Inspection Reports for
Signature Healthcare at Jackson Manor Reha and Welln
96 HIGHWAY 3444, ANNVILLE, KY, 40402
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
28% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
90% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 2
Date: May 2, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with Minimum Data Set (MDS) assessment submission and accuracy requirements as per federal and state guidelines.
Findings
The facility failed to ensure timely transmission of MDS assessments to CMS within 14 days for three sampled residents and failed to ensure accuracy of MDS assessments for three other sampled residents, including incorrect coding of fall history, antipsychotic medication use, and discharge status.
Deficiencies (2)
F0640: The facility failed to transmit Minimum Data Set (MDS) assessments to CMS within 14 days after completion for three residents (R12, R34, and R47).
F0641: The facility failed to ensure accuracy of MDS assessments for three residents (R107, R21, and R53), including incorrect coding of fall history, antipsychotic medication use, and discharge status.
Report Facts
Residents with late MDS submissions: 3
Residents with inaccurate MDS assessments: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding late and inaccurate MDS assessments. | |
| Administrator | Interviewed regarding expectations for timely and accurate MDS assessments. | |
| Clinical Reimbursement Consultant (CRC) | Interviewed confirming inaccuracies in MDS assessments. | |
| Director of Nursing (DON) | Interviewed regarding inaccurate MDS discharge assessment for resident R53. |
Inspection Report
Renewal
Census: 46
Capacity: 51
Deficiencies: 5
Date: Apr 28, 2025
Visit Reason
A Recertification Survey was initiated on 04/28/2025 and concluded on 05/02/2025 to assess compliance with long term care facility requirements. Additionally, a Life Safety Recertification Survey was conducted on 04/30/2025.
Findings
The facility was found not to be in compliance with 42 CFR 483.5 - 483.75 Subpart B, with deficiencies cited at the highest Scope and Severity of a 'D'. Life Safety Code deficiencies were also identified but the facility achieved substantial compliance with Life Safety Code on 05/21/2025 after a Plan of Correction and onsite revisit on 06/11/2025.
Deficiencies (5)
Failure to ensure Minimum Data Set (MDS) assessments were transmitted to CMS within 14 days after completion for three sampled residents.
Failure to ensure accuracy of Minimum Data Set (MDS) assessments for three sampled residents, including incorrect coding of fall history, antipsychotic medication use, and discharge status.
Failure to provide separation of hazardous areas by fire barriers, including a permanently mounted doorstop preventing door closure in the Dietary Manager office.
Failure to maintain doors protecting corridors in accordance with NFPA 101 Life Safety Code, including doors failing to latch and close properly.
Failure to maintain power strips and extension cords in accordance with NFPA 101 standards, including use of unapproved power strips and extension cords in multiple rooms.
Report Facts
Total census: 46
Facility capacity: 51
Residents sampled for MDS assessment review: 15
Residents affected by hazardous doorstop deficiency: 47
Rooms affected by power strip deficiency: 4
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
An Abbreviated Survey was conducted by representatives of the Office of Inspector General to investigate the facility.
Findings
The facility was found to be in regulatory compliance with no deficient practices cited.
Inspection Report
Abbreviated Survey
Census: 43
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
An Abbreviated Survey was conducted to investigate KY00040784, KY00041741, KY00043644, and KY00044494, initiated on 2025-01-08 and concluded on 2025-01-13.
Findings
The Office of Inspector General found the facility to be in regulatory compliance for the investigated cases KY00040784, KY00041741, KY00043644, and KY00044494.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| H. Rita Jones | RN | Representative of the Office of Inspector General who conducted the survey |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 21, 2023
Visit Reason
The investigation was conducted due to an allegation of verbal abuse between two residents (Resident #7 and Resident #8) at the facility on 08/02/2023.
Complaint Details
The complaint involved an allegation of verbal abuse between Resident #8 and Resident #7 on 08/02/2023. The allegation was investigated and found unsubstantiated. The incident was reported to the Ombudsman, DCBS, and OIG. Resident #7 was monitored with 15-minute safety checks following the incident.
Findings
The facility failed to ensure an environment free from verbal abuse involving one resident cursing at another. The allegation was investigated and found unsubstantiated as neither resident had willful intent to cause harm. Both residents were monitored and interventions were implemented to prevent further incidents.
Deficiencies (1)
F 0600: The facility failed to protect residents from verbal abuse when Resident #8 entered Resident #7's room and cursed at him/her on 08/02/2023. The incident was reported and investigated, but found unsubstantiated due to lack of willful intent.
Report Facts
Residents sampled: 18
BIMS score Resident #7: 3
BIMS score Resident #8: 4
Safety check interval: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Entered progress note about incident and separated residents |
| DON | Director of Nursing | Reported incident and oversaw monitoring and interventions |
| MD | Medical Director | Provided clinical insight on residents' cognitive status and abuse expectations |
| SSD #2 | Social Services Director (former) | Followed up on incident and updated care plans |
| SSD #1 | Social Services Director | Interviewed about abuse policies and resident monitoring |
| CNA #3 | Certified Nursing Assistant | Witnessed incident and reported abuse |
| Administrator | Facility Administrator | Oversaw facility response and quality assurance meetings |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, medication storage, and accident prevention in the nursing home.
Findings
The facility failed to ensure residents were notified in writing prior to room or roommate changes, left hazardous housekeeping carts unlocked, and did not secure medication storage areas properly. These issues posed potential harm to residents, especially those with severe cognitive impairment.
Deficiencies (3)
F 0559: The facility failed to ensure residents received written notice before a room or roommate change. Resident #4 was moved to a semi-private room without documented written notification to the resident or family.
F 0689: The facility failed to keep housekeeping carts locked, leaving chemicals accessible to residents. Observation showed an unlocked cart near Resident #1, posing a hazard.
F 0761: The facility failed to ensure medication rooms and carts were locked when unattended. Observation revealed unlocked medication room and cart near residents with severe cognitive impairment.
Report Facts
Days Resident #4 had a roommate: 8
Semi-private room daily rate: 232
Total semi-private room charge: 1936
BIMS score: 8
BIMS score: 11
BIMS score: 3
Number of wandering residents with BIMS ≤ 8: 3
Inspection Report
Routine
Census: 41
Deficiencies: 7
Date: Sep 25, 2020
Visit Reason
Routine inspection to assess compliance with care planning, resident supervision, staffing, medication administration, food storage, infection control, and other regulatory requirements.
Findings
The facility failed to develop and implement comprehensive care plans addressing toileting needs, ensure adequate supervision for residents at risk of elopement, provide timely incontinence care due to insufficient staffing, maintain proper food storage labeling, prevent medication errors, and implement appropriate COVID-19 isolation precautions for new admissions.
Deficiencies (7)
F 0656: The facility failed to develop a comprehensive care plan addressing toileting needs for Resident #15 and failed to implement the care plan for Resident #10, resulting in delayed incontinence care.
F 0689: The facility failed to ensure adequate supervision and update the Elopement Book with picture and identifying information for Resident #11 at risk for elopement.
F 0690: The facility failed to provide appropriate toileting assistance to Resident #15 who was occasionally incontinent, resulting in increased incontinence episodes.
F 0725: The facility failed to provide sufficient nursing staff to meet resident care needs, resulting in delayed call light responses and inadequate assistance with shaving for Residents #10, #15, #20, and #30.
F 0759: The facility failed to maintain medication error rates below 5%, with two medication errors observed during administration on 09/24/2020.
F 0812: The facility failed to ensure food was stored under sanitary conditions, with unlabeled and undated thickened liquids and food products observed in the kitchen refrigerator.
F 0880: The facility failed to implement appropriate infection prevention and control measures by not placing new admissions Resident #186 and Resident #187 in isolation per facility policy and CDC guidance.
Report Facts
Resident census: 41
Medication administration opportunities: 31
Medication errors: 2
Medication error rate: 6.45
Staff worked hours: 121
Expected staff hours: 133.25
Staff hours deficit: 12.25
Resident wait time for incontinence care: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Administered medications late and gave incorrect dose of Lorazepam | |
| Director of Nursing | Director of Nursing (DON) | Provided information on care plan reviews, staffing, medication administration monitoring, and infection control practices |
| Dietary Manager | Reported on food storage practices and monitoring | |
| State Registered Nurse Aide #1 | Reported staffing levels and isolation practices | |
| State Registered Nurse Aide #2 | Reported on incontinence care rounds and staffing adequacy | |
| Licensed Practical Nurse #1 | Reported on incontinence care rounds and staffing adequacy | |
| Facility Care Consultant | Reviewed medication orders and care policies |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 28, 2019
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain residents' dignity, insufficient nursing and dietary staffing, poor food quality and safety, unsanitary food handling practices, and inadequate infection prevention and control measures.
Complaint Details
The investigation was complaint-driven, triggered by allegations of undignified care, staffing shortages, poor food quality and safety, unsanitary food handling, and infection control failures. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to protect residents' rights to dignity, provide sufficient nursing and dietary staff, ensure food was palatable and served at safe temperatures, maintain sanitary food service conditions, and implement effective infection prevention and control practices. Multiple residents reported delays in care, cold and unpalatable food, and concerns about food safety. Observations confirmed staffing shortages, delayed call light responses, improper food handling, and lapses in infection control.
Deficiencies (6)
F 0550: The facility failed to maintain Resident #44's colostomy bag to prevent leakage, causing the resident to wait up to 30 minutes for staff assistance and feel bad about the situation.
F 0725: The facility failed to provide enough nursing staff to meet residents' needs, resulting in delayed meal tray delivery, call light responses up to 30 minutes, and resident dissatisfaction.
F 0802: The facility failed to employ sufficient dietary staff with appropriate skills, leading to untimely meal service, failure to follow recipes, and improper cooling and temperature monitoring of food.
F 0804: The facility failed to ensure food was palatable and served at safe temperatures; residents reported cold and unappetizing food, and a palatability test confirmed food was outside recommended temperature ranges.
F 0812: The facility failed to maintain sanitary food service conditions, including failure to clean a juice dispenser, improper handling of prepared meal trays, and failure of a Regional VP to wear a beard restraint in the kitchen.
F 0880: The facility failed to maintain an effective infection prevention and control program, including improper handling of wound care supplies for Resident #17 and failure to assist residents with hand hygiene before meals.
Report Facts
Residents affected: 1
Residents affected: 42
Wait time for colostomy bag replacement: 30
Meal delivery delay: 44
Potato salad temperature: 35
Potato salad temperature: 57.6
Potato salad temperature: 55.9
Call light response time: 30
Dietary staff employed: 5
Dietary staff working lunch: 3
Dietary staff working supper: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in infection control deficiency related to wound care for Resident #17 |
| Dietary Director | Named in dietary staffing and food preparation deficiencies | |
| Director of Nursing | DON | Interviewed regarding staffing and infection control deficiencies |
| Staff Development Coordinator | Infection Control Coordinator | Interviewed regarding infection control practices and hand hygiene |
| Regional VP | Observed entering kitchen without beard restraint during meal service |
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