Inspection Reports for
Signature Healthcare at Colonial Rehab and Wellness
708 BARTLEY AVENUE, BARDSTOWN, KY, 40004
Back to Facility Profile4 CMS Surveys
Inspection Report — Aug 21, 2025
Annual Inspection
Date: Aug 21, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Signature Healthcare at Colonial Rehab & Wellness.
Findings
No health deficiencies were found during the inspection. The level of harm and residents affected are unknown.
Inspection Report — Jul 11, 2024
Complaint Investigation
Date: Jul 11, 2024
Visit Reason
The inspection was conducted due to multiple allegations and incidents of sexual abuse and inappropriate sexual behaviors involving resident R63, as well as concerns about medication errors and infection control practices.
Complaint Details
The investigation was initiated due to complaints and allegations of sexual abuse involving resident R63. The facility substantiated one incident witnessed by staff on 09/04/2023 and unsubstantiated others due to lack of evidence. The facility also investigated a medication error involving resident R58 and infection control concerns involving resident R43.
Findings
The facility failed to have an effective system to ensure residents were protected from sexual abuse, failed to assess residents' capacity to consent, and did not update care plans accordingly. Additionally, a significant medication error occurred when a fentanyl patch was applied to the wrong resident, causing serious harm. The facility also failed to ensure proper infection prevention practices, as staff did not consistently use required personal protective equipment (PPE).
Deficiencies (3)
F600: The facility failed to protect residents from sexual abuse and did not assess residents' capacity to consent or update care plans after multiple incidents involving resident R63.
F760: The facility failed to prevent significant medication errors when a fentanyl patch was applied to the wrong resident, causing serious injury and hospitalization.
F880: The facility failed to maintain an infection prevention program by not ensuring staff donned required PPE when providing care to a resident on Enhanced Barrier Precautions.
Report Facts
Residents sampled for sexual abuse assessment: 24
BIMS score for R34: 6
BIMS score for R63: 11
Fentanyl patch dosage: 75
Resident R43 wound size: 0.6
Resident R43 wound size: 0.7
Resident R43 wound size: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nurse Aide | Failed to don required PPE when providing care to resident R43 on Enhanced Barrier Precautions. |
| KMA 1 | Kentucky Medication Aide | Agency staff involved in medication error applying fentanyl patch to wrong resident. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding sexual abuse incidents, medication error, and infection control practices. |
| Activities Director | Activities Director | Witnessed sexual abuse incident involving R63 and R34 on 09/04/2023. |
| Staff Development Coordinator | Staff Development Coordinator (SDC) | Provided training and interviews related to medication administration and infection control. |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Evaluated resident R63 after incidents of inappropriate sexual behavior. |
| Medical Director | Medical Director | Reviewed care and medication management for resident R63. |
| Administrator | Facility Administrator | Provided expectations for resident safety, care plan updates, and staff training. |
| Pharmacist | Pharmacist | Interviewed regarding medication error and fentanyl patch side effects. |
Inspection Report — Jul 11, 2024
Complaint Investigation
Date: Jul 11, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of sexual abuse, medication errors, and infection control issues at the nursing home.
Complaint Details
The complaint investigation was substantiated for sexual abuse involving Resident R63 touching Resident R34's breast on 09/04/2023. Multiple prior allegations were unsubstantiated but indicated systemic failures. The medication error involving Resident R58 receiving a fentanyl patch intended for another resident was confirmed. Infection control lapses were observed with staff failing to don PPE for a resident on Enhanced Barrier Precautions.
Findings
The facility failed to effectively prevent and manage sexual abuse incidents among residents, failed to develop and implement comprehensive care plans addressing inappropriate sexual behaviors, failed to prevent a significant medication error involving a fentanyl patch, and failed to ensure proper infection control practices including PPE use for residents on Enhanced Barrier Precautions.
Deficiencies (4)
F600: The facility failed to protect residents from sexual abuse and failed to assess residents' capacity to consent to sexual activity, resulting in multiple unsubstantiated incidents and one substantiated sexual abuse incident.
F656: The facility failed to develop and implement comprehensive care plans with interventions to address inappropriate sexual behaviors and assess residents' capacity to consent for four residents.
F760: The facility failed to ensure residents were free from significant medication errors when a fentanyl patch was applied to the wrong resident, causing serious adverse effects.
F880: The facility failed to maintain an infection prevention and control program by not ensuring staff donned required PPE when providing care to a resident on Enhanced Barrier Precautions.
Report Facts
Deficiencies cited: 4
BIMS score: 6
BIMS score: 12
BIMS score: 3
Fentanyl patch dosage: 75
Wound size: 0.6
Wound size: 0.7
Wound size: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nurse Aide | Failed to don required PPE when providing care to Resident R43 on Enhanced Barrier Precautions. |
| KMA 1 | Kentucky Medication Aide | Agency staff who applied fentanyl patch to wrong resident (R58). |
| Director of Nursing | DON | Interviewed regarding sexual abuse incidents, medication error, and infection control policies. |
| Activities Director | Activities Director | Witnessed sexual abuse incident involving R63 and R34 on 09/04/2023. |
| Staff Development Coordinator | SDC | Provided training and interviewed regarding infection control and medication error. |
| Pharmacist | Pharmacist | Interviewed regarding medication error involving fentanyl patch. |
| Administrator | Facility Administrator | Interviewed regarding expectations for resident safety, care plans, medication administration, and infection control. |
Inspection Report — May 14, 2021
Date: May 14, 2021
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitary standards in the facility's kitchen and food service operations.
Findings
The facility failed to ensure food was served at an appetizing temperature due to a non-functioning pellet warmer, resulting in resident complaints of cold food. Additionally, a dented can of apples was found stored in the kitchen, indicating failure to maintain proper food storage standards.
Deficiencies (2)
F 0804: The facility failed to ensure food was served at an appetizing temperature. The pellet warmer was not working, resulting in cold food complaints from residents and observed cool food temperatures on 05/11/2021.
F 0812: The facility failed to keep food stored under sanitary conditions. A dented can of apples was found stored on a shelf in the kitchen available for use.
Report Facts
Food temperature: 150.8
Food temperature: 141.2
Food temperature: 118.2
Date of resident council meeting: Feb 25, 2021
Date of grievance documentation: Feb 25, 2021
Date of grievance follow-up: Feb 26, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Reported pellet warmer not working and staff education on food temperature | |
| Director of Plant Operations | Reported maintenance efforts and delays in repairing pellet warmer | |
| Administrator | Aware of pellet warmer issue and resident grievances, expected quick repairs | |
| Dietary Aide | Reported damaged cans should be removed and placed on damaged food shelf |
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