Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Jefferson Manor Rehab & We during CMS and state inspections, most recent first.
Expired medications were found in a medication storage room and on two medication carts in the facility. Items such as Iodosorb, Medihoney, and HydrofaraBlue were expired, with dates ranging from February 2021 to December 2022. Staff interviews revealed uncertainty about the duration medications remain viable after opening, indicating a failure to adhere to facility policies on medication storage and administration.
The facility failed to assess two residents for self-administration of medications. A resident with intact cognition had Flonase at bedside without a physician's order, and another resident with moderate cognitive impairment had aspirin left on their tray without supervision. The facility's policy requires a prescriber's order and interdisciplinary team assessment for self-administration, which was not followed.
The facility failed to provide written notice of Medicare non-coverage to two residents, resulting in a lack of documentation and clarity regarding their care decisions. The Social Services Director only provided verbal notice and did not obtain signatures or document the representatives' choices, leading to potential misunderstandings about appeal rights and service continuation.
The facility failed to meet professional standards in wound care for two residents, as the LPN responsible was not certified and lacked adequate training. The DON and other staff did not provide sufficient oversight or documentation review, and the facility lacked a specific job description for a Wound Care Nurse.
A resident with a history of falls and moderate cognitive impairment was found on the floor after attempting to self-transfer from bed. Despite a care plan intervention to keep the bed in a low position, observations showed staff failed to maintain this precaution, leading to a deficiency in fall prevention measures.
The facility failed to maintain an effective infection prevention and control program during wound care for two residents. A Wound Care Nurse did not clean and disinfect surfaces and tools properly, and failed to provide incontinence care before wound treatment. The facility's policy lacked specific infection control measures for wound care, contributing to these deficiencies.
Expired Medications Found in Storage Room and Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored appropriately, leading to the presence of expired medications in one of the two medication storage rooms and two of the five medication carts. During a tour of the blue medication room, expired items such as Iodosorb, Medihoney, and HydrofaraBlue were found, with expiration dates ranging from February 2021 to December 2022. These expired items were confirmed by the Director of Nursing and the Signature Clinical Consultant. Additionally, expired medications were found on Medication Cart #1, including nitroglycerine, Atrovent inhaler, and Miralax, with expiration dates as far back as November 2023 and January 2023, respectively. Medication Cart #3 also contained expired medications, such as Breyna and Glycopyrolate, with expiration dates in April 2024. Interviews with staff revealed a lack of clarity regarding the duration for which medications remain viable after being opened. LPN5 was unsure of the exact timeframe, estimating it to be around 30 days, while LPN4 believed it to be between 28 to 30 days. The facility's policy on medication storage and administration was reviewed, indicating that outdated or deteriorated medications should be immediately removed and disposed of according to procedures. However, the presence of expired medications suggests a failure to adhere to these policies, contributing to the deficiency identified during the survey.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, R16 and R47, were assessed for the self-administration of medications to determine if the practice was clinically appropriate. For R16, a bottle of Flonase Allergy Relief nasal spray was observed on the resident's overbed table without any documented physician's orders for self-administration. Despite the resident's intact cognition, as indicated by a BIMS score of 15 out of 15, there was no evidence of an interdisciplinary team assessment or prescriber's order allowing self-administration. The Director of Nursing instructed an LPN to retrieve the medication, indicating a lack of clarity and communication regarding the resident's medication management. For R47, a small yellow pill was found on the resident's lunch tray, identified as aspirin. The resident, who had a BIMS score of 12 out of 15 indicating moderate cognitive impairment, stated that the nurse left the pills at the bedside without observing the resident take them. The care plan noted the resident's preference to take medications independently from a med cup, but there was no physician's order for self-administration. The LPN involved claimed to have observed the resident from outside the room, which contradicts the facility's policy requiring direct observation to ensure safe medication administration.
Failure to Provide Written Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue the appropriate notice for termination of Medicare Part A benefits for two residents, which could lead to a lack of understanding of appeal rights and the termination of care against the residents' or their representatives' wishes. The facility's policy required that the Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice of Non-coverage (ABN) be provided in writing and signed by the beneficiary or their representative. However, the Social Services Director (SSD) only provided verbal notice via telephone and did not send the written forms for signature or documentation. For the first resident, who was admitted with severe cognitive impairment, the SSD documented that verbal notice was given to the financial representative, but there was no signature or indication of the representative's choice regarding the continuation of services. The representative later stated that they did not recall receiving the notice or being presented with options, and would have chosen to discontinue services if asked. Similarly, for the second resident, who had moderate cognitive impairment, the SSD also provided verbal notice without obtaining a signature or documenting the representative's choice. The representative later stated they did not remember receiving a call or being asked about their preference for services. The facility's failure to provide written notices and obtain signatures as required by Medicare guidelines resulted in a lack of documentation and clarity regarding the residents' or their representatives' decisions about their care. This oversight was identified during a survey, and the facility was unable to provide additional information or documentation to rectify the situation before the survey concluded.
Deficiency in Wound Care Standards
Penalty
Summary
The facility failed to ensure that wound care services met professional standards of quality for two residents, as identified in a survey. The first resident, admitted with multiple diagnoses including an unstageable pressure ulcer, had physician orders for wound care that were not adequately overseen by qualified staff. The second resident, who developed a Stage IV pressure ulcer, also received wound care without proper oversight. Both residents' care was managed by a Licensed Practical Nurse (LPN) who was not certified in wound care and had only received on-the-job training. Interviews with facility staff revealed a lack of proper qualifications and oversight in wound care management. The Wound Care Nurse (WCN) was not certified and had limited training, while the Signature Clinical Coordinator, who was certified, did not regularly review the WCN's documentation or observe wound care procedures. The Nurse Practitioner and Medical Director also did not provide adequate oversight, as they did not regularly assess the wounds or ensure proper documentation and treatment. The Director of Nursing (DON) confirmed the absence of a certified wound care nurse and acknowledged that she did not regularly review wound care documentation or observe procedures. Additionally, the facility lacked a specific job description for a Wound Care Nurse, further contributing to the deficiency in ensuring professional standards of quality in wound care services.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate assistive devices were implemented to prevent accidents for a resident who was reviewed for falls. The resident, who had a post-surgical diagnosis of traumatic subdural hematoma and a history of falls, was found on the floor after attempting to get out of bed. A root cause analysis by the Interdisciplinary Team determined the fall was due to the resident's self-transfer. An intervention was put in place to keep the resident's bed in a low position when in bed, but observations revealed that staff failed to maintain this precaution. During observations, the resident's bed was repeatedly found not in the low position, despite the care plan's directive. The resident's representative confirmed that the bed was often not lowered, and a Certified Nursing Assistant acknowledged the requirement for the bed to be in a low position. The Director of Nursing stated that it was expected for staff to implement fall precautions, including lowering the bed, but this was not consistently done, leading to the deficiency.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during wound care for two residents. For Resident 71, the Wound Care Nurse (WCN) did not clean and disinfect the overbed table before placing a barrier for wound care supplies. Additionally, the nurse used scissors from the treatment cart without cleaning or disinfecting them before cutting the Kerlix to pack the resident's wound. After completing the wound care, the nurse failed to wash hands and don new gloves before cleaning the scissors, and did not wait the required three minutes for the disinfectant to dry before placing the scissors back into the treatment cart. For Resident 1, the WCN did not provide incontinence care to remove stool before starting wound care, despite the resident having a small bowel movement when moved to a side-lying position. Furthermore, the nurse used the same gauze to clean the wound twice, which is against proper infection control practices. These actions were confirmed by the WCN during an interview, acknowledging the failure to adhere to infection control protocols. The facility's policy on skin integrity did not include specific infection control measures related to wound care, contributing to the deficiencies observed. Interviews with the Director of Nursing and other staff confirmed the lapses in infection control practices, including the lack of knowledge about the appropriate dry time for disinfectant wipes. These deficiencies highlight a failure to provide a safe, sanitary, and comfortable environment for residents, particularly those with wounds requiring careful management.
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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) |
|---|---|---|---|---|
| Signature Healthcare At Jefferson Place Rehab & We | 0.2 mi | ★★★★★ | 0 | 0 |
| The Episcopal Church Home | 0.3 mi | ★★★★★ | 13 | 1 |
| Lyndon Crossing | 0.7 mi | — | 3 | 2 |
| Westport Place Health Campus | 1.5 mi | ★★★★★ | 5 | 0 |
| The Willows At Springhurst | 2.5 mi | ★★★★★ | 4 | 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.