Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Signature Healthcare Of East Louisville during CMS and state inspections, most recent first.
A resident with a state-appointed guardian and exit-seeking behaviors was not properly care planned, leading to an unsupervised exit from the facility. Despite known risks, the care plan did not reflect the resident's need for supervision or address the appointment of a guardian. This oversight resulted in an Immediate Jeopardy situation.
A resident under state guardianship, deemed wholly disabled, was allowed to exit a facility unsupervised, leading to an elopement incident. Despite policies for safety and supervision, staff failed to verify the resident's authorization status, resulting in the resident being found 0.2 miles away. The care plan did not reflect the resident's guardianship status or previous exit-seeking behavior, indicating deficiencies in monitoring and communication.
The facility failed to adhere to professional standards for food storage and labeling, as observed during a kitchen inspection. Rotting produce and improperly labeled food items were found, contrary to the facility's policies and FDA guidelines. Interviews with staff revealed a lack of adherence to protocols, with the CDM acknowledging the risk of illness from expired or spoiled food.
A facility failed to maintain an effective infection prevention and control program when an RN did not perform hand hygiene between administering medications to residents. Despite staff expectations for hand hygiene, the RN's actions did not align with the facility's protocols, leading to a deficiency.
The facility failed to conduct required checks against the Kentucky Adult Caregiver Misconduct Registry for two contracted employees, a Dietary Aide and a laundry employee, as mandated by KRS 209.032. The facility's policy included criminal background checks and a search of the State Nurse Aide Abuse Registry but omitted the KACMR checks. Interviews revealed that the DON and Administrator were unaware of the need for these checks, relying on the contract agency to perform them.
A facility was found to have deficiencies in medication storage and security. A personal lunch bag was improperly stored in a medication refrigerator, posing contamination risks. Additionally, an RN left a resident's medications unattended on a cart, violating facility policy. Staff interviews confirmed these actions were against established protocols.
Failure to Update Care Plan for Resident with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who became a ward of the state and was deemed wholly disabled. Despite the resident's need for assistance in managing personal and financial affairs, the care plan did not reflect the appointment of a state guardian or how this guardianship could affect the resident's care. Additionally, the care plan did not address the resident's exit-seeking behaviors, which were documented on multiple occasions. On a specific date, the resident exhibited exit-seeking behaviors and was placed on 15-minute checks. However, the facility did not update the care plan to include these behaviors or the necessary interventions. The resident was observed roaming the facility with personal items and expressing delusions of going home, yet these behaviors were not incorporated into the care plan. Consequently, the resident was able to exit the facility unsupervised, which was later identified as an Immediate Jeopardy situation. Interviews with facility staff revealed that the resident was known to roam the facility and required supervision at all times due to cognitive status and delusional behaviors. Despite this knowledge, the care plan was not updated to reflect the resident's needs for supervision and the risk of elopement. The failure to address these critical aspects in the care plan posed a significant risk to the resident's safety and well-being.
Removal Plan
- Resident #1's medical record was updated to include guardian information.
- The guardian was invited to attend a care conference, and the State guardian attended the meeting.
- Upon Resident #1's return to the facility, the Signature Care Consultant completed a skin, psychosocial, and pain assessment. No issues were noted.
- Resident #1 was placed on 1:1 supervision and remained 1:1 until discharge.
- Resident #1's care plan was updated to include 1:1 as an intervention by the Social Services.
- Social Services completed an exit seeking elopement observation and deemed resident #1 at risk for elopement.
- Social Services initiated an elopement care plan.
- Social Services added Resident #1 to the elopement binder.
- The Facility Corporation Consultant educated the identified receptionist on reviewing the elopement binder before allowing unsupervised residents out of the facility.
- All current residents were reassessed for exit-seeking observations by Social Services.
- Any residents identified as at risk for exit seeking had their care plans reviewed and revised as indicated.
- The Facility Corporation Consultant conducted a look back in the EMR on all events in the facility for exit-seeking behaviors; no concerns identified.
- The Facility Corporation Care Consultant completed a review of progress notes for exit-seeking behaviors and/or elopement identified in the EMR for all residents.
- The floor nurse assessed new admissions for exit seeking; none were identified as at risk for exit seeking.
- The MOS nurse prepared a list of the state guardians' residents. The MOS support implemented a state-appointed guardianship care plan for all identified residents.
- The Systemic Change sign posted by the Facility Administrator on the entry door states that authorized residents are only permitted beyond this point.
- The Facility Corporation Consultant educated the facility administrator and DON on the Elopement Policy, Leave of absence policy, Comprehensive Care Plan Policy, Safety and Supervision of Resident Policy, and Change of Condition Policy.
- The Facility Corporation Consultant, Director of Nursing, Administrator, or Unit Manager completed an in-service with all staff currently present or working in the facility on the Elopement Policy, Leave of absence policy, Comprehensive Care Plan Policy, Safety and Supervision of Resident Policy, and Change of Condition Policy.
- The Independent Risk Manager and NAME President of Clinical Services educated the Facility Administrator, Director of Nursing, Special Projects Administrator, Business Office Manager, HR Business Partner, Plant OPS Assistant, Environmental Services Manager, Plant Operations Director, Dietary Services Manager, Life Enrichment Director, Environmental Account manager, Unit Managers, MDS coordinators, Admissions Director, Rehabilitation Manager, Social Services, and Signature Care Consultant on needing to notify the State Guardian if their resident attempts and/or requests to leave facility unsupervised for approval.
- Facility Corporation Consultant, DON, ADON, or UM's will audit random resident's progress notes looking for exit-seeking behaviors until substantial compliance is achieved.
- Facility Corporation Consultant, DON, or UM's will audit all new admissions with an appointed State guardian to ensure a care plan is developed to include the State appointed guardian is notified if the resident requests or attempts to leave unsupervised until substantial compliance is achieved.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was under state guardianship and deemed wholly disabled. Despite having a Brief Interview of Mental Status (BIMS) score indicating cognitive intactness, the resident was legally unable to manage personal and financial resources and required supervision when leaving the facility. On the day of the incident, the resident informed the receptionist of her intention to step outside, and the receptionist allowed her to exit without verifying her authorization status or checking the elopement binder. The resident was later observed by a visitor walking with a rolling walker on a sidewalk, having crossed a three-lane road, approximately 0.2 miles from the facility. The facility's investigation revealed that the resident was outside unsupervised for about 10 to 15 minutes before being assisted back into the facility by staff. The facility's policies on safety, supervision, and elopement risk were not effectively implemented, as staff were not adequately informed about the resident's restrictions due to state guardianship. Interviews with various staff members, including the Human Resources Specialist, Certified Nursing Assistants, and the Director of Nursing, indicated a lack of awareness and communication regarding the resident's supervision needs. The resident's care plan did not reflect the state guardianship status or previous exit-seeking behavior, contributing to the oversight. The incident highlighted deficiencies in the facility's procedures for monitoring residents at risk of elopement and ensuring staff compliance with established safety protocols.
Removal Plan
- Education with everyone in the building regarding elopement.
- Elopement books checked to ensure they were on the halls.
- Signs posted advising staff not to let residents out of the facility.
- Leadership educating staff regarding elopement and Code Green, an overhead page to alert employees that a resident was missing and to begin looking for the missing resident.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a kitchen inspection. Multiple produce items were found rotting in the walk-in refrigerator, and several food items, including sleeves of bread and leftover tomatoes, lacked proper labeling or expiration dates. The facility's policies, which align with the FDA Food Code, require all foods to be stored, wrapped, labeled, and dated to prevent cross-contamination. However, observations revealed undated applesauce, unlabeled tomato slices, and improperly stored meats and produce, including a cracked watermelon and soggy cucumbers. Interviews with facility staff, including the District Certified Dietary Manager (CDM), Healthcare Services Registered Dietician (RD), Senior Director of Operations (SDO), and the Administrator, highlighted a lack of adherence to established protocols for food storage and labeling. The CDM, covering for the account manager, acknowledged the responsibility to check for decaying produce and stated that expired or spoiled food could increase residents' risk of illness. The SDO and Administrator emphasized the importance of following expiration dates and proper food storage guidelines, yet the observed deficiencies indicated a failure to consistently implement these practices.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of RN 7 during medication administration for Resident 65. RN 7 did not perform hand hygiene after administering medications to the resident and before preparing medications for another resident. This failure was observed during a medication administration session, where RN 7 also neglected to don gloves while administering insulin. The facility's reference book, 'Fundamentals of Nursing,' emphasizes the importance of hand hygiene as a basic technique for preventing and controlling infection transmission, which was not adhered to in this instance. Interviews with various staff members, including LPNs and the ADON, revealed a consistent expectation for hand hygiene practices to be followed between residents and during medication administration. The DON and Administrator also expressed expectations for adherence to the facility's medication administration policy, which includes handwashing between residents. Despite these expectations, the observed actions of RN 7 did not align with the established protocols, leading to a deficiency in the infection prevention and control program.
Failure to Conduct Required Background Checks on Contracted Employees
Penalty
Summary
The facility failed to ensure that contracted employees had their backgrounds checked against the Kentucky Adult Caregiver Misconduct Registry (KACMR) as required by Kentucky Revised Statutes (KRS) 209.032. This deficiency was identified during a review of personnel files for two contracted employees, a Dietary Aide and a laundry employee, who were hired without documentation of the required KACMR checks. The facility's policy on Abuse, Neglect, and Misappropriation of Property, revised in September 2023, included conducting criminal background checks and a search of the State Nurse Aide Abuse Registry but did not include the KACMR checks. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of awareness and responsibility for ensuring the KACMR checks were completed. The DON stated that she reviewed contracted employees' information related to education and tuberculosis checks but was unaware of the KACMR checks. The Administrator expected the contract agency to perform these checks before employment. Both acknowledged the importance of these checks in preventing individuals with a history of abuse from being employed at the facility, highlighting a gap in the facility's hiring process for contracted employees.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications, as observed during a survey. In one instance, a personal lunch bag containing food and drinks was found stored inside a locked medication refrigerator on the facility's 100 unit. This was against the facility's policy, which mandates that medication refrigerators should only be used for storing medications and biologicals, and not for any food items. The presence of food in the medication refrigerator posed a risk of contamination to both the medications and the food items. Additionally, during a medication administration observation, a registered nurse (RN) prepared a resident's medications and left them unattended on a medication cart. The medications included Aspirin, Isosorbide, Jardiance, and Protonix. The RN stepped away from the cart, leaving the medications unsecured and out of view, which was against the facility's policy that requires medications to be administered immediately after preparation and not left unattended. Interviews with various nursing staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that leaving medications unattended was against the facility's policy due to the risk of unauthorized access by residents. The facility's policies on medication administration and storage were reviewed, revealing that medications should be stored and administered according to professional principles and state and federal laws. The policies also emphasized that medications should be kept secure and not left unattended. Interviews with staff members, including the Administrator, reiterated the importance of adhering to these policies to prevent potential risks associated with improper medication storage and administration.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs At Stony Brook | 0.9 mi | — | 0 | 0 |
| Jeffersontown Rehabilitation | 1.5 mi | — | 3 | 0 |
| Louisville East Post Acute | 2.1 mi | — | 0 | 0 |
| Klondike Nursing And Rehabilitation Center | 2.8 mi | — | 2 | 0 |
| Seneca Place | 3.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.