Inspection Reports for Signature Healthcare at North Hardin Rehab and Wellness Center
599 ROGERSVILLE RD., RADCLIFF, KY, 40160
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 29, 2025, found deficiencies related to medication administration, personal privacy, assistance with activities of daily living, and food safety. Earlier inspections showed mixed results, including a February 27, 2025, complaint investigation where the facility was cited for failing to report an allegation of abuse within required timeframes. The main themes of deficiencies involved resident care issues such as medication and ADL assistance, as well as food service and privacy concerns. Complaint investigations included a substantiated case of delayed abuse reporting, which led to staff suspension and education, but most other allegations were unsubstantiated. The facility has taken corrective actions and provided staff education, though deficiencies have appeared in recent inspections without a clear pattern of improvement or worsening.
Deficiencies (last 1 years)
Deficiencies (over 1 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
8
6
4
2
0
Census
Latest occupancy rate
77% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 114
Capacity: 148
Deficiencies: 7
Date: May 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations of inadequate care, including failure to provide showers, call light response issues, assistance with meals, dental services, and assessment following a resident's call to 911.
Complaint Details
The complaint alleged inadequate care including failure to provide showers, call light response delays, lack of assistance with meals, dental care issues, and improper response to a resident's call to 911. The investigation included interviews, observations, and record reviews. Most allegations were unsubstantiated due to lack of evidence, but some deficiencies related to medication administration, privacy, ADL care, and food safety were cited.
Findings
The investigation found the facility in compliance with program requirements for most allegations, with no substantiated evidence of abuse or neglect. Some deficiencies were cited related to medication administration, personal privacy, ADL care, and food safety, with corrective actions implemented and education provided to staff.
Deficiencies (7)
Failure to ensure personal privacy and confidentiality of residents' personal health information for 1 of 57 sampled residents.
Failure to provide medication administration as prescribed, including medications left at bedside and not administered properly for 1 of 57 residents.
Failure to provide adequate assistance with activities of daily living (ADLs) for dependent residents.
Failure to provide proper treatment and assistive devices to maintain vision and hearing abilities for 1 of 57 residents.
Failure to provide routine and emergency drugs and biologicals properly and ensure secure storage for medications.
Failure to provide adequate food and drink in accordance with residents' preferences and dietary needs.
Failure to maintain food service equipment clean, sanitary, and in proper working order.
Report Facts
Total Facility Beds: 148
Total Certified Beds: 148
Survey Census: 114
Sample Size: 57
Medication Error Rate: 4.58
Resident Census: 115
Resident Census: 111
Resident Census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ronald Ballou | Regional Program Manager | Signed the final survey report and plan of correction acceptance letter |
| Desirae Hawkins | Administrator | Named as facility administrator involved in plan of correction and survey exit conference |
| Certified Medication Technician (CMT) #7 | Named in medication administration deficiency for improper medication handling | |
| Certified Medication Technician (CMT) #8 | Named in medication administration deficiency for medication disposal errors | |
| Certified Nursing Assistant (CNA) 1 | Named in ADL care deficiency for shower and bath assistance | |
| Director of Nursing (DON) | Named in multiple deficiencies including medication administration and privacy | |
| Assistant Director of Nursing (ADON) | Named in medication administration and privacy deficiencies | |
| Unit Manager(s) (UM) | Named in medication administration and privacy deficiencies | |
| Signature Care Consultant (SCC) | Named in medication administration and privacy deficiencies | |
| Dietary Manager (DM) | Named in food service deficiencies | |
| Account Manager | Named in food service deficiencies |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
The visit was an Abbreviated Survey to investigate specific allegations identified by survey IDs KY00042455, KY00042862, KY00043648, KY00044044, KY00044656, and KY00044694, focusing on compliance with 42 CFR 483 subpart B.
Complaint Details
The complaint investigation found that a Certified Nurse Aide (CNA2) reported an allegation of abuse involving a resident (R1) approximately 24 hours late. The facility failed to report the allegation to the Administrator and State Survey Agency within 2 hours and 5 working days as required. The allegation involved physical abuse by staff members. The facility suspended involved staff, educated staff on abuse reporting policies, and implemented a Quality Assurance & Process Improvement Program to prevent recurrence.
Findings
The facility was found not to be in substantial compliance on 01/23/2025 with one deficiency cited related to reporting alleged violations of abuse, neglect, exploitation, or mistreatment. The facility failed to ensure timely reporting of an allegation of abuse to the Administrator and State Survey Agency within required timeframes. Corrective actions and education were implemented to address the deficiency and ensure future compliance.
Deficiencies (1)
Failure to report allegations of abuse, neglect, exploitation, or mistreatment immediately and within required timeframes to the Administrator and State Survey Agency.
Report Facts
Survey Census: 122
Sample Size: 7
Supplemental Resident: 1
Residents with BIMS of 7 or below: 28
Residents with BIMS of 8 or above: 93
Facility Census: 121
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide CNA2 | Certified Nurse Aide | Reported the allegation of abuse approximately 24 hours late and was suspended pending investigation. |
| Director of Nursing | Director of Nursing | Received the abuse allegation report, placed resident on 1:1 supervision, educated staff on abuse policies, and reviewed progress notes and events. |
| Weekend Manager | Weekend Manager | Received abuse allegation from CNA2 and reported to Director of Nursing. |
| Administrator | Facility Administrator | Notified of abuse allegation, suspended CNA2, participated in education and quality assurance meetings, and responsible for implementation of corrective plan. |
| Social Service Assistant | Social Service Assistant | Conducted interviews with residents to identify abuse concerns. |
| Signature Care Consultant | Signature Care Consultant (SCC) | Educated facility staff on abuse policies and participated in quality assurance meetings. |
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