Signature Healthcare at Jefferson Manor Rehab & We

In the surveyor’s words

From the most serious findings on record at Signature Healthcare at Jefferson Manor Rehab & We, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Jun 6, 2024

  Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure drugs and biologicals were stored appropriately, without being expired, for one (1) of two (2) medication storage rooms, and two (2) of five (5) medication carts. A tour of the blue medication room, on 06/04/2024 at 11:45 AM, revealed a tube of Iodosorb with an expiration date of 02/2022, a tube of Medihoney with expiration date of 12/11/2022, and a tube of HydrofaraBlue with expiration date of 02/01/2021. […]

• No harm, potential for more than minimal, isolatedF554Jul 25, 2025

  Facility failed to follow policy prior to self-administering neb treatments.The findings include: Review of facility policy, Medication Administration Self-Administration by Resident, dated 01/2023, indicated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. PROCEDURES 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. […]

• No harm, potential for more than minimal, isolatedF554Jun 6, 2024

  Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure two (2) of 49 sampled residents (Resident (R)16 and R47) were assessed for self-administration of medications to ensure the practice was clinically appropriate. Observation on 06/03/2024 at 2:27 PM, revealed a bottle of Flonase Allergy Relief nasal spray on R16's overbed table. However, there was no documented evidence of Physician's Orders for self administration of medications. Additionally, observation, on 06/04/2024 at 12:37 PM, revealed a small yellow pill on R47's lunch tray. […]

• No harm, potential for more than minimal, isolatedF582Jun 6, 2024

  Based on interview, record review, review of the Centers for Medicare and Medicaid Services (CMS), Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, review of the CMS site, Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566 and review of facility policy, it was determined the facility failed to issue the appropriate notice for termination of Medicare part A benefits for two (2) of three (3) residents reviewed for beneficiary notification out of a total sample of 49 residents (Resident (R) 67 and R73). These failures had the potential to result in a lack of understanding of appeal rights and/or the termination of the current level of care against the resident's/representative's wishes. […]

• No harm, potential for more than minimal, isolatedF658Jun 6, 2024

  Based on interview, record review and review of the Kentucky Board of Nursing AOS #09 - Wound Assessment, Staging, and Treatment published in December 2023, it was determined the facility failed to ensure services provided or arranged by the facility meet professional standards of quality for two (2) of 49 sampled residents (Resident (R)71 and R1). The facility failed to have qualified wound care staff and physician oversight related to wound care. The findings include: Review of the Kentucky Board of Nursing Advisory Opinion Statement (AOS) #09 - Wound Assessment, Staging, and Treatment published in December 2023, provided by the facility revealed, .It is within the scope of licensed practical nursing practice for a licensed practical nurse who is educationally prepared and clinically… […]