Inspection Reports for
Phillips County Retirement Center
1300 STATE STREET, PO BOX 628, PHILLIPSBURG, KS, 67661-628
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
147% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
90% occupied
Based on a May 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 28, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-05-17.
Findings
All deficiencies have been corrected as of the compliance date of 2018-06-15, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: May 17, 2018
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found a most serious deficiency at an 'E' level, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-06-15.
Deficiencies (1)
The facility had an 'E' level deficiency indicating a pattern that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Contact person for information regarding the survey and plan of correction. |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 8
Date: May 17, 2018
Visit Reason
Health resurvey inspection to evaluate compliance with federal regulations and follow up on previous deficiencies.
Findings
The facility failed to maintain a safe, clean, and homelike environment, accurately code assessments, update care plans after significant changes, ensure appropriate medication diagnoses, follow up on diet orders, maintain safe food handling practices, and provide a functioning call light system in one hall.
Deficiencies (8)
F584: The facility failed to maintain an odor-free environment in a resident's room and the whirlpool room, placing residents at risk for an uncomfortable living environment.
F641: The facility failed to accurately code the Minimum Data Set assessments for 5 of 12 sampled residents regarding bowel incontinence and bowel training programs.
F657: The facility failed to update the care plan for a resident after a swallow study recommended a pureed diet, placing the resident at risk for aspiration.
F756: The facility's pharmacist failed to identify and address an inappropriate diagnosis for a scheduled antipsychotic medication for a resident, placing the resident at risk for adverse medication side effects.
F758: The facility failed to ensure an appropriate diagnosis for a scheduled antipsychotic medication for a resident, placing the resident at risk for adverse medication side effects.
F808: The facility failed to obtain a physician diet order for a resident after hospital discharge and swallow study recommendations, placing the resident at risk for aspiration.
F812: Dietary staff failed to follow safe food handling practices by not changing contaminated gloves and touching residents' food and drinking surfaces, placing residents at risk for foodborne illness.
F919: The facility failed to provide a functioning call light system in one hall, placing residents at risk of not receiving timely assistance.
Report Facts
Resident census: 36
Sample size: 12
Residents with inaccurate MDS coding: 5
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Involved in dietary communication and care plan updates for Resident #1 | |
| Dietary Manager BB | Received communication slip regarding resident diet and commented on food handling practices | |
| Administrative Nurse D | Verified care plan and diet order issues, and pharmacist consultant communication | |
| Administrative Nurse E | Verified MDS coding and care plan update issues | |
| Nurse Aide M | Provided observations on resident care and diet | |
| Maintenance Staff U | Verified call light system issues and maintenance rounds | |
| Administrative Staff A | Responsible for electrical maintenance and call light system repairs |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 9, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were corrected as of 10/28/2016, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Date of correction: Oct 28, 2016
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 9, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
All previously cited deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of 10/28/2016.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 9, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
All previously cited deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of 10/28/2016.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 8
Date: Sep 29, 2016
Visit Reason
Health Resurvey and Complaint Investigation #105318 conducted to investigate grievances, abuse allegations, and compliance with regulations.
Complaint Details
The investigation was complaint-driven, focusing on grievances about missing property, abuse allegations involving residents #29 and #1, and concerns about medication and care planning.
Findings
The facility failed to document and resolve grievances, report allegations of abuse and exploitation timely, complete criminal background checks for new hires, develop comprehensive care plans including medication monitoring, ensure drug regimens were free from unnecessary medications, provide adequate RN coverage, and maintain proper infection control practices.
Deficiencies (8)
F166: The facility failed to document, investigate, and resolve a resident's report of missing property, lacking a grievance tracking system.
F225: The facility failed to immediately report allegations of abuse and exploitation involving residents #29 and #1, and failed to investigate and prevent further abuse.
F226: The facility failed to complete criminal background checks for 4 of 5 staff hired since 8/2/16, lacking a system to verify receipt and results.
F279: The facility failed to develop a comprehensive care plan for Resident #19 that included medication-related interventions.
F329: The facility failed to ensure 5 sampled residents were free from unnecessary medications, lacked appropriate diagnoses for antipsychotic use, failed to monitor medication effectiveness, and did not develop individualized behavior monitoring.
F354: The facility failed to provide 8 consecutive hours of RN coverage 7 days a week for the 41 residents.
F428: The facility's pharmacy consultant failed to report drug regimen irregularities to the Director of Nursing for Residents #44 and #13, including incomplete behavior monitoring and lack of follow-up on inhaler use recommendations.
F441: The facility failed to maintain a sanitary environment by not following manufacturer instructions for disinfectants, contaminating surfaces with soiled gloves, and using a toilet brush without proper disinfection between rooms.
Report Facts
Resident census: 41
Dates lacking RN coverage: 7
Staff background checks pending: 4
Deficiency counts: 8
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 29, 2016
Visit Reason
The visit was a resurvey of the Assisted Living/Residential Healthcare facility to verify correction of previous deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 0
Date: Sep 29, 2016
Visit Reason
The survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, widespread. Due to these deficiencies and the facility's history of noncompliance from a prior abbreviated survey, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Report Facts
Enforcement effective date: Sep 14, 2016
Enforcement review deadline: Feb 23, 2017
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed letter regarding enforcement and plan of correction |
Inspection Report
Enforcement
Deficiencies: 0
Date: Sep 29, 2016
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, widespread. Due to these deficiencies and the facility's history of noncompliance from a prior abbreviated survey, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Report Facts
Denial of payment effective date: Sep 14, 2016
Termination recommendation date: Feb 23, 2017
Civil Money Penalty minimum amount: 5000
Days to request Informal Dispute Resolution: 10
Previous abbreviated survey date: Aug 23, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed letter regarding enforcement remedies and plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 29, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Phillips Co Retirement ALF dated 09/29/2016.
Findings
No deficiencies were cited in the related inspection report.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Aug 23, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at the facility.
Complaint Details
This Plan of Correction is related to a complaint investigation as indicated by the reference to the Phillips County complaint revised 08/23/2016.
Findings
The facility terminated a CNA involved in an incident of abuse, neglect, or exploitation (ANE) on 8/19/16. The facility updated its ANE policy to include interviewing other residents during investigations and mandated all employees as reporters. Staff were re-trained on the policy and reporting requirements, and resident council meetings were held to emphasize the importance of reporting ANE.
Deficiencies (4)
F223-L: The facility terminated the CNA on 8/19/16 and updated the ANE policy to include interviewing other residents and mandated reporting. Staff were re-trained and resident council meetings held to notify residents of reporting importance.
F225-L: The facility terminated the CNA on 8/19/16 and updated the ANE policy to include interviewing other residents and mandated reporting. Staff were re-trained and resident council meetings held to notify residents of reporting importance.
F226-F: The facility terminated the CNA on 8/19/16 and updated the ANE policy to include interviewing other residents and mandated reporting. Staff were re-trained and resident council meetings held to notify residents of reporting importance.
F520-F: The facility terminated the CNA on 8/19/16 and updated the ANE policy to include interviewing other residents and mandated reporting. Staff were re-trained and resident council meetings held to notify residents of reporting importance.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 23, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the facility was not in substantial compliance and conditions constituted immediate jeopardy to resident health or safety related to F 223 "L", CFR 483.13(b), and F225 "L", CFR 483.13(c)(1)(ii). Enforcement remedies including denial of payment for new admissions were imposed.
Deficiencies (1)
Noncompliance with F 223 "L", CFR 483.13(b), F225 "L", CFR 483.13(c)(1)(ii), and F226 "F", CFR 483.13(c) was determined to be Substandard Quality of Care.
Report Facts
Denial of payment effective date: Sep 14, 2016
Recommended termination date: Feb 23, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter regarding survey findings and enforcement |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Aug 23, 2016
Visit Reason
Complaint investigations were conducted based on allegations of verbal and physical abuse by Nurse Aide C towards residents, including Resident #1.
Complaint Details
The complaint investigation involved multiple allegations of verbal and physical abuse by Nurse Aide C towards Resident #1 and other residents. The allegations were substantiated by resident interviews, staff observations, and record reviews. The facility failed to protect residents and delayed appropriate action, including suspension and reporting to the state agency.
Findings
The facility failed to protect residents from verbal and physical abuse by Nurse Aide C, who continued working multiple shifts despite multiple abuse reports. The facility also failed to thoroughly investigate and report the abuse allegations to the state agency and did not suspend the accused staff promptly. The Quality Assessment and Assurance Committee failed to identify and correct these deficiencies effectively.
Deficiencies (4)
F 223: The facility failed to protect residents from verbal and physical abuse by Nurse Aide C, who pushed a resident against cupboards, made threatening statements, and engaged in other abusive behaviors.
F 225: The facility failed to investigate and report allegations of abuse to the state agency and allowed Nurse Aide C to continue working during the investigation, placing residents at immediate jeopardy.
F 226: The facility failed to implement its abuse, neglect, and exploitation policies by not suspending Nurse Aide C after multiple abuse allegations and allowing continued resident risk.
F 520: The facility failed to maintain an effective Quality Assessment and Assurance Committee that identified and corrected deficiencies related to abuse and reporting, placing all residents at risk.
Report Facts
Resident census: 40
Residents sampled for abuse: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide C | Nurse Aide | Named in multiple abuse allegations including physical and verbal abuse of residents. |
| Administrative Nurse B | Administrative Nurse | Verified reports of abuse and investigation status; responsible for facility response. |
| Therapy Staff H | Therapy Staff | Reported abuse allegations to administration and verified resident fear. |
| Nurse Aide A | Nurse Aide | Observed assisting Resident #1 during ambulation. |
| Nurse Aide D | Nurse Aide | Witnessed Nurse Aide C making fun of residents and reported it. |
| Nurse Aide E | Nurse Aide | Witnessed Nurse Aide C pushing a resident and reported the incident. |
| Licensed Nurse F | Licensed Nurse | Verified multiple reports of verbal threats by Nurse Aide C but did not report to administration. |
| Nurse Aide G | Nurse Aide | Provided care to Resident #1 and reported abuse allegations to administration. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 8, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for deficiencies at the 'F' severity level under the Life Safety Code survey, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Sep 8, 2016
Effective date for provider agreement termination: Dec 8, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and responsible for licensure certification and enforcement |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 8, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility had deficiencies at the 'F' level in Life Safety Code compliance, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Enforcement effective date: Sep 8, 2016
Provider agreement termination date: Dec 8, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and responsible for licensure certification and enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 12, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.25(h), and 483.75(e)(8) were corrected as of 04/06/2016.
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 6, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Phillips Co Retirement Center.
Findings
The plan addresses deficiencies related to assessing residents for elopement risk upon admission, implementing interventions for elopement prevention, staff training on Abuse Neglect and Exploitation (ANE) and elopement, and ensuring ongoing employee training compliance through Relias courses.
Deficiencies (3)
F279-D: Upon admission, residents will be assessed for elopement risk and appropriate care plan interventions implemented, including possible placement in a locked dementia unit or other monitoring measures. Staff are trained on ANE and elopement at hire and annually, and door alarm codes are changed monthly as policy states.
F323-J: Residents will be assessed on admission for elopement risk with care plans updated immediately. Staff training on ANE and elopement policies was conducted in March 2016, and door alarm codes are changed monthly or as needed with oversight by administration and Quality Assurance.
F497-D: A policy requires all employees to complete at least one Relias training course monthly, with consequences for non-compliance including wage reduction and possible termination. Documentation of in-person training will be attached to employee accounts and monitored by Quality Assurance and administration.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 5, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not in substantial compliance and was cited for immediate jeopardy to resident health or safety from March 18, 2016 through March 30, 2016 related to F323, CFR 483.25(h). Enforcement remedies including denial of payment for new admissions were imposed.
Deficiencies (1)
F323, CFR 483.25(h) was cited for substandard quality of care constituting immediate jeopardy to resident health or safety from March 18, 2016 through March 30, 2016.
Report Facts
Denial of payment effective date: Apr 25, 2016
Recommended provider agreement termination date: Oct 5, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to enforcement and dispute resolution process |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 3
Date: Apr 5, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#98502) and partial extended survey to assess compliance with care plan development, supervision, and nurse aide training requirements.
Complaint Details
Complaint #98502 triggered the inspection. The complaint involved failure to develop adequate care plans and supervision leading to resident elopement and injury. The complaint was substantiated with findings of immediate jeopardy related to supervision failures.
Findings
The facility failed to develop a comprehensive care plan including elopement risk interventions for one resident who eloped and sustained injuries. The facility also failed to provide adequate supervision to prevent the resident's elopement and subsequent injury. Additionally, one nurse aide did not receive the required 12 hours of annual in-service education.
Deficiencies (3)
483.20(d), 483.20(k)(1) The facility failed to develop a comprehensive care plan including elopement risk interventions for Resident #1 who eloped and was injured.
483.25(h) The facility failed to ensure adequate supervision to prevent Resident #1's elopement and injury, placing the resident in immediate jeopardy.
483.75(e)(8) The facility failed to provide the required 12 hours of annual in-service education for one nurse aide employed for one or more years.
Report Facts
Resident census: 38
Certified Nurse Aides employed: 28
CNAs employed one or more years: 17
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Verified care plan lacked elopement interventions and confirmed interventions were added after elopement |
| Administrative Nurse F | Administrative Nurse | Verified resident was assessed as elopement risk and confirmed failure to supervise leading to injury |
| Nurse Aide B | Nurse Aide | Witnessed resident eloping from dining room |
| Nurse C | Charge Nurse | Reported resident eloped and confirmed knowledge of resident's exit-seeking behavior |
| Hospital Nurse D | Hospital Nurse | Found resident after fall and provided emergency care |
| Medical Provider E | Medical Provider | Treated resident for injuries sustained from fall after elopement |
| Administrative Staff G | Administrative Staff | Managed door code changes after elopement incident |
| Office Staff H | Office Staff | Responsible for tracking CNA education hours |
| Administrator G | Administrator | Acknowledged CNA lacked required education hours |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 29, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected by 07/17/2015 as documented in this revisit report.
Inspection Report
Follow-Up
Deficiencies: 11
Date: Jul 29, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by 07/17/2015 as verified during this revisit.
Deficiencies (11)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected by 07/17/2015.
Regulation 483.20(d), 483.20(k)(1) was corrected by 07/17/2015.
Regulation 483.20(d)(3), 483.10(k)(2) was corrected by 07/17/2015.
Regulation 483.20(k)(3)(i) was corrected by 07/17/2015.
Regulation 483.25 was corrected by 07/17/2015.
Regulation 483.25(h) was corrected by 07/17/2015.
Regulation 483.25(j) was corrected by 07/17/2015.
Regulation 483.25(l) was corrected by 07/17/2015.
Regulation 483.60(c) was corrected by 07/17/2015.
Regulation 483.60(b), (d), (e) was corrected by 07/17/2015.
Regulation 483.65 was corrected by 07/17/2015.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 18, 2015
Visit Reason
The visit was a resurvey of the Assisted Living/Resident Healthcare facility to verify compliance following a previous inspection.
Findings
The resurvey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Enforcement
Deficiencies: 0
Date: Jun 18, 2015
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be a 'G' level. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended.
Report Facts
Denial of Payment Effective Date: Sep 18, 2015
Termination Recommendation Date: Dec 18, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 11
Date: Jun 18, 2015
Visit Reason
The visit was a health resurvey to investigate compliance with prior deficiencies and regulatory requirements.
Findings
The facility had multiple deficiencies including failure to thoroughly investigate and report resident falls, failure to develop and revise comprehensive care plans, failure to monitor hydration and medication regimens, improper medication labeling and storage, and inadequate infection control practices.
Deficiencies (11)
F225: The facility failed to thoroughly investigate and report two falls with injury for Resident #44 to the appropriate state agency.
F279: The facility failed to develop a comprehensive care plan for Resident #43 to direct staff on palliative care service needs.
F280: The facility failed to review and revise the care plan for Resident #8 to include physician's order to increase fluid intake.
F281: The facility failed to obtain a physician ordered urinalysis for Resident #27 as directed.
F309: The facility failed to thoroughly assess and seek guidance for Resident #44 who had continued, unresolved pain.
F323: The facility failed to ensure the resident environment remained free of accident hazards and failed to complete root cause analysis for Resident #44 who had multiple falls including injuries.
F327: The facility failed to monitor and provide increased fluids for Resident #8 who had a physician's order for increased fluid and signs of dehydration.
F329: The facility failed to ensure Residents #23, #26, and #27 had drug regimens free from unnecessary drugs by failing to follow up on pharmacy consultant recommendations and obtain appropriate diagnoses.
F428: The facility failed to act upon pharmacy consultant recommendations for Residents #23, #26, and #27 and failed to obtain ordered lab tests and proper medication monitoring.
F431: The facility failed to ensure insulin products were properly labeled and dated and failed to properly store Tylenol suppositories.
F441: The facility failed to provide adequate infection control practices including proper use of personal protective equipment, disposal of contaminated waste, and staff training to prevent spread of infectious diseases such as C-Difficile.
Report Facts
Residents reviewed: 11
Residents reviewed for accidents: 4
Falls with injury not reported: 2
Tylenol administrations for pain: 17
Tylenol administrations for pain: 29
Tylenol administrations for pain: 1
Insulin vials observed: 11
Insulin pens observed: 2
Inspection Report
Enforcement
Deficiencies: 0
Date: Jun 18, 2015
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be at a 'G' level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective September 18, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Report Facts
Denial of Payment Effective Date: Sep 18, 2015
Termination Recommendation Date: Dec 18, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 17, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm. These deficiencies relate to noncompliance with Life Safety Code requirements.
Report Facts
Effective date for denial of payments: Jul 17, 2015
Provider agreement termination date: Oct 17, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process related to cited deficiencies. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 17, 2015
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, and not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Jul 17, 2015
Provider agreement termination date: Oct 17, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter and coordinated survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 16, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the prior survey completed on 2014-04-16.
Findings
All previously reported deficiencies identified by regulation numbers 483.25(h), 483.25(l), 483.60(c), 483.60(b), (d), (e), and 483.65 were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 5
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 16, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.25(h), 483.25(l), 483.60(c), 483.60(b), (d), (e), and 483.65 were corrected as of the revisit date.
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 16, 2014
Visit Reason
The licensure survey was conducted as part of the facility's renewal process to assess compliance with regulatory requirements.
Findings
The survey resulted in a finding of no deficiency citations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Apr 10, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection related to medication management, chemical storage, and equipment handling.
Findings
The facility failed to properly store chemicals, provide required medication reviews and risk-benefit statements, maintain locked storage for drugs and narcotics, ensure correct medication labeling, and properly store nebulizer masks and oxygen tubing. Corrective actions and ongoing monitoring plans were described for each deficiency.
Deficiencies (5)
F323-E: A facility policy was drafted to store all chemicals in a padlocked, designated area on each hall with staff education and daily maintenance checks to ensure areas remain locked.
F329-D: Failed to provide GDR or risk vs benefit statements for continued use of antipsychotic medications and failed to specify water flush amounts between medications for tube feeding.
F428-D: Pharmacy consultant to perform GDRs and risk vs benefit reviews every six months for residents on specified medications, with tracking and care plan reviews.
F431-E: Failed to keep all drugs and biologicals in locked storage and ensure narcotics were double locked; medication labeling errors were corrected and monitored.
F441-D: Failed to properly store one resident's nebulizer mask and oxygen tubing; policies and education implemented with ongoing monitoring.
Report Facts
Completion date: Apr 23, 2014
Completion date: May 16, 2014
Completion date: Apr 26, 2014
Completion date: Apr 23, 2014
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 5
Date: Apr 9, 2014
Visit Reason
The visit was a health resurvey to assess compliance with federal regulations following prior deficiencies.
Findings
The facility was found to have multiple deficiencies including unsafe storage of chemicals, failure to attempt gradual dose reductions for antipsychotic medications, improper medication labeling, unsecured medication carts, and inadequate infection control practices related to oxygen therapy equipment storage.
Deficiencies (5)
F323: The facility failed to provide a safe environment by not securely storing hazardous chemicals accessible to cognitively impaired residents on multiple halls.
F329: The facility failed to ensure gradual dose reductions or risk versus benefit statements were made for antipsychotic medications for 2 of 5 residents and failed to provide proper water flushes between medications administered via feeding tube for 1 resident.
F428: The pharmacist consultant failed to notify the Director of Nursing or physician about the need for gradual dose reductions or risk versus benefit statements for continued antipsychotic use in 2 residents.
F431: The facility failed to keep all drugs and biologicals in locked storage, ensure narcotics were double locked, and maintain correct medication labeling for 2 residents.
F441: The facility failed to properly store a nebulizer mask and oxygen tubing, risking infection control breaches.
Report Facts
Census: 40
Sample size: 13
Residents reviewed for unnecessary medication: 5
Medications administered via feeding tube: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Verified chemical storage issues, medication administration practices, and infection control deficiencies | |
| Maintenance C | Stated chemicals should be securely stored in locked areas | |
| Pharmacist Consultant D | Confirmed lack of gradual dose reduction requests and risk versus benefit statements for antipsychotic medications | |
| Nurse B | Observed medication administration and verified medication label correction procedures | |
| Nurse N | Observed feeding tube medication administration and water flush practices | |
| Physician K | Physician | Stated expectation for water flushes between medications administered via feeding tube |
| Nurse F | Observed medication cart locking practices and resident behavior | |
| Nurse Aide H | Reported resident behavior observations |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 3, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the initial survey.
Findings
The report confirms that the previously identified deficiencies have been corrected as of the dates listed. No uncorrected deficiencies remain.
Deficiencies (1)
Regulation 483.25, tag F0309 deficiency was corrected on 2014-02-07.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 5, 2014
Visit Reason
This document is a plan of correction submitted by Phillips County Retirement Center in response to deficiencies cited in a complaint investigation.
Findings
The plan addresses updates to the bowel evacuation protocol and the implementation of a new transportation policy, including staff education and monitoring to ensure compliance.
Deficiencies (2)
F0000: This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. Statement of Deficiencies will be taken to the facility's Quality Assurance Committee.
F309-G: The standing order protocol with the bowel evacuation protocol was updated and staff educated. The protocol is placed in medication records and monitored for compliance.
Report Facts
Plan of Correction Completion Date: Feb 5, 2014
Plan of Correction Completion Date: Feb 7, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Glendening | Assistant Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Jan 28, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#71903) regarding the facility's failure to provide adequate care and services to Resident #1.
Complaint Details
The complaint investigation #71903 found substantiated deficiencies related to Resident #1's care, including inadequate bowel management and unsafe transport practices leading to injury.
Findings
The facility failed to provide necessary bowel management assessments and medications to prevent constipation for Resident #1. Additionally, the facility failed to prevent multiple foot abrasions when staff transported the unresponsive resident in a wheelchair across a rough, sloping asphalt parking lot to the hospital.
Deficiencies (1)
483.25 Care and services were not provided to maintain Resident #1's highest well-being, including failure to assess and manage bowel movements and prevent constipation. The facility also failed to prevent foot abrasions caused by transporting the unresponsive resident in a wheelchair over rough terrain to the hospital.
Report Facts
Resident census: 46
Days without bowel movement: 5
Medication dosage: 30
Distance to hospital: 75
Slope degree: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Nurse | Stated facility policy on bowel management and transport procedures |
| Nurse A | Nurse | Reported staff transported residents by wheelchair and notified EMS for unresponsive residents |
| Nurse B | Nurse | Reported staff transported residents by wheelchair and notified EMS for unresponsive residents |
| Nurse Aide E | Nurse Aide | Described transporting alert residents by wheelchair and caution on rough route |
| Nurse Aide F | Nurse Aide | Described transporting alert residents by wheelchair and caution on rough route |
| Administrative Staff D | Administrative Staff | Reported no prior transportation policy and development of new policy after incident |
| Physician G | Physician | Stated two staff should have transported the resident due to medical condition |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 8, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the prior CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.25(l), 483.60(c), and 483.60(b), (d), (e) were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.25(l): Previously cited deficiency was corrected by the revisit date.
Regulation 483.60(c): Previously cited deficiency was corrected by the revisit date.
Regulation 483.60(b), (d), (e): Previously cited deficiency was corrected by the revisit date.
Report Facts
Deficiencies corrected: 3
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 8, 2013
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at Phillips County Retirement Center.
Findings
The report documents that the previously reported deficiency with regulation 28-39-158(a) was corrected as of 04/08/2013. No other deficiencies are listed.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected on 04/08/2013.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 8, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.25(l), 483.60(c), and 483.60(b), (d), (e) were corrected by the revisit date of 04/08/2013.
Deficiencies (3)
Regulation 483.25(l) deficiency was corrected by 04/08/2013.
Regulation 483.60(c) deficiency was corrected by 04/08/2013.
Regulation 483.60(b), (d), (e) deficiencies were corrected by 04/08/2013.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 8, 2013
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at Phillips County Retirement Center.
Findings
The report documents that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 04/08/2013.
Deficiencies (1)
Regulation 28-39-158(a) deficiency previously cited was corrected on 04/08/2013.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 12, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Re-Inspection
Census: 48
Deficiencies: 1
Date: Mar 11, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to employ a full-time certified dietary manager for the 48 residents. Observations and interviews confirmed the dietary manager was not certified and had been overseeing the kitchen without a CDM license since January 2013.
Deficiencies (1)
28-39-158(a) Dietary services require a full-time certified dietary manager. The facility failed to employ a certified dietary manager for the 48 residents residing in the facility.
Report Facts
Census: 48
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 7, 2013
Visit Reason
The inspection was a licensure resurvey to assess compliance for renewal of the facility's license.
Findings
The licensure resurvey resulted in a finding of no deficiency citations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Mar 7, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses deficiencies related to lab monitoring, pharmacy consultant reviews, insulin expiration procedures, and staff education. The facility outlines corrective actions including monitoring, staff inservices, and oversight responsibilities.
Deficiencies (4)
F329-D: Lab was drawn on resident #29 on 3.7.13. The facility will monitor lab draws and medication reviews to ensure appropriate lab monitoring.
F428-E: The Pharmacy Consultant was informed of deficiencies related to monthly reviews and will be monitored for completeness and timeliness of reviews.
F431-D: Procedures will be implemented to ensure outdated insulin is not used, including expiration date stickers and monitoring by nursing staff and Pharmacy Consultant.
S0600-E: An employee in the Dietary Department will enroll in the Certified Dietary Manager program starting June 3, 2013.
Report Facts
Date of lab draw: Mar 7, 2013
Plan of Correction completion dates: Mar 21, 2013
Certified Dietary Manager program start date: Jun 3, 2013
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 31, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the plan of correction.
Findings
The report confirms that the deficiency identified under regulation 483.10(b)(11) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.10(b)(11) deficiency was previously cited and has been corrected as of 10/31/2012.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 31, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the prior survey conducted on 2012-10-15.
Findings
The revisit report shows that the previously cited deficiency under regulation 483.10(b)(11) was corrected as of 2012-10-31. No other deficiencies are listed as outstanding.
Deficiencies (1)
Regulation 483.10(b)(11) deficiency was corrected by the revisit date of 2012-10-31.
Report Facts
Deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Date: Oct 15, 2012
Visit Reason
The inspection was conducted as a complaint investigation (#60401) regarding the facility's failure to promptly and adequately notify the physician of falls with head trauma and anticoagulation therapy for two residents.
Complaint Details
The complaint investigation (#60401) found the facility did not promptly notify the physician of falls with head trauma and elevated INR levels for two residents on anticoagulation therapy. The facility delayed reporting elevated INR to the physician's assistant and hospital, which contributed to delayed emergency care.
Findings
The facility failed to promptly notify the physician about falls with head trauma and elevated anticoagulation levels for two residents on Coumadin therapy, resulting in delayed hospital transfer and treatment. Documentation and communication deficiencies were noted in reporting elevated INR levels and fall incidents.
Deficiencies (1)
F 157: The facility failed to promptly and adequately notify the physician of falls with head trauma and anticoagulation therapy for two residents, resulting in delayed hospital intervention and increased risk of harm.
Report Facts
Census: 51
PT/INR laboratory test result: 39.6
INR laboratory test result: 3.89
PT/INR laboratory test result: 3.56
PT/INR laboratory test result: 18.8
INR laboratory test result: 1.74
PT/INR laboratory test result: 30.7
INR laboratory test result: 2.95
Inspection Report
Plan of Correction
Deficiencies: 8
Date: N074003 POC U9TJ11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies during a regulatory inspection.
Findings
The plan outlines corrective actions for multiple deficiencies including flooring replacement, cleaning protocols, correct coding for bowel incontinence, diet order accuracy, diagnosis review for antipsychotic medications, hand hygiene training, and paging system functionality.
Deficiencies (8)
F584-D: The flooring in the whirlpool room is being replaced and cleaning protocols have been enhanced to address odor and cleanliness issues.
F641-E: Nurses will be educated on correct coding related to bowel incontinence and bowel training protocols to ensure accurate MDS coding.
F657-D: The correct diet order will be requested for resident #1 and staff will be re-educated on updating care plans and diet orders.
F756-D: The correct diagnosis for resident #25 will be reviewed and monitored to prevent recurrence, with ongoing education for providers on antipsychotic medication diagnoses.
F758-D: Diagnosis review and monitoring for resident #25 will continue monthly with education for providers and consultation with pharmacists.
F808-D: Diet orders for resident #1 will be tracked and staff re-educated on importance and accuracy of diet cards and care plan updates.
F812-E: Staff will be trained on hand hygiene and glove use with ongoing monitoring of dining rooms for infection control issues.
F919-E: The paging system will be reprogrammed and nursing staff trained to monitor and report any malfunctions.
Report Facts
Complete Date: May 24, 2018
Complete Date: Jun 15, 2018
Complete Date: May 30, 2018
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N074003 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility identified as State ID N074003 ASPEN.
Findings
No deficiencies or findings are listed in this Plan of Correction document. It contains no records or details of corrective actions.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N074003 POC 07KI11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for Phillips Co Retirement ALF.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a corrective action plan submission.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: N074003 POC 7MQ511
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection report.
Findings
The plan outlines corrective actions for multiple deficiencies including grievance policy implementation, ANE reporting, background checks, care planning, antipsychotic medication diagnosis, RN staffing, pharmacy consultant involvement, and housekeeping training.
Deficiencies (9)
F0000 Statement of Deficiencies will be taken to the facility's Quality Assurance Committee on October 10, 2016.
F166-D The facility has created and implemented a formal grievance policy and procedure. The social services director will review the policy with all new residents upon admission and at least annually at resident council meetings.
F225-D The ANE reporting policy was reviewed with the employee involved immediately after the alleged event. The employee was given a written notice about termination for failure to report future incidents promptly.
F226-E The facility will conduct online background checks through KDADS to verify all employee record checks regardless of criminal history. Results will be placed in employee files.
F279-D A policy for care planning addressing medication administration records, black box warnings, and problem areas of care has been written. Nursing staff will be trained and random audits conducted.
F329-E Education on proper diagnosis for antipsychotic prescriptions will be provided to medical and nursing staff. Policies on PRN medication review and pharmacy consultant recommendations have been updated and will be monitored.
F354-F The facility is advertising to hire a part-time RN and has rearranged nursing schedules to ensure 8 hours of RN coverage daily. The DON is responsible for assuring coverage.
F428-D The DON met with the pharmacy consultant regarding drug regimen irregularities. Behavior logs will be individualized and inservice training provided. New behavior logs will be implemented by October 28, 2016.
F441-F Housekeeping staff have been retrained on chemical use, hand washing, glove use, and infection control. An information sheet on chemicals will be placed in the housekeeping room and monitored by supervisors.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N074003 POC CP8D11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as CP8D11 for facility State ID N074003 ASPEN.
Findings
No deficiency records or findings are included in this Plan of Correction document. It serves as a corrective action response to a previous inspection.
Inspection Report
Plan of Correction
Deficiencies: 11
Date: N074003 POC F43H11
Visit Reason
This document is a Plan of Correction submitted by Phillips Co Retirement Center in response to deficiencies identified in a prior inspection report.
Findings
The Plan of Correction outlines multiple corrective actions including staff re-training on incident reporting, implementation of new policies on palliative care, hydration, provider rounds, pain management, root cause analysis, pharmacy consultant follow-up, medication tracking, and infection control.
Deficiencies (11)
F225-D Nursing staff will be re-trained on when incidents need to be reported to the State and the facility's Abuse, Neglect, and Exploitation policy will be reviewed. DON and ADON will follow-up on falls to determine reporting needs.
F279-D The facility developed a Palliative Care/Hospice Policy to be implemented immediately, integrating staff and family input and ensuring care plan communication during shift reports.
F280-D A Hydration Policy will be implemented by July 15, training staff to offer fluids regularly and update care plans promptly with new orders.
F281-D A Provider Rounds Policy will be implemented to document resident visits and orders, with nurse education and management follow-up.
F309-D Nursing staff will be re-educated on pain as the 5th vital sign and the Pain Management policy will be reviewed for improvements.
F323-G The facility will implement a Root Cause Analysis Policy involving DON/ADON, charge nurses, and family within 48 hours of incidents.
F327-D A Hydration Policy will be implemented with education for nursing and dietary staff and management follow-up.
F329-D A Pharmacy Consultant Policy was developed to ensure follow-up with physicians within 10 days of recommendations and re-education of staff on diagnosis documentation.
F428-D The Pharmacy Consultant Policy provides nursing staff direction after visits and requires management follow-up to ensure orders are carried out.
F431-E A Medication Tracking Policy was implemented to clarify responsibility for dating and discarding insulins, with procedures posted in the medication room.
F441-F Staff will be re-educated on infection control and resident isolation policies, including proper disposal of isolation garbage and handling of infectious laundry.
Report Facts
Complete Date: Jul 13, 2015
Complete Date: Jul 8, 2015
Complete Date: Jul 15, 2015
Complete Date: Jul 17, 2015
Complete Date: Jun 29, 2015
Complete Date: Jun 23, 2015
Complete Date: Jul 10, 2015
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N074003 POC FVQ011
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by Phillips Co 101512 Complaint.
Findings
The facility developed and revised policies related to Anticoagulation Therapy and fall follow-up procedures, including notifying the provider after certain resident incidents. These policy changes will be reviewed with current and new nursing staff and monitored through routine fall and incident report reviews.
Deficiencies (2)
F0000 statement of deficiencies will be taken to the next Quality Assurance/Assessment Committee meeting.
F157-D The facility revised the Coumadin/Anticoagulation Care Plan to include provider notification after unwitnessed falls or injuries and updated related policies and documentation. These changes will be reviewed with nursing staff and monitored for compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Glendening | Assistant Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N074003 POC PZPY11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of the Aspen facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves solely as a record of the Plan of Correction submission.
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