Signature Healthcare Of East Louisville
Signature Healthcare of East Louisville in Louisville, KY — inspection on January 3, 2025.
Found 4 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
of the event.
The Medical Director reviewed the plan and made no further suggestions.
The medical
jeopardy to resident health or Administrator will hold a Quality Assurance meeting weekly for 4 weeks; then, it will decrease to safety monthly for recommendations and further follow-up regarding the above-stated plan.
Moving forward, the facility administrator will continue to be the person who presents the information and audits at
Facility Administrator, Medical Director, Director of Nursing , Assistant Director of Nursing, Staff Development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MOS Coordinator.
The QAPI Committee will determine at what frequency any ongoing audits must continue.
The Administrator is responsible for the implementation of this plan. ·An Ad Hoc Quality Assurance meeting was held on 12/23/2024 with the Medical Director, the Special Projects Administrator, the Director of Nursing , the Signature Care consultant , the [NAME] President of Clinical Services, and the Clinical Reimbursement Specialist.
Regarding the plans formulated and implemented on 12/23/2024.
The Special Projects Administrator presented the plan and information at the QAPI meeting on 12/23/2024.
The Facility Medical Director was notified on 12/23/2024 by the facility administrator of the immediate jeopardy and the abatement plan.
The Medical Director reviewed the plan and made no further suggestions.
The medical director stated the plan was appropriate and would be effective.
Starting on 12/23/2024, the Facility Administrator will hold a Quality Assurance meeting weekly till compliance; then, it will decrease to monthly for recommendations and further follow-up regarding the above stated plan.
Moving forward, the facility administrator will continue to be the person who presents the information and audits at the QAPI Meetings, and the following members are expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing , Staff Development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MOS Coordinator.
The QAPI Committee will determine at what frequency any ongoing audits must continue.
The Administrator is responsible for the implementation of this plan.
The jeopardy removal date is 12/24/2024.
185350 01/03/2025
Signature Healthcare of East Louisville 2529 Six Mile Lane Louisville, KY 40220
was under State Guardianship, however, he stated he was not aware that an individual under State
jeopardy to resident health or safety In an interview with the Director of Nursing (DON) on 12/17/2024 at 1:30 PM, the DON stated that she was notified of the event on 11/27/2024 and notified the Administrator and the Regional Support
the building to her knowledge.
She reported elopement risk assessments were completed quarterly and with a significant change.
In an interview on 12/17/2024 at 4:39 PM, the Administrator reported that a facility visitor had alerted staff that a resident was seen outside the facility without supervision. He reported that staff responded, and the resident returned after about 10 minutes.
The Administrator stated R1 told him she was trying to go to the bus station to go to a doctor's appointment. He reported there was no previous history of the resident trying to leave the facility.
Per the interview, the Administrator stated R1 was not authorized to sign out of the building [facility].
The survey team conducted an IJ Removal and Partial Extended Survey on 01/02/2025 through 01/03/2025.
The State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 12/24/2024.
Remaining non-compliance continued at a S/S of a D at
Review of the Admission assessment dated [DATE] revealed the resident was assessed on admission for elopement risk.
The elopement assessment noted on 10/31/2023, R1 to be ambulatory without wandering into unsafe areas, not making statements about leaving, and not demonstrating behaviors that may indicate an attempt to leave the facility and was not found to be an elopement risk.
Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2023 indicated a Brief Mental Status Score (BIMS) of 11 out of 15 indicating the resident had moderate cognitive impairment.
Further review of the MDS indicated the resident required moderate assistance to ambulate 10 feet and utilized a wheelchair for mobility and did not exhibit any behavioral symptoms, including wandering, during the assessment period.
Further review of the MDS revealed the resident did not exhibit any behavioral symptoms, including wandering, required moderate assistance to ambulate 10 feet, and utilized a wheelchair for mobility.
Review of R1's Nurse's Note, dated 09/17/2024, revealed the resident exhibited exit- seeking behaviors when she had an associated urinary tract infection. R1 was placed on 15-minute checks until the exit-seeking behaviors resolved.
185350
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 185350 B.
Wing 01/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Signature Healthcare of East Louisville 2529 Six Mile Lane Louisville, KY 40220
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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.