Signature Healthcare at Heritage Hall Rehab & Well

In the surveyor’s words

From the most serious findings on record at Signature Healthcare at Heritage Hall Rehab & Well, in the surveyor’s own words.

• Immediate jeopardy, isolatedF602Sep 29, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF610Sep 29, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF656Sep 29, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF684Sep 29, 2023

  Based 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 [DATE], 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). […]

• Immediate jeopardy, isolatedF835Sep 29, 2023

  Based 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. […]