Inspection Reports for
Signature Healthcare of Elizabethtown
1850 VETERAN'S WAY, ELIZABETHTOWN, KY, 42701
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
53% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
An abbreviated survey was initiated on 04/04/2025 and concluded on 04/09/2025 to investigate complaint KY00045572.
Complaint Details
Complaint KY00045572 was investigated and found to have no deficiencies; the facility was in substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B. No deficiencies were issued related to complaint KY00045572.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
A Complaint Survey was conducted from 01/02/2025 through 01/03/2025 to investigate KY00044558.
Complaint Details
Complaint KY00044558 was unsubstantiated with no regulatory deficient practice identified.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B. The complaint KY00044558 was unsubstantiated with no regulatory deficient practice identified.
Inspection Report
Deficiencies: 1
Date: Oct 25, 2024
Visit Reason
The inspection was conducted to assess compliance with Kentucky regulations regarding pre-employment background checks, specifically the Kentucky Adult Caregiver Misconduct Registry (KACMR) checks for contracted dietary employees.
Findings
The facility failed to complete the Kentucky Adult Caregiver Misconduct Registry checks prior to employment for 2 of 3 contracted dietary employees. The checks were completed only during the State Survey Agency survey on 10/24/2024, after the employees had already started work.
Deficiencies (1)
F 0606: The facility did not complete Kentucky Adult Caregiver Misconduct Registry checks prior to employment for 2 contracted dietary employees. The checks were completed on 10/24/2024, after the employees began work on 09/04/2024 and 09/11/2024.
Report Facts
Date employment began for DA 1: Sep 4, 2024
Date employment began for [NAME] 1: Sep 11, 2024
Date KACMR checks completed: Oct 24, 2024
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse involving a resident being forced to take medication against their will and inadequate supervision leading to resident-to-resident altercations.
Complaint Details
The complaint involved allegations that an RN forced Resident #2 to take medication by holding the resident's nose. The RN was witnessed by staff and subsequently resigned. The complaint also included inadequate supervision leading to resident-to-resident abuse involving Residents #1, #3, and #4.
Findings
The facility failed to honor a resident's right to refuse medication, with an RN observed forcing medication administration by holding the resident's nose. Additionally, the facility failed to provide adequate supervision to prevent resident-to-resident altercations, resulting in injuries and repeated aggressive behaviors among residents.
Deficiencies (2)
F 0550: The facility failed to honor Resident #2's right to refuse medication, with an RN observed holding the resident's nose to force medication administration on 06/18/2023. Staff interviews and observations confirmed the incident and the RN subsequently resigned.
F 0689: The facility failed to provide adequate supervision to prevent resident-to-resident altercations involving Residents #1, #3, and #4. Resident #3 physically assaulted Residents #1 and #4 on separate occasions, causing injury and requiring interventions including 15-minute checks and medication adjustments.
Report Facts
Residents sampled: 7
Medication refusal incident date: Jun 18, 2023
Resident #3 hitting Resident #1 times: 6
Resident #3 hitting Resident #1 times: 7
Resident #3 admission date: Nov 14, 2023
BIMS score Resident #2: 6
BIMS score Resident #3: 3
Psychotropic medication dose: 20
Duration without negative behaviors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #3 | Named as perpetrator who forced medication administration on Resident #2 and resigned | |
| Certified Medical Technician (CMT) #6 | Observed assisting medication administration and ensuring resident safety during choking incident | |
| Registered Nurse (RN) #2 | Interviewed regarding medication refusal and abuse policies | |
| Director of Nursing (DON) | Received reports of abuse, instructed staff actions, and provided interviews | |
| Administrator | Received abuse allegation reports and provided interviews | |
| Certified Nursing Assistant (CNA) #8 | Witnessed RN forcing medication administration on Resident #2 | |
| Licensed Practical Nurse (LPN) #3 | Reported on resident-to-resident altercations and supervision | |
| Advanced Practice Registered Nurse (APRN) | Provided psychiatric care and medication management for Resident #3 |
Inspection Report
Routine
Deficiencies: 1
Date: Jul 1, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control policies, specifically related to COVID-19 precautions for newly admitted residents.
Findings
The facility failed to place a newly admitted, unvaccinated resident in isolation and on droplet precautions as required by policy. Appropriate signage and Personal Protective Equipment (PPE) were not placed outside the resident's room, increasing the risk of COVID-19 spread.
Deficiencies (1)
F 0880: The facility failed to implement infection prevention and control by not placing a newly admitted, unvaccinated resident in isolation and on droplet precautions for fourteen days as required. No signage or PPE was available outside the resident's room to indicate isolation status.
Report Facts
Residents sampled: 18
Days for isolation: 14
Date of resident admission: Jun 25, 2021
Inspection Report
Annual Inspection
Deficiencies: 7
Date: May 31, 2019
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident privacy, incomplete implementation and revision of comprehensive care plans, inadequate nutritional monitoring, improper medication administration practices, and food storage violations.
Deficiencies (7)
F 0583: The facility failed to ensure a resident's right to personal privacy and confidentiality during personal care for one resident. Staff did not pull the privacy curtain and failed to knock or introduce themselves before entering the resident's room.
F 0656: The facility failed to implement the comprehensive care plan for one resident when a CNA did not spoon liquids as care planned, causing the resident to cough.
F 0657: The facility failed to revise care plans for four residents related to nutrition and falls, despite significant weight loss and multiple falls.
F 0692: The facility failed to ensure one resident with significant weight loss was placed on weekly weights as required by facility policy.
F 0693: The facility failed to ensure a resident fed by gastrostomy tube received appropriate care, as a nurse did not check tube placement prior to administering flushes and medications.
F 0761: The facility failed to ensure drugs were labeled in accordance with professional principles; an opened bottle of liquid medication was not dated.
F 0812: The facility failed to ensure food stored in the walk-in freezer was dated, with items such as hush puppies and french fries found unlabeled.
Report Facts
Residents sampled: 21
Weight loss percentage: 26.3
Weight loss percentage: 10.5
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | RN | Named in feeding tube placement deficiency |
| Licensed Practical Nurse #1 | LPN | Named in medication labeling deficiency |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and expectations |
| Certified Nurse Aide #1 | CNA | Named in care plan implementation deficiency |
| Certified Nurse Aide #2 | CNA | Named in privacy violation deficiency |
| Certified Nurse Aide #3 | CNA | Named in privacy violation deficiency |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding care plan update responsibilities |
| Licensed Practical Nurse #5 | LPN | Interviewed regarding care plan update responsibilities |
| Dietary Aide #1 | Dietary Aide | Named in food storage deficiency |
| Dietary Manager | Dietary Manager | Named in food storage deficiency |
| Registered Dietitian | RD | Named in nutritional monitoring deficiency |
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