Signature Healthcare At Colonial Rehab & Wellness
SIGNATURE HEALTHCARE AT COLONIAL REHAB & WELLNESS in BARDSTOWN, KY — inspection on July 11, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 R63's room observed R63 exposing himself to the female resident who also alleged R63 touched her left breast.
The Long-Term Care Facility Self-Reported Incident Form 5-Day Follow-Up Report (5Day) revealed R63 admitted exposing himself but could not recall why. 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 R63 and R34 had been in an activity when the Activities Director (AD) witnessed R63's hand down the front of 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 R63 on 1:1 observation.
Continued review revealed when R63 was interviewed he stated he had (touched 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 R63 was escorted out of the facility, taken to the local law enforcement agency and charged with sexual abuse.
185342
Form Approved OMB
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
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.
185342
Form Approved OMB
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