Inspection Reports for
Signature Healthcare at Colonial Rehab and Wellness

708 BARTLEY AVENUE, BARDSTOWN, KY, 40004

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 2 deficiencies/year

Deficiencies are regulatory findings recorded during state inspections.

57% better than Kentucky average
Kentucky average: 4.7 deficiencies/year

Deficiencies per year

4 3 2 1 0
2021
2024
2025

Inspection Report

Annual Inspection
Deficiencies: 0 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

Complaint Investigation
Deficiencies: 4 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
NameTitleContext
CNA 3Certified Nurse AideFailed to don required PPE when providing care to Resident R43 on Enhanced Barrier Precautions.
KMA 1Kentucky Medication AideAgency staff who applied fentanyl patch to wrong resident (R58).
Director of NursingDONInterviewed regarding sexual abuse incidents, medication error, and infection control policies.
Activities DirectorActivities DirectorWitnessed sexual abuse incident involving R63 and R34 on 09/04/2023.
Staff Development CoordinatorSDCProvided training and interviewed regarding infection control and medication error.
PharmacistPharmacistInterviewed regarding medication error involving fentanyl patch.
AdministratorFacility AdministratorInterviewed regarding expectations for resident safety, care plans, medication administration, and infection control.

Inspection Report

Deficiencies: 2 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
NameTitleContext
Dietary ManagerReported pellet warmer not working and staff education on food temperature
Director of Plant OperationsReported maintenance efforts and delays in repairing pellet warmer
AdministratorAware of pellet warmer issue and resident grievances, expected quick repairs
Dietary AideReported damaged cans should be removed and placed on damaged food shelf

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