Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Louisville Gardens Care Center during CMS and state inspections, most recent first.
The facility did not maintain proper infection control practices, including failing to post required isolation signage for residents with COVID-19, not separating soiled linens from infected and non-infected residents, and staff not performing hand hygiene during incontinence care. These actions were inconsistent with CDC guidelines and the facility's own policies.
A resident with a deep tissue injury and multiple chronic conditions did not receive wound care as ordered by the physician. Observation and record review revealed that the dressing on the resident's heel was not changed as required, and staff confirmed the treatment was missed.
Two residents did not receive prescribed anticonvulsant medications as ordered because the medications were not available in the facility. Nursing staff and nurse practitioners attempted to obtain the necessary prescriptions and contact the pharmacy, but delays in communication and prescription processing led to multiple missed doses. Facility policy required advance ordering and documentation of medications, but these procedures were not effectively followed, resulting in the deficiency.
A resident's admission paperwork was not completed in a timely manner and was signed by the resident instead of the designated POA, despite facility policy. Additionally, an LPN failed to accurately document and administer scheduled medications for another resident, recording medications as given before actual administration and noting a medication as unavailable. These actions resulted in incomplete and inaccurate medical records.
The facility did not maintain sufficient nursing staff, resulting in missed showers, delayed call light responses, and prolonged wait times for care and meal delivery. Staff and residents reported frequent understaffing, with some units left without an aide and only a nurse present. Observations confirmed that call lights were left unanswered for over 30 minutes, and staff struggled to complete required care tasks due to inadequate staffing.
The facility did not complete required quarterly care conferences for multiple residents and failed to maintain accurate or updated care plans, including not reflecting a resident's true continence status and not updating a care plan after a resident sustained a major injury from a fall. Interviews with residents and staff confirmed these deficiencies, and facility policy required more timely and accurate care planning.
The facility did not consistently provide scheduled showers or alternative hygiene care to several residents who required assistance with ADLs, as confirmed by documentation and interviews with residents and staff. Residents with various medical conditions and cognitive statuses missed scheduled showers, and staff acknowledged challenges in completing all assigned showers due to staffing issues. Facility policy on documenting hygiene care and refusals was not consistently followed.
Two residents did not receive prescribed care as ordered: one did not have a preventative dressing changed on schedule after a pressure ulcer, with staff documenting care in error, and another experienced repeated missed doses of a dialysis-related medication due to pharmacy delays and lack of proper medication receipt tracking. Facility policies for medication ordering and documentation were not followed, resulting in gaps in care.
The facility assigned an unqualified staff member to the Activities Director position without verifying required credentials or enrollment in a state-approved training course, as confirmed by personnel file review and staff interviews. This failure had the potential to impact all residents in the facility.
A facility failed to document and treat a pressure ulcer timely for a resident. Initially, the ulcer was incorrectly documented on the left gluteal fold, but later assessments revealed it was on the right buttock. No treatment was recorded for several days, and an order for care was delayed. The Regional Clinical Director confirmed the documentation error and treatment delay.
Failure to Maintain Infection Control Practices and Hand Hygiene
Penalty
Summary
The facility failed to maintain infection prevention and control practices to prevent the spread of COVID-19 and did not ensure staff performed proper hand hygiene during incontinence care. Sixteen residents tested positive for COVID-19 within a two-week period, and records showed that these residents had physician orders for droplet isolation precautions. However, observations revealed that required signage indicating isolation precautions was missing from the rooms of residents who tested positive, and staff confirmed that these signs should have been posted to alert staff and visitors to use personal protective equipment (PPE). Additionally, the facility did not separate soiled linens from residents with COVID-19 from those without, despite staff concerns about cross-contamination. Laundry staff and CNAs reported that all soiled laundry was mixed together and placed in the same receptacle, and biohazard bags or other methods to differentiate contaminated laundry were not used. This practice was inconsistent with CDC guidance and the facility's own policies, which require clear identification of contaminated laundry to ensure safe handling. Further, staff failed to adhere to hand hygiene protocols during resident care. During incontinence care for a resident, a CNA did not perform hand hygiene before donning gloves, after glove removal, or between tasks, and handled both the resident’s personal items and bed linens with contaminated gloves. The facility’s policy and CDC guidelines require hand hygiene before and after glove use and after contact with potentially contaminated surfaces, but these procedures were not followed during the observed care.
Failure to Administer Physician-Ordered Wound Care
Penalty
Summary
Staff failed to administer wound care treatment as ordered by the physician for a resident with multiple complex medical conditions, including morbid obesity, diabetes, congestive heart failure, and a deep tissue injury to the right lateral heel. The physician's order specified that the wound should be cleansed with normal saline, patted dry, treated with betadine, covered with an ABD pad, and wrapped with gauze daily and as needed during the night shift. Review of the Treatment Administration Record (TAR) showed documentation of the wound treatment being performed on one date, but observation revealed that the dressing had not been changed as required by the order. On observation, the dressing on the resident's right lateral heel was found to be dry and intact, with the date on the dressing indicating it had not been changed on the previous day as ordered. Certified Nursing Assistants present at the time confirmed that the wound treatment had not been performed according to the physician's instructions. This lapse in care was identified during a review of records, direct observation, and staff interviews, and was cited as a deficiency affecting one resident reviewed for wounds.
Failure to Provide Timely Medication Administration Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered in a timely manner to two residents. One resident, admitted with multiple complex diagnoses including epilepsy and requiring ventilator support, had a physician order for lacosamide to control seizures. The medication was not administered on two consecutive days because the pharmacy required a prescription, and the medication was not available in the facility. Nursing staff notified the nurse practitioner, who contacted the pharmacy, but the medication was still not received before the resident was readmitted to the hospital. Another resident with diagnoses including cerebral palsy, epilepsy, and profound intellectual disability had a physician order for phenobarbital suppositories to be administered three times daily. The medication was not administered for several days because the pharmacy required an updated prescription, and multiple attempts by nursing staff to provide the prescription were unsuccessful. The resident did not receive the medication until the prescription was finally sent electronically and the pharmacy delivered the medication. Facility policy required that all medications be ordered and received in advance, with documentation maintained by the charge nurse and verification by the receiving nurse. Despite these procedures, the facility did not ensure that medications were available for administration as ordered, resulting in missed doses for both residents.
Deficiencies in Timely Admission Paperwork and Medication Administration Documentation
Penalty
Summary
The facility failed to ensure timely completion of admission paperwork for one resident and accurate medication administration documentation for another. For the first resident, the admission agreement was not completed in a timely manner, as the paperwork was signed by the resident instead of the designated Power of Attorney (POA), despite the resident having moderate dementia and a POA in place. The facility's policy requires that the admission agreement be signed by the resident or their representative at the time of admission, and a copy placed in the resident's permanent file. The interim administrator confirmed that the admission paperwork was not completed as required. For the second resident, there were discrepancies in the documentation and administration of medications. An LPN administered several prescribed medications but failed to administer the Flonase nasal spray, Artificial Tears, and Lidocaine patch at the scheduled time. Despite this, the LPN documented on the Medication Administration Record (MAR) that the Flonase and Artificial Tears had been administered, and noted the Lidocaine patch as unavailable. The LPN later acknowledged that she typically completed treatments at a later time and had documented administration before actually giving the medications, which is contrary to facility policy. The facility's policies on medication administration and documentation require that medications be administered within one hour of the prescribed time and that documentation occur immediately after administration, not before. The policies also specify that all relevant details, including reasons for withheld or unavailable medications, must be accurately recorded. The failure to follow these procedures resulted in inaccurate records for the resident's medication administration.
Failure to Provide Adequate Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. The facility assessment indicated a staffing plan that included seven nurses and ten CNAs per day, but payroll-based journal data showed a one-star staffing rating for the second quarter. Several residents did not receive scheduled showers, and both staff and residents reported frequent delays in care, including long wait times for call light responses and missed appointments. Staff interviews confirmed that there were not enough aides at times, and the removal of a dedicated shower aide further impacted the ability to provide timely care. Direct observations revealed that call lights remained unanswered for extended periods, with some residents waiting over 30 minutes for assistance. Meal trays were also delayed, and there were instances where no aide was present on a unit, leaving only a nurse to manage care and medication administration. Staff were observed being unaware of the absence of assigned aides, and the DON confirmed that call lights should not go unanswered for more than 30 minutes, yet this expectation was not met. Staff also reported difficulties in obtaining assistance for two-person tasks and noted that aides were frequently no-call, no-shows, leaving units understaffed. Resident interviews corroborated these findings, with reports of waiting up to 90 minutes for care and call lights going unanswered for significant periods. One resident reported forgetting the reason for activating the call light due to the long wait, despite having a medical concern to report. Policy reviews indicated that the facility was expected to provide timely responses to resident needs, with a goal of responding to call lights within five minutes, but this standard was not achieved. The deficiency was investigated under a specific complaint number and affected all residents in the facility.
Failure to Complete Quarterly Care Conferences and Maintain Accurate, Updated Care Plans
Penalty
Summary
The facility failed to ensure that care conferences were completed at least quarterly for several residents, and did not maintain accurate or updated care plans for others. Specifically, three residents did not have documented evidence of quarterly care conferences, despite policy requiring these to be held in conjunction with the quarterly MDS assessment. Interviews with residents and staff confirmed that these conferences either did not occur or were not documented, and in some cases, residents were not invited to participate in their own care planning process. Additionally, the facility did not ensure care plan accuracy for a resident regarding incontinence care. The care plan inaccurately identified the resident as being incontinent of bowel and bladder and having an indwelling urinary catheter, when in fact the resident was continent and had never had a catheter. Interviews with the resident, an LPN, and the DON confirmed the inaccuracies in the care plan, and there was no explanation for why the care plan did not reflect the resident's actual condition. Furthermore, the facility failed to update the care plan for another resident after a significant change in condition, specifically following a fall that resulted in a major injury and subsequent hospitalization and surgery. Although immediate post-fall interventions were documented, the care plan was not revised to reflect the new risk or interventions after the resident returned from the hospital. Facility policy required care plans to be updated after significant changes or hospitalizations, but this was not done in this case.
Failure to Provide Scheduled Showers and Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents received showers as scheduled, as evidenced by record reviews, interviews, and policy review. Seven residents who required assistance with activities of daily living (ADL) did not consistently receive showers according to their individualized care plans and the facility's shower schedule. Documentation showed missed or rescheduled showers, and in several cases, there was no evidence that alternative hygiene measures, such as bed baths, were offered or provided after a shower was refused or missed. Residents affected had a range of medical conditions, including dementia, urinary incontinence, emphysema, systemic lupus erythematosus, muscle weakness, schizoaffective disorder, diabetes, aphasia, hemiplegia, depression, multiple sclerosis, and other chronic illnesses. Many were cognitively intact and expressed the importance of choosing their bathing method. Care plans and MDS assessments indicated varying levels of assistance required, from partial to total dependence on staff for bathing. Despite these documented needs and preferences, the facility did not consistently follow through with scheduled showers or provide appropriate alternatives when showers were missed or refused. Interviews with residents, CNAs, LPNs, and the Administrator confirmed the inconsistency in providing scheduled showers. Staff reported being unable to complete all assigned showers, sometimes due to the absence of a dedicated shower aide. Facility policy required documentation of showers or baths, including refusals and interventions taken, but records often lacked evidence of follow-up or alternative hygiene care. The deficiency was identified during a complaint investigation and had the potential to affect additional residents who were dependent on staff for bathing.
Failure to Administer Prescribed Treatments and Medications as Ordered
Penalty
Summary
The facility failed to ensure that prescribed treatments and medications were administered as ordered for two residents. For one resident with a history of dementia, cognitive communication deficit, and muscle weakness, there was a physician's order to apply Skin Prep to the left sacrum and cover with a bordered dressing every Monday, Wednesday, and Friday as a preventative measure following the healing of a Stage II pressure ulcer. However, observation and interviews revealed that the dressing was not changed according to the prescribed schedule. Documentation on the treatment administration record indicated that wound care was completed on certain dates, but interviews with nursing staff confirmed that this documentation was made in error, and the dressing had not been changed as required. Another resident with end stage renal disease, multiple comorbidities, and dependence on dialysis had a physician's order for sevelamer hydrochloride to be administered before meals as a potassium binder. Review of medication administration records and progress notes showed multiple instances over several months where the medication was not given because it was unavailable. Notes indicated repeated delays in receiving the medication from the pharmacy, and staff interviews confirmed confusion regarding the ordering process and significant delays in delivery. The resident reported not receiving the medication for extended periods and experiencing symptoms such as nausea and diarrhea during these gaps. Facility policy required that medication orders and receipt records be maintained and that medications be ordered in advance based on pharmacy lead times. However, the facility did not have a process to record the receipt of medications from the specific pharmacy supplying the sevelamer, and shipping invoices were incomplete. The lack of proper documentation, ordering, and follow-up led to the residents not receiving their prescribed treatments and medications as ordered.
Unqualified Staff Assigned as Activities Director
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by regulation. Review of the personnel file for the current Activities Director showed that she was originally hired as a receptionist and later transferred to the Activities Director position. The job description for the Activities Director role specifies that the individual must meet certain qualifications, such as being a qualified therapeutic recreation specialist, a licensed activities professional, having relevant experience, or having completed a state-approved training course. However, there was no evidence in her employee file to demonstrate that she met any of these qualifications. Interviews with the Human Resources Director, the Administrator, and the Activities Director herself confirmed that she did not possess the required qualifications and was not enrolled in a state-approved training course at the time of her appointment. The Activities Director also stated she was unsure how to enroll in the necessary course and had not received information about enrollment until after the deficiency was identified. This lack of a qualified professional in the Activities Director role had the potential to affect all 40 residents in the facility.
Failure to Document and Treat Pressure Ulcer Timely
Penalty
Summary
The facility failed to accurately document and implement timely treatment for a pressure ulcer in a resident. Upon admission, the resident was noted to have a pressure ulcer on the left gluteal fold, but subsequent assessments revealed the ulcer was actually on the right buttock. The initial skin assessment documented a pressure ulcer on the left gluteal fold, measuring one centimeter long, one centimeter wide, and 0.1 centimeters deep. However, a later assessment by the wound nurse practitioner identified a Stage II pressure ulcer on the right buttock, measuring four centimeters long, three centimeters wide, and 0.1 centimeters deep. The treatment administration record showed no evidence of treatment for the pressure ulcer from January 13 to January 17. An order for treatment was not received until January 16, which included cleansing the area with normal saline, applying Triad paste, and covering with a dressing daily. The Regional Clinical Director confirmed the documentation error and the delay in treatment implementation. This deficiency was investigated under Complaint Number OH00161526.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Meadows Skilled Nursing And Rehab | 4.7 mi | — | 0 | 0 |
| Canterbury Villa Of Alliance | 4.8 mi | — | 3 | 0 |
| Altercare Of Louisville Ctr For Rehab & Nsg Care | 5.2 mi | — | 1 | 0 |
| Saint Joseph Care Center | 5.7 mi | — | 17 | 0 |
| Mccrea Manor Nsng And Rehab Ctr Llc | 5.7 mi | — | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.