Inspection Report Summary
The most recent inspection on April 18, 2025, identified deficiencies related to residents' rights, specifically a failure to ensure informed consent and participation in treatment. Earlier inspections were not provided for comparison, so broader inspection patterns cannot be determined from the available information. The main issue involved residents’ rights and consent for physical contact, with no other types of deficiencies noted. There were no complaint investigations or enforcement actions such as fines or license suspensions listed in the available reports. Without additional historical data, it is unclear whether this reflects a new or ongoing concern.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure residents and/or their representatives were fully informed and consented to physical contact between residents, specifically involving residents R203 and R209.
Complaint Details
The complaint involved concerns that the facility did not obtain consent or notify the representative of resident R203 about physical contact and bed sharing with resident R209. The facility's investigation found no sexual aggressiveness and determined the complaint was unsubstantiated.
Findings
The facility failed to obtain consent for physical contact between residents R203 and R209, and failed to notify R203's representative about the contact. Documentation was lacking in the medical records, and the facility had no policy or consent form regarding physical contact between residents. The investigation found no sexual aggressiveness, only companionship, and determined the complaint was unsubstantiated.
Deficiencies (1)
Failure to ensure residents and/or their representatives were informed and consented to physical contact between residents R203 and R209.
Report Facts
BIMS score: 3
BIMS score: 8
Medication dosage: 1
Dates of admission and discharge: R203 admitted 07/07/2023, discharged 11/01/2024; R209 admitted 01/04/2024, discharged 09/20/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Documented progress notes and participated in interviews regarding resident R209's behavior and facility policies |
| Administrator | Administrator | Provided interview statements about facility policies and notification practices |
Inspection Report
Abbreviated Survey
Census: 127
Deficiencies: 1
Date: Apr 18, 2025
Visit Reason
A Standard Recertification and Abbreviated Survey was conducted to investigate multiple survey IDs and assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance and was cited with deficiencies at the highest Scope and Severity level of 'F'. The investigation included review of resident rights, consent for physical contact, and care planning, with findings of failure to ensure informed consent and participation in treatment.
Deficiencies (1)
Failure to ensure residents' right to be informed and participate in treatment, including lack of consent for physical contact for two residents.
Report Facts
Survey Census: 127
Sample Size: 26
Supplemental Residents: 9
Date Survey Completed: Apr 18, 2025
Date of Compliance: Apr 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Signature Care Consultant | Consultant | Conducted review of events and educated staff on policies and procedures related to residents' rights and informed consent |
| Director of Nursing | Director of Nursing | Educated on State Operational Manual and involved in corrective action plan |
| Staff Development Coordinator | Staff Development Coordinator | Participated in education and training on residents' rights and consent policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Participated in education and training on residents' rights and consent policies |
Inspection Report
Routine
Deficiencies: 4
Date: Apr 15, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with food service safety standards, including proper storage, preparation, distribution, and serving of food in accordance with professional standards and facility policies.
Findings
The facility failed to ensure food safety standards were met, including staff not properly wearing hairnets, food items being uncovered or improperly dated, pans stacked wet without drying, and food held at unsafe temperatures below 135 degrees Fahrenheit on the steam table. Facility policies and staff training on food safety were reviewed and found to be in place, but not consistently followed.
Deficiencies (4)
Staff hairnets not covering hair as required.
Multiple food items uncovered in freezer and refrigerator, some with expired or incomplete dates.
Metal pans stacked wet without allowing sufficient dry time.
Food item on steam table held below required temperature of 135 degrees Fahrenheit.
Report Facts
Food temperature: 130
Date of observation: Apr 15, 2025
Date of survey completion: Apr 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Interviewed regarding staff training, food safety policies, and observations of deficiencies. |
| Administrator | Administrator | Interviewed regarding expectations for dietary staff compliance with food safety policies. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 30, 2020
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Signature Healthcare at Hillcrest.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 15, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including care planning, urinary and bowel continence care, nutritional status, respiratory care, and psychotropic medication use.
Findings
The facility was found deficient in developing and implementing comprehensive care plans, assessing and managing urinary incontinence, preventing urinary tract infections, maintaining nutritional status with appropriate physician notification, providing proper tracheostomy care, and ensuring appropriate use of psychotropic medications.
Deficiencies (5)
Failed to develop and implement a comprehensive person-centered care plan for urinary incontinence for Resident #15.
Failed to assess Resident #15 upon admission for baseline elimination status and improper catheter care observed for Resident #27.
Failed to maintain acceptable nutritional parameters and notify physician of 10% weight loss for Resident #102.
Failed to provide appropriate tracheostomy care for Resident #50 per facility policy.
Failed to ensure Resident #32 remained free from unnecessary psychotropic medications; prescribed antipsychotic for inappropriate diagnosis.
Report Facts
Sampled residents: 28
Weight loss percentage: 10
Medication dosage: 0.5
Dates: Nov 15, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | Interviewed regarding failure to develop care plan for Resident #15's incontinence and lack of bowel and bladder assessment | |
| Director of Nursing | DON | Interviewed regarding expectations for staff to follow policies and develop appropriate care plans |
| Certified Nurse Aide #2 | CNA | Observed placing wash cloths on bed frame during catheter care, an infection control issue |
| Certified Nurse Aide #1 | CNA | Interviewed about proper placement of wash cloths during catheter care |
| Registered Nurse #1 | RN Charge Nurse | Interviewed about infection control concerns with catheter care |
| Assistant Director of Nursing | ADON | Interviewed about catheter care policies and physician notification of weight loss |
| Registered Dietitian | RD | Interviewed regarding Resident #102's weight loss and lack of physician notification |
| Registered Nurse #2 | RN | Observed providing tracheostomy care and admitted to leaving out steps and breaking sterile field |
| Medical Director/Physician | Physician | Interviewed about inappropriate use of Risperdone for Resident #32 |
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