Signature Healthcare Of East Louisville

F-F656, at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy on 12/23/2024.

The facility provided an acceptable IJ Removal Plan on 12/26/2024 at 7:56 PM, alleging removal of the IJ on 12/24/2024. 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

F-F689.

The findings include:

Review of the facility policy titled, Safety and Supervision of Resident, last reviewed/revised date of 09/15/2023, revealed the resident safety and the supervision would be appropriate based on the individual resident needs, as well as, through identified safety risks and hazards. Additionally, the policy stated it would include a combination of employee training, employee monitoring, and reporting processes to mitigate or remove the hazards to the extent possible.

Continued review of the policy, dated 09/15/2023, revealed the information obtained from the medical history, physical exam, observation of the resident, and the Minimum Data Set (MDS) would be utilized to target interventions, to reduce the potential for accidents, and to monitor the effectiveness of the interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 185350 Department of Health & Human Services Printed: 09/11/2025 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 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

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 0689 Review of the facility policy titled, Elopement, reviewed and revised date of 09/12/2024, revealed residents would be evaluated for risk of elopement and preventative interventions implemented for those identified as Level of Harm - Immediate an elopement risk. Further review of the policy revealed each resident should be evaluated upon admission jeopardy to resident health or and reevaluated as needed. The policy further revealed residents displaying exit-seeking behavior would be safety evaluated for elopement risk as well as residents with a known history of substance use disorder. The policy identified that an elopement risk binder would be kept at a secure location known by stakeholders and Residents Affected - Few routine checks of the entrance and exit doors would be completed to ensure their proper functioning.

Review of the facility policy titled, Resident Leave of Absence, review and revision date of 11/07/2018, stated

the organization promotes person-centered care and affords leave from the facility based on physician approval. A leave of absence (LOA) was defined as a period the resident was away from the facility while maintaining the status of the resident. The Guideline of the policy identified that a resident may be afforded leave based on physician orders and approval, appropriate supervision by a responsible party when indicated and instructions provided to the responsible party for care and medication administration. Ongoing

review of the guideline stated a resident who wished to take an unsupervised leave of absence may do so contingent on a completed and signed written Release of Responsibility for Leave of Absence form, approval of the Licensed Health Professional, Documentation of Interdisciplinary agreement, and inclusion of the leave of absence in the care plan.

On 12/20/2024 at 11:20 AM the facility Special Projects Administrator stated the facility had no policy that identified specific considerations for residents assigned a State Guardian.

Closed Record Review of Resident R1's Face Sheet located in the closed medical record, revealed the facility admitted the resident on 10/31/2023 with diagnosis of vascular dementia, moderate, with psychotic features, and cognitive communication deficit. Continued review of Resident R1's closed medical record revealed the resident had been under state guardianship and deemed wholly disabled to manage both personal and financial affairs on 01/22/2024, including the loss of the right to vote.

Review of the Admission assessment dated [DATE REDACTED] revealed the resident was assessed on admission for elopement risk. The elopement assessment noted on 10/31/2023, Resident 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 Resident R1's Nurse's Note, dated 09/17/2024, revealed the resident exhibited exit- seeking behaviors when she had an associated urinary tract infection. Resident R1 was placed on 15-minute checks until the exit-seeking behaviors resolved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 185350 Department of Health & Human Services Printed: 09/11/2025 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 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

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 0689 Review of the Annual comprehensive MDS with an ARD date of 11/07/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating the resident was cognitively intact. Further Level of Harm - Immediate review of the MDS indicated Resident R1 was independent in ambulation with use of a rolling walker and capable of jeopardy to resident health or ambulation to the maximum assessed distance of 150 feet and resident did not exhibit any behavioral safety symptoms that included wandering during the assessment period. Continued review of the annual comprehensive MDS, dated [DATE REDACTED], revealed the resident was independent in ambulation with use of a Residents Affected - Few rolling walker with the assessment tool indicating Resident R1 was able to independently ambulate the maximum distance on the assessment tool of 150 feet using a walker.

Review of the Comprehensive Care Plan that included all active and resolved problem statements revealed Resident R1 was care planned for elopement with a start date of 11/27/2024. Further review of the Comprehensive Care Plan revealed the resident having a newly appointed State Guardian on 01/22/2024 was not included

on the plan of care or how the state guardianship could effect resident care, e.g., affecting the resident's right to vote, make decisions on where the resident lived, major health care decisions, etc. Additionally, the care plan did not include the resident's exit-seeking behavior noted 09/17/2024, in which the resident was placed

on 15 minute checks.

Observation of the facility initiated on 12/16/2024 at 6:30 PM, revealed the front entrance of the facility was accessible via a doorway which had a locked keypad. The front entrance opened into an office area and the residential areas/hallways were accessible through another doorway with a locked keypad. The second interior keypad doorway was observed to be locked on 12/16/2024 at 6:45 PM upon initiation of the investigation and required staff assistance to pass through the doorway. On 12/17/2024 through 12/20/2024

the second door was observed to be unlocked during business hours 8:00 AM through 5:00 PM while the reception desk was attended. Residents and Visitors would require the assistance of a staff member to enter

the code to exit through both keypad locking doors after business hours.

Review of the facility investigation revealed that on 11/27/2024 at 12:15 PM a visitor to the facility reported to staff that she saw someone she recognized to be a resident, outside the facility unaccompanied and unsupervised. Per the investigation, upon notifying staff, multiple staff went outside to search for Resident R1. Ongoing review of the facility investigation revealed staff reported upon exiting the facility to search for Resident R1, Resident R1 was visualized walking with a walker on the sidewalk. Staff approached and talked to the resident, then assisted Resident R1 back into the facility. The facility investigation revealed Resident R1 re-entered the facility at approximately 12:25 PM.

The State Surveyor drove to the location where Resident R1 was first reportedly seen by the facility visitor, the route was also verified by Google Maps, and was noted to be 0.2 miles from the facility. Google Maps indicated it was a six (6) minute walk from the facility.

Resident R1 was not observed or interviewed as she had transferred to another facility with a locked dementia unit on 12/16/2024.

In an interview with Receptionist 1, on 01/03/2025 at 1:40 PM, she stated she had walked with the resident back to the facility. Per the interview, the resident had crossed the three (3) lane road and had walked an additional approximate distance of 30 feet on the sidewalk. She stated the resident had crossed the three-lane road at the red light and the resident told her she knew how to push the button to cross the road.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 185350 Department of Health & Human Services Printed: 09/11/2025 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 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

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 0689 The Weather Underground, a website that reports current and historical weather conditions for a specific city location, revealed the temperatures on 11/27/2024 was between 54 - 59 degrees Fahrenheit (F) in this Level of Harm - Immediate location. jeopardy to resident health or safety In an interview with Resident R1's State Guardian, on 12/20/2024 at 10:14 AM, she stated Resident R1 was a ward of the state and was deemed wholly disabled. She stated the resident was not capable of managing her own resources Residents Affected - Few and required supervision when leaving the building.

In an interview with the Human Resources Specialist (HRS) on 12/19/2024 at 9:12 AM, she stated that on

the day of the incident [11/27/2024] she worked the receptionist desk. She stated she was relieving the receptionist and had been doing a little bit of everything that included answering the phone, transferring calls, and pushing the button to let someone out of the facility. Per the interview, she stated the facility's Thanksgiving Luncheon was taking place at the time. The HRS stated she knew Resident R1 and had talked to her before, even earlier in the day on 11/27/2024. The HRS stated Resident R1 seemed like her normal self. She said Resident R1 came to the desk and stated she was going to step outside. Per the HRS, she was aware of the resident's sign out book and the elopement book but did not check either before allowing the resident to exit the building.

In further interview, on 12/19/2024 at 9:12 AM, the HRS stated there was a lot going on and she assumed Resident R1 had signed out on the facility sign out sheet and opened the door and allowed Resident R1 to leave the building without supervision. The HRS stated she did not recall Resident R1 being in the elopement book. HRS stated that while she didn't look in the book that day, she had looked in it before. The HRS stated she was not sure of

the exact time Resident R1 exited the building but stated she thought the resident was gone from the building approximately 10 minutes when it was determined that Resident R1 had exited the building and thought approximately 15 minutes had passed when Resident R1 returned. HRS stated Resident R1 did not appear any different when she returned.

She stated that after the event, education was started with everyone in the building, the elopement books were checked to ensure they were on the halls. She stated the facility posted signs which advised staff not to let residents out of the facility. However, she stated she was unaware of how long the signs had been in place. HRS stated that she had never seen Resident R1 with exit seeking behaviors.

In an interview on 12/17/2024 at 2:00 PM, Certified Nursing Assistant (CNA) 2, stated she knew who Resident R1 was and stated she worked on 11/27/2024, but she was not assigned to the resident. She reported the resident left the facility independently during the Thanksgiving Family luncheon and reported that a family member visiting another resident informed staff that they had seen Resident R1 at the red light with her walker. CNA 2 stated that she and CNA 3 immediately ran outside and started to look for Resident R1. CNA 2 stated CNA 3 found the resident and stated Resident R1 wanted to walk back to the facility. CNA 2 stated Resident R1 was placed on 1:1 supervision upon return to the facility. CNA 2 reported Resident R1 did not have any injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 185350 Department of Health & Human Services Printed: 09/11/2025 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 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

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 0689 In an interview on 12/17/2024 at 3:52 PM, CNA 3 stated a family member approached him on 11/27/2024

during the Thanksgiving luncheon and told him they had seen a female wearing glasses using a walker Level of Harm - Immediate outside on the sidewalk. CNA 3 stated he immediately informed the nearest nurse and then went outside on jeopardy to resident health or foot running toward the church and saw Resident R1 walking on the sidewalk. CNA 3 stated he caught up with her and safety she turned toward him when he called her name. CNA 3 stated the resident stated she was going to the doctor to see about her ear. CNA 3 reported that another employee [Receptionist 1] had gotten in her car Residents Affected - Few and drove to assist with looking for Resident R1. CNA 3 reported that Resident R1 declined to ride in the car back to the facility but wanted to walk back with the Receptionist 1 and CNA 3 drove the car back to the facility. CNA 3 reported

the resident had no injuries and did not experience a fall. CNA 3 stated the resident was placed on 1:1 supervision and leadership instructed staff to give Resident R1 space but to watch her continually. CNA 3 stated the leadership began educating staff regarding elopement and Code Green, which was an overhead page to alert employees that a resident was missing and to begin looking for the missing resident.

In an interview with the Receptionist 1 on 12/17/2024 at 2:40 PM, she indicated that she was coming into work for her 1:00 PM shift on 11/27/2024 and after entering the building, she learned Resident R1 had left the building unattended. The Receptionist 1 stated she used her personal vehicle to help in the search for Resident R1. The Receptionist stated she walked back with Resident R1 to the building after Resident R1 declined to ride back in the car. Per the Receptionist, she had no knowledge of any injury to Resident R1 as a result of the incident.

In an interview with Licensed Practical Nurse 6 (LPN 6) on 01/03/2025 at 1:43 PM, LPN 6 stated she regularly worked on the 200 hall were Resident R1 resideed. She stated she was familiar with Resident R1. LPN 6 stated Resident R1 would roam within the facility with her personal items and stated she never saw her try to get out. LPN 6 stated she had seen Resident R1 standing at the door looking out and talking to herself with delusional verbalizations. LPN 6 went on to say that Resident R1 would sometimes lay on the couch in the sunroom, kept to herself, and did not wander into other people's rooms. LPN 6 stated everyone kind of knew to watch her.

In an interview with the Activities Assistant (AA) on 12/18/2024 at 3:45 PM, he stated that he knew Resident R1 and that due to her cognitive status and behavior of being in constant motion, and needing to be observed at all times, Resident R1 was not permitted to go outside unassisted. The AA went on to say that residents were taken out onto the porch with supervision when weather permitted for activities such as exercises. He stated Resident R1 was permitted to go outside during the supervised smoking times in the enclosed supervised smoking area to allow for additional time outdoors.

In an interview with the Assistant Business Office Manager (ABOM), on 12/19/2024 at 10:11 AM, she stated

she had been employed with the facility for approximately two (2) weeks. ABOM stated that during her onboarding process she received training regarding the elopement binder and the smoker's box with the list of residents who were allowed to go out of the facility unsupervised. ABOM went on to say that if she was not familiar with a resident, she would get someone to verify the resident before allowing a resident to leave the facility. She also stated that residents who leave the facility were to sign out when they leave.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 185350 Department of Health & Human Services Printed: 09/11/2025 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 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

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 0689 In an interview with the Business office Manager (BOM) on 12/20/2024 at 12:44 PM, she stated that she had been employed at the facility since October 2024. The BOM stated that she would check the elopement Level of Harm - Immediate binder and check with administration or nursing before allowing a resident to exit the building. She added jeopardy to resident health or that if a resident was under State Guardianship, then the State Guardian made the final decision regarding a safety resident [ability to leave the facilty unspervised].

Residents Affected - Few In an interview on 12/19/2024 at 9:45 AM, the Social Services Assistant (SSA) stated she knew Resident R1 and the resident had a history of being homeless prior to being admitted to the facility. She stated the resident would keep her personal items with her as she roamed in the facility. Per the interview, the SSA stated Resident R1 had in

the past asked her to call the sheriff's office to take her to her home or the Salvation Army to come get her.

The SSA stated that although Resident R1 did not make attempts to leave the facility after being advised that she could not leave, the resident would verbally voice being upset with not being able to leave. The SSA stated Resident R1 did not have a home to go to and that was a delusion. Further, she stated the BIMS score was not an accurate depiction of judgement, insight, and decisional capacity. The SSA stated she was aware Resident R1 had a State Guardian and would require supervision if Resident R1 left the building.

In a phone interview with the Primary Care Physician (Physician/Medical Director) for Resident R1 who also serves as

the facility Medical Director on 12/19/2024 at 11:15 AM, he stated that he was informed that Resident R1 had left the building without supervision on 11/27/2024 and was returned to the building on 11/27/2024. On further inquiry with the Physician/Medical Director, he stated he was aware that Resident R1 was under State Guardianship, however, he stated he was not aware that an individual under State Guardianship was not eligible to leave

the facility without supervision.

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 nurse. The DON stated an investigation was started. She stated Resident R1 had no previous attempts to exit 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 Resident 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 Resident R1 was not authorized to sign out of the building [facility].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 185350