Signature Healthcare of Elizabethtown

In the surveyor’s words

From the most serious findings on record at Signature Healthcare of Elizabethtown, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Mar 25, 2026

  Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free of significant medication errors for 1 of 10 sampled residents reviewed for narcotic administration, Resident (R)1. On 03/12/2026, R1 was administered 5 times the intended dose of Morphine (a schedule II opioid analgesic used to treat severe pain and misuse of the medicine can cause addition, overdose, or death) on three separate instances. R1 was pronounced dead on 03/12/2026 at 5:53 PM. The facility's failure to have an effective system to ensure residents were free from significant medication errors was likely to cause serious injury, impairment, or death to a resident. […]

• No harm, potential for more than minimal, patternF606Oct 25, 2024

  Based on interview, record review, and review of facility policy, the facility failed to complete the Kentucky (KY) Adult Caregiver Misconduct Registry checks prior to beginning employment on 2 of 3 contracted dietary employees, Dietary Aide (DA) 1 and [NAME] 1. DA 1 began employment at the facility on 09/04/2024, and [NAME] 1 began employment on 09/11/2024. However, the facility failed to complete the KY Caregiver Misconduct Registry checks for both employees prior to employment, as the check were not completed until 10/24/2024, during the State Survey Agency (SSA) survey. […]

• No harm, potential for more than minimal, isolatedF609Mar 25, 2026

  Based on observation, interview, record review, and review of facility policy, the facility failed to report alleged violations involving abuse, neglect, mistreatment, or any reasonable suspicion of a crime, as required, to state agencies for 1 of 10 sample residents, Resident (R)1. (Refer to F760)The findings include:Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property revised 09/15/2023, revealed the Reporting Guidelines noted, Any abuse allegation must be reported to the State within two hours. Any reasonable suspicion of a crime with serious bodily injury must be reported to the State and Police. […]

• No harm, potential for more than minimal, isolatedF580Feb 13, 2026

  Based on interview, record review, facility document review, and facility policy review, the facility failed to notify the Nurse Practitioner (NP), Medical Director (MD) and management staff when the administration of an immediate (STAT, statim) order for medication was delayed due to not being received from the pharmacy timely. This failure affected 1 (Resident #105) of 1 resident reviewed for notifications. The findings included: A facility policy titled, Physicians Orders, revised 01/30/2026, indicated, 3. Licensed Nurses are expected to notify the physician with any concerns related to new physician orders or potential need for changes in orders. A Resident Face Sheet indicated the facility admitted Resident #105 on 12/06/2025. […]

• No harm, potential for more than minimal, isolatedF550Nov 8, 2023

  Based on observation, interview, record review, and review of facility's policy, it was determined that the facility failed to ensure residents were treated with dignity and respect in a manner that enhanced the resident's quality of life for one (1) of seven (7) sampled resident residents (Resident #2). The facility failed to honor Resident #2's right to refuse taking his/her medication. On 06/18/2023, Registered Nurse (RN) #3 was observed by staff holding Resident #2's nose during medication administration. The RN was overheared telling Resident #2, see there you go, after making him/her take the medication. On 10/27/2023 observation revealed Resident #2 was in his/her room, in bed sitting up, looking at television. Resident #2 was non-verbal so he/she was unable to be interviewed. […]