Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Signature Healthcare At Colonial Rehab & Wellness during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment engaged in multiple incidents of inappropriate sexual behavior with other residents. The facility failed to assess residents' capacity to consent and did not update care plans to address these behaviors. Despite several incidents, the facility often unsubstantiated the allegations and lacked effective systems to protect residents from sexual abuse.
The facility failed to develop and implement comprehensive care plans for residents exhibiting inappropriate sexual behavior, particularly for a resident who repeatedly engaged in such behavior with others. Despite cognitive assessments indicating severe impairment in some residents, the facility did not assess their capacity to consent or implement protective measures. This inaction led to repeated incidents, culminating in a substantiated case of abuse, highlighting a significant deficiency in resident care and protection.
A significant medication error occurred when a resident was mistakenly administered a fentanyl patch intended for their roommate, leading to altered mental status and hospitalization. The facility's medication administration process failed to prevent this error, as required verification procedures were not effectively followed. The resident, who was not prescribed fentanyl, experienced adverse effects consistent with opioid side effects, highlighting a breakdown in the facility's medication management system.
A facility failed to maintain an effective infection prevention and control program when a CNA did not adhere to Enhanced Barrier Precautions (EBP) for a resident with a pressure wound. Despite signage and available PPE, the CNA entered the room without a gown, only wearing gloves, while providing incontinent care. The CNA admitted to forgetting the gown, despite training on PPE use to prevent infection spread. Interviews confirmed the CNA self-reported the incident, highlighting a breach in infection control protocols.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by multiple incidents involving a resident, R63, who engaged in inappropriate sexual behaviors with other residents. The facility did not have an effective system to assess residents' capacity to consent to sexual activities, nor did it update care plans to address these behaviors. Incidents included R63 kissing another resident, R2, and fondling the breast of R34, among others. Despite these occurrences, the facility often unsubstantiated the incidents and failed to implement adequate monitoring or interventions. R63, a resident with vascular dementia and moderate cognitive impairment, was involved in several incidents of inappropriate sexual behavior. The facility's documentation revealed that R63's care plan was not updated to reflect these behaviors, and there was no specific documentation alerting staff to his potential for such actions. The facility's response to these incidents was inadequate, as they did not substantiate the allegations or take sufficient steps to prevent recurrence. The facility's failure to assess the capacity of residents to consent to sexual activities further contributed to the deficiency. The facility's policies and procedures were insufficient in addressing the issue of sexual abuse. The facility did not provide a policy regarding the determination of a resident's ability to consent, and staff interviews indicated a lack of clarity on how to assess consent. The psychiatric nurse practitioner stated that determining consent was beyond her scope of practice, and the facility had not involved her in such assessments. The facility's inaction and lack of effective systems to protect residents from sexual abuse led to the identification of Immediate Jeopardy and Substandard Quality of Care.
Failure to Implement Comprehensive Care Plans for Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents exhibiting inappropriate sexual behavior, specifically for four residents. Resident 63 was observed engaging in inappropriate sexual behavior with other residents on multiple occasions, including kissing and fondling, without the facility adequately addressing these behaviors in his care plan. Despite being cognitively intact, as indicated by a BIMS score of 15/15, the facility did not define triggers for his inappropriate behaviors or implement effective interventions, such as consistent one-on-one supervision. Resident 2, who was involved in incidents with Resident 63, was assessed to have severe cognitive impairment with a BIMS score of 3, indicating an inability to consent to sexual activity. The facility failed to assess her capacity to consent and did not develop a care plan to protect her from potential abuse. Similarly, Resident 34, who was also involved in an incident with Resident 63, had a BIMS score indicating severe cognitive impairment, yet the facility did not assess her capacity to consent or implement protective measures in her care plan. The facility's inaction led to repeated incidents of inappropriate sexual behavior by Resident 63, culminating in a substantiated case of abuse. Despite previous unsubstantiated allegations, the facility did not effectively monitor or supervise Resident 63, allowing further incidents to occur. The lack of a comprehensive care plan and failure to implement necessary interventions resulted in a situation where residents were not adequately protected from abuse, leading to severe psychosocial harm.
Significant Medication Error Involving Fentanyl Patch
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was mistakenly administered a fentanyl patch. The resident, who was not prescribed fentanyl, developed altered mental status and was sent to the emergency room for evaluation. Upon assessment, the ER nurse discovered a 75 mcg fentanyl patch on the resident's left upper arm/shoulder, which was not documented in the facility's records as part of the resident's medication regimen. The resident's roommate, however, had an active order for a fentanyl patch, indicating a medication error had occurred. The facility's policies required the use of two resident identifiers and triple medication verifications prior to medication administration, but these procedures were not effectively followed. The agency Kentucky Medication Aide (KMA) responsible for administering the fentanyl patch was unable to be contacted for clarification, and the Staff Development Coordinator, who was the second signature on the controlled drug record, did not recall observing the patch being placed on the resident. The resident's condition deteriorated, leading to hospitalization with a discharge diagnosis of encephalopathy secondary to fentanyl side effects. The incident highlights a breakdown in the facility's medication administration process, as the resident received a medication intended for another individual. The facility's documentation and verification processes failed to prevent this significant medication error, resulting in the resident experiencing adverse effects consistent with fentanyl side effects in someone who was opioid naive. The facility's inability to contact the KMA and the lack of immediate corrective action further compounded the issue.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Certified Nurse Aide (CNA) 3, who did not adhere to the required Enhanced Barrier Precautions (EBP) for Resident 43. The resident, who was admitted with conditions including acute osteomyelitis, diabetes, and peripheral vascular disease, had a pressure wound that necessitated EBP. Despite the presence of signage indicating the need for Personal Protective Equipment (PPE) and an isolation cart with PPE available, CNA 3 entered the resident's room without donning the required gown, although gloves were worn. The deficiency was observed when CNA 3 provided incontinent care to Resident 43 without the appropriate PPE. The CNA admitted to forgetting to don a gown while engaging in conversation with the resident during care. This lapse occurred despite the facility's policy and training on the importance of PPE to prevent the spread of infections, particularly in rooms designated for EBP due to the risk of transmitting Multidrug-Resistant Organisms (MDRO). Interviews with facility staff, including the Staff Development Coordinator and the Infection Preventionist/Director of Nursing, confirmed that CNA 3 self-reported the incident and acknowledged the importance of following infection control protocols. The facility's policies clearly outlined the need for PPE in high-contact care activities, yet the failure to adhere to these protocols resulted in a breach of infection control measures.
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Illustrative
What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bardstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bardstown Health & Rehabilitation | 1.4 mi | ★★★★★ | 0 | 0 |
| Loretto Living Center At Loretto Motherhouse, Inc | 11.2 mi | ★★★★★ | 0 | 0 |
| Sansbury Care Center | 13.7 mi | ★★★★★ | 0 | 0 |
| Springfield Nursing And Rehabilitation Center | 16.8 mi | ★★★★★ | 7 | 0 |
| Green Meadows Health & Rehabilitation | 16.9 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 July 2026) and official state health department websites.