Inspection Reports for
Signature Healthcare of South Louisville
1120 CRISTLAND ROAD, LOUISVILLE, KY, 40214
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
21% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Date: Jan 23, 2025
Visit Reason
Routine inspection to assess compliance with healthcare regulations including respiratory care, medication administration, medical record accuracy, infection control, and other care standards at Signature Healthcare of South Louisville.
Findings
The facility failed to follow physician orders for supplemental oxygen administration, maintain medication error rates below 5%, accurately document insulin dosages, and ensure proper infection control practices related to enhanced barrier precautions. Deficiencies were noted in respiratory care, medication administration, medical record keeping, and infection prevention.
Deficiencies (4)
F 0695: The facility failed to ensure physician orders were followed for supplemental oxygen administration for 1 of 5 residents, with oxygen concentrator set at 4 L/min instead of the ordered 3 L/min.
F 0759: The facility failed to maintain medication error rates below 5%, evidenced by 2 medication errors out of 34 opportunities affecting 1 of 5 residents observed during medication pass.
F 0842: The facility failed to maintain a complete and accurate medical record for 1 of 5 residents, with insulin dosages documented incorrectly and inconsistently with physician orders.
F 0880: The facility failed to ensure staff wore proper personal protective equipment when providing care to a resident on enhanced barrier precautions, with staff observed wearing only gloves instead of gown and gloves.
Report Facts
Medication error rate: 5.88
Medication errors: 2
Medication opportunities: 34
Resident sample size: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Named in supplemental oxygen administration finding |
| RN 4 | Registered Nurse | Named in supplemental oxygen administration finding |
| RN 7 | Registered Nurse | Named in medication administration and insulin pen preparation finding |
| LPN 5 | Licensed Practical Nurse | Named in inaccurate insulin dosage documentation finding |
| CNA 12 | Certified Nursing Assistant | Named in infection control PPE noncompliance finding |
| Director of Nursing | Director of Nursing | Provided statements on expectations for oxygen administration, medication administration, documentation, and infection control |
| Nurse Practitioner | Nurse Practitioner | Provided statements on oxygen administration and medication expectations |
| Facility Pharmacist | Facility Pharmacist | Provided statements on insulin pen preparation and manufacturer instructions |
| Chief Executive Officer | Chief Executive Officer/Administrator | Provided statements on staff expectations for following physician orders and infection control |
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 4
Date: Jan 23, 2025
Visit Reason
A Recertification, COVID-19 Focused Infection Control and Abbreviated Survey was conducted to investigate compliance with federal regulations, including follow-up on previous deficiencies.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B, with deficiencies cited at the highest Scope and Severity of 'D'. Deficiencies involved respiratory care, medication error rates, and resident records including infection prevention and control.
Deficiencies (4)
Failure to ensure physician orders were followed related to supplemental oxygen administration for 1 of 5 residents sampled for respiratory care.
Medication error rate exceeded 5%, evidenced by 2 medication errors out of 34 opportunities.
Failure to maintain complete and accurate medical records for 1 of 5 residents sampled, including documentation of medication administration and physician orders.
Failure to establish and maintain an infection prevention and control program, including failure to ensure staff wore proper personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions.
Report Facts
Survey Census: 93
Sample Size: 24
Supplemental Residents: 0
Residents assessed for insulin orders: 14
Residents assessed for oxygen administration: 16
Medication error rate: 5.88
Medication errors: 2
Residents sampled for infection control: 24
Facility census: 94
Inspection Report
Routine
Deficiencies: 7
Date: Oct 11, 2019
Visit Reason
Routine inspection of Signature Healthcare of South Louisville to assess compliance with regulatory requirements including resident assessments, medication administration, respiratory care, pharmaceutical services, food safety, and infection control.
Findings
The facility was found deficient in timely transmission of discharge Minimum Data Set (MDS) assessments, accurate coding of resident tobacco use in MDS, adherence to physician orders for oxygen administration, documentation and security of controlled medications, secure storage of refrigerated scheduled medications, proper food storage and labeling, and staff hand hygiene during medication administration.
Deficiencies (7)
F 0640: The facility failed to transmit a discharge Minimum Data Set (MDS) within fourteen days for one resident discharged to an acute care hospital.
F 0641: The facility failed to accurately code tobacco use in the annual MDS for one resident who smoked cigarettes.
F 0695: The facility failed to follow physician orders for oxygen administration for one resident; oxygen was set at three liters instead of the ordered four liters.
F 0755: The facility failed to ensure staff documented removal and reconciliation of controlled medications at shift change and failed to keep medication carts locked when unattended.
F 0761: The facility failed to ensure refrigerated scheduled medication boxes were secured to medication refrigerators and failed to audit the presence of these boxes every shift.
F 0812: The facility failed to store food in accordance with professional standards; opened foods were undated and canned food labels were damaged or undated.
F 0880: The facility failed to ensure staff performed hand hygiene before and after medication administration and between residents.
Report Facts
Residents sampled: 18
Discharges per month: 50
Controlled medication count discrepancies: 23
Controlled medication count discrepancies: 24
Hydrocodone tablets observed: 18
Oxycodone tablets observed: 12
Lorazepam vials observed: 1
Medication carts observed unlocked: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse | Named in oxygen administration deficiency and hand hygiene observations |
| RN #2 | Registered Nurse | Named in controlled medication documentation deficiency and hand hygiene observations |
| RN #3 | Registered Nurse | Named in controlled medication documentation deficiency and hand hygiene observations |
| LPN #2 | Licensed Practical Nurse | Named in controlled medication documentation deficiency and food storage observations |
| LPN #5 | Licensed Practical Nurse | Named in controlled medication documentation deficiency |
| LPN #6 | Licensed Practical Nurse | Named in medication storage and security deficiency |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including oxygen administration, medication documentation, medication storage, and infection control |
| Administrator | Administrator | Interviewed regarding facility expectations and awareness of deficiencies |
| East Unit Manager | Unit Manager | Interviewed regarding medication storage and documentation deficiencies |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed regarding staff education and infection control practices |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and labeling deficiencies |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 26, 2018
Visit Reason
The inspection was conducted to assess compliance with resident rights, infection prevention and control, and wound care practices at Signature Healthcare of South Louisville.
Findings
The facility failed to maintain resident dignity by not covering urine drainage bags and failed to prevent possible infection spread due to improper hand hygiene and urine drainage bag placement. Several staff members were observed not following proper infection control protocols during wound care and catheter care.
Deficiencies (2)
F 0550: The facility failed to maintain a resident's dignity by not covering the urine drainage bag, which was visible to other residents and visitors.
F 0880: The facility failed to provide and implement an effective infection prevention and control program, including proper hand hygiene and ensuring urine drainage bags were kept off the floor to prevent infection.
Report Facts
Residents sampled: 18
Residents affected by dignity issue: 1
Residents affected by infection control issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed improper wound care and hand hygiene practices |
| LPN #3 | Licensed Practical Nurse | Forgot to change gloves and wash hands during wound care |
| CNA #1 | Certified Nursing Assistant | Responsible for placing dignity covers on urine drainage bags |
| Director of Nursing | Director of Nursing | Monitored staff compliance with dignity and infection control practices |
| Assistance Director of Nursing | Assistant Director of Nursing | Commented on proper glove use and hand washing during wound care |
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