Inspection Reports for Signature HealthCARE at Heritage Hall Rehab & Wellness Center
KY, 40342
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Immediate Jeopardy
Deficiencies: 10
Date: Sep 29, 2023
Visit Reason
The inspection was conducted due to multiple serious concerns including failure to protect residents' rights and dignity, failure to notify medical director of significant events, multiple abuse incidents, misappropriation of narcotic medications by a staff member, inaccurate resident assessments, and failure to develop and implement comprehensive care plans.
Findings
The facility failed to protect residents from dignity violations, abuse, neglect, and misappropriation of narcotic medications by a nurse who was impaired and stole morphine. The facility also failed to notify the medical director timely, conduct thorough investigations promptly, and ensure accurate assessments and care plans for residents, resulting in immediate jeopardy to resident health and safety.
Deficiencies (10)
Failure to honor resident's right to a dignified existence, self-determination, communication, and to exercise rights, including an incident where a nurse aide told a resident to use the bathroom in his/her brief.
Failure to notify the Medical Director of change in medical condition and cause of death for a resident who choked on a cheeseburger.
Failure to protect residents from abuse including physical and verbal abuse by residents and staff.
Misappropriation of narcotic medications by a registered nurse who was impaired on duty, stole morphine from medication carts, and was arrested. Facility failed to immediately investigate and report the incident.
Failure to conduct a thorough and timely investigation of narcotic diversion and failure to protect residents from ongoing danger.
Failure to accurately assess and reflect a resident's current status, specifically regarding supervision needs during meals for a resident with dysphagia.
Failure to develop and implement a comprehensive care plan that meets all the resident's needs, including lack of interventions to assist or monitor a resident with swallowing problems during meals.
Failure to provide appropriate treatment and care according to orders, resident preferences and goals, resulting in a resident found unresponsive with a partially eaten cheeseburger and pronounced dead.
Failure to administer the facility in a manner that enables effective and efficient use of resources, including failure to immediately investigate narcotic diversion and take timely corrective action.
Failure to respond appropriately to all alleged violations, including delayed investigation and notification related to narcotic diversion by a nurse.
Report Facts
Residents sampled: 61
Morphine bottle volume: 30
Morphine bottle volume discrepancy: 4
Morphine dose: 0.25
Morphine dose: 0.5
Morphine dose: 1
Counts of syringes found: 7
Counts of charges against RN #1: 8
Counts of charges against RN #1: 21
Counts of charges against RN #1: 7
Counts of charges against RN #1: 7
Counts of charges against RN #1: 3
Counts of charges against RN #1: 3
Counts of charges against RN #1: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Implicated in narcotic diversion, impaired on duty, arrested, and terminated |
| LPN #4 | Licensed Practical Nurse | Reported suspicious behavior of RN #1 and observed morphine diversion |
| LPN #3 | Licensed Practical Nurse | Witnessed RN #1 take morphine from pocket and return it to medication cart |
| Medical Director | Notified late of narcotic diversion and resident death; expressed concern about care | |
| Administrator | Facility Administrator | Delayed response to narcotic diversion incident and investigation |
| DON | Director of Nursing | Delayed response and investigation of narcotic diversion; defended RN #1 initially |
| SRNA #2 | State Registered Nurse Aide | Reported suspicious behavior of RN #1 |
| SRNA #6 | State Registered Nurse Aide | Reported resident choking incident and food safety concerns |
| LPN #9 | Licensed Practical Nurse | Found resident unresponsive with cheeseburger; reported observations |
| ST #1 | Speech Therapist | Provided swallowing evaluation and education for Resident #66 |
| Regional Clinical Dietitian | Reviewed nutrition therapy evaluation for Resident #66 | |
| MDS Coordinator | Responsible for MDS and care plan accuracy; noted discrepancies for Resident #66 | |
| ADON | Assistant Director of Nursing | Responsible for ensuring MDS and care plan accuracy; unaware of Resident #66 supervision needs |
| LPN #1 | Licensed Practical Nurse | Witnessed morphine diversion and reported to DON |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Sep 29, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to protect residents' rights and dignity, failure to notify the medical director of changes in condition and death, abuse and neglect incidents, misappropriation of resident property including narcotics, inaccurate resident assessments, incomplete care plans, and failure to provide appropriate treatment and care.
Complaint Details
The complaint investigation was triggered by allegations of failure to protect residents' rights and dignity, failure to notify medical director of significant events, abuse and neglect incidents, narcotic diversion by a nurse, inaccurate assessments and care plans, and failure to provide appropriate treatment and supervision, resulting in resident harm and death. Immediate jeopardy was identified related to narcotic diversion and failure to protect residents from harm.
Findings
The facility was found to have multiple deficiencies including failure to protect residents' dignity, failure to notify the medical director of significant events, multiple abuse incidents involving residents and staff, narcotic diversion by a nurse leading to immediate jeopardy, inaccurate assessments and care plans for residents, and failure to provide appropriate treatment and supervision, resulting in resident harm and death.
Deficiencies (9)
Failure to protect resident's right to a dignified existence, self-determination, communication, and to exercise rights.
Failure to notify the Medical Director of change in medical condition and cause of death.
Failure to protect residents from abuse including physical, verbal, and neglect involving multiple residents and staff.
Failure to protect residents from misappropriation of property and narcotic diversion by a nurse, resulting in immediate jeopardy.
Failure to conduct a timely and thorough investigation of narcotic diversion and failure to protect residents from ongoing danger.
Failure to accurately assess and reflect resident's current status, including supervision needs during meals.
Failure to develop and implement a comprehensive care plan that meets all resident's needs, including supervision during meals for a resident with dysphagia.
Failure to provide appropriate treatment and care according to orders, resident preferences and goals, resulting in resident death.
Failure to administer the facility in a manner that enables effective and efficient use of resources, including failure to immediately investigate narcotic diversion.
Report Facts
Residents sampled: 61
Residents affected by abuse: 8
Residents affected by misappropriation: 4
Morphine bottle volume: 30
Morphine bottle volume observed: 16.25
Morphine doses: 7
Morphine doses stolen: 8
Counts of Wanton Endangerment: 21
Counts of Possession of Controlled Substance: 7
Counts of Theft by Unlawful Taking or Disposition: 7
Counts of Knowingly Abuse or Neglect of an Adult by Stealing: 3
Counts of Tampering with Physical Evidence: 3
Count of Drug Paraphernalia: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Narcotic diversion, impairment, and misappropriation of Morphine |
| LPN #4 | Licensed Practical Nurse | Reported suspicious behavior of RN #1 and observed Morphine diversion |
| LPN #3 | Licensed Practical Nurse | Witnessed RN #1 take Morphine from pocket and place it back in medication cart |
| LPN #1 | Licensed Practical Nurse | Reported RN #1's suspicious behavior and found backpack with syringes |
| SRNA #2 | State Registered Nurse Aide | Observed RN #1's suspicious behavior and reported to nursing staff |
| Medical Director | Medical Director | Notified late about narcotic diversion and resident death; provided clinical input |
| Administrator | Facility Administrator | Delayed response and investigation of narcotic diversion incident |
| Interim Director of Nursing | Director of Nursing | Involved in narcotic diversion incident response and investigation |
| SRNA #5 | State Registered Nurse Aide | Made inappropriate comment in presence of resident |
| Hospitality Aide #1 | Hospitality Aide | Verbally abusive to resident |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 28, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow the comprehensive Person-Centered Resident Care Plan for Resident #58, which resulted in a fall with injury due to improper application of a wheelchair seatbelt.
Complaint Details
The complaint investigation found that Resident #58, who required two-person assistance and had severe cognitive impairment, fell due to improper seatbelt application by LPN #4. The fall resulted in bruising above the eye. The facility's interdisciplinary team reviewed the fall and mandated staff education on proper seatbelt use. The resident was assessed post-fall with no pain reported, and appropriate notifications were made.
Findings
The facility failed to follow Resident #58's care plan for correct seatbelt application in the wheelchair, resulting in a fall and injury. The resident required two-person assistance for transfers and had severe cognitive impairment. Staff, including LPN #4, did not properly secure the seatbelt, leading to the resident sliding out of the wheelchair and sustaining bruising. The facility's interdisciplinary team reviewed the incident and mandated staff education on proper seatbelt use.
Deficiencies (2)
Failure to follow the comprehensive Person-Centered Resident Care Plan for correct application of the wheelchair seatbelt, resulting in a fall with injury for Resident #58.
Failure to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in a fall due to improper seatbelt application.
Report Facts
Resident sample size: 20
BIMS score: 5
Fall risk score: 25
Date of fall: Jul 23, 2021
Transfer assistance: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in the finding for improper application of the wheelchair seatbelt leading to Resident #58's fall |
| State Registered Nurse Aide #3 | State Registered Nurse Aide | Interviewed regarding Resident #58's transfer needs and care plan |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan revisions and staff education following the fall |
| Administrator | Administrator | Interviewed regarding expectations for care plan adherence to prevent falls |
| Corporate Consultant | Corporate Consultant | Interviewed regarding care plan and fall prevention interventions |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 21, 2019
Visit Reason
The inspection was conducted following a complaint regarding Resident #54's inappropriate sexual behavior towards Resident #13 and the facility's failure to protect residents from abuse.
Complaint Details
The complaint investigation was triggered by an incident on 03/11/19 where Resident #54 was witnessed inappropriately touching Resident #13's chest area. The facility was aware of Resident #54's history of sexually inappropriate behavior but failed to have adequate interventions in place. The investigation included interviews, record reviews, and psychiatric consultations.
Findings
The facility failed to ensure residents were free from abuse, specifically sexual abuse by Resident #54 towards Resident #13. The facility also failed to develop and implement comprehensive care plans addressing Resident #54's sexual behaviors, failed to submit timely Minimum Data Set (MDS) assessments for two residents, and failed to accurately assess and care plan for contractures in Resident #55. Additionally, the facility failed to implement care plan interventions for pressure ulcer prevention for Resident #146 and failed to properly label and store medications.
Deficiencies (5)
Failure to protect residents from sexual abuse by Resident #54 towards Resident #13.
Failure to submit Minimum Data Set (MDS) assessments within required timeframes for Residents #1 and #2.
Failure to ensure Resident #55's comprehensive assessment accurately reflected contractures and functional limitations.
Failure to develop and implement a comprehensive care plan for Residents #54, #55, and #146 addressing sexual behaviors, contractures, and pressure ulcer prevention respectively.
Failure to properly label and store medications, including lack of open date on eye drop bottles.
Report Facts
Residents sampled: 22
Residents affected: 3
MDS late submissions: 2
BIMS score: 99
BIMS score: 3
BIMS score: 12
Medication expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Registered Nursing Assistant #1 | SRNA | Witnessed Resident #54 inappropriately touching Resident #13 and reported the incident |
| Licensed Practical Nurse #3 | LPN | Reported Resident #54's history of inappropriate behaviors towards staff |
| Unit Manager | Unaware of Resident #54's sexual behaviors prior to incident; failed to review psychiatric consults | |
| Director of Nursing | DON | Acknowledged Resident #54's sexual behaviors and lack of care plan interventions |
| Administrator | Acknowledged facility awareness of Resident #54's behaviors and care plan deficiencies | |
| MDS Coordinator #1 | LPN | Reported late MDS submissions due to staff leave and resignation |
| MDS Coordinator #2 | RN | Acknowledged oversight in MDS submissions and care plan accuracy |
| Licensed Practical Nurse #40 | LPN | Provided care to Resident #55 on Functional Maintenance Program |
| State Registered Nurse Aide/Kentucky Medication Aide #4 | SRNA/KMA | Reported use of hospital-supplied medication without proper labeling |
| Licensed Practical Nurse #1 | LPN/Wound Nurse | Reported responsibility for ensuring pressure relieving devices were in place |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 26, 2018
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to notify physicians and family of significant changes in residents' conditions, failure to develop and implement baseline care plans, failure to revise comprehensive care plans, inadequate pressure ulcer care, and failure to maintain residents' nutritional status.
Complaint Details
The visit was complaint-related due to allegations of failure to notify physicians and family of significant changes in residents' conditions, inadequate care planning, pressure ulcer care deficiencies, and nutritional neglect.
Findings
The facility failed to notify physicians and family of significant changes in residents' conditions for two residents, failed to develop and implement baseline care plans within 48 hours for one resident, failed to revise comprehensive care plans for two residents, failed to provide appropriate pressure ulcer care for one resident, and failed to maintain adequate nutritional status for one resident with significant weight loss. Additionally, medication labeling deficiencies were observed.
Deficiencies (6)
Failure to notify physician and family of significant changes in residents' conditions for Resident #19 and Resident #93.
Failure to develop and implement a baseline care plan within 48 hours of admission for Resident #23.
Failure to revise comprehensive care plans for Resident #19 and Resident #93 to include significant changes such as pressure ulcers and weight loss.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Resident #19.
Failure to maintain adequate nutritional status and notify physician of significant weight loss for Resident #93.
Failure to label medications and biologicals with open dates and expiration dates on two medication carts.
Report Facts
Residents sampled: 20
Weight loss percentage: 12
Weight loss pounds: 25
Pressure ulcer size: 4
Pressure ulcer size: 1
Pressure ulcer size: 3
Medication expiration days: 28
Medication expiration days: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in failure to notify physician and revise care plan for Resident #19 |
| LPN #3 | Licensed Practical Nurse | Named in failure to revise care plan and notify physician for Resident #19 |
| LPN #4 | Licensed Practical Nurse | Named in failure to notify physician and revise care plan for Resident #19 |
| RN #2 | Registered Nurse | Named in failure to complete admission assessment and baseline care plan for Resident #23 |
| RN #3 | Registered Nurse | Named in skin assessment and care plan responsibilities for Resident #23 |
| SRNA #1 | State Registered Nursing Assistant | Named in reporting skin changes for Resident #19 and Resident #23 |
| Physician #1 | Physician | Named in expectation to be notified of changes in residents' conditions |
| Dietary Manager | Named in weight monitoring and nutritional interventions for Resident #93 | |
| Registered Dietician | Named in weight monitoring and nutritional interventions for Resident #93 | |
| Interim Director of Nursing | Director of Nursing | Named in oversight of care plan revisions and notification procedures |
| Administrator | Named in oversight of care plan revisions and notification procedures | |
| Unit B Manager | Named in weight monitoring and notification for Resident #93 | |
| Unit Manager (UM) #1 | Named in medication labeling expectations | |
| LPN #1 | Licensed Practical Nurse | Named in medication labeling deficiencies |
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