Signature Healthcare at Heritage Hall Rehab & Well

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 out of 23 sampled residents, Resident (R) 81. Record review of R81's Baseline Care Plan did not address R81's primary language of Tagalog.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. Observation of medication administration on 07/31/2025 at 8:00 AM, revealed 2 medication errors out of 33 medication observations to result in a 6.06 percent medication error rate.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents. Observation on 07/29/2025 at 6:22 AM revealed 2 of 2 medication carts located on the short-term rehab unit were unlocked and no staff was in the area. Additional observation on 07/31/2025 at 8:00 AM-8:18 AM, during medication administration on the short-term rehab unit, Registered Nurse (RN) 4 walked away from the medication cart that was left at the nurses' station to administer medication inside resident rooms on three different occasions without locking the medication cart.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) signage for Enhanced Barrier Precautions (EBP), and review of the facility's policy, the 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 the development and transmission of communicable diseases and infections for four of nine residents investigated for infection control, Resident (R) 55, R16, R40, and R30.

Inspectors wroteBased on interview, record review, review of the facility's investigation, review of the police report, and review of the facility's policies, and the Kentucky Incident Based Reporting System (KYIBRS) Report, it was determined the facility failed to ensure residents were free from misappropriation of property for four (4) of sixty-one (61) sampled residents (Residents #1, #2, #3, and 62). Three (3) residents, Resident #1, #2, and #3 had medication misappropriated. A facility employee acceptable ten thousand dollars ($10,000) from Resident #62. Licensed Practical Nurse (LPN) #4 reported to the Director of Nursing (DON) that Registered Nurse (RN) #1 was exhibiting suspicious behaviors of wearing a backpack at work; being in the bathroom for long periods of time, and acting weird. [...]

Inspectors wroteBased on interview, record review, review of the facility's investigation, and review of the facility's policies, and the Kentucky Incident Based Reporting System (KYIBRS) Report it was determined the facility failed to ensure an thorough investigation was conducted timely; and failed to protect the safety of the residents after they were informed of an allegation of misappropriation related to narcotic (Morphine) drug diversion for three (3) of sixty-one (61) sampled residents (Residents #1, #2, and #3). Residents #1, #2, and #3 were prescribed Morphine (an opioid given to relieve moderate to severe pain). The Administrator and the Director of Nursing (DON) became aware of an allegation of misappropriation that Registered Nurse (RN) #1 had diverted narcotic medications on 08/26/2023. However, an investigation was not initiated until 08/27/2023. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and/or implement a Comprehensive Care Plan (CCP) to ensure it met the residents' medical, nursing, mental, and psychosocial needs as identified on his/her comprehensive assessment and other assessments for one (1) of sixty-one (61) sampled residents (Residents #66). The facility assessed Resident #66 as requiring a pureed, nectar thick diet and needing supervision with meals. The resident had a diagnosis of Dysphagia. Resident #66 had a Physician's Order for nectar thickened liquids, and a pureed diet with double portions at dinner. Review of Resident #66's CCP, dated [DATE], revealed the facility care planned the resident as at risk for dehydration related to his/her risk of aspiration, and a mechanically altered diet. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the residents received quality of care based on the facility's identified care and treatment needs, and failed to ensure professional standards of practice were provided that would meet the residents' physical, mental, and psychosocial needs for one (1) of sixty-one (61) sampled residents (Resident #66). The facility assessed Resident #66, on 11/28/2022, as needing a pureed, nectar thick diet and supervision with meals. Resident #66 was found unresponsive, slumped over at the dining room table after lunch, with a partially eaten cheeseburger on the table. Staff called the Emergency Medical Services (EMS). Prior to EMS' arrival Resident #66 was moved to the floor. [...]

Inspectors wroteBased on interview, record review, review of the facility's policy and the Administrator's job description it was determined, the facility failed to be administered in a manner which enabled its' effective use of resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to immediately conduct an investigation of an allegation of misappropriation residents' narcotic medications. Licensed Practical Nurse (LPN) #4 reported to the Director of Nursing (DON) that Registered Nurse (RN) #1 was exhibiting suspicious behaviors of wearing a backpack at work; being in the bathroom for long periods of time, and acting weird. While the DON was in the facility, on 08/11/2023 at 3:00 AM, RN #1 stayed in the bathroom for extended periods and walked around with a backpack. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility's abuse policy, it was determined the facility failed to ensure an environment that was free from abuse involving eight (8) of sixty-one (61) sampled residents (Residents #9, #35, #41, #50, #59, #66, #69 and #74). 1. On 01/11/2023, Resident #74 grabbed Resident #35's right arm causing a skin tear. 2. On 08/24/2022, Resident #41 was observed sitting on the side of Resident #69's bed holding Resident #69's arm and yelling at Resident #69, resulting in a bruise to the arm and a scratch to Resident #69's face. 3. On 03/11/2023, Resident #66 hit Resident #59 with his/her grabber device. 4. On 09/13/2023, State Registered Nursing Assistant (SRNA) #6 observed SRNA #5 when she made a comment in the presence of Resident #9 and his/her spouse. SRNA #5 stated, Why do I have to be the one to wipe the asses. 5. [...]

Inspectors wroteBased on interview, record review, review of the facility's investigation, and review of the facility's policy, it was determined the facility failed to protect residents' rights and dignity for one (1) of sixty-one (61) sampled residents (Resident #73). Review of the Facility's Investigation revealed on 10/31/2022, State Registered Nurse Aide (SRNA) #2 told Resident #73 to use the bathroom in his/her brief.

Inspectors wroteBased on interview, record review and review of the facility's policy, it was determined the facility failed to notify the Medical Director (MD) of the change in the medical condition and the cause of death for one (1) of sixty-one (61) sampled residents (Resident #66). Interview with the MD revealed he was not notified that Resident #66 required supervision and monitoring during meals per the Speech Therapy (ST) evaluations. In addition, the MD was not informed that the resident's death was from choking on a cheeseburger on 06/24/2023.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to accurately assess and reflect the resident's current status for one (1) of sixty-one (61) sampled residents (Resident #66). Review of Resident #66's Annual Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident as setup help only for functional status when eating. However, review of Resident #66's Speech Therapy (ST) Notes, dated 06/11/2023, revealed impulsivity continued, and the resident required minimal to moderate verbal cues to slow the food intake rate and consume appropriate bolus (bite) size.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to follow the comprehensive Person-Centered Resident Care Plan for one (1) of twenty (20) sampled residents, Resident #58. Resident #58's Comprehensive Care Plan (CCP) was not followed for correct application of the seat beat while he/she was in the wheelchair, which resulted in a fall with an injury for Resident #58.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to prevent a fall for one (1) of twenty (20) sampled residents, Resident #58. Resident #58 had a fall in the hallway due to the improper application of the seat beat to the residents wheel chair cushion which resulted in an injury.

Inspectors wroteBased on interview, record review and review of facility Policy, it was determined the facility failed to ensure residents are free from abuse for one (1) of twenty-two (22) sampled residents (Resident #13). Resident #54 had a history of exhibiting sexually inappropriate behavior and making inappropriate sexual remarks towards staff. The resident also had a history of being aggressive with other residents. However, the facility failed to have interventions in place to ensure residents were protected from Resident #54's sexual behaviors. On 03/11/19, State Registered Nursing Assistant (SRNA) #1 reported witnessing Resident #54 inappropriately touching Resident #13's chest area.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 1.16, it was determined the facility failed to submit Minimum Data Set (MDS) Assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for two (2) of twenty-three (23) sampled residents (Resident #1 and Resident #2). Resident #1's Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 01/23/19 was not submitted to CMS until 03/18/19. In addition, Resident #2's Quarterly MDS Assessment, with an ARD of 01/11/19, was not submitted to CMS until 03/18/19.

Inspectors wroteBased on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to ensure that a resident's comprehensive assessment accurately reflects the resident's status for one (1) of twenty-two (22) sampled residents (Resident #55). Resident #55's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 01/25/19, revealed the resident had contractures to his/her right and left elbows and hands requiring a splinting/orthotic device. However, the admission Minimum Data Set (MDS) assessment dated [DATE], did not reflect the resident's Functional Limitations in Range of Motion (ROM), nor was the MDS Assessment coded for an active diagnosis of Contractures.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for three (3) of twenty-two (22) sampled residents (Resident #54, #55, and #146). Although Resident #54 had a history of exhibiting sexually inappropriate behavior towards staff and being aggressive with other residents, the facility failed to develop and implement a Comprehensive Care Plan (CCP) to address the resident's sexual behaviors. On 03/11/19, staff witnessed Resident #54 inappropriately touching Resident #13's chest area. (Refer to F-600) Resident #55 was admitted with contractures to his/her bilateral hand, wrists, and elbows. [...]

Inspectors wroteBased on observation, interview and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals were labeled in accordance with accepted professional principles and include the expiration date. Observation on 03/19/18 at 1:20 PM, revealed one (1) bottle of Timolol eye drops 0.25 % and one bottle of of Timolol eye drops 0.5%, which had been opened and had not been marked to indicate the date they were opened or the expiration or end-of-use date.