Signature Healthcare At Colonial Rehab & Wellness

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 (

F-F656) at a Scope and Severity (S/S) of a E; while the facility monitors the safety effectiveness of systemic changes and quality assurances activities.

Residents Affected - Some The findings include:

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 Resident R63 and Resident R2 kissing and the facility unsubstantiated the incident. Additionally, on 08/14/2022, approximately 6 months after the first incident between the two residents (Resident R63 and Resident R2), Resident R63 kissed Resident R2 after Resident R2 reportedly asked for a kiss and the facility considered the incident mutual. However, when interviewed during the facility's investigation, Resident R2 could not recall the incident.

a). Review of the clinical record for Resident 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 Resident R63's Comprehensive Care Plan, dated 02/12/2022, revealed the facility referred Resident R63 to the physician for interventions related to inappropriate behaviors. Continued review of the care plan revealed staff were to observe Resident 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 Resident R63's sexual tendencies. The goal listed for Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 16 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 0656 Review of Resident R63's Comprehensive Care Plan revealed on 08/15/2022, the Problem was noted that Resident R63 was affectionate towards other resident that was not able to consent consistently and interventions which Level of Harm - Immediate included the facility provided the resident with supervision by staff as needed; psychosocial evaluation as jeopardy to resident health or needed; and every 15 minute checks. Continued review revealed however, lack of interventions necessary to safety address Resident R63's inappropriate sexual behaviors towards female residents.

Residents Affected - Some Review of Resident R63's psychiatrist/psychologist notes, dated 02/17/2023, revealed to begin Sertraline (a medication used to treat depression, obsessive compulsive disorder, panic attacks, post-traumatic stress disorder, and social anxiety disorder) 50 milligrams (mg) daily for anxiety and possible sexually inappropriate behaviors. The note also indicated no psychosocial concerns and to monitor for changes in mood or behavior.

b). Review of Resident R2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2024 revealed the facility assessed the resident as having a BIMS of 3, which indicated severe cognitive impairment. Review of the Quarterly MDS with an ARD of 02/11/2022 revealed a BIMS score of 6, indicating severe cognitive impairment.

Review of Resident R2's care plan, revealed documentation to suggest the facility assessed the resident to have the capacity to consent to being kissed by other residents. Additionally, there was no evidence to suggest the resident's care plan was developed to include interventions to prevent or protect the resident from abuse.

2. Review of facility record investigation notes, dated 02/16/2023, a fell ow resident stated Resident R63 appeared to be fondling Resident R34's breast and the facility unsubstantiated the allegations of inappropriate sexual behavior although an order for daily medication doses for the resident's behaviors began for Resident R63. The facility failed to ensure the resident's care plan was implemented to provide supervision of the resident's behaviors and to monitor for his triggers.

Review of Resident R63's care plan revealed a Problem/focus dated 02/20/2023 that the resident demonstrated inappropriate behaviors with other residents. The interventions listed for this problem included to assist resident away from other residents as needed, to determine the cause for inappropriate behavior and refer to

a physician for intervention, to encourage participation in structured activities as he will attend, and to observe for triggers of inappropriate behaviors.

3. Review of facility clinical notes, dated 05/17/2023, revealed Resident R33 reported to staff that Resident R63 exposed himself to her.

a). Review of Resident R63's care plan revealed on 05/18/2023, the resident's care plan was revised to include interventions for: 1:1 staff supervision; assist Resident R63 away from other residents as needed; determine the cause for his inappropriate behaviors; observe for triggers for his inappropriate behaviors. Further review revealed no description of sexual behaviors or triggers staff to observe for to address the resident's inappropriate behaviors.

b). Review of the Quarterly MDS with an ARD of 03/16/2023 revealed a BIMS score of 12, indicating moderate cognitive impairment.

Review of Resident R33's care plan revealed no documentation to support the resident was assessed for the capacity to consent to sexual activity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 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 0656 4. Review of the facility records, dated 08/09/2023, revealed Resident R63 admitted he exposed his penis to Resident R34 but stated he did not know why. Approximately, less than a month later, Resident R63 was witnessed to have his hand Level of Harm - Immediate down the front of Resident R34's shirt touching her breast. The facility failed to implement the resident's care plan to jeopardy to resident health or include observing for triggers for the resident's inappropriate behaviors and to move the resident away from safety other resident's.

Residents Affected - Some a). Review of Resident R63's care plan review, on 08/09/2023, revealed the facility placed Resident R63 on 1:1 supervision; however the facility did not provide documentation such supervision occurred from 08/19/2024 midnight through 11:00 AM on 09/04/2024. On 09/04/2023 at approximately 10:30 AM, the Activities Director witnessed Resident R63, in the hallway, with his hand down the front of Resident R34's shirt touching her right breast. The staff failed to implement the resident's care plan by providing 1:1 supervision for the resident.

b.) Review of the clinical record for Resident R34 revealed the facility admitted the resident on 06/17/2021, with diagnoses that included epileptic seizures related to external causes with status epilepticus; encephalopathy unspecified; and unspecified convulsions.

Review of the Quarterly MDS with an ARD of 07/06/2023 , revealed the facility assessed Resident R34 to have a BIMS score of six out of 15 on 07/06/2023, which indicated severe cognitive impairment.

Review of a Progress Note for Resident R34 dated 09/04/2023, revealed the facility assessed the resident to have no injury following the incident of Resident R63 touching her breast. Review further revealed no documentation to support

the facility assessed Resident R34 for the capacity to consent to sexual activity.

In interview on 05/16/2024 at 4:37 PM, the Activities Director stated she witnessed Resident R63 putting his hand down the front of Resident R34's shirt touching her right breast. She stated Resident R34 yelled out when Resident R63 did that, and Resident R63 then took his hand out of Resident R34's shirt. The Activities Director further stated the two residents were immediately separated and Resident R63 was placed on 1:1 supervision.

In interview on 05/16/2024 at 2:50 PM, the Director of Nursing (DON) stated previous allegations of (sexual)behaviors by Resident R63 had been unsubstantiated, but the incidents had became more frequent. She stated, even though those allegations had been unsubstantiated or lacked enough evidence to confirm, the facility implemented actions to prevent further episodes, to include observing for the resident's behaviors, triggers, and one-on-one supervision. The DON said the event on 09/04/2023, had been witnessed by staff and the facility substantiated abuse. She stated, Everyone knew Resident R63 and knew to be aware of his movements when he was out in the facility. The DON stated residents' care plans were developed/updated when an allegation of (abuse) was brought to staffs' attention.

Interview with the DON on 07/03/2024 at 9:22 AM revealed the IDT team discussed and determined a resident's ability to be involved in a relationship. The IDT team utilized the BIMS score, along with other

observations such as how the resident managed their daily activities as the worked to determine the resident's ability.

In interview on 05/24/2024 at 2:19 PM, the Administrator stated it was his expectation for residents to be safe from sexual abuse or any type of abuse. He stated he also expected residents' care plans to be updated any time there was a change in a resident. Per the Administrator, he stated it was his expectation that the facility's policies would be followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 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 10 of 16 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 11 of 16 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 12 of 16 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 13 of 16 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 14 of 16 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 15 of 16 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 16 of 16 185342