Inspection Reports for
Signature Healthcare at North Hardin Rehab and Wellness Center
599 ROGERSVILLE RD., RADCLIFF, KY, 40160
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
77% occupied
Based on a May 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 8
Date: May 29, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory standards for nursing home care, including privacy, medication administration, activities of daily living, sensory services, pharmaceutical services, medication storage, food preferences, and kitchen sanitation.
Findings
The facility was found deficient in multiple areas including failure to protect resident personal health information privacy, improper medication administration and disposal, inadequate assistance with activities of daily living, failure to ensure residents received needed sensory services, unsecured medications, failure to follow resident food preferences, and poor kitchen sanitation with dust accumulation on equipment.
Deficiencies (8)
F 0583: The facility failed to ensure the privacy and confidentiality of residents' personal health information when a computer screen displaying PHI was left open and visible to passersby.
F 0658: The facility failed to ensure staff provided medication administration within professional standards by not observing a resident take medications before signing off.
F 0677: The facility failed to provide necessary assistance with activities of daily living, including bathing and nail care, for two residents who were dependent on staff.
F 0685: The facility failed to ensure a resident received proper treatment and assistive devices to maintain hearing abilities by not following through on an audiology referral.
F 0755: The facility failed to ensure proper disposal of medication when a dropped medication capsule was thrown in the trash instead of a medication disposal system.
F 0761: The facility failed to secure medications properly when inhalers and nasal spray were left unsecured at a resident's bedside without orders allowing self-administration.
F 0806: The facility failed to provide meals in accordance with a resident's food preferences when gravy was served on top of meat instead of on the side as specified.
F 0812: The facility failed to maintain kitchen equipment in a clean and sanitary condition as dust was observed on the dish machine and range hood grates.
Report Facts
Residents sampled: 57
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 6 | Unit Manager | Acknowledged computer screen left open exposing PHI |
| Licensed Practical Nurse 3 | LPN | Responsible for logging out of computer but failed to lock screen |
| Certified Medication Aide 7 | CMA | Failed to observe resident taking medications |
| Unit Manager 5 | Unit Manager | Observed improper medication disposal and commented on medication storage |
| Director of Nursing | DON | Provided multiple interviews on policy expectations and deficiencies |
| Certified Nursing Assistant 1 | CNA | Reported on shower/bath schedules and ADL care |
| Certified Medication Aide 2 | CMA | Reported on ADL care and shower/bath assistance |
| Licensed Practical Nurse 10 | LPN | Described grievance process for lost hearing aids |
| Social Service Assistant | SSA | Discussed scheduling of hearing services and vendor communication |
| Certified Medication Aide 8 | CMA | Observed improperly disposing of medication and leaving medications unsecured |
| Registered Nurse 14 | RN | Administered morning medications and discussed medication handling |
| Food Service Manager | FSM | Confirmed food preference error and kitchen sanitation issues |
| Administrator | Administrator | Provided multiple interviews on policy expectations and deficiencies |
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. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a failure to timely report an allegation of abuse involving Resident 1.
Complaint Details
The complaint involved an allegation of abuse reported by Certified Nurse Aide (CNA)2 regarding abuse incidents involving CNA8, CNA9, CNA10, and Licensed Practical Nurse (LPN)2. The allegation was substantiated as the facility confirmed the failure to report timely and suspended CNA2 for the delay in reporting.
Findings
The facility failed to report an allegation of abuse to the Administrator and State Survey Agency within the required 2-hour timeframe. The allegation involved multiple staff members and was reported approximately 24 hours after the incident occurred.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and the results of the investigation to proper authorities. An allegation of abuse involving Resident 1 was reported approximately 24 hours after the incident occurred, exceeding the required 2-hour reporting timeframe.
Report Facts
Residents Affected: 7
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA2 | Certified Nurse Aide | Reported the abuse allegation and was suspended for failure to report timely |
| CNA8 | Certified Nurse Aide | Alleged to have abused Resident 1 |
| CNA9 | Certified Nurse Aide | Alleged to have abused Resident 1 |
| CNA10 | Certified Nurse Aide | Alleged to have abused Resident 1 |
| LPN2 | Licensed Practical Nurse | Alleged to have abused Resident 1 |
| Director of Nursing | Director of Nursing | Provided interview regarding reporting and investigation |
| Administrator | Administrator | Provided interview regarding reporting and investigation |
| Weekend Manager | Weekend Manager | Received abuse report from CNA2 and notified DON |
Inspection Report
Routine
Deficiencies: 1
Date: May 3, 2024
Visit Reason
The inspection was conducted to evaluate compliance with nutritional guidelines and menu portion sizes for residents receiving pureed diets.
Findings
The facility failed to ensure that menu items were served in the approved portion sizes as specified by the Registered Dietician. Observations and interviews revealed that pureed meal portions were smaller than the recommended amounts on the Diet Guide Sheet.
Deficiencies (1)
F 0803: The facility failed to serve pureed meal portions in the recommended sizes approved by a Registered Dietician. Observations showed 2-ounce portions served instead of the prescribed 8 ounces for pureed cheese lasagna and other items.
Report Facts
Portion size: 2
Recommended portion size: 8
Recommended portion size: 3.25
Recommended portion size: 4
Recommended portion size: 3
Portion size: 8
Inspection Report
Routine
Census: 120
Deficiencies: 2
Date: May 3, 2024
Visit Reason
The inspection was conducted to evaluate compliance with nutritional and food safety standards, including menu portion sizes and food storage practices at the facility.
Findings
The facility failed to ensure menu items were served in the approved portion sizes meeting residents' nutritional needs. Additionally, food items in storage were found unlabeled, undated, or expired, posing potential risks to residents.
Deficiencies (2)
F 0803: The facility failed to serve menu items in the approved portion sizes as per the Diet Guide Sheet, with observed pureed meal portions smaller than specified. Staff did not follow the portion sizes approved by a Registered Dietician.
F 0812: The facility failed to store food in accordance with professional standards, with multiple food items found unlabeled, undated, or expired in walk-in coolers. This posed a potential risk to 115 of 120 residents.
Report Facts
Residents affected: 120
Residents affected: Many residents affected by portion size deficiency (exact number not specified)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Dietary Manager | Interviewed regarding menu portion sizes and food storage practices | |
| Regional Dietician | Interviewed regarding menu approval and portion size guidelines | |
| District Manager | Interviewed regarding menu approval and food storage policies | |
| Director of Operation | Interviewed regarding portion sizes and potential outcomes | |
| Director of Nursing | Interviewed regarding expectations for dietary orders and food storage | |
| Administrator | Interviewed regarding expectations for dietary guidelines and food storage policies |
Inspection Report
Routine
Deficiencies: 17
Date: Jun 7, 2019
Visit Reason
Routine inspection of Signature Healthcare at North Hardin Rehab & Wellness to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, maintenance, assessment accuracy and timeliness, care planning, wound care, catheter care, hydration, medication storage, infection control, and respiratory care. Several residents had care plan and documentation deficiencies, improper infection control practices, and failure to follow physician orders.
Deficiencies (17)
F 0550: The facility failed to ensure one resident was treated with dignity and respect when a nurse exposed the resident's nude buttocks by opening a door during wound care.
F 0584: The facility failed to maintain the interior in good repair for one resident whose room had multiple holes in the wall below the window.
F 0637: The facility failed to complete a Significant Change in Status Minimum Data Set assessment for one resident admitted to hospice.
F 0638: The facility failed to ensure quarterly Minimum Data Set assessments were completed timely for one resident, with a 41-day delay.
F 0640: The facility failed to transmit a completed discharge Minimum Data Set assessment to the state for one resident.
F 0641: The facility failed to ensure accurate Minimum Data Set assessments for two residents, including failure to document indwelling urinary catheter and tracheostomy care.
F 0655: The facility failed to develop a baseline care plan that identified the immediate care needs of one resident, including hydration, fall prevention, and comfort measures.
F 0656: The facility failed to develop a comprehensive care plan with interventions for one resident's PICC line care.
F 0657: The facility failed to revise a resident's care plan to reflect increased need for assistance with activities of daily living identified during a comprehensive assessment.
F 0677: The facility failed to ensure one resident received necessary assistance with bathing, resulting in a seven-day gap without a shower.
F 0686: The facility failed to provide appropriate pressure ulcer care for one resident when a nurse used a dirty urinary incontinence brief to dry a pressure ulcer.
F 0690: The facility failed to ensure two residents' indwelling urinary catheters were secured to prevent injury.
F 0692: The facility failed to offer sufficient fluid intake to maintain proper hydration for one resident who was observed without a glass or pitcher for fluids.
F 0694: The facility failed to ensure safe and appropriate administration of IV fluids for one resident by not providing required PICC line dressing changes.
F 0695: The facility failed to provide safe and appropriate respiratory care for one resident by not consistently providing tracheostomy care as ordered.
F 0761: The facility failed to ensure drugs and biologicals were stored properly in two medication carts, including compromised packaging and improper storage temperature.
F 0880: The facility failed to maintain infection control practices for three residents, including improper hand hygiene during wound care, leaking urinary catheter drainage bag, and failure to use personal protective equipment when providing care to a resident with MRSA.
Report Facts
Residents sampled: 33
Deficiencies cited: 16
Delay in quarterly MDS assessment: 41
Fluid intake deficit: 1335
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #8 | Licensed Practical Nurse | Named in dignity violation and wound care deficiency |
| LPN #4 | Unit Manager | Named in care plan and PICC line care deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies and facility expectations |
| SRNA #12 | State Registered Nurse Aide | Named in failure to use PPE for MRSA resident |
| SRNA #13 | State Registered Nurse Aide | Named in failure to use PPE for MRSA resident |
| LPN #3 | Licensed Practical Nurse | Named in wound care infection control deficiency |
| RN #2 | Registered Nurse | Named in medication storage deficiency |
| LPN #9 | Licensed Practical Nurse | Named in medication storage deficiency |
| LPN #10 | Licensed Practical Nurse | Named in PPE use deficiency |
| LPN #7 | Licensed Practical Nurse | Named in tracheostomy care deficiency |
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