/30/2025; and therapy to look at the need for footrests for Resident R400's wheelchair dated 01/30/2024.

Review of a Change in Condition Assessment in Resident R400's EMR dated 01/29/2025, revealed on that date the resident sustained a fall. Per review, Resident R400 was assessed and found to have no mental or physical changes. Continued review revealed the provider was notified, and ordered an x-ray for Resident R400's left ankle. Further

review revealed recommendations to prevent further falls were Resident R400 needed to be supervised when transferring.

Review of a Change in Condition assessment dated [DATE REDACTED], revealed Resident R400 sustained another fall. Per review, Resident R400 was assessed and found to have no mental or physical changes. Continued review revealed

the provider placed Resident R400 on neurological (neuro) checks, with no new interventions put in place per the note.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 Continued review of Resident R400's medical record revealed no fall risks had been completed prior to her fall on 01/29/2025. Per review, on 01/29/2025, a fall risk assessment was performed and the resident had scored a Level of Harm - Immediate 16, which indicated a low risk of falling. Review of a second fall risk assessment was performed on jeopardy to resident health or 02/03/2025, and Resident R400 scored 25, which indicated a moderate risk of falling. safety

Review of the medical record revealed a Post Fall Assessment was performed and documented in Resident R400's Residents Affected - Few EMR on 02/03/2025. Review of the Post Fall Assessment revealed Resident R400 had fallen while trying to transfer to

the toilet. Further review revealed interventions were put in place for Resident R400 to call for assistance when transferring and a consult was placed for both Physical Therapy (PT) and Occupational Therapy (OT) evaluations.

Review of Resident R400's Physician Orders in her EMR revealed an order for PT to consult and treat from 01/25/2025 through 02/21/2025. In addition, review of the Physician Orders revealed an order for OT to consult and treat Resident R400 from 01/29/2025 through 02/26/2025.

Observation on 02/04/2025 at 9:18 AM, of Resident R400 revealed bruising observed to her right ankle. In interview, at the time of observation, Resident R400 stated she had fallen.

Observation on 02/10/2025 at 10:06 AM, revealed Resident R400 was taken to the front lobby by a staff member and allowed to sign herself out to go unaccompanied outside to smoke.

In additional interview with Resident R400 on 02/04/2025 at 9:18 AM, she stated she had fallen while transferring to her wheelchair. Resident R400 stated she was able to sign herself out and go off the facility property, and often did that and went outside to smoke. She reported the facility had been changing the rules on smoking since her admission. The resident said they were letting her go out by herself, but now told her she could only go out

during resident smoke breaks.

In interview on 02/06/2025 at 2:50 PM, CNA 2 stated Resident R400 signed herself out and sat by the building doors at the end of Hall B to smoke. She said staff let her and her husband go in and out when they requested to do that. CNA 2 said she was not sure if Resident R400 was assessed to be able to smoke unsupervised or not. She stated she was not sure who did residents' smoking assessments. The CNA said Resident R400 had fallen trying to transfer to toilet twice. She reported the facility was trying to prevent further falls for Resident R400 by educating her to press her call button and ask for assistance when going to the bathroom or when she was transferring from bed to wheelchair. CNA 2 further stated Resident R400 had weakness on her right side due to a stroke and that was why she kept falling.

In interview on 02/06/2025 at 3:16 PM, Registered Nurse (RN) 5 stated when Resident R400 first came to the facility less than a month ago, staff let her go outside the doors at the end of hallway B to smoke, unsupervised.

She said however, now Resident R400 had been told she could no longer do that and needed to go out in the courtyard to smoke with the other residents during smoke breaks. RN 5 said smoking assessments were done quarterly in the EMR system, they pop up on the work list in the EMR when they need to be completed.

She stated a smoking assessment should have been done on Resident R400 upon her admission; however, she was unsure if one had been completed for her or not. The RN said Resident R400 had experienced two falls since her admission to the facility, and both falls occurred during transfers to and from her wheelchair. She stated to prevent further falls for Resident R400 they had educated the resident to use the call bell and ask for help with transferring to and from her wheelchair, bed, toilet, etc. RN 5 further stated they had instructed her not to transfer herself without assistance, and were also, keeping the resident's bed in a low position to help prevent falls when getting out of bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 In interview on 02/07/2025 at 8:58 AM, LPN 6 stated Resident R400 was a smoker and when she first arrived at the facility, she was told she could go out into the parking lot and smoke. She said however, now Resident R400 had to Level of Harm - Immediate sign out and have someone with her when she went out to smoke. LPN 6 reported if Resident R400 asked her to go jeopardy to resident health or outside to smoke unsupervised she would tell her she preferred she go out with the smoking group and have safety staff with her. She stated Resident R400 should have had a smoking evaluation done upon admission and it could be found under the Evaluations tab in the EMR. The LPN said smoking evaluations were also done quarterly as Residents Affected - Few part of the evaluations that came up to be done in the EMR. She reported Resident R400 had weakness on the one side, and had trouble with her wheelchair fitting into the bathroom. LPN 6 stated Resident R400's leg got tangled up in her wheelchair and she lost her balance which was the cause of one of her falls, and said however, she was not sure why the resident fell the second time. She additionally said the intervention they performed was to educate Resident R400 to call for help before getting up.

In interview with RN 1 on 02/07/2025 at 10:07 AM she stated she was the East UM for night shift. RN 1 stated Resident R400 and her spouse did what they wanted to do, and had observed staff and learned the code to the doors in order to go in and out on their own. She said the couple had now been told they must sign in and out and get someone to go with them when they went out to smoke. RN 1 reported smoking assessments should be done on admission, quarterly, and if there was a change in a resident's condition. She said Resident R400 had fallen over the foot pedal on her wheelchair with her first fall, and she had not heard about her falling again. The RN stated she was not sure of the interventions put in place to prevent Resident R400 from falling again; however, would educate/ask the resident to call first, and staff would help her get to the toilet.

In interview on 02/10/2025 at 8:14 AM, with the OT and PT they said Resident R400 was currently getting PT, OT, and Speech Therapy (ST). The OT stated her assistant usually saw Resident R400, whose goals for OT were grooming, toileting, and upper body and lower body dressing. The OT said for toileting that meant doing both transferring and performing hygiene. The OT said Resident R400 had her OT evaluation on 01/27/2025, and her OT started after that initial assessment. The PT stated Resident R400's PT assessment was done on 01/25/2025 and her PT started on that same day. During the interview a note from PT was reviewed which noted Resident R400 had weight bearing issues and it was that issue that was preventing her from progressing. The PT said Resident R400's ankle had been injured from the falls she experienced. The PT stated with the fall that occurred on 01/30/2025, Resident R400 had received an x-ray which showed no fracture, but Resident 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 Resident R400's weight bearing status from the provider. Per the therapists in interview, on Thursday, 02/06/2025, Resident 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 that Resident R400 was agreeable to therapy but needed her pain controlled first.

In interview on 02/12/2025 at 9:38 AM, the DON stated Resident R400 had behaviors, and did whatever she wanted.

She said Resident R400 could and did sign h [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 45914 potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure a Residents Affected - Many performance review was completed for every Certified Nursing Assistant (CNA) at least once every 12-months for five out of five CNAs' personnel records reviewed, CNA #2, #18, #20, #31, and #32.

Additionally, the facility failed to provide evidence of regular in-service education based on the outcome of

these reviews for three of five records reviewed, CNA #18, #31, and #32.

The findings include:

The State Survey Agency requested a staffing policy on 02/11/2025 at 3:05 PM; however, the facility did not provide a policy. During an interview, at that time, with the Executive Director he stated the facility did not have a staffing policy. He stated they based staffing off the facility's assessment.

Review of the facility's policy titled, Job Description; Certified Nursing Assistant, dated 02/01/2024, revealed CNAs were to attend a minimum of 12 hours of continuing education programs provided by the center in order to maintain certification.

Review of CNA2's personnel file revealed a hire date of 02/25/2022 and 13.41 annual training hours completed. However, there was no documentation of a performance evaluation in the previous 12 months.

Review of CNA18's personnel file revealed a hire date of 01/18/2021 and only 5.63 annual training hours completed. Further review revealed no performance evaluation documented in the previous 12 months.

Review of CNA20's personnel file revealed a hire date of 11/01/2019 and 22.75 annual training hours completed but no documentation of a performance evaluation in the previous 12 months.

Review of CNA31's personnel file revealed a hire date of 08/25/2023 and no annual training hours were documented. Further review revealed no documentation of a performance evaluation within the previous 12 months.

Review of CNA32's personnel file revealed a hire date of 05/09/2022 and only one annual training hour was documented. Further review revealed no performance evaluation documented within the

previous 12 months.

In an interview with [NAME] President of Regional Clinical Operations (VPRCO), on 02/13/2025 at 3:04 PM,

she stated the facility had acquired new ownership, and trainings and education were provided through in-services, and skill fairs to ensure staff were meeting training needs. She stated the prior owners had provided the training/education documents but they had failed to provide the performance evaluations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0730 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 and facility processes. She stated if the Level of Harm - Minimal harm or performance evaluations were not completed, staff could not benefit from the provided feedback regarding potential for actual harm the tasks they performed well or what areas that needed improvement. Additionally, she stated her expectations were that CNAs were evaluated when hired and annually to assess their competencies, skills, Residents Affected - Many and knowledge and their required training would be met annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 51417 Residents Affected - Few Based on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs were labeled in accordance with professional standards.

Observations revealed undated, opened, unlabeled and expired medications in 1 of 5 medication carts and 1 of 2 treatment carts. Those medications included topical creams, and one oral pill.

The findings include:

Review of the facility's policy titled, Medication Storage, dated 02/01/2024, revealed The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. The medications are destroyed in accordance with our Destruction of Unused Drugs Policy. The policy did not address documenting on open/expiration dates, unlabeled medications, or the long-term storage of ointments/creams in the labeled, pharmacy supplied protective plastic storage bag.

Review of the facility's policy titled, Medication Administration, dated 02/02/2024, revealed, Identify expiration dates. If expired, notify nurse manager.

1. During observation on 02/04/2025 at 10:57 AM of the men's memory care unit's treatment cart revealed one tube of Silvasorb gel topical medication used to treat a variety of skin wounds with an expiration date of 07/2024. This medication was not labeled and had no identifier. Additional observation revealed one tube of Diclofenac 1% topical medication used to treat arthritic pain without an open date and was not in a storage bag for Resident (R) 87.

During an interview on 02/04/2025 at 10:57 AM with Registered Nurse (RN) 1, she stated that pharmacy usually go through the carts about once a month.

2. During observation of the medication cart for the B hall on 02/04/2025 at 3:50 PM, revealed a pill separated from the pack in the top drawer of the medication cart. Further observation revealed the medication was Cyclobenzaprine (a muscle relaxant) 5 milligrams (mg). The medication was unlabeled and had no resident identifier.

During an interview on 02/04/2025 at 3:50 PM with Licensed Practical Nurse (LPN) 2, she stated that night shift must have left it and that she would destroy it immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0761 During an interview on 02/06/2025 at 2:05 PM with the Unit Manager, she stated that expired medications were not to be in the carts and were to be discarded according to the facility's policy. She stated that the Level of Harm - Minimal harm or nursing staff were to go through the medication carts weekly and monthly, and that included the treatment potential for actual harm carts. She stated medications were to be labeled with the open date and initials, and kept in their bag and separated individually. She stated that random or floating pills were expected to be wasted. She stated Residents Affected - Few medications should be patient (resident) identifiable and in their individual containers. The Unit Manager stated there was too much of an opportunity for a negative outcome.

During an interview on 02/06/2025 at 2:40 PM with Staff Development, she stated it was difficult to discern a medication for a resident if it was left unlabeled in the medication cart, which could result in a potential medication error. She stated that education was provided annually during the skills fair on medication administration and ordering medication from the pharmacy. She stated medications come prepackaged individually with the resident's name. She stated she teaches the rights of medication administration, locking

the med carts, how to properly open medications, and how to properly discard medications.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or 51281 potential for actual harm Based on observation, interview, record review and review of facility documentation, policies, and Plan of Residents Affected - Few Correction (POC), the facility failed to ensure it was administered in a manner that enabled it to use its' resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

During the Revisit Survey from 04/01/2025 through 04/04/2025, the State Survey Agency (SSA) identified continued non-compliance for the facility in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (

F-F656). potential for actual harm 3. Based on observation, interview, and record review, the facility failed to ensure all drugs were labeled in Residents Affected - Few accordance with professional standards regarding expired ophthalmic drops and a loose, unlabeled pill found

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

F-F761).

In interview with the Assistant Director of Nursing (ADON) on 04/03/2025 at 4:11 PM, she stated the facility's POC was a team effort which was overseen by the Administrator and nursing team. She stated it was her expectation staff would find and discard any expired medications on the medication 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Minimal harm or potential for actual harm 45914

Residents Affected - Many Based on observation, interviews, and record review the facility failed to ensure it electronically submitted complete and accurate direct care staffing information, to the Centers for Medicare and Medicaid Services (CMS) for one of four quarters in 2024.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50442 potential for actual harm Based on observation, interview, record review, and review of the facility's documentation and policies, the Residents Affected - Some facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections for 2 of 3 sampled residents (Resident (R) 20 and Resident R67).

Observations of Licensed Practical Nurse (LPN)6 of Resident R20 and Resident R67 during wound care revealed the LPN failed to perform hand hygiene when moving from a dirty task to a clean task. Additionally, the LPN failed to ensure a barrier was in place before placing supplies on the table. In an interview with the Wound Doctor,

she stated this practice could contaminate the wound and cause an infection.

The findings include:

Review of the facility's policy titled, Wound Treatment and Management, with a date implemented of 02/01/2024 and a date revised of 02/14/2024, revealed the purpose of the policy was to promote wound healing of various types of wounds by providing evidence-based treatments in accordance with current standards of practice and physicians orders.

Review of the facility's policy titled, Hand Hygiene, revised on 02/16/2024, revealed that all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy outlined the technique for hand hygiene with alcohol based hand rub (ABHR), soap and water, and listed under what conditions each should be performed. Further review of the policy revealed the use of gloves did not replace hand hygiene. If the task required gloves, hand hygiene should be performed prior to donning gloves and immediately after removing gloves.

Review of the facility's policy titled, Enhanced Barrier Precautions, revised on 02/01/2024, revealed that it was the practice of the facility to implement Enhance Barrier Precautions (EBP) for the prevention and transmission of multidrug resistant organisms. Further review of the policy stated that clear signage should be posted on the resident's door stating the type of personal protective equipment (PPE) needed for high contact resident care activities. PPE, such as gown and gloves, would be made immediately available outside the room's door and ABHR should be both inside and immediately outside the resident's door. The policy outlined who would be placed on EBP and defined what activities were considered high contact resident care activities.

1. Review of Resident R20's Electronic Medical Record (EMR) revealed the facility admitted the resident on 11/15/2022 with the medical diagnoses of chronic obstructive pulmonary disease (COPD), schizoaffective disorder, chronic pain syndrome, and fibromyalgia.

Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2025 revealed Resident R20 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0880 Review of Resident R20's Comprehensive Care Plan (CCP), undated, revealed the resident was care planned for the focus of altered skin integrity related to an abscess of left leg (resolved) and a wound on the left hip. The Level of Harm - Minimal harm or goal for this focus was Resident R20's altered skin integrity would show signs of healing. Resident R20 was also care planned potential for actual harm for the focus of enhanced barrier precautions (EBP) due to altered skin integrity. The goal of this focus was resident would have a reduced likelihood of transmission of resistant organisms through target date. The Residents Affected - Some interventions for this focus were to educate resident and/or family on the need for enhanced barrier precautions; enhanced barrier precautions implemented during high touch care activities; and staff must wear a gown and gloves when providing high touch care.

Review of Resident R20's Physician Orders in her EMR revealed she had an order for the abscess of the left hip/leg to cleanse with normal saline, pat dry, and apply calcium alginate with silver. The wound was to be covered with border gauze. Wound care was to be done daily. She also has an order for Enhanced Barrier Precautions (EBP) related to her wound.

Observation of wound care for Resident R20 on 02/07/2025 at 2:44 PM provided by Licensed Practical Nurse (LPN) 6 revealed that she hand sanitized and put on PPE prior to entering Resident R20's room. Once in the resident's room,

the LPN raised the resident's bed and moved other items in the room on the bedside table without washing her hands or changing her gloves. The table and sink that LPN6 placed her items on were not cleaned and a barrier was not placed. LPN6 then removed the dressing from the resident's wound and did not wash her hands or change her gloves prior to opening the sterile items needed for the wound care. After opening the bandages, she washed her hands and changed gloves, then reached into her pocket to remove her bottle of normal saline used to do the wound cleansing. She did not wash her hands or change her gloves. The wound was smaller than a dime in size and had yellow drainage. She cleaned the wound and only changed her gloves, however, did not wash her hands. Her gown touched against the open dressings on the table multiple times during wound care. She placed the calcium alginate on the wound and then put on the border gauze. She touched the resident's bed controls and bedside table prior to taking off her gloves and washing her hands. She then threw away the Normal Saline(NS) and all the other items left from the wound care.

On 02/03/2025 at 2:43 PM in an interview with Resident R20, she stated that she had a boil on her left hip, adding she has had one in the past, which had healed.

In an interview with LPN4 on 02/06/2025 at 3:33 PM she said Resident R20 had a boil on her left hip and was getting wound care for it. She stated she had only seen it once, so she was unable to state if it was healing or not. Per the interview, she stated the wound had drainage but no offensive odor. LPN4 stated Resident R20's treatments were provided on day shift. She stated the resident's wound was cleaned with calcium alginate with border dressing.

2. Review of Resident R67's Electronic Medical Record (EMR) revealed the facility admitted her on 10/14/2022 with medical diagnoses including cerebral infarction due to embolism of the left middle cerebral artery, dementia, type II diabetes mellitus, chronic diastolic heart failure, and chronic kidney disease stage 3A.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0880 Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/2024 revealed the facility did not conduct a BIMS score for the resident. The facility assessed Resident R67 as having a Level of Harm - Minimal harm or pressure ulcer and at risk for developing pressure ulcers/injuries. Additionally, the record indicated Resident R67 had potential for actual harm one stage 2 and one stage 4 pressure ulcer. Further review revealed the facility assessed Resident R67 as having 2 unstageable deep tissue injuries. Treatment for the PUs: pressure reducing device for bed, nutrition and Residents Affected - Some hydration interventions, PU injury care, and applications of ointments/medications (other than to feet).

Review of Resident R67's current Comprehensive Care Plan (CCP) from 01/15/2025 revealed the facility care planned her for the focus of potential skin impairment related to incontinence, diabetes mellitus, current skin impairment, and limited mobility. The interventions for this focus were incontinence care every shift and as needed for incontinence episodes. Further review revealed the facility would ensure the resident received her treatments as ordered; complete observation of the resident's skin during care and report any concerns to the nurse.

Review of a Wound Care Note from 02/06/2025 revealed a stage IV pressure ulcer on her sacrum that was 0. 8-centimeter (cm) x 0.3 cm x 0.1 cm. The pressure ulcer on the sacrum was assessed as having a surface area of 0.24 cm squared, with moderate serous exudate. It had 90% granulating tissue and 10% slough. The pressure ulcer was noted to have improved as evidenced by the decreased surface area. The current treatment plan for the pressure ulcer was to cleanse with normal saline, pat dry and apply alginate rope and Leptospermum honey. Further review of the note revealed staff were to use a gauze island with border to cover the pressure ulcer. Further review of the note revealed that the pressure ulcer was not likely to heal and the wound physician had recommended an assessment for ultrasound mist therapy.

Observation of wound care performed on 02/07/2025 at 2:05 PM by licensed practical nurse LPN6 for Resident R67 revealed Certified Nursing Assistant (CNA) 9 and CNA11 were in the room to help roll Resident R67. Both CNAs performed hand hygiene and put on gown and gloves. Continued observations revealed LPN6 performed hand hygiene and donned (put on) a gown and gloves prior to entering Resident R67's room. She did not wipe off the bedside table nor place a barrier on the bedside table prior to placing the supplies for the wound treatment onto the table. An unopened dressing fell to the floor and LPN6 retrieved the package placed it back onto the table. LPN6 indicated she forgot to bring the normal saline for cleansing Resident R67's wound. She removed her personal protective equipment (PPE) and left the room. When she returned, she had donned a new gown and had gloves in her hands and proceeded to put the gloves on inside the room and then lowered the head of Resident R67's bed and uncovered Resident R67. There was no dressing over the sacral wound as LPN6 explained it was removed just prior during incontinence care. LPN6 did not change her gloves or wash her hands after lowering the head of Resident R67's bed and removing the resident's bed covers and brief. She proceeded to open

the sterile wound care supplies with the same contaminated gloves. Continued observations revealed LPN6 wiped the wound with gauze moistened with NS and patted it dry. She did not change gloves or wash her hands after cleaning the wound; and then she used her gloved fingers to wipe the Leptospermum honey onto

the wound. She then took off her gloves, washed her hands, and placed new gloves on. After donning new gloves, LPN6 pressed the silence button on the tube feed pump, and did not perform hand hygiene or change her gloves. She packed the calcium alginate rope into the wound and placed a border gauze undated and unlabeled over the wound. LPN6 labeled and dated the dressing after it was adhered to Resident R67.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 39 185165 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0880 In an interview on 02/07/2025 at 2:40 PM with LPN6 regarding the wound care treatment she provided to both Resident R20 and Resident R67, she stated she forgot to do some things during the wound treatment such as performing Level of Harm - Minimal harm or hand hygiene when she returned to the room after leaving to go and get the normal saline for the wound potential for actual harm cleansing. LPN6 did not comment regarding her not washing her hands or changing gloves when she moved from a dirty task to a clean task (such as after cleaning the wound and then immediately putting the Residents Affected - Some Leptospermum honey and calcium alginate onto the wound without washing her hands and changing her gloves). LPN6 stated she should remove her gloves, perform hand hygiene, and then put on new gloves when moving from dirty to clean in a wound care, such as after removing an old dressing. Further, LPN6 stated hand hygiene and a glove change should be done after cleansing the wound. Additionally, 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.

In an interview with the Director of Nursing (DON) on 02/12/2025 at 9:38 AM, she stated her expectation for wound care was for staff to have a clean field on which to do wound care. She stated there should be a barrier placed and staff should clean the table prior to placing the barrier. Further, she stated staff should clean their hands and put on new gloves after touching items in the room such as the bed controls, tube feed pump, or the resident. She stated staff should change gloves after cleaning the wound and wash their hands and/or use hand sanitizer each time their gloves were 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 39 185165