Signature Healthcare At Colonial Rehab & Wellness

F-F600) at a Scope and Severity (S/S) of a E; while the facility monitored the effectiveness of systemic changes and quality assurance activities.

The findings include:

Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property dated 10/17/2022, revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident.

The State Survey Agency (SSA) requested a policy regarding determining a resident's ability to consent; however, the facility did not provide such policy.

Review of the Long-Term Care Facility Self-Reported Incident Form Initial Report (IR), received on 08/09/2023, revealed a staff member passing by Resident R63's room observed Resident R63 exposing himself to the female resident who also alleged Resident R63 touched her left breast. The Long-Term Care Facility Self-Reported Incident Form 5-Day Follow-Up Report (5Day) revealed Resident R63 admitted exposing himself but could not recall why. Resident R63 was accepted into an area facility for evaluation and treatment. Additionally, the facility unsubstantiated the incident while acknowledging the incident occurred. The 5Day reveals no indication regarding assessment of

the residents' capacity to consent to sexual activity.

Review of the facility's Initial Report dated 09/04/2023 and Final Report/5 Day Follow-Up investigation documentation, revealed Resident R63 and Resident R34 had been in an activity when the Activities Director (AD) witnessed Resident R63's hand down the front of Resident R34's shirt, appearing to touch her breast. Per review, the AD separated the residents, reported the incident to the Director of Nursing (DON), and the facility placed Resident R63 on 1:1

observation. Continued review revealed when Resident R63 was interviewed he stated he had (touched Resident R34's breast) but could not recall why. Further review revealed the facility's Administrator substantiated the allegation of sexual abuse which had been witnessed by a staff member. In addition, review of the investigation information revealed local law enforcement was immediately notified and Resident R63 was escorted out of the facility, taken to the local law enforcement agency and charged with sexual abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 1. Review of Resident R34's clinical record revealed the facility admitted the resident on 06/17/2021, with diagnoses to include encephalopathy unspecified, unspecified convulsions, and epileptic seizures related to external Level of Harm - Immediate causes, with status epilepticus (prolonged seizure, seizure lasting more than 5 minutes or when seizures jeopardy to resident health or occur very close together). safety

Review of Resident R34's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of Residents Affected - Some 06/17/2021 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Continued MDS review revealed on 09/04/2023, the facility also assessed Resident R34's BIMS score to be six (6) out of fifteen (15) indicating severe cognitive impairment.

Continued review of Resident R34's clinical record revealed no indication of an assessment conducted regarding the resident's capacity to consent to sexual relations.

Review of Resident R34's clinical record progress note 09/04/2023, revealed the facility assessed the resident to have no injury following the encounter with Resident R63. Per review of the note, Resident R34 was assessed by psychiatry to have no mental distress noted, with no mention of inappropriate sexual behaviors.

During an interview on 05/16/2024 at 4:37 PM, with the Activities Director, she stated she witnessed Resident R63 putting his hand down Resident R34's shirt touching her right breast (on 09/04/2023). She stated Resident R34 yelled out and Resident R63 took his hand out of Resident R34's shirt, and the two residents were immediately separated. The Activities Director further stated Resident R63 was placed on 1:1 observation.

2. Review of Resident R63's clinical record revealed the facility admitted the resident on 09/07/2018, with diagnoses to include: vascular dementia, without behavioral disturbance; psychotic disturbance; mood disturbance; and anxiety.

Review of Resident R63's MDS with an ARD of 09/07/2018, revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Continued MDS review revealed the facility assessed Resident R63 on 08/30/2023, on an unscheduled BIMS assessment, with a score of eleven (11) out of fifteen (15) also indicating moderate impairment.

Review of Resident R63's care plan, undated, revealed on 02/20/2023, the facility care planned Resident R63 for behaviors with

the problem/focus of the resident demonstrating inappropriate behaviors with other residents. Per review, the interventions dated 02/20/2023, included to assist resident away from other residents as needed; determine

the cause for the inappropriate behavior and refer to a physician/psychiatrist for intervention; encourage participation in structured activities as he would attend; and observe for triggers of inappropriate behaviors.

Continued review of Resident R63's clinical record progress note revealed previous allegations/incidents of sexual abuse beginning on 02/24/2022 when Resident R63 and Resident R2, while sitting at a dining room table lightly kissed each other on the lips.

Review revealed on 08/14/2022, Resident R63 and Resident R2 kissed each other while attending an activity; and on 05/17/2023, Resident R63 allegedly exposed himself to Resident R33. Per record review, on 08/09/2023 staff responded to Resident R24 yelling from her room and upon entering the room Resident R24 told them Resident R63 entered her room exposed himself. Further review revealed the facility unsubstantiated all those incidents/allegations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Review of Resident R63's clinical progress notes revealed assessments by psychiatry on 08/17/2022, 02/17/2023, 05/19/2023, and 05/26/2023, after inappropriate behaviors with no psychosocial concerns noted. Level of Harm - Immediate jeopardy to resident health or Review of progress notes for Resident R63, on 07/18/2023, revealed Resident R63 requested condoms and staff supplied safety them.

Residents Affected - Some Additional review of Resident R63's care plan revealed the facility did not address the resident's continued acts of inappropriate behavior (exposing himself or unwanted sexual touching) in his care plan after each unsubstantiated allegation. Further review revealed no documentation noting the facility specifically addressed the behaviors of Resident R63 to alert staff of his potential sexual behaviors.

Interview with State Registered Nursing Assistant (SRNA) 7 on 05/16/2024 at 1:56 PM, revealed she provided 1:1 observation of Resident R63 in February or March, 2023 because the resident had kissed another resident.

During an interview with Licensed Practical Nurse (LPN) 1 on 05/15/2024 at 9:15 AM, she stated she believed Resident R63 was not a danger to female residents, but believed there might have been opportunities for Resident R63 to interact independently and without supervision with female residents and inappropriately touch those residents.

Interview with the SDC on 07/11/2024 at 1:26 PM, revealed the facility recently adopted an assessment tool to determine a resident's capacity to consent to sexual relationships and education had been provided to staff regarding this assessment over the past few days.

During an interview on 07/03/2024 at 3:34 PM with the psychiatric nurse practitioner, she stated there were many factors that went into determining consent. She stated the BIMS score was used, the resident's Power of Attorney (POA) was contacted, and if the resident was in charge of their own health care. She stated it was a composite of many different evaluations. Further, she stated other factors that were taken into account were if the resident was on pain medication or psychotropic medication, whether the resident had an infection. She stated many factors were involved in making a consent determination. The psychiatric nurse practioner stated as a nurse practitioner, evaluating someone for consent to engage in sexual activitiy was beyond her scope of practice to determine consent. She stated the term consent was actually a legal term and two physicians were required to determine capacity. She stated the facility had not asked her to be involved with determining a resident's capacity for consent.

During an interview on 07/03/2024 at 1:37 PM, with the MDS Nurse Coordinator, she stated Resident R63 had a potential for reoccurrence of inappropriate behaviors. She stated Resident R63's care plan was discussed in the facility's morning meetings, and his behaviors escalated after his stroke. The MDS Nurse Coordinator stated

she knew Resident R63 before and after his stroke and the resident had definitely changed after the stroke. She stated however, Resident R63 had not had enough of a significant change to discuss doing a change in condition assessment. The MDS Nurse Coordinator further stated Resident R63 was being discussed in the facility's Interdisciplinary Team (IDT) meetings to determine his ability to be involved in relationships.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 During an interview on 07/02/2023 at 11:42 AM, the Medical Director stated Resident R63's care was reviewed in the facility's morning meetings and Quality Assurance Performance Improvement (QAPI) meetings. She stated a Level of Harm - Immediate psychiatric provider evaluated Resident R63 after each allegation of inappropriate sexual behaviors. The Medical jeopardy to resident health or Director stated the Psychiatric Nurse Practitioner started Resident R63 on medication to control some of his sexual safety impulsivity, had increased the medication after another incident of sexually inappropriate behavior, but the resident had continued to have the inappropriate sexual behaviors. Residents Affected - Some

During interview with the Director of Nursing (DON) on 05/16/2024 at 2:50 PM, she stated previous allegations of inappropriate sexual behaviors by Resident R63 had been unsubstantiated. She stated, even though the allegations were unsubstantiated or lacked enough evidence to confirm, the facility implemented actions to prevent further episodes of Resident R63's inappropriate sexual behavior. Per the DON in interview, the incident that occurred on 09/04/2023, was witnessed by a staff member and was substantiated by the facility. The DON stated all of the alleged incidents involving Resident R63 were reported to the State Survey Agency (SSA) and investigated, but found to be unsubstantiated due to lack of sufficient evidence.

In continued interview with the DON on 05/16/2024 at 2:50 PM, she stated the facility educated staff on all allegations of abuse. She stated she ensured all residents were safe by informing staff of the incident/allegations during morning meetings. According to the DON in interview, residents' care plans were updated when the allegation of (abuse) was brought to staffs' attention. She stated education related to residents' rights was provided to all residents. She stated all dining and group activities were monitored by staff to decrease the chance of inappropriate resident-to-resident interaction. The DON stated three of the four previous incidents involving Resident R63 occurred in the dining room which also served as the activities area.

She said the other incidents occurred when Resident R63 was going to his room and allegedly went into a female resident's room and exposed himself to that resident. The DON stated however, that incident was unsubstantiated. She stated residents who wandered had staff that kept eyes on them and those residents were redirected when necessary. The DON further stated she and other members of management were involved in monitoring of residents during activities and during dining times.

In additional interview with the DON on 07/03/2024 at 12:13 PM, she stated the facility assessed residents who were cognitively intact to determine their ability to make rational and informed decisions, and one of those determinants was the BIMS score assessment. Further, she stated the residents' physical and mental health were evaluated. The DON stated the residents were educated on the risk of sexually transmitted infections, risk of having a relationship and possible poor outcomes. Lastley, the DON stated condoms were provided to the residents with education provided to the residents on what type of affection is appropriate while in public.

During an interview with the Administrator on 05/24/2024 at 2:19 PM, he stated it was his expectation residents would be safe from sexual abuse or any other type of abuse. The Administrator stated he expected residents' care plans to be updated any time there was a change in the resident. He stated if any resident was found to be adversely affected from an incident, they were to have a physical assessment and if necessary, to be seen by psychiatry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49267 jeopardy to resident health or safety Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free of any significant medication errors for one of seven sampled residents (Residents Residents Affected - Few (R)58).

On 05/03/2022, Resident R58 developed increased altered mental status and was sent to the emergency room (ER) for evaluation. During assessment of Resident R58 at the ER, the ER nurse discovered a 75 microgram (mcg) fentanyl patch (narcotic medication used to treat severe pain) on the resident's left upper arm/shoulder. However,

review of the facility's information for Resident R58 revealed no documentation noting fentanyl as one of Resident R58's medications. Review of Resident R2's (Resident R58's roommate) orders revealed that resident had an active order for a 75 mcg fentanyl patch. The Director of Nursing (DON) assessed Resident R2 and did not find the resident's prescribed fentanyl patch.

The facility's failure to have an effective system to ensure residents were free from significant medication (med) errors is likely to cause serious injury, impairment, or death.

Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/03/2024 and determined to exist on 05/03/2022 at 42 CFR 483.45, Residents are Free of Significant Med Errors, (

F-F760) at a Scope and Severity (S/S) of a D while the facility monitors the effectiveness of systemic changes and quality assurances activities.

The findings include:

Review of the facility's policy titled, Medication Administration, dated 09/2018, revealed two resident identifiers and triple medication verifications were required prior to medication administration. Continued policy review revealed the resident identifier methods to use might include: checking residents' identification bands; checking residents' photographs attached to the medical record; or verifying a resident's identification with other nursing care personnel. Further review revealed medications supplied for one resident should never be administered to another resident.

Review of the facility's policy titled, Notification of Change of Condition dated 07/07/2022, and last revised 09/15/2023, revealed the facility must inform the resident, consult with the physician, and notify the resident's representative when there was a significant change in the resident's physical, mental or psychosocial status, or a decision to transfer or discharge a resident from the facility was made. Further review of the policy revealed the medical provider was to provide guidance related to the resident's change in condition.

Review of the facility's policy titled, Controlled Medication dated 11/13/2023, and last reviewed 05/30/2024, revealed the facility was to ensure controlled medications recordkeeping was in place in accordance with federal, state, and other applicable laws and regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of the fentanyl patch package insert revealed the following common adverse effects which included: nausea, vomiting, insomnia, dizziness, constipation, hyperhidrosis (excessive sweating), fatigue, feeling cold, Level of Harm - Immediate anorexia, diarrhea, somnolence (excessive sleepiness), and headache. jeopardy to resident health or safety 1. Review of Resident R58's closed medical record Face Sheet revealed the facility admitted the resident on 04/21/2022, with diagnoses of pneumonia, parkinson's disease, and need for assistance with personal care. Residents Affected - Few

Review of Resident R58's 5-Day Minimum Data Set (MDS), dated [DATE REDACTED], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition.

Review of Resident R58's Physician Order Report dated 04/03/2022 through 05/03/2022 revealed no documented evidence of an order in place for a 75 microgram (mcg) fentanyl patch.

Review of Resident R58's, Medication Administration Record (MAR) dated 05/01/2022 through 05/03/2022 revealed no documentation noting administration of a fentanyl patch. Further review revealed Resident R58 had an order for Tylenol 325 milligrams (mg), two tablets every four hours as needed for mild pain.

Review of Resident R58's progress note dated 05/03/2022 at 10:11 AM, revealed the resident felt unwell and documentation noting a decline in mental status. Continued review revealed documentation noting Resident R58 experienced arousal difficulty and failed to swallow her medications. Per review of the progress note, staff notified the physician and received orders to draw blood for laboratory (lab) values; obtain an x-ray; and an electrocardiogram (EKG). Further review revealed Resident R58's family decided later to have the resident sent to the hospital for evaluation.

Review of the facility's Event Report dated 05/03/2022, for this incident involving Resident R58 revealed the resident had been lethargic and drowsy, but oriented to person, place, time, and situation. Continued review revealed Resident R58 received an incorrect medication, and the facility transferred the resident to the hospital.

Review of the facility's document titled, Investigation undated, revealed the facility determined Resident R58's roommate had a fentanyl patch ordered which was documented as changed on 05/02/2022 and placed on

the resident's roommate's left shoulder by an agency Kentucky Medication Aide (KMA). Further review revealed the facility made multiple unsuccessful attempts to contact the KMA. In addition, review revealed

the facility determined a medication error had occurred after ER staff called the facility to clarify orders upon discovering the fentanyl patch on Resident R58.

Review of the Emergency Medical Services (EMS) run sheet dated 05/03/2022 for Resident R58 revealed the following information at 9:42 AM-call received for person with altered mental status and lethargy for two days, onset on 05/02/2022 at 8:00 AM. Per review of the EMS run sheet at 9:51 AM, EMS made contact with Resident R58, and the assessment of the resident revealed she was sitting up in wheelchair, confused, only oriented to her name, and was found to have a pulse oximetry (ox) reading of 81% on room air (oxygenation status significant for hypoxia). Review revealed Resident R58 was placed on two liters of oxygen per nasal cannula and the resident's oxygenation status improved to 97%. Further review of the EMS run sheet revealed at 10:01 AM, EMS left facility with Resident R58 to transfer to hospital and at 10:51 AM, EMS arrived at the hospital with the resident and gave report to the triage nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of Resident R58's hospital records dated 05/03/2022 revealed the resident presented to the emergency room (ER) with confusion, nausea, vomiting, and lethargy. Per review, during the assessment of Resident R58, the ER Level of Harm - Immediate Registered Nurse (RN) discovered a 75 microgram (mcg) fentanyl patch with no initials, date, or time located jeopardy to resident health or on the resident's left upper chest/shoulder area. Continued review of the hospital records, revealed the ER safety RN contacted the nursing facility and informed the facility's Director of Nursing (DON) that Resident R58 had the fentanyl patch in place. Review of the hospital records also revealed the Assistant DON (past not current) Residents Affected - Few called the ER and reported to the ER nurse a medication error occurred regarding the fentanyl patch which had been placed on Resident R58 on 05/02/2022 at 9:00 AM. Further review revealed the ER nurse informed Resident R58's family of the medication error made at facility. Additional review revealed Resident R58 remained as an inpatient at the hospital for five days and upon discharge the resident was discharged to another facility.

Review of Resident R58's, Discharge Summary, dated 05/10/2024 revealed a discharge diagnosis of encephalopathy secondary to fentanyl side effect.

2. Review of Resident R2's medical record Face Sheet revealed the facility admitted the resident on 08/22/2020, with diagnoses of dementia, chronic lymphocytic leukemia, and chronic pain syndrome.

Review of Resident R2's Annual MDS with an ARD of 06/16/2024, revealed the facility assessed the resident to have

a BIMS score of one out of 14, indicating severely impaired cognition.

Review of Resident R2's, Physician Order Report dated 04/03/2022 through 05/03/2022, revealed the resident had an active order for a fentanyl patch 75 mcg to be changed every three days.

Review of Resident R2's MAR dated 05/02/2022, revealed KMA 1 documented a fentanyl patch was applied to Resident R2's left shoulder between 6:15 AM and 10:00 AM on that date.

Review of Resident R2's Controlled Drug Record revealed fentanyl patch 75 mcg documented as applied to the left shoulder of the resident on 05/02/2022, by KMA 1.

The State Survey Agency (SSA) Surveyor attempted interview with Resident R2 on 05/16/2024 at 9:37 AM; however,

the resident was not interviewable.

In interview with KMA 1 on 05/15/2024 at 10:48 AM and on 07/03/2024 at 10:53 AM, she stated she was employed by an agency, and worked per diem (by the day) at the facility during 2022. She stated she had been a KMA since 2015. KMA 1 stated she did not recall Resident R58, had never placed a fentanyl patch on a resident and did not recall any incident at the facility of putting a fentanyl patch on the wrong resident. She stated she did not recall ever being asked about a medication error at the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 In interview with the Staff Development Coordinator (SDC) on 05/16/2024 at 9:39 AM, she stated she was

the nurse working with the agency KMA who passed medications in Resident R58's room on 05/02/2022. The SDC Level of Harm - Immediate also indicated she was the 2nd signature when the KMA signed out the fentanyl patch; however, the SDC did jeopardy to resident health or not recall observing the KMA place the patch on a resident. The SDC stated later on 05/02/2022 the resident safety appeared sleepier than usual on that date but answered questions without difficulty. The SDC stated nursing continued to monitor Resident R58 and notified the physician and the following day the resident displayed increased Residents Affected - Few drowsiness and was sent out to the hospital. She further stated the facility's policy required two patient identifiers to be confirmed prior to administration of medications. Additionally, the SDC stated she was unaware of any education provided to the KMA.

On 05/23/2024 at 12:23 PM, the SSA Surveyor requested contact information for the previous DON; however, the facility was unable to locate or provide that information.

The SSA Surveyor attempted telephonic (phone) interview with Resident R58's family; however, no return call was received.

In an interview with the Pharmacist on 07/03/2024, he stated there had been no obvious interactions with Resident R58's medications and the concern with a fentanyl patch was giving someone a sudden dose of that medication at that strength. The Pharmacist stated the symptoms experienced by Resident R58 were consistent with fentanyl side effects in someone who was opioid naive, meaning that person was not prescribed the medication or had only recently used opioid drugs.

During an interview with the DON on 05/23/2024 at 12:48 PM and at 1:34 PM, she stated the medication error involving Resident R58 was reported to the state and an event form was completed. The DON stated notifications were made to both the physician and to Resident R58's family. She stated identifiers used for medication administration at the facility included: pictures of residents on the MAR; residents' names on their doors; residents' name and birthdate; and verification of the resident with other staff. The DON stated if medication errors occurred, staff received education in-services on the rights of medication administration and reporting responsibilities. She further stated the rights of administration helped prevent medication errors and adverse effects to residents.

Interview with the DON, on 07/03/2024 at 12:13 PM, revealed medication administration now includes a down-time system including a printable medication administrtion record that includes the resident's room number and a picture of the resident.

During an interview with the Administrator on 05/23/2024 at 1:49 PM, he stated it was his expectation for staff to properly identify residents prior to medication administration. The Administrator stated medication errors were reviewed during the facility's monthly Quality Assurance Performance Improvement (QAPI) meetings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 45990 potential for actual harm Based on observation, interview, record review, and review of the facility's policies, it was determined the Residents Affected - Few facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions to protect one (1) out of ten (10) sampled Residents (R), Resident R43.

Observation revealed Resident R43's room door had a sign posted noting the resident was on Enhanced Barrier Precautions (EBP). However, further observation revealed Certified Nurse Aide (CNA) 3 entered Resident R43's room without donning Personal Protective Equipment (PPE) as required.

The findings include:

Review of the facility's policy titled, Enhanced Barrier Precautions revised 03/25/2024, revealed the facility's infection control policies and practices were intended to maintain a safe, sanitary, and comfortable environment to help prevent and manage transmission of diseases and infections. Continued policy review revealed Enhanced Barrier Precautions (EBP) were additional measures to attempt to decrease transmission of Multidrug-Resistant Organisms (MDRO). Per review of the policy, when a resident was placed on EBP, appropriate signage was to be placed at the resident's room entrance, for staff to know the instructions for

the use of Personal Protective Equipment (PPE), and to ensure personnel were aware of the need and the type of precautions to be used. Further review revealed EBP were indicated when contact precautions did not apply and when a resident had chronic wounds and or indwelling medical devices regardless of MDRO status.

Review of the facility policy titled, Infection Control dated 01/23/2024, revealed the policies and practices were intended to help prevent and manage transmission of diseases and infections. Additional review revealed guidelines for implementing isolation precautions, including standard and transmission-based precautions.

Review of the facility's policy titled, Infection Prevention and Control Policies revised 10/2018, revealed programs were established to help prevent development and transmission of communicable diseases and infections. Continued review revealed prevention of infection included educating and ensuring staff adhered to proper techniques and procedures, implemented appropriate isolation precautions, and followed guidelines such as from the Centers for Disease Control and Prevention (CDC).

Review of the facility's signage for Enhanced Barrier Precautions (procedure to be used) revealed providers and staff must wear gloves and a gown for high contact resident care activities including changing briefs or assisting a resident with toileting.

Review of Resident R43's face sheet revealed the facility admitted the resident on 02/13/2024 with diagnoses to include acute osteomyelitis (bone infection); diabetes; and peripheral vascular disease (decreased blood flow by narrowed vessels to limbs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of Resident R43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/15/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of Level of Harm - Minimal harm or thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. potential for actual harm

Review of Resident R43's order set dated 04/08/2024, revealed an order for EBP related to the resident's pressure Residents Affected - Few wound.

Review of Resident R43's Comprehensive Care Plan (CCP) dated 04/08/2024, with revision date of 5/22/2024, revealed the facility identified a problem for the resident of infection control related to pressure wound. Continued review of the care plan revealed interventions for staff to use PPE as indicated.

Review of Resident R43's progress note dated 05/23/2024 at 4:14 PM, revealed the resident had a wound to the right lateral ankle measuring 0.6 centimeters (cm) x 0.7 cm x 0.2 cm with light serous (clear to yellow fluid) drainage.

Review of the weekly skin assessment for Resident R43 documented on the Medication Administration Record (MAR) dated 05/21/2024, revealed a notation of 2, which indicated the resident had existing skin impairment. Further review revealed however, no indication of the location.

On 05/22/2024 at 1:15 PM, observation revealed EBP signage for Resident R43's on the resident's door. Review of

the EBP signage posted revealed staff were to don PPE, including gloves and a gown when providing high contact resident care activities which included changing briefs or assisting in toileting. Continued observation revealed an isolation cart that contained PPE available for use. Further observation revealed CNA 3 failed to don the required PPE prior to entering Resident R43's room. During interview at the time of observation, CNA 3 stated

she had only donned gloves to provide incontinent care for Resident R43.

In an additional interview with CNA 3 on 05/23/2024 at 12:30 PM, she stated she had gone in to answer Resident R43's call light and once she was in the room, the resident asked her to provide incontinent care which was changing the resident's adult brief. She stated she started talking to Resident R43 during care and simply forgot to don

a gown, but had donned gloves. CNA 3 said as soon as she exited Resident R43's room with the soiled brief to discard, and saw the (State Survey Agency) Surveyor, she remembered she should have donned a gown prior to changing Resident R43's brief. She stated the facility provided training on donning PPE for EBP rooms and

she knew better. When asked why it was important to don proper PPE for isolation rooms, she stated it was to prevent the spread of germs from staff to residents. The CNA further stated she reported herself to the Director of Nursing (DON) and was provided isolation training at that time.

During an interview with the Staff Development Coordinator (SDC) on 05/23/2024 at 1:40 PM, she stated CNA 3 had self-reported the incident of not donning the PPE and additional isolation training had been provided for the CNA at that time. She stated all staff were trained when providing direct resident care/touch care, to don proper PPE for infection prevention. The SDC further stated it was her expectation that staff followed the training received for infection prevention.

During an interview with the Infection Preventionist (IP)/DON on 05/23/2024 at 1:50 PM, she stated CNA 3 had reported the incident of not wearing the PPE immediately and training was provided for the CNA at that time. She stated transmission was a concern and staff should be following the facility's policy, signage, and trainings for isolation precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 185342 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185342 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare at Colonial Rehab & Wellness 708 Bartley Avenue Bardstown, KY 40004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 In an interview with the Administrator on 05/23/2024 at 12:40 PM, he stated his expectations were for staff to follow all the facility's infection control trainings and the signage posted on residents' doors when providing Level of Harm - Minimal harm or resident care as a prevention measure. He further stated staff had received infection control trainings potential for actual harm including training on EBP.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 185342