Signature Healthcare of Bowling Green

Based on interview, record review, and review of facility policy, the facility failed to ensure confidentiality of medical records for one (Resident (R) 83) of 11 residents sampled during medication pass. Facility staff failed to ensure that R83's medical information was secured when unattended, so as to prevent unauthorized access to the record. The findings include:Review of a facility policy, titled Resident Rights, last revised 01/31/2025, revealed residents have the right to privacy and confidentiality. Further review of the policy revealed the unauthorized release, access, or disclosure of resident information is prohibited.Review of a Face Sheet revealed the facility admitted R83 on 07/16/2020 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and depression.Observation of medication pass, on 09/02/2025 at 7:20 PM with Certified Nurse Aide (CNA)1, revealed the computer screen on the medication cart was left open, displaying R83's medical information, while CNA1 was in a resident room and the medication cart and computer was unattended. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for two (R68 and R83) of eight residents reviewed for infection control. Staff failed to use personal protective equipment (PPE) for R68, who was on contact precautions. In addition, staff failed to perform hand hygiene when indicated, including before and after resident contact/care for R83. The findings include: 1. Review of a facility policy titled, Infection Control, revised 01/31/2025, revealed the facility intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of a facility policy titled, Transmission Based Precautions (TBP), revised 01/31/2025, revealed TBP were initiated when a resident developed signs and symptoms of a transmissible infection or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to ensure three of three residents (R) reviewed out of a sample size of 42 for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, (R381, R71, and R95) whose Medicare therapy services were terminated, received an estimated cost for services if they chose to pay for the services themselves. This had the potential for residents not to be able to make an informed decision as to whether to continue therapy services. The findings include: The State Survey Agency (SSA) Contractor Surveyor asked the Administrator for the facility's Beneficiary Notice of Medicare Non-Coverage policy; however, such policy was not provided prior to exiting the survey. 1. Review of the undated Resident Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab for R381, revealed the facility admitted the resident on 01/11/2024. Review of the information provided by the facility for R381 revealed the resident was discontinued from skilled therapy services on 01/30/2024, due to having exhausted the Medicare benefit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two residents of 42 sampled residents' (R) Resident Assessment Instruments ([NAME]) accurately reflected the resident's hospice designation for R88 and ability to communicate for R58. This failure could result in the residents' needs, strengths, and areas of decline not being addressed appropriately for R 88 and R58. The findings include: During an interview with the Director of Nursing (DON) on 06/27/2024 at 10:32 AM, she stated she would check for a specific policy related to accurate Minimum Data Set (MDS) Assessments; however, further stated the facility followed the Centers for Medicare and Medicaid Services (CMS) RAI Manual for MDS instructions. No additional policy was provided. 1. Review of R88's undated admission Record located in the electronic medical record (EMR) under the Census tab revealed the facility admitted the resident on 04/16/2021, with diagnoses including advanced dementia, depressive disorder, and anxiety disorder. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of facility policy it was determined the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations of the kitchen on 02/19/19 and 02/20/19, revealed during lunch tray-line, [NAME] #1 inserted the thermometer into the foods past the stem to the handle, which was not sanitized, was the handle was coming in contact with the foods. In addition, dishes were stored improperly. Review of the Census and Condition, dated 02/19/19, revealed one-hundred twenty-five (125) of one-hundred twenty-nine residents received their meals from the kitchen. The findings include: 1. Review of facility policy titled, Food Temperatures, last revised 01/04/19, revealed staff are to wash, rinse, sanitize a dial face, metal probe-type thermometer with an alcohol wipe and re-sanitize after each use and staff are to insert thermometer into center of product. Observation of [NAME] #1 on 02/19/19 at 11:28 AM, revealed [NAME] #1 checked the temperature of foods on tray-line and inserted the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure they developed and/or implemented 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 six (6) of thirty-three (33) sampled residents (Residents #30, #76, #79, #83, #110 and #374). The facility failed to implement care plans for Residents #30, #76, #79, #83, and #374 related to ADL assistance and failed to develop person centered interventions for falls related to Resident #110's severely impaired cognition. The findings include: Review of the facility Policy titled Comprehensive Care Plans , dated 07/19/18, revealed the following: A person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure five (5) of thirty-three sampled residents who were unable to carry out activities of daily living received the necessary services to maintain personal and oral hygiene (Residents #38, #76, #83, #86, and #427). The facility failed to provide oral hygiene to Resident #427, failed to ensure two (2) staff provided bathing for Resident #76, and failed to provide bathing every three (3) times a week for Residents #38, #83 and #86. The findings include: Review of Facility Policy titled Certified Nursing Assistant Job Description, dated 12/2011, revealed the following: Perform direct care duties under the supervision of licensed nursing personnel, provide personal care such as grooming, bathing, dressing, and oral care of residents daily and as needed. Review of the facility policy titled, Certified Nursing Assistant Job Description, dated December 2011, revealed the following: Perform direct care duties under the supervision of licensed nursing personnel, provide personal care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure each resident was treated with respect and dignity and ensure care was provided in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for two (2) of thirty-three (33) sampled residents (Residents #38 and #67). The findings include: Review of the facility's policy, Resident Rights, revised 08/16/18, revealed all residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. Further review of the policy revealed when providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility. 1. Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process, for two (2) of thirty-three (33) sampled residents (Residents #86 and #87). The findings include: Review of the facility's policy, MDS Assessment Completion, revised 02/16, revealed the facility will conduct and submit resident assessments in accordance with the RAI Manual including deferral and state submission timeframes. Further review revealed a Significant Change in Status assessment will be completed on the fourteenth (14th) calendar day after determination of a Significant Change in status. 1. Record review revealed the facility admitted Resident #86 on 10/06/17 with diagnoses which included Dementia with Behavioral Disturbances, Hypothyroidism, Osteoarthritis and Gastroesophageal Reflux disease (GERD). Review of the Quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and changes in conditions for three (3) of thirty-three (33) sampled residents (Residents #37, #44, and #110). Resident #37 sustained a fall on 09/12/18 and Resident #44 sustained falls on 08/19/18 and 02/07/19, however, the comprehensive care plans were not updated to reflect new interventions after the therapy department determined physical therapy was not indicated. In addition, Resident #110 sustained falls on 12/31/18, 01/03/19, 01/07/19 and 02/08/19; however, the comprehensive care plans was not updated to reflect new interventions. The findings include: Review of facility policy titled Falls, last revised 08/16/18, revealed it is the intent of the facility to provide residents with assistance and supervision in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of facility policy, it was determined the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for two (2) of thirty-three sampled residents (Residents #37 and #44). Residents #37 and #44 had falls for which interventions were implemented to consult Physical Therapy (PT)/Occupational Therapy (OT). When therapy evaluated the residents, it was determined the falls were not related to the residents' decline and therapy was not indicated. However, another intervention was not implemented to prevent future falls. The findings include: Review of facility policy titled Falls, last revised 08/16/18, revealed it is the intent of the facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. Interdisciplinary Team (IDT)/Director of Nursing (DON)/or designee reviews during At Risk Meeting to identify additional referrals, consults, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of facility policy, it was determined the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for two (2) of thirty-three (33) sampled residents (Residents #86 and #110). The facility failed to assess Resident #110 and Resident #86 for possible interventions to improve the resident's noted decline in bowel and bladder continence. The Findings Include: Review of the Facility Policy titled Bowel and Bladder Management, dated 04/27/16, revised 7/19/18 revealed the Facility will evaluate, monitor and track resident's bowel and bladder patterns and will identify the need for early intervention. Further review revealed facility will evaluate Bowel and Bladder status upon admission, readmission, quarterly and annual and with significant change. The IDT team will review bowel and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of facility policy, it was determined the facility failed to maintain medical records on each resident that are accurately documented for one (1) of thirty-three (33) sampled residents (Resident #65). The findings include: Review of the facility policy titled, Charting and Documentation, dated 07/02/18, revealed the following: Services provided to the resident, or any changes in the resident's medical condition or mental condition, shall be documented in the resident's medical record. Guidelines: For all skilled residents, documentation will occur at least daily. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum the date and time treatment was provided, name and title of individual who provided care, assessment data and/or any unusual findings obtained during the procedure/treatment, signature and title of the individual documenting. Record Review revealed the facility admitted Resident #65 on 12/21/18 with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.