Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 3
Jul 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, abuse prevention, and infection control at Signature Healthcare of Georgetown.
Findings
The facility was found deficient in maintaining a safe environment due to loose drain covers creating tripping hazards, failure to follow abuse reporting policies for an alleged sexual abuse incident, and failure to properly implement infection prevention and control precautions for a resident under Enhanced Barrier Precautions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide a safe, clean, comfortable, and homelike environment due to loose drain access covers on 100 and 400 Halls creating tripping hazards. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow Abuse Policy when an employee did not immediately report an allegation of sexual abuse involving Resident 28. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an infection prevention and control program; CNA did not wear appropriate PPE while providing care to Resident 58 under Enhanced Barrier Precautions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
BIMS score: 8
BIMS score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HK1 | Housekeeper | Reported overhearing inappropriate conversation involving Resident 28 |
| CNA2 | Certified Nurse Aide | Involved in alleged inappropriate conversation with Resident 28 |
| HKS | Housekeeping Supervisor | Received report from HK1 but did not follow up |
| DON | Director of Nursing | Interviewed regarding expectations for building safety and abuse reporting |
| Administrator | Facility Administrator | Interviewed regarding expectations for building safety and abuse reporting |
| CNA1 | Certified Nurse Aide | Observed not wearing gown while providing care under Enhanced Barrier Precautions for Resident 58 |
| IP | Infection Preventionist | Provided training and education details on infection control |
| RCC | Regional Clinical Consultant | Provided on-the-spot training for CNA1 on Enhanced Barrier Precautions |
Inspection Report
Routine
Census: 47
Deficiencies: 14
Dec 3, 2021
Visit Reason
The inspection was conducted to evaluate compliance with residents' rights to access survey results, care planning, treatment, infection control, staffing, and other regulatory requirements.
Findings
The facility failed to ensure residents had access to survey results, develop and implement comprehensive care plans addressing individual needs, provide care and assistance for activities of daily living, maintain infection prevention and control practices, ensure proper medication storage, provide adequate staffing, and follow physician orders for treatments and care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure residents had the right to examine the results of the facility's most recent survey and Plan of Correction. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish mechanisms for documenting and communicating resident's choices regarding treatment and advance directives. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a person-centered Comprehensive Care Plan for six sampled residents addressing specific care needs such as gastrointestinal bleed, Foley catheter, oxygen therapy, pressure ulcer prevention, and feeding assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plans to reflect changes in residents' needs and provide updated feeding instructions for two sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow professional standards of practice including proper wound care, medication administration, and infection control during suprapubic catheter irrigation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure support for residents in their choice of activities, including providing preferred music and meaningful engagement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care and assistance to perform activities of daily living for residents unable to do so, including timely response to call lights and assistance with toileting and feeding. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide treatment and care according to orders, resident preferences, and goals, including following speech therapy feeding recommendations and ensuring proper feeding techniques. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, including off-loading heels and following physician orders for wound care and skin assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including appropriate catheter care and urinary continence restoration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift, resulting in extended wait times for call light responses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure drugs and biologicals were labeled and stored according to professional principles and manufacturer guidelines, including improper storage of influenza vaccines and monoclonal antibodies, and unsecured medications in a resident's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care, including proper labeling and timely changing of oxygen tubing and humidification bottles. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish and maintain an infection prevention and control program, including failure to follow hand hygiene, maintain sterility during procedures, and properly educate and monitor visitors and staff on PPE use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 47
Staffing: 12
Staffing: 2.5
Staffing: 1.5
Weight: 89.2
Weight: 121
Weight: 125.4
Temperature: 42
Temperature: 30
Weight: 87.6
Oxygen tubing use days: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Performed wound care and medication administration with deficiencies; failed to maintain sterility during suprapubic catheter irrigation |
| SRNA #5 | State Registered Nurse Aide | Provided feeding care unaware of special feeding instructions for Resident #33; assigned to Resident #29 |
| LPN #2 | Licensed Practical Nurse | Reported on care plan responsibilities and feeding instructions; responsible for oxygen tubing changes |
| ADON #1 | Assistant Director of Nursing | Provided multiple interviews on care plan expectations, infection control, and oxygen therapy |
| DON | Director of Nursing | Provided multiple interviews on care plan expectations, infection control, and oxygen therapy |
| Administrator | Administrator | Provided multiple interviews on facility expectations for care, infection control, staffing, and medication storage |
| RN #4 | Registered Nurse | Agency nurse who failed to educate visitor on PPE doffing |
| SRNA #10 | State Registered Nurse Aide | Failed to educate visitor on PPE doffing |
| OT | Occupational Therapist | Evaluated Resident #11 and made feeding assistance referral |
| SLP | Speech Language Pathologist | Provided feeding recommendations for Resident #33 |
| RD | Registered Dietician | Assessed Resident #11 and requested re-weighing |
Inspection Report
Routine
Deficiencies: 5
May 30, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, food storage, infection control, and overall facility conditions.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, unsafe storage of oxygen tanks and personal hygiene products, improper food storage and labeling, overdue kitchen range hood servicing, and inadequate infection prevention and control practices including improper hand hygiene and wound care techniques.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to treat resident with dignity and respect by posting multiple neon-orange signs with personal care information in resident's room, violating privacy and confidentiality. | Level of Harm - Minimal harm or potential for actual harm |
| Unsecured oxygen tank left on floor in resident's room creating accident hazard. | Level of Harm - Minimal harm or potential for actual harm |
| Unlocked and unattended cabinet containing personal hygiene products with warning labels accessible to cognitively impaired residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly label frozen food items with food names and use by dates; lack of thermometer and temperature logs in deep freezer; overdue kitchen range hood servicing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to establish and maintain an infection prevention and control program including improper hand hygiene and gloving techniques during incontinence and wound care for a resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 30
Residents affected: 1
Residents affected: 1
Residents affected: 1
Signs posted: 10
Additional signs: 2
Frozen food items without labels: 11
Range hood cleaning overdue by months: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding dignity/privacy concerns, oxygen tank safety, food storage, infection control expectations |
| Licensed Practical Nurse #4 | LPN | Interviewed about signs posted in Resident #4's room and privacy concerns |
| Licensed Practical Nurse #5 | LPN | Interviewed about signs posted in Resident #4's room and privacy concerns |
| Occupational Therapist | OT | Placed signs in Resident #4's room and interviewed about privacy concerns |
| Physical Therapist | PT | Interviewed about privacy concerns related to signs in Resident #4's room |
| Administrator | Administrator | Interviewed about expectations for privacy, oxygen tank safety, food safety, and infection control |
| State Registered Nursing Assistant #6 | SRNA | Interviewed about oxygen tank handling |
| Licensed Practical Nurse #9 | LPN | Interviewed about oxygen tank handling |
| State Registered Nursing Assistant #8 | SRNA | Interviewed about oxygen tank handling |
| Licensed Practical Nurse #10 | LPN | Interviewed about oxygen tank handling and food cabinet locking |
| Director of Dietary | Director of Dietary | Interviewed about food labeling, freezer temperature monitoring, and range hood servicing |
| Dietary Aide #1 | Dietary Aide | Interviewed about food labeling and stock rotation |
| Dietary Manager | Dietary Manager | Interviewed about range hood servicing |
| Chief Executive of Operations | CEO | Interviewed about food safety and range hood servicing responsibilities |
| State Registered Nursing Assistant #3 | SRNA | Observed and interviewed regarding improper hand hygiene and gloving during incontinence care |
| State Registered Nursing Assistant #4 | SRNA | Observed and interviewed regarding improper hand hygiene and gloving during incontinence care |
| Licensed Practical Nurse #6 | LPN | Observed and interviewed regarding improper wound care technique and hand hygiene |
| Signature Care Consultant #1 | SCC | Observed wound care and provided guidance on proper technique |
| Staff Development Coordinator | SDC | Interviewed about infection control education and staff training |
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