Inspection Reports for Access Mental Health LLC
500 PEABODY, PEABODY, KS, 66866
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 4, 2022 found no deficiencies, confirming the facility was in compliance with all surveyed regulations. Earlier inspections showed a pattern of deficiencies primarily related to resident care planning, infection control including COVID-19 protocols, food service sanitation, and management of residents’ personal funds. Several complaint investigations substantiated issues with resident supervision, including multiple elopement incidents that at times resulted in immediate jeopardy findings, as well as concerns about nutritional assessments and discharge planning. Enforcement actions included civil money penalties and immediate jeopardy findings in prior years, but no fines or license suspensions were listed in the available reports. The facility appears to have made improvements over time, correcting prior deficiencies and achieving compliance in the most recent surveys.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
41 residents
Based on a January 2022 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 4, 2022
Visit Reason
A revisit survey for a Targeted Infection Control/Covid-19 survey was conducted on 05/04/2022 to verify correction of all previous deficiencies cited on 01/14/2022.
Findings
All deficiencies have been corrected as of the compliance date of 02/28/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Compliance date: Feb 28, 2022
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Feb 28, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a regulatory survey.
Findings
The facility was cited for multiple deficiencies including failure to distribute interest in trust accounts, maintain windows, develop Care Area Assessments, review and revise care plans, complete discharge summaries, initiate interventions following falls, maintain sanitary food service conditions, enforce COVID-19 protocols, notify residents of COVID outbreaks, maintain sanitary kitchen environment, and provide adequate ventilation.
Deficiencies (11)
Failed to distribute interest in the trust account to residents with account balances greater than $50.00.
Failed to maintain windows in the resident rooms and commons area in a safe, clean, and homelike manner.
Failed to develop a Care Area Assessment (CAA) for triggered areas of the MDS.
Failed to review and revise the care plan.
Failed to complete a discharge summary at the time of discharge from the facility.
Failed to initiate appropriate interventions following a fall.
Failed to store and serve food under sanitary conditions to prevent the spread of foodborne illness.
Failed to ensure visitors were screened appropriately for COVID, staff wore face masks effectively, and quarantine of unvaccinated residents was timely following a COVID outbreak.
Failed to notify all residents/responsible parties of COVID outbreak.
Failed to provide a sanitary environment for residents and staff in the kitchen.
Failed to have adequate ventilation to control odor of unknown sources in residents' environment.
Report Facts
Deficiencies cited: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice F Baldridge | Administrator | Administrator who submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 11
Date: Jan 14, 2022
Visit Reason
The inspection was a Health Resurvey and investigation of multiple complaints related to the facility's compliance with regulatory requirements.
Complaint Details
The inspection included investigation of multiple complaints (#168052, #165309, #164108, #163977, #163857, #163385, #162944, #162864, #162061, #161733, #161426, #160819, #160784, #160553, and #168859).
Findings
The facility was found deficient in multiple areas including failure to manage residents' personal funds with interest-bearing accounts, inadequate maintenance and cleanliness of windows, incomplete comprehensive assessments and care plans, failure to complete discharge summaries, inadequate fall interventions, unsafe shower chair, unsanitary food storage and preparation conditions, ineffective infection prevention and control practices including COVID-19 screening and quarantine, failure to timely notify residents and families of COVID-19 outbreaks, unsanitary kitchen environment, and inadequate ventilation causing malodorous conditions.
Deficiencies (11)
Failure to establish a system to ensure residents with personal funds over $50 received interest-bearing accounts and distribution of interest.
Failure to maintain windows in resident areas in a safe, clean, and homelike manner.
Failure to complete required Care Area Assessments (CAA) for multiple residents related to psychotropic medications, falls, and ADL functional potential.
Failure to review and revise care plans timely for residents, including fall interventions and anticoagulant use.
Failure to complete discharge summary for a resident at time of discharge.
Failure to initiate appropriate fall interventions following resident falls and failure to provide a safe shower chair with a large crack.
Failure to store and serve food under sanitary conditions, including dirty kitchen equipment and undated food containers.
Failure to maintain an effective infection prevention and control program, including inadequate COVID-19 visitor screening, improper mask use by staff, and failure to quarantine unvaccinated residents timely after staff COVID-19 outbreak.
Failure to notify residents, representatives, and families timely of COVID-19 outbreak in the facility.
Failure to provide a sanitary environment in the kitchen, including debris buildup on floors.
Failure to provide adequate ventilation to control malodorous odors in the facility.
Report Facts
Residents with trust accounts: 35
Resident census: 41
Visitor log entries missing temperatures: 20
Staff positive for COVID-19: 4
Residents unvaccinated for COVID-19: 3
Length of delay in quarantine: 4
Length of crack in shower chair: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Responsible for completion of Care Area Assessments and acknowledged failure to isolate unvaccinated residents timely after COVID-19 staff outbreak. |
| Dietary Manager X | Dietary Manager | Acknowledged kitchen cleaning schedules were mostly blank and staff failed to clean as scheduled; confirmed improper mask use by staff. |
| Licensed Nurse G | Licensed Nurse | Stated nurses are responsible for initiating new interventions following falls. |
| Certified Medication Aide S | Certified Medication Aide | Kept log of resident accounts and verified interest was not figured in. |
| Maintenance Staff U | Maintenance Staff | Removed shower chair with crack from shower room. |
| Social Service Staff X | Social Service Staff | Confirmed kitchen floor was dirty and expected to be cleaned daily. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
A revisit survey was conducted from 11/30/2020 to 12/02/2020 to verify correction of all previous deficiencies cited on 09/17/2020.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 10/31/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Dates of revisit survey: 11/30/2020 to 12/02/2020
Previous deficiency citation date: 09/17/2020
Compliance date: 10/31/2020
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
A revisit survey was conducted from 11/30/2020 to 12/02/2020 to verify correction of all previous deficiencies cited on 08/20/2020.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 09/30/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 17, 2020
Visit Reason
This document is a plan of correction submitted by the facility in response to deficiencies cited during a survey conducted on 9/17/2020.
Findings
The facility developed and implemented a facility-wide system to assure continued compliance with regulations, including written bed-hold agreements and timely registered dietitian assessments for residents.
Deficiencies (2)
Failure to provide a written bed-hold agreement with duration and current private pay rate.
Failure to ensure timely registered dietitian assessments for new residents, significant changes, and annual comprehensive assessments.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Date: Sep 17, 2020
Visit Reason
The inspection was conducted as an investigation of complaints #155929, #155834, and #155438 regarding regulatory compliance at Franklin Healthcare of Peabody LLC.
Complaint Details
The investigation was triggered by complaints #155929, #155834, and #155438. The findings substantiated failures related to bed hold notices and nutritional care.
Findings
The facility failed to provide proper 'Bed Hold' notices specifying the duration of bed-hold policy for four residents transferred to acute care. Additionally, the facility failed to ensure timely nutritional assessments and interventions for a resident with significant weight loss, resulting in inadequate monitoring and care.
Deficiencies (2)
Failure to issue 'Bed Hold Notice' specifying the duration of the bed-hold for four residents upon transfer.
Failure to maintain nutrition/hydration status by not providing timely registered dietician assessments and nutritional interventions for a resident with significant weight loss.
Report Facts
Resident census: 41
Residents transferred since June 2020: 5
Residents requiring Bed Hold Notice: 4
Weight loss percentage: 12.7
Weight loss percentage: 6.53
Weight loss percentage: 5.2
Weight loss percentage: 6.69
Bed hold duration (days): 21
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Aug 20, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on August 20, 2020.
Findings
The facility developed and implemented corrective actions addressing multiple deficiencies including residents' rights to choose where to eat, access to trust funds outside business hours, housekeeping and maintenance standards, accurate comprehensive assessments, baseline care plans, restorative nursing, elopement assessments, choking risk assessments, staffing based on resident needs, social service documentation, cleaning schedules, COVID-19 social distancing, antibiotic stewardship, and abuse neglect training.
Deficiencies (14)
Failure to recognize residents' right to choose where to eat.
Failure to make trust funds available outside normal business hours.
Failure to maintain housekeeping and maintenance standards.
Failure to provide accurate comprehensive assessments.
Failure to develop baseline care plans within 48 hours of admission.
Failure to develop and implement restorative nursing into comprehensive care plans.
Failure to develop and implement restorative nursing to prevent decrease in range of motion.
Failure to complete elopement assessments and care plan interventions timely.
Failure to staff based on resident needs and services required.
Failure to timely document social service needs and referrals.
Failure to develop and implement daily, weekly, monthly cleaning schedules.
Failure to maintain social distancing in dining area to prevent COVID-19 spread.
Failure to implement an effective antibiotic stewardship program.
Failure to provide abuse, neglect, and exploitation training to staff.
Report Facts
Deficiencies cited: 14
Dates for completion: 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice F Baldridge | Administrator | Administrator who submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 14
Date: Aug 20, 2020
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations triggered by multiple complaints and incidents including elopement and resident altercations.
Complaint Details
Complaint investigations included incidents of resident elopement, resident-to-resident altercation, and failure to provide adequate supervision and care.
Findings
The facility was found deficient in multiple areas including failure to provide adequate supervision leading to immediate jeopardy elopement, failure to support resident self-determination, inaccurate resident assessments, inadequate baseline and comprehensive care plans especially for restorative services, insufficient nursing staff, failure to provide medically-related social services after a resident altercation, unsanitary food preparation conditions, failure to maintain social distancing in dining areas, ineffective antibiotic stewardship, and failure to provide required nurse aide in-service training.
Deficiencies (14)
Failure to provide adequate supervision for resident #86 who eloped and was found 37 miles away, constituting immediate jeopardy.
Failure to support resident choice to eat in his room for Resident 28.
Failure to ensure availability of resident funds on weekends for 38 residents.
Failure to maintain a safe, clean, comfortable, and homelike environment with multiple maintenance issues.
Failure to complete accurate comprehensive assessments for multiple residents including cognitive, dental, medication, and range of motion assessments.
Failure to develop individualized baseline and comprehensive care plans including restorative care for multiple residents.
Failure to provide restorative services to maintain or improve mobility and range of motion for multiple residents.
Failure to assess elopement risk and develop interventions for resident #86 and failure to monitor resident #17 during meals to prevent choking.
Failure to ensure adequate nursing staff to meet resident needs and ensure quality of care.
Failure to provide medically-related social services to resident #25 following a resident-to-resident altercation.
Failure to store and prepare food under sanitary conditions in the kitchen including staff not wearing masks properly and dirty equipment.
Failure to ensure social distancing in the common dining area to prevent spread of COVID-19.
Failure to ensure an effective antibiotic stewardship program including monitoring antibiotic use and applying McGeers Criteria.
Failure to provide required annual in-service training for nurse aides on Abuse, Neglect, and Exploitation.
Report Facts
Census: 40
Residents reviewed: 19
Elopement risk score: 24
Distance resident traveled: 37
Staffing: 2
Number of residents requiring assistance with bathing: 15
Number of residents requiring assistance with dressing: 5
Number of residents requiring assistance with toileting: 4
Number of residents requiring assistance with eating: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN H | Licensed Nurse | Charge nurse on 08/15/20 day shift during resident #86 elopement |
| CNA P | Certified Nurse Aide | Only other nursing staff on 08/15/20 day shift during resident #86 elopement |
| Administrative Nurse D | Administrative Nurse | Verified lack of restorative program and staffing issues |
| Social Services X | Social Services Staff | Interviewed regarding resident #25 altercation and follow-up |
| Licensed Nurse G | Licensed Nurse | Charge nurse on 08/13/20 and interview regarding resident care and antibiotic stewardship |
| Administrative Staff A | Administrator | Provided information on elopement and courtyard supervision |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 11, 2020
Visit Reason
An offsite revisit was conducted on 06/11/2020 for all previous deficiencies cited on 11/29/18 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of 06/02/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 19, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated 05.19.2020 for the facility identified as ASPEN.
Findings
The Plan of Correction addresses deficiencies previously cited as past non-compliance under tags F0000 and F689-J, with corrective actions and completion dates provided.
Deficiencies (2)
Deficiency cited as Past Non-compliance under tag F0000
Deficiency cited as Past Non-compliance under tag F689-J
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice Vangotten | Regional Manager | Submitted and modified the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 6, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a deficiency-free COVID-19 survey conducted on May 6, 2020.
Findings
The facility was found to be deficiency-free during the COVID-19 survey conducted on May 6, 2020.
Deficiencies (1)
Deficiency free covid survey
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 6, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Date: Mar 9, 2020
Visit Reason
A complaint survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS due to complaint investigation #152645 regarding a resident elopement incident.
Complaint Details
Complaint investigation #152645 found the facility not in substantial compliance with 42 CFR 483 subpart B due to failure to prevent resident elopement. The resident exited through a locked door, walked 3.5 miles crossing a busy highway, and was found face down in a ditch. Immediate jeopardy was identified.
Findings
The facility failed to provide adequate supervision to prevent one resident from leaving the facility without staff knowledge, resulting in the resident walking approximately 3.5 miles, crossing a busy highway, and being found face down in a ditch, placing the resident in immediate jeopardy. The facility implemented corrective actions including one-on-one supervision, door alarm checks, resident re-assessments, staff re-education, and elopement drills.
Deficiencies (1)
Failed to provide adequate supervision to prevent one resident from leaving the facility without staff knowledge, resulting in immediate jeopardy.
Report Facts
Census: 32
Distance walked by resident: 3.5
Speed limit: 55
BIMS score: 10
Skin scrape size: 4
Skin scrape size: 0.25
Discolored area size: 3
Skin scrape size: 2
Puncture wound size: 0.25
Temperature: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide C | Certified Nurse Aide | Interviewed and last saw resident in room at 07:35 AM on 05/17/2020 |
| Licensed Nurse B | Licensed Nurse | Notified and participated in facility search; assessed resident's vitals and skin after elopement |
| Administrative Staff A | Administrative Staff | Interviewed regarding resident elopement and door alarm functionality; identified need for immediate action |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Date: Mar 9, 2020
Visit Reason
A complaint survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS on 03/09/2020 due to concerns about resident supervision and safety.
Complaint Details
The complaint investigation #152645 found the facility not in substantial compliance with 42 CFR 483 subpart B due to inadequate supervision leading to resident elopement and immediate jeopardy.
Findings
The facility failed to provide adequate supervision to prevent one resident from leaving the facility unnoticed, resulting in the resident walking approximately 3.5 miles, crossing a busy highway, and being found face down in a ditch, placing the resident in immediate jeopardy.
Deficiencies (1)
Failed to provide adequate supervision to prevent one resident from leaving the facility without staff knowledge, resulting in immediate jeopardy.
Report Facts
Census: 32
Distance walked by resident: 3.5
Speed limit: 55
Injury size: 4
Injury size: 0.25
Injury size: 3
Injury size: 2
Injury size: 0.25
Injury size: 0.25
Temperature: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide C | Certified Nurse Aide | Interviewed regarding last seen time of resident and search efforts |
| Licensed Nurse B | Licensed Nurse | Notified of resident missing, participated in search and assessment of resident injuries |
| Administrative Staff A | Interviewed about resident elopement and door alarm functionality |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Mar 9, 2020
Visit Reason
A complaint survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS on 03/09/2020 due to complaint investigation #150975 regarding failure to adequately supervise a resident at risk for elopement.
Complaint Details
The complaint investigation #150975 found the facility failed to monitor Resident 1 who required one-to-one supervision during outings. The resident eloped near a highway with a 55 mph speed limit after staff left her unattended in the facility van on 03/04/2020. The facility was found not in substantial compliance with federal regulations.
Findings
The facility failed to provide adequate one-to-one supervision for Resident 1 during an outing, resulting in the resident eloping near a heavily traveled highway. Staff left the resident unattended in the facility van for a minimum of five minutes, contrary to the care plan. The resident was found and returned safely, but the facility was not in substantial compliance with 42 CFR 483 subpart B.
Deficiencies (1)
Failure to provide adequate supervision to prevent elopement of a cognitively impaired resident requiring one-to-one supervision during outings.
Report Facts
Census: 36
Speed limit: 55
Minimum time unattended: 5
Date of elopement incident: Mar 4, 2020
Date of survey: Mar 9, 2020
Date of staff education completion: Mar 5, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Staff Z | Left resident unattended in van during outing | |
| Social Services Staff X | Assisted other resident in store and notified police after resident eloped | |
| Licensed Nurse G | Licensed Nurse | Reported resident was an elopement risk and described incident |
| Administrative Staff A | Administrator | Reported facility system failure and awareness of resident's supervision needs |
| Certified Medication Aide R | Certified Medication Aide | Reported staff should provide one-to-one supervision during outings |
| Administrative Nurse D | Administrative Nurse | Reported staff failed to provide one-to-one supervision during outing |
| Physician GG | Physician | Aware of elopement incident and supervision requirements |
| Outside Resource Staff KK | Chief of Police | Received call about missing resident and confirmed description |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 5, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited as past noncompliance on 03/05/2020.
Findings
The plan addresses deficiencies identified in the prior inspection, specifically related to tags F0000 and F689-J, both cited as past noncompliance.
Deficiencies (2)
Deficiency related to tag F0000 cited as past noncompliance
Deficiency related to tag F689-J cited as past noncompliance
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 25, 2019
Visit Reason
A revisit survey was conducted on 4/25/19 to verify correction of all previous deficiencies cited on 2/28/19.
Findings
All deficiencies have been corrected as of the compliance date of 4/5/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Apr 5, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection, detailing corrective actions for each cited deficiency.
Findings
The Plan of Correction outlines specific corrective actions for multiple deficiencies related to resident care preferences, resident rights, staffing, clinical documentation, medication administration, dietary services, infection control, and facility maintenance. The facility describes measures to prevent recurrence and monitoring plans to ensure sustained compliance.
Deficiencies (19)
Failure to update and audit resident shower/bathing preferences
Resident rights not adequately discussed or monitored
Weekend mail delivery not properly managed
Physician notification and orders for hospital transfers not consistently obtained
Facility maintenance and housekeeping issues
Baseline care plans not completed timely for new admissions
Comprehensive care plans including behaviors not consistently developed
Discharge plans not consistently in place
Employee performance reviews incomplete
Staffing sheets not properly posted or maintained
Blood pressure and pulse documentation and monitoring deficient
Blood pressure and pulse monitoring prior to medication administration deficient
Documentation of behaviors for residents on psychotropic medications deficient
Dietary staff not properly preparing pureed food items
Dietary kitchen sanitation and equipment issues
Dumpster lids not properly maintained
Facility assessment incomplete or outdated
Blood sugar monitoring and glucometer cleaning deficient
Infection control nurse education and infection control practices deficient
Report Facts
Audit frequency: 2
Audit frequency: 3
Audit frequency: 5
Audit frequency: 90
Audit frequency: 90
Audit frequency: 60
Audit frequency: 3
Audit frequency: 4
Audit frequency: 90
Audit frequency: 90
Audit frequency: 60
Audit frequency: 6
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse F | Licensed Nurse | Named in blood sugar and glucometer cleaning deficiency and corrective action |
| Bryan Roby | Submitted the Plan of Correction | |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 19
Date: Feb 28, 2019
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation involving multiple complaint investigation numbers.
Complaint Details
The visit was complaint-related as it included multiple complaint investigation numbers: 129242, 132883, 132915, 132974, 136514, 136663, 137907, 138653, and 138770.
Findings
The facility was found deficient in multiple areas including failure to provide resident choice in bathing, failure to inform residents of their rights, failure to provide mail on weekends, failure to notify physicians of hospital transfers, inadequate housekeeping and maintenance, failure to develop baseline and comprehensive care plans, failure in discharge planning, lack of nurse aide in-service training, incomplete nurse staffing postings, failure to act on pharmacist recommendations, failure to monitor behaviors related to psychotropic medications, improper food preparation, unsanitary food storage and disposal, lack of facility assessment, and failure to maintain an effective infection prevention and control program including antibiotic stewardship.
Deficiencies (19)
Failed to provide resident #77 his/her choice of bathing.
Failed to inform residents of their rights on an ongoing basis.
Failed to ensure residents could receive mail on Saturdays.
Failed to notify and obtain physician's order for hospital transfer of resident #7.
Failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment.
Failed to develop baseline care plan within 48 hours of admission and failed to provide resident #79 a summary of the baseline care plan.
Failed to develop and implement a comprehensive care plan for resident #7 related to behaviors.
Failed to develop an effective discharge plan for resident #1.
Failed to complete yearly nurse aide performance reviews and provide required 12 hours of in-service education for 6 direct care staff.
Failed to post nurse staffing information daily including actual hours worked and resident census.
Failed to act timely on consultant pharmacist recommendations to monitor blood pressure and pulse for resident #79.
Failed to monitor behaviors for resident #79 related to administration of psychotropic medications.
Failed to provide puree diets in a form designed to meet individual needs as ordered.
Failed to store and prepare food under sanitary conditions in the kitchen.
Failed to dispose of garbage properly; dumpsters lacked lids.
Failed to conduct and document a facility-wide assessment to determine necessary resources for resident care.
Failed to establish and maintain an infection prevention and control program including proper sanitization of blood glucose monitor and hand hygiene.
Failed to establish and maintain an infection prevention and control program including tracking and trending infections.
Failed to establish an antibiotic stewardship program including antibiotic use protocols and monitoring system.
Report Facts
Residents sampled: 13
Deficiency counts: 18
Resident census: 37
Resident urine colony count: 50000
Resident urine colony count: 60000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Nursing Staff | Reported unawareness of bathing choices and failed to wash hands before blood glucose testing. |
| Staff B | Administrative Nursing Staff | Verified failures in care planning, discharge planning, infection control, and nurse staffing posting. |
| Staff C | Consultant Nursing Staff | Reported lack of infection control and antibiotic stewardship training. |
| Staff E | Administrative Nursing Staff | Verified failure to notify physician for hospital transfer and lack of infection control documentation. |
| Staff K | Direct Care Staff | Reported resident bathing preferences and behaviors. |
| Staff L | Direct Care Staff | Reported resident bathing preferences and behaviors. |
| Staff O | Direct Care Staff | Reported resident bathing preferences and behaviors. |
| Staff J | Direct Care Staff | Verified failure to monitor blood pressure and pulse and behaviors. |
| Staff MN | Dietary Staff | Remade pureed meals with thickener added. |
| Staff T | Dietary Staff | Prepared pureed meals without thickener. |
| Staff U | Laundry Staff | Reported lack of washing machine temperature monitoring. |
| Maintenance Staff M | Maintenance Staff | Verified housekeeping concerns and lack of washing machine programming. |
| Guardian Z | Resident's Guardian | Reported lack of discharge planning and assistance. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 19, 2019
Visit Reason
A revisit survey was conducted on 2/18/19 and 2/19/19 for all previous deficiencies cited on 12/13/18.
Findings
All deficiencies have been corrected as of the compliance date of 12/13/18 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Dec 13, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#KS00136217) regarding a resident elopement incident.
Complaint Details
Complaint investigation #KS00136217 found the resident eloped from the facility on 12/7/18 without staff knowledge, placing the resident in immediate jeopardy. The resident was found walking five blocks away in cold temperatures. The facility's investigation revealed a malfunctioning service hall door possibly allowed the exit. The resident was identified as at risk for elopement and had a wanderguard alarm, but supervision failed.
Findings
The facility failed to ensure adequate supervision and safety measures for one resident at risk of elopement, who exited the facility unnoticed and walked five blocks away in cold weather, placing the resident in immediate jeopardy. The facility identified a malfunctioning service hall door as a possible exit point and implemented multiple corrective actions to abate the immediate jeopardy.
Deficiencies (1)
Failure to ensure one resident received adequate supervision and/or assistive devices to prevent elopement, resulting in the resident exiting the facility unnoticed and walking outside in cold weather.
Report Facts
Census: 42
Residents reviewed for elopement: 3
Distance resident walked: 5
Outside temperature: 35
Outside temperature: 42
Date of elopement: Dec 7, 2018
Date survey completed: Dec 13, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff C | On duty at time of elopement and observed resident after return | |
| Administrative staff D | Observed resident walking on road and stopped to return resident to facility | |
| Administrative staff A | Identified concern with service hall door and demonstrated door alarm issue | |
| Maintenance staff F | Reported door needed replacement and participated in door alarm testing | |
| Direct care staff E | Verified supervised smoking and wanderguard alarm on morning of elopement | |
| Administrative staff E | Observed resident walking on road and offered ride back to facility |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 13, 2018
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 most serious deficiency to be F689, "J", CFR 483.25 with actual harm that is not immediate jeopardy. The facility was found to have substandard quality of care and will not be given the opportunity to correct deficiencies before remedies are imposed.
Deficiencies (1)
Deficiency F689, "J", CFR 483.25 with actual harm that is not immediate jeopardy
Report Facts
Civil Money Penalty: 4400
Denial of payment effective date: Jan 10, 2019
Termination effective date: Jun 13, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Roby | Administrator | Named as facility administrator in the report |
| Caryl Gill | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
| Patty Brown | Interim Commissioner | Interim Commissioner of Kansas Department for Aging & Disability Services |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 13, 2018
Visit Reason
This document is a Plan of Correction submitted by Peabody Westview Manor in response to deficiencies cited related to missing residents and elopement risk.
Findings
The facility identified deficiencies related to missing residents and elopement risk, including inadequate staff education and door alarm functionality. Corrective actions include resident assessments, staff re-education, door alarm upgrades, and ongoing monitoring.
Deficiencies (1)
Deficiency related to missing residents and elopement risk, including inadequate staff education and door alarm issues.
Report Facts
Staff re-education completion: 100
Monitoring duration: 90
Monitoring duration: 90
Monitoring frequency: 3
Resident re-assessment: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Diana Melander | Submitted the Plan of Correction to KDADS | |
| Caryl Gill | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 7
Date: Nov 29, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #KS00135619 and KS00135211.
Complaint Details
The inspection was triggered by complaint investigations #KS00135619 and KS00135211.
Findings
The facility was found deficient in multiple areas including failure to properly manage residents' personal funds and trust accounts, failure to maintain a safe, clean, and homelike environment, failure to properly safeguard and dispose of narcotic medications, failure to maintain a sanitary kitchen, and failure to maintain resident medical records in an accurate and organized manner.
Deficiencies (7)
Failure to establish a system to ensure residents received interest on personal funds held in interest-bearing accounts.
Failure to maintain proper accounting and records of residents' personal funds, including negative balances and lack of quarterly statements.
Failure to notify Medicaid residents when their personal trust accounts approached resource limits.
Failure to provide a safe, clean, comfortable, and homelike environment, including maintenance issues and unsanitary conditions.
Failure to implement and monitor the storage, safekeeping, and destruction of narcotic medications, resulting in missing narcotics.
Failure to ensure a sanitary kitchen environment for food preparation, storage, and service.
Failure to maintain resident medical records in a complete, accurate, readily accessible, and systematically organized manner.
Report Facts
Residents with personal fund trust accounts: 38
Residents with Medicaid as payor source: 37
Negative balance accounts: 16
Missing hydrocodone tablets: 119
Hydrocodone pills delivered: 201
Residents reviewed for pharmacy issues: 4
Residents with Medicaid notification failure: 3
Lights not functioning: 10
Residents census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Nursing Staff | Named in narcotic medication mismanagement and missing medication incident. |
| Staff F | Certified Medication Aide | Involved in narcotic medication handling and missing medication incident. |
| Staff D | Charge Nurse | Involved in narcotic medication incident and medication availability. |
| Administrative Staff H | Interviewed regarding personal funds and trust accounts management. | |
| Housekeeping Staff J | Interviewed regarding housekeeping supplies and cleaning. | |
| Housekeeping/Maintenance Staff K | Interviewed regarding facility maintenance and supply issues. | |
| Direct Care Staff G | Involved in narcotic medication availability and resident care. | |
| Consulting Staff E | Pharmacy consultant interviewed regarding narcotic medication disposal. | |
| Dietary Staff I | Interviewed regarding kitchen sanitation and cleaning. | |
| Administrative Nursing Staff B | Interviewed regarding narcotic medication incident and medical record filing. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 5, 2018
Visit Reason
An off-site survey was conducted for the deficiency cited on August 2, 2018.
Findings
The deficiency cited on August 2, 2018 was corrected as of the compliance date of August 30, 2018.
Report Facts
Deficiency compliance date: Aug 30, 2018
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 30, 2018
Visit Reason
This document is a Plan of Correction submitted by Franklin Healthcare of Peabody in response to deficiencies cited during a prior inspection, addressing discharge planning for residents.
Findings
The plan outlines corrective actions including updating care plans for residents, revising discharge plans for all residents, staff in-service training on patient-centered discharge planning, and monthly audits of discharge plans for three months.
Deficiencies (1)
Care plans for residents #1, 2, and 3 were not adequately addressing discharge needs.
Report Facts
Audit sample size: 20
Date of compliance: Aug 30, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Diana Melander | Submitted the Plan of Correction to KDADS | |
| Lacey Hunter | Added the Plan of Correction | |
| Caryl Gill | Modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 2, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a "D" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective August 30, 2018.
Deficiencies (1)
Most serious deficiency found was a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Aug 2, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#00131575) focusing on the facility's discharge planning process.
Complaint Details
The complaint investigation found the facility failed to provide discharge planning for residents #1, #2, and #3. Resident #1 expressed desire to move closer to family but reported lack of assistance and documentation. Staff interviews confirmed failure to document discharge planning and lack of facility policy on discharge planning.
Findings
The facility failed to provide adequate discharge planning for 3 of 3 residents reviewed, including lack of documented discharge plans and failure to assist residents in relocating to preferred living environments.
Deficiencies (1)
Failure to provide discharge planning for residents, including lack of documented discharge plans and failure to assist residents with moving to preferred living environments.
Report Facts
Census: 40
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social services/activity staff D | Reported resident's desire to live closer to family and lack of active participation in discharge planning | |
| Administrative nursing staff B | Reported facility made phone calls for alternate placement but failed to document; verified lack of discharge plan |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 28, 2018
Visit Reason
An off-site survey was conducted for the deficiency cited on May 17, 2018, to verify correction.
Findings
The deficiency cited on May 17, 2018, was corrected as of the compliance date of June 15, 2018.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 24, 2018
Visit Reason
An offsite revisit survey was conducted on 05/24/2018 for all previous deficiencies cited on 03/05/2018.
Findings
All deficiencies have been corrected as of the compliance date of 04/09/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 17, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with 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 June 15, 2018.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person for the survey and plan of correction. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: May 17, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#129563) regarding the facility's failure to accurately assess and prevent elopement of a resident with a prior history of eloping.
Complaint Details
Complaint investigation #129563 focused on the facility's failure to prevent elopement of resident #1, who left the facility grounds without staff knowledge on 5/15/18 and was missing for approximately 1 hour and 30 minutes before being located.
Findings
The facility failed to properly assess resident #1 for elopement risk upon admission, resulting in the resident eloping from the facility on 5/15/18 without staff knowledge. The resident was found approximately 2 blocks away after about 1.5 hours. The facility's door alarm system was sometimes disabled, and staff monitoring was inconsistent. The resident refused a wanderguard device and medication, and staff failed to document door checks adequately.
Deficiencies (1)
Failure to accurately assess resident #1 for elopement risk and prevent elopement.
Report Facts
Census: 29
Elopement duration: 1.5
Visual checks frequency: 15
Date of survey: May 17, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Maintenance Staff | Reported door lock status and found resident during elopement. |
| Staff B | Administrative Nursing Staff | Reported door locking schedules and monitoring responsibilities. |
| Staff C | Licensed Nursing Staff | Reported on resident supervision and door unlocking practices. |
| Staff D | Licensed Nursing Staff | Directed search for resident and reported on resident's behavior. |
| Staff G | Direct Care Staff | Reported resident's behavior on the night of elopement and assisted in search. |
| Administrator | Notified during resident elopement incident. | |
| Director of Nursing | DON | Notified during resident elopement incident and involved in search. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 15, 2018
Visit Reason
The plan of correction addresses an incident of resident elopement that occurred on 5/15/18, outlining corrective actions taken by the facility including staff training and updated care plans.
Findings
The facility updated the affected resident's care plan, terminated the responsible nurse aide, and conducted staff in-service training on wandering and elopement policies. The facility also implemented audits and elopement drills to ensure compliance and resident safety.
Deficiencies (1)
Failure to intervene when a resident left the facility unaccompanied on 5/15/18 at approximately 8:30 pm.
Report Facts
Date of incident: May 15, 2018
Date of compliance: Jun 15, 2018
Audit frequency: 25
Elopement drill frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Reed | Administrator | Submitted plan of correction |
| Shirley Boltz | Contact for plan of correction assistance | |
| Joolsen | Administrator | Submitted plan of correction |
| Caryl Gill | Modified plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 10, 2018
Visit Reason
A complaint survey was conducted on 4/10/18 for complaint #KS 00127564.
Complaint Details
Complaint #KS 00127564 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 10, 2018
Visit Reason
A complaint survey was conducted on 4/10/18 for complaint #KS 00127564.
Complaint Details
Complaint #KS 00127564 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Apr 9, 2018
Visit Reason
This document is a Plan of Correction submitted by Franklin Healthcare of Peabody, LLC in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including environmental issues in resident shower rooms, hallways, and rooms; care plan revisions related to falls; discharge planning process improvements; quality of care regarding skin integrity; accident hazard prevention; medication regimen reviews focusing on black box warnings; food procurement and sanitation issues; infection prevention and control; and immunization compliance.
Deficiencies (11)
Environmental issues in resident shower rooms, hallways, and rooms requiring repairs and cleaning.
Care plan timing and revision to address root causes of falls.
Discharge planning process improvements and staff inservicing.
Quality of care related to skin integrity and wound care assessments.
Free of accident hazards and supervision related to resident falls.
Drug regimen review and reporting irregularities, including black box warnings.
Drug regimen free from unnecessary drugs with focus on black box warnings.
Free from unnecessary psychotropic medications and PRN use.
Food procurement, storage, preparation, and serving sanitation issues.
Infection prevention and control including labeling and storage of resident personal items.
Influenza and pneumococcal immunizations compliance and education.
Report Facts
Date of correction: Apr 9, 2018
Audit frequency: 25
Audit duration: 8
Audit frequency: 60
Audit frequency: 2
Monitoring duration: 4
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 5, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-04-09.
Deficiencies (1)
Most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Census: 42
Deficiencies: 10
Date: Mar 5, 2018
Visit Reason
The inspection was a Health Resurvey and Complaint Investigations #124760 and #123546.
Findings
The facility failed to provide maintenance/housekeeping services to ensure a safe and sanitary environment, failed to revise care plans with appropriate interventions after falls, failed to develop and implement effective discharge planning, failed to adequately monitor skin issues, failed to investigate falls to identify root causes, failed to identify and report medication irregularities including black box warnings (BBW), failed to store and prepare food under sanitary conditions, and failed to implement infection control practices to prevent cross contamination.
Deficiencies (10)
Failed to provide maintenance/housekeeping services for 20 of 30 resident rooms and 2 of 2 resident shower rooms to ensure a safe and sanitary environment.
Failed to revise care plan with new appropriate intervention after a fall to prevent future falls for resident (#31) with repeated falls.
Failed to develop and implement an effective discharge planning process focusing on resident's discharge goals for resident (#43).
Failed to adequately monitor skin issues/abrasions for resident (#93) sampled for skin.
Failed to investigate to identify root cause for 1 of 3 falls for resident (#31) with history of falls to prevent future falls.
Pharmacy consultant failed to identify and report irregularities to medical director and director of nursing to ensure residents had appropriate identification and monitoring for adverse consequences associated with medications including antipsychotics regarding lack of black box warnings for 5 residents (#24, #30, #36, #40, #7).
Facility failed to ensure residents had appropriate identification and monitoring for adverse consequences associated with administration of antipsychotic medications regarding black box warnings for 4 residents (#24, #36, #40, #7).
Failed to maintain and store food under sanitary conditions including undated opened food items, dirty kitchen equipment, and damaged kitchen surfaces.
Failed to ensure infection control practices to prevent cross contamination and infections including unmarked personal hygiene items and shared bathroom items.
Failed to provide education and opportunity to receive or refuse pneumococcal immunization for 3 residents (#16, #24, #25) and failed to document education and consent/refusal.
Report Facts
Residents present: 42
Resident sample size: 13
Deficiency count: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Direct care staff | Provided information about black box warnings and infection control practices |
| Staff K | Direct care staff | Provided information about black box warnings and pharmacy communication |
| Staff F | Licensed nurse | Discussed care plan interventions and black box warnings |
| Staff B | Administrative nursing staff | Confirmed deficiencies and pharmacy communication about black box warnings |
| Staff L | Dietary staff | Provided information about food storage and sanitation |
| Staff C | Licensed nursing staff | Verified pneumococcal vaccine education deficiencies |
| Staff I | Direct care staff | Provided information about infection control and resident care |
| Staff H | Direct care staff | Provided information about fall procedures |
| Staff M | Pharmacy consultant | Discussed black box warning medication list and staff education |
| Administrative staff A | Administrator | Discussed discharge planning expectations |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 5, 2017
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 had been corrected.
Findings
The revisit confirmed that all previously cited deficiencies related to regulations 483.12(a)(3)(4)(c)(1)-(4), 483.24, 483.25(k)(l), and 483.25(d)(1)(2)(n)(1)-(3) were corrected as of 05/26/2017.
Report Facts
Deficiency correction completion date: May 26, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 25, 2017
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 most serious deficiencies related to F323, 'J', CFR 483.25(d)(1)(2)(n)(1)-(3), which was determined to be immediate jeopardy, resulting in enforcement remedies including a civil money penalty and potential termination of provider agreement.
Deficiencies (1)
Deficiency related to F323, 'J', CFR 483.25(d)(1)(2)(n)(1)-(3) determined to be immediate jeopardy
Report Facts
Civil Money Penalty: 4200
Effective date for denial of payment: 2017
Termination effective date: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonita Robinson-Bradley | Administrator | Named as facility administrator in relation to the survey and deficiencies |
| Caryl Gill | RN, BSN, Complaint coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 3
Date: May 25, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#115629) and partial extended survey focusing on allegations of abuse, neglect, and elopement incidents.
Complaint Details
Complaint investigation #115629 focused on allegations of abuse, neglect, and elopement incidents involving Resident #2. The facility failed to report the elopement incident timely and failed to provide adequate supervision and care.
Findings
The facility failed to thoroughly investigate and immediately report an elopement incident involving Resident #2, who left the facility without staff knowledge and was found near railroad tracks. The facility also failed to provide adequate care and supervision, including proper assessment and monitoring of wandering/elopement risk, and failed to maintain proper documentation such as the walking pass sign-in/out sheet.
Deficiencies (3)
Failed to thoroughly investigate and immediately report an elopement incident to the state agency.
Failed to provide necessary care and services, including adequate assessment, for a resident who left the facility without staff knowledge and returned.
Failed to provide adequate supervision to prevent elopement and failed to correctly identify a resident at risk for elopement.
Report Facts
Census: 46
Sampled residents: 3
Elopement duration: 1.5
BIMS score: 15
Temperature: 70
Wind gusts: 8.1
Audit frequency: 25
Audit duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Charge Nurse | Worked 2-10 shift on 4/28/17, unaware resident was gone, involved in post-elopement care |
| Administrative Nurse A | Administrative Nurse | Verified care plan components and policy compliance, provided statements on elopement procedures |
| Nurse C | Charge Nurse | Day shift charge nurse on 4/28/17, unaware resident was gone, documented resident's refusal to return |
| Administrative Staff D | Administrative Staff | Acknowledged lack of knowledge of resident's whereabouts during elopement |
| Activity Staff F | Activity Staff | Notarized witness statement regarding walking pass sign-in/out sheets and care plan team communication |
| Nurse E | Nurse | Observed resident walking near railroad tracks and interacted with resident during elopement |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 28, 2017
Visit Reason
The document is a Plan of Correction submitted by Westview Manor in response to deficiencies cited related to resident elopement and walking pass policy following a complaint investigation.
Complaint Details
This Plan of Correction is in response to a complaint investigation related to a resident elopement incident on 04/28/2017.
Findings
The facility had deficiencies related to a resident walking beyond designated walking paths without timely notification to nursing staff, inadequate monitoring of walking passes, and incomplete wandering/elopement risk assessments. The facility implemented staff training, revised policies on walking passes and elopement risk assessments, and took disciplinary action against responsible staff.
Deficiencies (3)
Resident was assessed not at risk for elopement but walked beyond designated path without timely notification to nurse.
Failure to adhere to facility policy for notifying administrator and Director of Nursing of elopement incident.
Inadequate wandering/elopement risk assessments and walking pass system.
Report Facts
Distance resident walked beyond walking pass: 200
Time resident returned before walking pass expired: 30
Date of resident assessment for elopement risk: Apr 3, 2017
Date of staff training on elopement and walking pass policy: May 19, 2017
Retention period for sign out/in sheets: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonita Robertson Bradley | Administrator | Administrator named in submission of Plan of Correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 5, 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
The revisit confirmed that the deficiencies identified in the prior survey were corrected as of 10/21/2016, with all corrective actions completed.
Report Facts
Correction completion date: Oct 21, 2016
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 20, 2016
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services 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 that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from September 26, 2016 through October 18, 2016. Immediate jeopardy was abated by the time of the report.
Deficiencies (1)
Noncompliance with F309, "J", CFR 483.25 resulting in immediate jeopardy to resident health or safety.
Report Facts
Civil Money Penalty: 5000
Denial of payment effective date: Nov 10, 2016
Termination effective date: Apr 20, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonita Robinson-Bradley | Administrator | Named as facility administrator in the report. |
| Caryl Gill | RN BSN, Complaint Coordinator | Signed the report as Complaint Coordinator. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 2
Date: Oct 20, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#106573) and partial extended survey focusing on the facility's failure to adequately monitor and assess respiratory status and seek physician involvement for a resident with significant respiratory distress.
Complaint Details
Complaint investigation #106573 focused on the facility's failure to adequately monitor and assess respiratory status and seek physician involvement for Resident #1, who had significant respiratory distress and decline in physical health over a two-day period.
Findings
The facility failed to adequately monitor and assess respiratory status and seek timely physician involvement over a two-day period for Resident #1, who had chronic obstructive pulmonary disease, asthma, and advanced pulmonary fibrosis. The resident experienced significant respiratory distress, oxygen desaturation, and decline in physical health, which was not promptly addressed by staff, resulting in delayed hospital transfer and immediate jeopardy to the resident's health.
Deficiencies (2)
Failure to notify physician and reassess resident in a timely manner despite significant respiratory distress and oxygen desaturation.
Failure to adequately monitor and assess respiratory status and seek physician involvement over a 2 day period for Resident #1.
Report Facts
Census: 47
Sample size: 6
Heart rate: 130
Oxygen saturation: 56
Respirations: 46
Oxygen liters: 15
Heart rate: 128
Respirations: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Nurse | Nurse on duty during resident's respiratory distress; failed to promptly notify physician and delayed hospital transfer. |
| Administrative Nurse C | Administrative Nurse | Stated expectation for nurse to notify physician immediately upon resident's condition change and heart rate elevation. |
| Nurse D | ER Nurse | Provided assessment of resident upon arrival at emergency room. |
| Nurse Practitioner E | Nurse Practitioner | Stated expectation for immediate physician notification and that resident's outcome would have been different if hospital transfer was sooner. |
| Nurse Aide A | Nurse Aide | Commented that resident should have been sent to hospital sooner. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 27, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a complaint investigation related to a resident's respiratory status and the facility's nursing assessment and notification procedures.
Complaint Details
This Plan of Correction is in response to a complaint investigation (Franklin complaint 10202016) regarding the facility's handling of a resident's respiratory decline and related nursing care.
Findings
The facility identified deficiencies related to timely assessment, monitoring, and notification of changes in a resident's respiratory status. The Plan of Correction outlines staff in-service training on physical assessment, notification policies, documentation requirements, and nursing communication to ensure compliance with federal requirements.
Deficiencies (1)
Failure to properly assess and monitor a resident's respiratory status and notify the physician timely.
Report Facts
Date of resident assessment: Sep 27, 2016
Date of Plan of Correction completion: Oct 21, 2016
Training date: Oct 18, 2016
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 15, 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
The revisit confirmed that the previously cited deficiency with ID Prefix F0441 related to regulation 483.65 was corrected as of 06/15/2016. No other deficiencies were noted.
Deficiencies (1)
Deficiency with ID Prefix F0441 related to regulation 483.65
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 15, 2016
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.
Findings
The report confirms that the previously identified deficiencies, including the one referenced under regulation 28-39-158(a), have been corrected as of the revisit date.
Deficiencies (1)
Deficiency under regulation 28-39-158(a) previously cited
Report Facts
Deficiency correction date: Jun 15, 2016
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 15, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to address compliance with Federal Medicare and Medicaid requirements.
Findings
The plan of correction addresses infection control measures including the use of a recommended disinfectant, staff education on infection prevention, and monitoring of dietary management certification progress.
Deficiencies (2)
Infection control deficiency related to preventing the spread of infections in resident living areas.
Dietary management deficiency related to staff certification and oversight by a Registered Dietitian.
Report Facts
Complete Date: Jun 15, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonita Robertson Bradley | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: May 18, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with 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 based on the credible allegation of compliance.
Deficiencies (1)
Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 1
Date: May 18, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #88391 and #100428.
Findings
The facility failed to employ a full-time certified dietary manager for the 47 residents who reside in the facility and receive meals from one kitchen. Dietary Staff D was observed overseeing meal service but was not certified, though currently enrolled in a dietary manager training program.
Deficiencies (1)
Failure to employ a full-time certified dietary manager for the facility residents.
Report Facts
Census: 47
Sample size: 9
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 29, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office 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 at the '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)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: Jun 29, 2016
Termination effective date: Sep 29, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 31, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies at Westview Manor of Peabody.
Findings
The report documents that previously identified deficiencies under regulations 483.35(i) and 483.70(c)(2) were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.70(c)(2)
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 31, 2015
Visit Reason
This document is a Plan of Correction submitted by Westview Manor of Peabody in response to deficiencies cited during a complaint investigation.
Complaint Details
This Plan of Correction is related to a complaint investigation as indicated by the reference to the complaint ID and the nature of the corrective actions.
Findings
The plan addresses deficiencies related to cleaning and maintenance of kitchen equipment, including the grill, stove top, oven, shelf, and sprinkler heads, as well as proper reporting and tagging of defective equipment. Staff were in-serviced on cleaning procedures and equipment defect reporting, and the stove was serviced and repaired.
Deficiencies (2)
Cleaning of the grill, stove top, oven, shelf, and sprinkler heads was deficient.
Improper procedures for reporting defects on equipment and tagging equipment when out of service.
Report Facts
Complete Date: Jul 27, 2015
Complete Date: Jul 31, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Cindy Edwards | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 20, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies that constitute no actual harm with 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 based on the credible allegation of compliance and the submitted plan.
Deficiencies (1)
'F' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Jul 20, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#89331 and #89333) regarding the facility's failure to maintain sanitary conditions and safe operating equipment in the kitchen.
Complaint Details
The visit was triggered by complaint investigations #89331 and #89333. The complaints were substantiated as the facility failed to maintain sanitary and safe conditions in the kitchen oven, which posed a fire hazard and risk to residents.
Findings
The facility failed to maintain cleanliness of the kitchen oven and failed to keep the oven in safe operating condition. Observations revealed a dirty oven with food buildup and a malfunctioning oven that caught fire twice. Staff did not immediately notify administration of the hazards, and the oven was used despite known safety issues.
Deficiencies (2)
Failure to maintain cleanliness of 1 of 1 ovens in the kitchen serving 51 residents.
Failure to maintain 1 of 1 ovens in safe operating condition, including incidents of fire and malfunctioning thermostat.
Report Facts
Resident census: 51
Incident times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff A | Verified oven caught fire and was turned off; confirmed cold menu implemented | |
| Dietary Staff C | Verified cleaning duties, oven issues, and uncertainty about oven use after fire incident | |
| Dietary Staff E | Attempted to light pilot causing flame whoosh; filed incident report | |
| Maintenance Staff D | Verified oven was dirty and frequently needed temperature adjustments | |
| Maintenance Staff G | Verified thermostat out of adjustment and dirty grill pilots causing flames | |
| Administrative Staff B | Verified delayed notification of oven issues and expectation for immediate reporting | |
| Administrative Staff F | Instructed Dietary Staff E to complete incident report |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Apr 23, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously reported deficiencies at Westview Manor of Peabody.
Findings
All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date 04/23/2015.
Deficiencies (7)
Deficiency related to regulation 483.10(b)(5) - (10), 483.10(b)(1)
Deficiency related to regulation 483.10(g)(1)
Deficiency related to regulation 483.13(c)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.60(b), (d), (e)
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Apr 1, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior survey. It outlines corrective actions to address the cited deficiencies and ensure compliance with Federal, Medicare, and Medicaid requirements.
Findings
The plan of correction addresses multiple deficiencies including client notification of advocacy groups, posting of survey reports, staff background checks, monitoring of liver function related to Tylenol use, ensuring sanitary drainage in the ice maker, and insulin monitoring procedures. Compliance monitoring responsibilities are assigned to various facility staff.
Deficiencies (7)
Failure to inform clients in writing about state client advocacy groups and complaint procedures.
Lack of proper notice about locations to view previous survey reports.
Failure to obtain background checks on required staff prior to their start date.
Inadequate monitoring of liver function tests related to Tylenol use and dosage exceeding recommended limits.
Failure to ensure a 2 inch air gap in the drain line of the ice maker for sanitary drainage.
Failure to monitor Tylenol orders exceeding recommended dosage of 4,000mg in 24 hours.
Lack of insulin monitoring form and procedures to check insulin container dates and expiration.
Report Facts
Recommended Tylenol dosage limit: 4000
Air gap size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Edwards | Administrator | Administrator responsible for monitoring compliance and submitted the plan of correction |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 7
Date: Mar 24, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements and investigate complaints.
Complaint Details
The visit was triggered by a complaint investigation #83733.
Findings
The facility failed to post state agency contact information for complaints, did not make survey results readily accessible to residents, failed to conduct criminal background checks for some employees, allowed residents to receive excessive doses of Tylenol without proper pharmacist intervention, had an ice machine drain without a proper air gap, and failed to properly label an insulin pen.
Deficiencies (7)
Failed to post names, addresses, and telephone numbers of pertinent state survey and certification agencies with a statement that residents may file complaints.
Failed to make the most recent survey results readily accessible to residents.
Failed to provide written evidence of criminal background checks for 2 of 5 employees reviewed.
Failed to ensure drug regimen was free from unnecessary drugs for 2 residents receiving excessive doses of Tylenol (4000 mg daily) without timely pharmacist intervention.
Failed to ensure the ice machine drain line had a 2 inch air gap for sanitary drainage.
Failed to ensure pharmacist consultant identified and acted on irregularities in drug regimen related to excessive Tylenol dosing for 2 residents.
Failed to ensure appropriate labeling of an insulin pen in medication room for an insulin-dependent resident.
Report Facts
Census: 50
Residents sampled: 14
Residents reviewed for medication regimen: 5
Tylenol dosage: 4000
Tylenol dosage frequency: 4
Insulin units: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Administrative Staff | Verified lack of posting state agency contact information and survey results accessibility. |
| Social Service Staff G | Social Service Staff | Verified lack of posting state agency contact information. |
| Administrative Staff H | Administrative Staff | Reported background check documentation practices. |
| Administrative Nurse B | Administrative Nurse | Verified lack of background check documentation and commented on Tylenol dosage. |
| Nurse G | Nurse | Provided information about residents' pain complaints and Tylenol dosage awareness. |
| Dietary Manager E | Dietary Manager | Verified ice machine drain pipe condition. |
| Nurse C | Nurse | Verified insulin pen was not dated when opened. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Mar 24, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective April 23, 2015.
Deficiencies (1)
Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the survey findings and plan of correction. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 3, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies, isolated, with no harm but potential for more than minimal harm that is not immediate jeopardy. An acceptable plan of correction was required to be submitted within ten calendar days.
Deficiencies (1)
Deficiencies found at 'D' level, isolated with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: Jan 3, 2015
Termination effective date: Apr 3, 2015
Plan of correction submission timeframe: 10
Fair hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Edwards | Administrator | Facility administrator named in the report. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution and appeals. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Joe Ewert | Commissioner of Survey, Certification and Credentialing Commission | Copied on the report. |
| Audrey Sunderraj | Director | Copied on the report. |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Feb 11, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25(l), 483.30(b), 483.35(i), 483.60(c), and 483.65 were corrected as of the revisit date.
Deficiencies (6)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.30(b)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jan 23, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior inspection report outlining deficiencies and corrective actions to achieve substantial compliance with Federal Medicare and Medicaid requirements.
Findings
The plan addresses multiple deficiencies including care plan updates for bracelet use, medication administration and vital signs monitoring, staffing requirements for a Registered Nurse, dietary staff hygiene practices, pharmacist monitoring of physician orders, and housekeeping infection control protocols.
Deficiencies (6)
Care plan updated to reflect use of bracelet and ensure compliance.
Medication orders and vital signs monitoring reviewed and protocol established.
Registered Nurse to be provided 8 hours per day each week.
Dietary staff must rewash items dropped on kitchen floor and follow hair restraint policy.
Consulting pharmacist to monitor vital signs and blood pressure orders monthly.
Housekeeping to use 9:1 water and bleach disinfectant and follow infection control protocols.
Report Facts
Deficiency completion dates: Jan 23, 2014
Deficiency completion dates: Jan 24, 2014
Deficiency completion dates: Feb 11, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonita Robertson Boydston | Administrator | Administrator submitting the plan of correction |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 6
Date: Jan 13, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #71010 to assess compliance with care planning, medication administration, staffing, food sanitation, infection control, and other regulatory requirements.
Complaint Details
The visit was triggered by a complaint investigation #71010. The findings included failure to revise care plans, medication errors, staffing shortages, food sanitation issues, pharmacy notification failures, and infection control deficiencies.
Findings
The facility failed to revise a resident's care plan after applying a wanderguard bracelet, failed to ensure residents were free from unnecessary medications including failure to monitor blood pressures as ordered, failed to provide 8 consecutive hours of RN coverage daily, failed to maintain sanitary food handling practices, failed to notify the facility of medication irregularities by the pharmacy consultant, and failed to maintain adequate infection control practices.
Deficiencies (6)
Failed to revise care plan for resident with wanderguard bracelet for safety concerns.
Failed to ensure residents were free from unnecessary drugs; failed to obtain blood pressure prior to medication administration and failed to notify physician of out-of-parameter blood pressures.
Failed to provide a Registered Nurse for 8 consecutive hours a day, 7 days a week.
Failed to distribute and serve food under sanitary conditions; staff used soiled potholder and violated hairnet policy.
Pharmacy consultant failed to notify facility of medication irregularities related to blood pressure monitoring and physician notification.
Failed to maintain infection control program to prevent spread of infection and maintain sanitary environment; improper cleaning practices observed.
Report Facts
Census: 47
Residents reviewed: 12
Residents reviewed for unnecessary medication: 5
Dates without 8 consecutive RN hours: 40
Blood pressure readings out of physician parameters: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Verified care plan not updated and RN coverage issues; confirmed physician orders and staff expectations |
| Nurse C | Nurse | Verified blood pressure monitoring orders and uncertainty about physician notifications |
| Dietary Staff G | Dietary Staff | Observed using soiled potholder to handle food |
| Dietary Staff F | Dietary Staff | Confirmed infection control training and hairnet policy |
| Housekeeping Staff B | Housekeeping Staff | Observed improper cleaning practices with cloth rag and chemical use |
| Housekeeping Staff D | Housekeeping Staff | Described cleaning procedures and infection notification process |
| Administrative Staff H | Administrative Staff | Commented on wanderguard use and hairnet policy violation |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 13, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with 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 based on the credible allegation of compliance and the plan.
Deficiencies (1)
Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonita Boydston | Administrator | Named as facility administrator in the report. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Sue Hine | Regional Manager | Copied on the letter as Regional Manager. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 17, 2013
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in 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 deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy.
Deficiencies (1)
Deficiencies classified as 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payment: Oct 17, 2013
Effective date for termination of provider agreement: Jan 17, 2014
Days to request fair hearing: 60
Days to submit IDR request: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonita Boydston | Administrator | Named as facility administrator. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution and appeals. |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter. |
| Joe Ewert | Commissioner of Survey, Certification and Credentialing Commission | CC'd on letter. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 10, 2013
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
The report confirms that the deficiencies previously identified under regulations 483.10(b)(11) and 483.25 were corrected by 03/18/2013, with no uncorrected deficiencies remaining at the time of this revisit.
Deficiencies (2)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.25
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 18, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a complaint survey conducted at Westview Peabody on 03/18/2013.
Findings
The facility implemented multiple corrective actions including staff in-service on recognizing Acute Change of Condition (ACOC), use of the CMS INTERACT SBAR Communication Form, hot rack charting, and physician notification protocols. The Director of Nursing and Medical Director established parameters for physician notifications and daily monitoring processes to ensure compliance.
Deficiencies (1)
Deficiencies related to recognizing and managing Acute Change of Condition (ACOC), documentation, physician notification, and monitoring.
Report Facts
Days for monitoring new admits: 72
Days for monitoring incident reports: 72
Days for monitoring residents on antibiotics: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonita Robertson Boydston | Administrator | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Added the Plan of Correction on 03/19/2013. | |
| Mary Jane Kennedy | Modified the Plan of Correction on 04/19/2013. |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Mar 18, 2013
Visit Reason
The inspection was conducted as a Complaint Investigation #63991 and a partial extended survey to assess the facility's compliance with regulations related to resident care and notification of changes in condition.
Complaint Details
The visit was triggered by Complaint Investigation #63991. The complaint involved failure to assess and notify changes in condition for residents, resulting in harm.
Findings
The facility failed to adequately assess and monitor elevated temperatures, respiratory distress, and changes in condition for two sampled residents, and failed to notify the physician timely. This resulted in harm to the residents due to delayed treatment and placed them in immediate jeopardy. The facility also failed to provide fever medication as ordered and to thoroughly assess respiratory status.
Deficiencies (2)
Failure to notify the physician of elevated temperatures, changes in condition, and respiratory distress for Resident #2.
Failure to adequately monitor elevated temperatures, provide fever medication as ordered, accurately assess respiratory status, and notify the physician for Residents #1 and #2.
Report Facts
Resident census: 50
Elevated temperature readings: 104.1
Oxygen levels: 76
Blood pressure readings: 90
Tylenol doses: 2
Tamiflu dosage: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Stated staff should closely monitor and assess changes in condition and notify physician | |
| Nurse C | Stated staff should frequently assess and record elevated temperatures and respiratory distress and administer medications as ordered | |
| Nurse D | Stated facility had no standing orders for physician notification and staff should administer medications as ordered and notify physician |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 31, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that the deficiencies identified under regulation numbers 483.15(a) and 483.65 were corrected as of 10/31/2012.
Deficiencies (2)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 18, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior survey related to compliance with Federal Medicare and Medicaid requirements.
Findings
The plan addresses disciplinary and reeducation actions taken for dietary staff regarding use of foul language and infection control practices, including glove use during injections. Compliance monitoring is assigned to various facility committees and staff.
Deficiencies (2)
Identified dietary staff has been disciplined and reeducated on dignity and respect related to foul language and services provided.
All dietary staff has been reeducated on proper infection control standards of practice regarding food preparation with skin wounds on hands, wrists or arms. Identified nursing staff has been reeducated on standards of practice regarding infection control and proper glove use during injections.
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 2
Date: Oct 9, 2012
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements related to resident dignity and infection control practices.
Findings
The facility failed to promote dignity and respect for residents, evidenced by staff using inappropriate language and demeaning behavior. Additionally, infection control practices were inadequate, including staff not wearing gloves when required and handling food with open skin lesions, risking disease transmission.
Deficiencies (2)
Failure to promote care in a manner that maintains or enhances each resident's dignity and respect, including staff using inappropriate language toward residents.
Failure to establish and maintain an infection control program to prevent the development and transmission of disease and infection, including improper glove use and handling of food with open skin lesions.
Report Facts
Census: 51
Sample size: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Nurse | Observed administering injection without gloves |
| Nurse D | Nurse | Verified staff should wear gloves before administering injections |
| Dietary Staff F | Dietary Staff | Observed with open skin lesion on hand serving food without gloves |
| Dietary Staff A | Dietary Staff | Verified staff should wear gloves when handling food with open skin lesions |
| Nurse Aide E | Nurse Aide | Involved in incident where dietary staff used inappropriate language |
| Administrative Staff C | Administrative Staff | Verified employees sign form to not curse and treat residents with respect |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 17, 2011
Visit Reason
This report documents a revisit conducted to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit confirmed correction of the previously cited deficiency identified by regulation 28-39-158(a) with correction completed on 09/17/2011.
Deficiencies (1)
Deficiency previously reported under regulation 28-39-158(a) corrected
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 17, 2011
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report confirms that the previously cited deficiency under regulation 483.30(b) was corrected as of 09/17/2011.
Deficiencies (1)
Deficiency related to regulation 483.30(b)
Report Facts
Deficiency correction date: Sep 17, 2011
Inspection Report
Census: 50
Deficiencies: 1
Date: Aug 25, 2011
Visit Reason
The inspection was conducted to assess compliance with dietary services regulations, specifically to verify the employment of a full-time qualified dietary manager as required by state regulations.
Findings
The facility failed to employ a full-time qualified dietary manager as required. Dietary staff and records confirmed the absence of state certification for the dietary manager position.
Deficiencies (1)
Failed to employ a full-time qualified dietary manager for the 50 residents.
Report Facts
Census: 50
Inspection Report
Plan of Correction
Deficiencies: 8
Date: N057002 POC 3U5M11
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 of Correction details corrective actions taken for multiple deficiencies including financial management of Resident Trust accounts, facility maintenance issues, medication management, kitchen cleanliness, and medical record organization. Systematic changes and monitoring plans are described to prevent recurrence.
Deficiencies (8)
Clients with funds over $50 in their Resident Trust account did not receive interest on those funds.
Client accounts were allowed to go into negative balances.
Records related to Resident Trust accounts required auditing for compliance.
Residents were not informed or educated about the amount of funds in their Resident Trust Account and risk of losing Medicaid or SSI eligibility.
Facility maintenance issues including wall hangings, lighting repairs, bare wires, cracked tiles, mattress and dresser placement, cleaning of showers, toilet door repairs, and supply closet organization.
Medication management deficiencies including narcotics destruction and medication room security.
Kitchen equipment and cleanliness issues including stove replacement, microwave replacement, sink cleaning, wall cleaning, refrigerator cleaning, silverware tray replacement, and removal of supplies from storage floor.
Medical record filing and overflow records management requiring organization and quarterly review.
Report Facts
Complete Date: Dec 31, 2018
Audit start date: Apr 1, 2019
Medication room audits frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Diana Melander | Submitted the Plan of Correction to KDADS | |
| Lacey Hunter | Added the Plan of Correction | |
| Janice VanGotten | Modified the Plan of Correction |
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