Signature Healthcare of Georgetown

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 out of 4 hallways, 100 Hall and 400 Hall. Observations on 07/07/2025 revealed the drain access covers on the 100 and 400 Hall were loose, creating a possible tripping hazard.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to follow its Abuse Policy when an employee did not immediately report an allegation of abuse to the Administrator or his designee for 1 of 2 residents reviewed for reporting alleged sexual abuse, Resident (R) 28. On 07/07/2025 at 2:10 PM a housekeeper (HK) 1 reported to the State Survey Agency (SSA) Surveyor that on approximately 07/05/2025, she overheard Certified Nurse Aide (CNA) 2 having a sexually inappropriate conversation with R28. However, that incident was not reported and investigated.

Inspectors wroteBased on observation, interview, record review, and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to follow infection control precautions for 1 of 9 sampled residents under Enhanced Barrier Precautions (EBP), Resident (R) 58. Observation on 07/08/2025 revealed Certified Nurse Aide (CNA) 1 changing linens and removing garbage for a resident under EBP precautions (R58) without wearing appropriate personal protective equipment (PPE).

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents had the right to examine the results of the facility's most recent survey and Plan of Correction. Observations on 11/30/2021 through 12/02/2021, revealed the survey results were not readily accessible to the resident, family members and legal representatives of the resident. In addition residents voiced that they were unaware they could view the latest survey results and did not know where the results were kept for them to view.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Medicare and Medicaid's (CMS) Resident Assessment Instrument (RAI) 3.0 Manual, and review of the facility's policy, it was determined the facility failed to develop and implement a person-centered Comprehensive Care Plan (CCP) for each resident's care needs for six (6) of twenty-two (22) sampled residents (Resident #11, #14, #18, #27, #29, and #38). 1. Resident #29's CCP, initiated on 03/12/2019, revealed the facility failed to develop a care plan related to care measures for a resident with a Gastrointestinal Bleed upon return to the facility from the hospital. Additionally, the facility failed to develop the CCP related to incontinence care for a dependent resident. 2. Resident #38's CCP, initiated on 06/16/2021, revealed the facility failed to develop a care plan related to his/her Foley catheter. 3. [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure sufficient nursing staff to provide nursing services and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for seven (7) of twenty-two (22) sampled residents (Resident's #2, #6, #20, #23, #27, #29, and #30). Interviews with Resident #6, Resident #20, and Resident #27, on 11/30/2021, revealed they had to wait up to an hour for their call bell to be answered. In addition, interview with Resident #23, on 11/30/2021, revealed it may take up to thirty (30) to forty-five (45) minutes for call lights to be answered during mealtimes During Resident Group Interview conducted on 11/30/2021, Residents #2 and #29, revealed they had to wait extended wait periods for assistance after the call lights were activated. [...]

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers guideline, review of the nursing manual [NAME] and [NAME]. (n.d.). Fundamentals of Nursing, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the CDC, and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19 for two (2) of twenty-two (22) sampled residents, Resident #18 and Resident #37. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish mechanisms for documenting and communicating the resident's choices to the interdisciplinary team and to the staff responsible for the resident's care for one (1) of twenty-two (22) sampled residents (Resident #42). Record review revealed Resident #42 was admitted to the facility on [DATE], with a Physician's Order for Code status: Full Code. Observation, on [DATE] at 3:30 PM, revealed a printed Advance Directive/Informed Consent form, dated [DATE], available at the nursing station in a binder with the Advance Directive/Informed Consent forms. The Advance Directive/Informed Consent form for Resident #42 had Full Code handwritten in large letters, in the top right corner. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure two (2) of twenty-two (22) sampled residents' care plans, Resident #11 and #33, were revised to reflect the care needs of the residents. 1. Review of Resident #33's Comprehensive Care Plan (CCP), initiated on 07/18/2020, revealed the facility failed to revise the resident's Nutritional Status focus area to ensure the staff was provided Resident #33's correct feeding instructions. 2. Review of Resident #11's (CCP), initiated on 04/14/2016, revealed the facility failed to revise the resident's Nutritional Status focus area to ensure the staff was provided Resident #11's correct feeding instructions, as directed by the Physician's orders, dated 11/16/2021.

Inspectors wroteBased on observation, interview, record review, facility policy review, review of [NAME] and [NAME]. (n.d.). Fundamentals of Nursing, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to follow professional standards of practice for two (2) of twenty-two (22) sampled residents, Residents #18 and #30. 1. Observation of Registered Nurse (RN) #1, on [DATE] at approximately 10:30 AM, revealed she performed the incorrect wound care to Resident #18's left great toe. Further observation revealed RN #1 administered a discontinued medication to the skin rash on Resident #18's face. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADL) received necessary services for two (2) of twenty-two (22) sampled residents (Resident #11 and Resident #29). Interview with Resident #29, on 12/01/2021, revealed approximately two (2) months ago, he/she used the call light to request staff assistance with toileting. However, the resident stated he/she had a bowel movement and soiled self because he/she had to wait an extended time for the call light to be answered by staff. Further, the resident stated he/she was very embarrassed about the incident. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure support for residents in their choice of activities, both facility-sponsored group and individual activities for one (1) of twenty-two (22) residents, Resident #21. There was no documented evidence Resident #21 participated in his/her preferred activities in August, September, October, or November of 2021, and he/she only attended and participated in minimal activities during the last four (4) months at the facility. Observation of Resident #21, on 11/30/2021, 12/01/2021, 12/02/2021, and 12/03/2021, revealed the resident was in his/her room, in bed with the lights dimmed. The television was on and tuned to an action/adventure television station. There was no radio observed in the room.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of twenty-two (22) sampled residents (Resident #33). Record review revealed Resident #33 had a history of weight loss and Dysphagia (difficulty swallowing) and was evaluated and treated by Speech Language Pathologist (SLP) from 09/20/2021 through 10/15/2021, when the resident was discharged from Speech Therapy with recommendations for feeding instructions. However, current Physician's Orders, revealed an order dated 10/27/2021, with feeding recommendations that differed from the SLP recommendations. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide or ensure each resident received necessary treatment and services, such as off-loading heels from the mattress, following Physician's orders for wound care, and doing weekly skin assessments, to promote healing and prevent new ulcers from developing for one (1) of twenty-two (22) sampled residents, Resident #18.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to restore continence for resident with urinary incontinence for one (1) of twenty-two (22) sampled residents (Resident #2). Review of Resident #2's Quarterly Urinary Continence Evaluation, dated 07/12/2021, revealed the resident was continent of bladder. However, review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/14/2021, and 11/14/2021, revealed the resident was occasionally incontinent of bladder. Although there was a change in the resident's ability to maintain urinary continence, there was no documented evidence the resident received appropriate treatment and services to restore continence to the extent possible. Interview with Resident #2, on 12/01/2021, revealed he/she had occasional episodes of urinary incontinence. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to maintain the usual body weight or the desirable body weight range for one (1) of twenty-two (22) sampled residents, Resident #11. Resident #11's weight was not rechecked after a documented significant weight change.

Inspectors wroteBased on observation, interview, record review and review of the facility's Oxygen Administration - Nasal Cannula, Clinical Practice Guideline, it was determined the facility failed to ensure respiratory care was provided consistent with professional standards of practice for three (3) of twenty-two (22) sampled residents (Resident #7, Resident #14, and Resident #27). Observation on 11/30/2021 of Resident #7, Resident #14, and Resident #27, revealed their oxygen tubing was unlabeled. Additional observation revealed Resident #27's humidification bottle on the oxygen concentrator was dated 11/16/2021.

Inspectors wroteBased on observation, interview, review of the document from the Centers for Disease Control and Prevention (CDC) Vaccine Storage and Handling, review of the product insert instructions for Imdevimab (monoclonal antibodies), review of the product insert instructions for Afluria Quadrivalent vaccine (influenza vaccine), and review of the facility's policies, it was determined the facility failed to store medications according to appropriate environmental controls to preserve their integrity, affecting two (2) unopened boxes of influenza vaccine, one (1) opened and used vial of influenza vaccine, and one (1) box of SARS-CoV-2 monoclonal antibodies. In addition, the facility failed to ensure drugs and biological's were stored to ensure the safety of residents and the integrity of the medication for one (1) of twenty-two (22) sampled residents, Resident #30. [...]

Inspectors wroteBased on observation, interview and review of the facility's policies, it was determined the facility failed to store foods in accordance with professional standards for food service safety and failed to ensure the cooking appliances were in accordance with National Fire Protection Association (NFPA) standards. Observations of the kitchen on 05/28/19 revealed frozen meats and vegetables stored in the kitchen freezer without labels with food names and use by dates. Additional observation revealed a deep freezer, full of frozen vegetables, which did not have a thermometer or documented evidence of a temperature log. Further observation of the kitchen, on 05/28/18 revealed the range hood servicing was past due.

Inspectors wroteBased on observation, interview and review of the facility's policy, it was determined the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for one (1) of thirty (30) total sampled residents (Resident #4). Observation of resident's room, on 05/29/19, revealed multiple neon-orange signs related to direct personal care posted on each wall surrounding Resident #4's bed. Further observations revealed additional signage posted above the resident's head of bed describing daily personal care tasks to be performed by facility staff for Resident #4.

Inspectors wroteBased on observation, interview, record review, review of the facility's policy, and review of the Safety Data Sheets (SDS), it was determined the facility failed to ensure the resident environment remained as free of accident hazards as is possible. Observation on 05/28/19 revealed an unlocked and unattended cabinet, in the main unit hallway of a unit were cognitively impaired and mobile residents resided, containing personal hygiene products with warning labels. Additionaly, observation during initial tour on 05/28/19 on the Transitional Care Unit (TCU) TCU, revealed an unsecured oxygen canister in Resident #62 room.

Inspectors wroteBased on observation, interview, and review of the facility's policies, it was determined 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 one (1) of four (4) residents reviewed for infections out of a total of thirty (30) sampled residents (Resident #43). Observation of incontinence care provided to Resident #43 on 05/30/19 revealed direct care staff failed to perform proper hand hygiene and gloving technique prior to and during delivery of perineal care. In addition, observation of wound care provided to Resident #43 on 05/30/19 revealed licensed staff failed to perform proper hand hygiene and gloving technique prior to and during delivery of bilateral buttocks/sacral wound treatment. [...]