Inspection Reports for
Signature HealthCARE at Rockford Rehab & Wellness Center
KY
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Abbreviated Survey
Census: 99
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
An abbreviated survey was conducted to investigate KY00044147, KY00046395, and KY00046393.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B. No deficiencies were issued related to the investigated cases.
Report Facts
Sample Size: 7
Supplemental Resident: 2
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide safe and appropriate pain management to residents requiring such services, specifically focusing on three residents who did not receive prescribed pain medications as ordered.
Complaint Details
The visit was complaint-related, focusing on allegations that the facility failed to provide adequate pain management to residents. The complaint was substantiated based on observations, interviews, and record reviews confirming medication administration failures.
Findings
The facility failed to ensure that three residents (R20, R30, and R59) received their prescribed scheduled doses of pain medications due to medication unavailability and delays in pharmacy supply. The facility's policies on medication ordering, emergency kits, and pain management were reviewed, and interviews with staff revealed gaps in medication administration and monitoring processes.
Deficiencies (3)
Failure to provide prescribed scheduled doses of Hydrocodone 10 mg/Acetaminophen 325 mg to Resident 20 for 28 consecutive hours due to medication unavailability.
Failure to provide prescribed scheduled doses of Tramadol 25 mg to Resident 30 on multiple occasions due to medication unavailability and pharmacy delays.
Failure to provide prescribed scheduled doses of Tramadol 25 mg to Resident 59 on multiple occasions due to medication unavailability and pharmacy delays.
Report Facts
Hours medication not administered: 28
Medication doses missed: 6
Medication doses missed: 2
BIMS scores: 15
BIMS scores: 9
BIMS scores: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 7 | LPN | Responsible for administering medications and managing medication availability, including use of Emergency Drug Kit. |
| Unit Manager 2 | UM | Managed medication stock levels and expected staff to follow medication ordering and administration protocols. |
| Staff Development Coordinator | SDC | Provided staff education on use of Emergency Drug Kit and pain management. |
| Assistant Director of Nursing | ADON | Oversaw medication monitoring and refill processes, expected nurses to take necessary steps to obtain medications. |
| Director of Nursing | DON | Set expectations for medication administration, refill processes, and use of Emergency Drug Kit. |
| Administrator | Administrator | Oversaw overall facility operations, expected staff to manage medication stock and pain assessments, and handle prior authorizations. |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 31, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including care planning, wound care, respiratory care, nutrition, medication storage, and communication of therapy recommendations.
Findings
The facility failed to develop and implement comprehensive care plans for several residents, failed to provide appropriate wound care and infection control, failed to maintain proper respiratory care and emergency equipment for tracheostomy residents, failed to identify and address significant weight loss in a resident, failed to provide special eating equipment and supervision as recommended, and failed to maintain medication storage at proper temperatures.
Deficiencies (7)
Failed to develop and implement a comprehensive care plan that meets all the resident's needs, including one on one supervision with meals and use of handled cups for Resident #78.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Residents #62, #78, and #190, including failure to follow infection control procedures.
Failed to identify and address significant weight loss for Resident #40, including failure to notify physician and update care plan.
Failed to provide safe and appropriate respiratory care for residents with tracheostomies, including lack of emergency equipment at bedside, failure to monitor oxygen saturation during care, and failure to assess residents' condition before and after tracheostomy care for Residents #21, #26, and #66.
Failed to obtain physician notification and orders for changes in condition, including speech therapy recommendations for Resident #78 and significant weight loss for Resident #40.
Failed to provide special eating equipment and appropriate supervision for Resident #78 as recommended by speech therapy.
Failed to maintain medication room refrigerator at proper temperature and improperly stored intravenous medications with oral medications in the East hall medication room.
Report Facts
Weight loss: 16
Weight loss percentage: 14.9
Medication room refrigerator temperature: 32
Medication room refrigerator temperature: 34
BIMS score: 4
BIMS score: 11
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in wound care deficiencies for failing to follow infection control procedures and physician orders. |
| Speech Therapist | Provided feeding supervision recommendations for Resident #78 that were not communicated to nursing. | |
| Certified Nursing Assistant #3 | CNA | CNA for Resident #78, unaware of need for one on one supervision with eating. |
| Minimum Data Set staff | Reported lack of care plan updates and communication failures regarding Resident #78 and Resident #40. | |
| Signature Care Nurse Consultant | Discussed communication breakdowns and care plan deficiencies. | |
| Dietary Manager | Acknowledged failure to notify dietician of Resident #40's weight loss and lack of interventions. | |
| LPN #2 | Licensed Practical Nurse | Observed missing emergency trach supplies for Resident #66 and lack of suction setup for Resident #21. |
| RN #6 | Registered Nurse | Observed lack of suction setup for Resident #21 and inability to provide emergency care. |
| LPN #5 | Licensed Practical Nurse | Observed performing trach care without monitoring oxygen saturation or assessing lung sounds. |
| East Unit Manager | Reported lack of emergency cart supplies and staff education deficiencies. | |
| Medical Director | Discussed concerns about wound care and respiratory care education and supply issues. | |
| LPN #8 | Licensed Practical Nurse | Performed trach care without applying pulse oximeter before and during care. |
| LPN #7 | Licensed Practical Nurse | Reported refrigerator temperature issues and improper medication storage. |
| Administrator | Acknowledged concerns about trach care supplies and weight loss notification failures. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 7, 2018
Visit Reason
The inspection was conducted following a complaint regarding inadequate supervision that resulted in a resident (Resident #37) falling from a wheelchair onto the parking lot pavement during transport.
Complaint Details
The complaint investigation was substantiated by observations and interviews confirming inadequate supervision by the Escort and transport driver, leading to the resident's fall. The Escort lacked orientation and specific job instructions, and the facility failed to train the Escort for this role.
Findings
The facility failed to provide adequate supervision for Resident #37, who fell from a wheelchair due to an unlocked wheel and lack of escort presence. Additionally, the facility failed to ensure medications were properly labeled with dates opened and failed to remove expired nutritional feeding bottles.
Deficiencies (2)
Failure to provide adequate supervision to prevent accidents, resulting in Resident #37 falling from wheelchair onto pavement.
Failure to ensure medications were accurately labeled with the date opened on two of four medication carts and failure to remove expired nutritional feeding bottles.
Report Facts
Residents sampled: 20
Resident #37 Brief Interview for Mental Status score: 11
Medication carts with unlabeled medications: 2
Expired nutritional feeding bottles: 8
Insulin flex pens not labeled: 4
Nebulizer solution packages not labeled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nursing | Interim Director of Nursing (DON) | Assessed Resident #37 after fall and provided statements about Escort role and supervision |
| Escort | Escort | Responsible for escorting residents to appointments; lacked orientation and specific job instructions |
| Unit Manager | Unit Manager | Provided statements on Escort responsibilities and medication cart audits |
| Staff Development Coordinator | Staff Development Coordinator | Reported no evidence of Escort training |
| Administrator | Administrator | Provided statements on transport driver and Escort responsibilities |
| Registered Nurse #3 | Registered Nurse (RN) | Interviewed regarding medication labeling policy and observations |
| Registered Nurse #1 | Registered Nurse (RN) | Interviewed regarding medication labeling policy and observations |
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