Inspection Reports for
Signature Healthcare at Jefferson Place Rehab and We
1705 HERR LANE, LOUISVILLE, KY, 40222
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Date: Jun 18, 2025
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitary conditions in the facility's dietary services.
Findings
The facility failed to serve food under sanitary conditions as Dietary Aide 2 did not perform hand hygiene after handling soiled items and did not wear a finger cot over a wound while handling food. Interviews confirmed staff awareness of proper handwashing and glove use policies, but noncompliance was observed.
Deficiencies (1)
F 0812: The facility failed to procure food from approved sources and serve food under sanitary conditions. Dietary Aide 2 did not perform hand hygiene after touching soiled cloths and did not wear a finger cot over a wound while handling food.
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
An Emergency Preparedness Recertification Survey and a Life Safety Code Recertification Survey were conducted on 06/17/2025 in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) requirements for long term care facilities.
Findings
Signature Healthcare at Jefferson Place was found to be in compliance with the Requirements for Participation in Medicare and Medicaid during the Emergency Preparedness Recertification Survey and Life Safety Code Recertification Survey.
Report Facts
Number of smoke compartments: 6
Survey date: Jun 17, 2025
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 18, 2021
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to reasonably accommodate resident needs, maintain food safety standards, and implement an effective infection prevention and control program.
Complaint Details
The investigation was complaint-driven, focusing on issues related to resident accommodations, food safety, and infection control. The complaint was substantiated with findings of minimal harm affecting few to many residents.
Findings
The facility failed to ensure the call light was within reach of a nonverbal resident, improperly stored and labeled food items, and did not consistently enforce mask and eye protection use among staff, visitors, and hospice personnel, increasing the risk of infection spread.
Deficiencies (3)
F 0558: The facility failed to reasonably accommodate the needs of Resident #79 by not ensuring the call light button was within reach on two occasions.
F 0812: The facility failed to store and label food properly, evidenced by opened and undated salad dressing containers in the walk-in refrigerator.
F 0880: The facility failed to maintain an infection prevention and control program, as staff, visitors, and hospice personnel did not consistently wear masks and eye protection in resident care areas.
Report Facts
Residents sampled: 74
Date survey completed: Sep 18, 2021
COVID-19 positive staff: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #8 | Provided care for Resident #79 and discussed importance of call light accessibility and mask use. | |
| Licensed Practical Nurse (LPN) #6 | Discussed importance of call light accessibility and PPE use in infection control. | |
| Director of Nursing (DON) | Reported call light should be within reach and monitored PPE compliance. | |
| Administrator | Stated expectations for call light placement and PPE use. | |
| Dietary Manager | Reported on food labeling and dating practices. | |
| Certified Nursing Assistant (CNA) #14 | Observed not following proper PPE protocols. | |
| Certified Nursing Assistant (CNA) #15 | Observed not wearing gown in droplet isolation room. | |
| Hospice Registered Nurse (RN) | Observed not wearing eye protection and reported lack of instruction. | |
| Registered Nurse (RN) #1 | Described PPE requirements and infection control practices. | |
| Medical Records Staff/Registered Nurse (RN) | Observed improper mask use. | |
| Director of Nursing/Infection Preventionist (DON/IP) | Monitored PPE compliance and provided infection control education. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 8, 2019
Visit Reason
The inspection was conducted based on complaints alleging failures in resident care, medication management, infection control, and care plan implementation at Signature Healthcare at Jefferson Place Rehab & Wellness.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inadequate resident care, medication errors, infection control lapses, and failure to follow care plans. The complaint was substantiated with findings of multiple deficiencies affecting resident safety and care quality.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, incomplete implementation of care plans, inadequate assistance with activities of daily living, ineffective control and documentation of controlled medications, failure to monitor and document psychotropic medication use properly, unsafe food temperature handling and poor hand hygiene practices, inaccurate medication administration records, and lapses in infection prevention and control practices.
Deficiencies (8)
F 0558: The facility failed to accommodate Resident #221's needs by not keeping the urinal within reach while the resident was in bed, causing incontinence episodes.
F 0656: The facility failed to implement Resident #30's care plan related to behavior management, administering psychotropic medication without prior behavioral interventions.
F 0677: The facility failed to provide showers and grooming to Resident #221 as scheduled, resulting in poor hygiene and unshaven appearance.
F 0755: The facility failed to maintain an effective system to safeguard, control, and account for controlled medications for Residents #9, #33, and #36, with discrepancies in medication administration documentation and suspected drug diversion.
F 0758: The facility failed to ensure Resident #30 was free from unnecessary psychotropic medication by not monitoring behaviors or implementing non-pharmacological interventions prior to medication administration.
F 0812: The facility failed to ensure food was heated and held at safe temperatures and failed to follow hand hygiene protocols during food temperature testing, risking foodborne illness.
F 0842: The facility failed to maintain accurate clinical records related to medication administration for Residents #9, #30, #33, and #36, with missing documentation of medication administration on MARs.
F 0880: The facility failed to maintain an effective infection control program, as observed when a nurse handled a dropped medication with bare hands and failed to perform hand hygiene during medication administration to Resident #62.
Report Facts
Doses of Ativan signed out: 15
Doses of Ativan signed out: 32
Scheduled showers missed: 2
Residents sampled: 19
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication discrepancy and suspected drug diversion |
| LPN #4 | Licensed Practical Nurse | Observed mishandling medication and infection control breach |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and documentation |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding behavior management and medication documentation |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding urinal placement and hygiene care |
| ADON #1 | Assistant Director of Nursing | Interviewed regarding medication audits and care plan implementation |
| ADON #2 | Assistant Director of Nursing | Interviewed regarding shower scheduling and urinal use |
| DON | Director of Nursing | Interviewed regarding overall nursing practices and medication management |
| Administrator | Facility Administrator | Interviewed regarding facility policies and staff compliance |
| Dietary Manager | Dietary Manager | Observed and interviewed regarding food temperature and hand hygiene |
| Pharmacy Consultant | Consultant Pharmacist | Interviewed regarding medication audits and discrepancies |
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