Inspection Reports for
Signature Healthcare at Jefferson Manor Rehab and We
1801 LYNN WAY, LOUISVILLE, KY, 40222
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Date: Jul 25, 2025
Visit Reason
The inspection was conducted to assess compliance with facility policies regarding medication self-administration, specifically focusing on the use of nebulizer treatments by residents.
Findings
The facility failed to follow its policy requiring a physician's order and an interdisciplinary assessment before allowing a resident to self-administer nebulizer treatments. Resident #17 was observed self-administering nebulizer treatments without an order or documented assessment, and staff acknowledged the lack of required documentation and oversight.
Deficiencies (1)
F 0554: Facility failed to follow policy prior to self-administering nebulizer treatments. Resident #17 self-administered treatments without a physician's order or interdisciplinary assessment as required by facility policy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Stated lack of knowledge of any residents assessed to self-administer medications and confirmed no assessment or order for Resident #17. |
| Registered Nurse #7 | Registered Nurse | Reported no residents with orders to self-administer medications and expressed concerns about safety of self-administered nebulizer treatments. |
| Nurse Practitioner | Nurse Practitioner | Acknowledged knowledge of Resident #17 self-administering nebulizer treatments prior to survey but noted facility had not contacted her until after survey. |
| Director of Nursing | Director of Nursing | Expected staff to complete self-administration assessment and obtain physician's order before resident self-administered medications. |
| Administrator | Administrator | Expected staff to follow regulations, obtain necessary documents, and adhere to facility policy. |
Inspection Report
Abbreviated Survey
Census: 89
Deficiencies: 1
Date: Jul 24, 2025
Visit Reason
A Recertification and Abbreviated survey was conducted from 07/21/2025 to 07/24/2025 to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance due to a deficiency related to resident self-administration of medications. Corrective actions were implemented and the facility achieved substantial compliance by 08/19/2025.
Deficiencies (1)
Facility failed to follow policy prior to self-administering nebulizer treatments for resident #17.
Report Facts
Survey Census: 89
Sample Size: 18
Date of Compliance: Aug 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Assessed resident #17's ability to self-administer ipratropium-albuterol nebulizer and involved in corrective actions |
| Licensed Practical Nurse #6 | Licensed Practical Nurse (LPN) | Interviewed regarding knowledge of residents' self-administration of medications |
| Registered Nurse #7 | Registered Nurse (RN) | Interviewed regarding residents' self-administration of medications |
| Nurse Practitioner | Nurse Practitioner (NP) | Interviewed about resident #17's self-administration of nebulizer treatments |
| Staff Development Coordinator | Staff Development Coordinator (SDC) | Completed education with staff on Residents Rights Policy and Medication Administration Policy |
| Signature Care Consultant | Signature Care Consultant (SCC) | Completed education with Director of Nursing and staff on Residents Rights Policy and Medication Administration Policy |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 6, 2024
Visit Reason
Routine inspection of Signature Healthcare at Jefferson Manor Rehab & Wellness to assess compliance with regulatory standards including medication administration, resident rights, wound care, fall prevention, medication storage, and infection control.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, failure to issue proper Medicare non-coverage notices, inadequate wound care staffing and oversight, failure to implement fall prevention interventions, expired medications in storage and carts, and lapses in infection prevention and control during wound care.
Deficiencies (6)
F 0554: The facility failed to ensure two residents were assessed for self-administration of medications with documented physician orders. Medications were found at bedside without orders or proper supervision.
F 0582: The facility failed to issue appropriate Medicare Non-Coverage notices and document beneficiary or representative choices for two residents, risking lack of understanding of appeal rights and termination of care.
F 0658: The facility failed to ensure wound care services met professional standards, lacking certified wound care staff and adequate physician oversight for two residents with pressure ulcers.
F 0689: The facility failed to implement adequate fall prevention interventions for one resident by not ensuring the bed was kept in the lowest position while the resident was in bed.
F 0761: The facility failed to ensure drugs and biologicals were stored appropriately, with expired medications found in one medication storage room and two medication carts.
F 0880: The facility failed to maintain an effective infection prevention and control program during wound care for two residents, including failure to disinfect surfaces and instruments properly and failure to provide incontinence care prior to wound treatment.
Report Facts
Residents sampled: 49
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Medication storage rooms inspected: 2
Medication carts inspected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| WCN1 | Wound Care Nurse / Licensed Practical Nurse | Named in infection control and wound care deficiencies |
| LPN1 | Licensed Practical Nurse | Named in medication self-administration deficiency |
| LPN5 | Licensed Practical Nurse | Named in medication storage deficiency |
| Director of Nursing | Director of Nursing (DON) | Named in oversight and medication self-administration deficiencies |
| Social Services Director | Social Services Director (SSD) | Named in Medicare Non-Coverage notice deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Feb 15, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding failure to follow care plans, medication management, infection control, food safety, and vaccination administration at the nursing home.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to follow care plans, medication errors, infection control lapses, food safety violations, and vaccination administration failures. Substantiation status is not explicitly stated.
Findings
The facility failed to follow the care plan for a resident at risk for falls due to a nonfunctional call light, failed to account for controlled medications properly, left medication carts unlocked with loose pills, stored expired food, failed to maintain infection control with outdated oxygen tubing, and failed to provide pneumococcal vaccinations to some residents.
Deficiencies (7)
F 0656: The facility failed to follow the care plan for Resident #70 by not ensuring the call light was functional and within reach, increasing fall risk.
F 0689: The facility failed to ensure a nursing home area was free from accident hazards by not providing a functioning call light for Resident #70, posing a fall risk.
F 0755: The facility failed to account for controlled medication properly for Resident #26, with a missing pill and failure to sign out medication as required.
F 0761: The facility failed to maintain medication carts properly, leaving them unlocked and containing loose, unpackaged pills, and left medications unattended at a resident's bedside.
F 0812: The facility failed to store and serve food in accordance with professional standards, including expired milk in the refrigerator and missing documentation of food and sanitation temperatures.
F 0880: The facility failed to maintain an effective infection control program by not changing Resident #13's oxygen tubing, which was outdated by several months.
F 0883: The facility failed to provide pneumococcal vaccinations to three residents and lacked a process to ensure vaccination consents were obtained and documented.
Report Facts
Residents sampled: 18
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Missing pills: 1
Loose pills: 61
Expired milk cartons: 6
Fall risk score: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to sign out controlled medication for Resident #26 |
| RN #1 | Registered Nurse | Observed medication cart unlocked and left unattended |
| RN #2 | Registered Nurse | Provided interviews regarding call light and medication administration |
| RN #3 | Registered Nurse | Discussed importance of signing out controlled medications and oxygen tubing changes |
| RN #4 | Registered Nurse | Observed medication cart cleanliness and loose pills |
| CNA #1 | Certified Nursing Assistant | Responsible for ensuring call light functionality |
| Unit Manager #1 | Unit Manager | Responsible for monitoring call lights, medication carts, and vaccination consents |
| Director of Nursing | Director of Nursing | Oversaw nursing practices and infection control; acknowledged deficiencies |
| Administrator | Administrator | Provided administrative oversight and interviews |
| Assistant Dietary Director | Assistant Dietary Director | Responsible for monitoring food storage and safety |
| Food Service Director | Food Service Director | Responsible for food temperature documentation and safety |
| Admissions Coordinator | Admissions Coordinator | Prepared admission packets including vaccination consents |
| Medical Records Director | Medical Records Director | Responsible for assembling admission packets |
Viewing
Loading inspection reports...
