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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.