Signature Healthcare At Colonial Rehab & Wellness
SIGNATURE HEALTHCARE AT COLONIAL REHAB & WELLNESS in BARDSTOWN, KY — inspection on July 11, 2024.
Found 3 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
F-F600.
The facility's failure to have an effective system to ensure residents' care plans were developed and implemented with interventions necessary to prevent abuse 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 08/14/2022 at 42 CFR 483.21, Develop/Implement Comprehensive Care Plan (
Review of the facility's policy titled, Comprehensive Care Plans, dated 02/09/2024, revealed each resident's Comprehensive Care Plan was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and was to be revised as necessary with changes.
Review of facility policy Abuse, Neglect, and Misappropriation of Property, revised 05/08/19, revealed upon admission and periodically thereafter the facility assessed residents for potential vulnerabilities/concerns.
Additionally, the resident's plan of care would address these vulnerabilities or concerns.
Continued review of the policy revealed as part of the facility's investigation into an incident, the facility Inter-Disciplinary Care Planning Team initiated or reviewed a care plan for affected resident(s) to address the resident(s) condition with measures implemented to prevent recurrence.
Further review revealed no language regarding assessing a resident's ability for the capacity to consent to sexual activity.
1.
Review of facility record progress notes, dated 02/22/2022, revealed staff witnessed R63 and R2 kissing and the facility unsubstantiated the incident.
Additionally, on 08/14/2022, approximately 6 months after the first incident between the two residents (R63 and R2), R63 kissed R2 after R2 reportedly asked for a kiss and the facility considered the incident mutual.
However, when interviewed during the facility's investigation, R2 could not recall the incident.
a).
Review of the clinical record for R63 revealed the facility admitted him on 09/07/2018, with diagnoses that included: anxiety, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance.
Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact.
Review of R63's Comprehensive Care Plan, dated 02/12/2022, revealed the facility referred R63 to the physician for interventions related to inappropriate behaviors.
Continued review of the care plan revealed staff were to observe R63 for triggers to inappropriate behaviors; however, review revealed no triggers were defined for this intervention.
Additional interventions included to provide one to one (1:1) supervision until psych (Psychiatrist) could see the resident.
Review additionally revealed no documented evidence of interventions implemented for R63's sexual tendencies.
The goal listed for R63's behavioral care plan was his behaviors would not result in disruption of others environment and had a goal date of 08/24/2023.
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