Inspection Reports for Agewise Living Inc
204 W. WASHINGTON AVENUE, STERLING, KS, 67579-1614
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 19, 2025, found no deficiencies and confirmed the facility was in compliance with all surveyed regulations. Earlier inspections showed multiple deficiencies related primarily to resident care plan adherence, medication regimen reviews, dietary management, food safety, fall prevention, and staff training. Complaint investigations related to care plan adherence and resident safety were substantiated in January 2025, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most prior deficiencies were corrected by subsequent revisit surveys, indicating the facility has taken steps to address identified issues. This suggests an improving trend with recent inspections showing compliance after periods of cited deficiencies.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
10.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
68% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
26 residents
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
A revisit survey was conducted on 03/19/25 to verify correction of all previous deficiencies cited on 01/23/25.
Findings
All deficiencies cited in the prior inspection have been corrected as of 02/18/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Feb 18, 2025
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 achieve substantial compliance.
Findings
The plan addresses multiple deficiencies including fall prevention, fluid restriction monitoring, medication regimen reviews, dietary management, food storage, water management, and staff in-service education, with corrective actions and audit plans detailed for each.
Deficiencies (7)
Failure to adhere to fall prevention interventions including proper use of gait belts, motion sensors, and non-slip materials.
Inaccurate monitoring of physician-ordered fluid restrictions.
Medication regimens not reviewed monthly by Consultant Pharmacist with proper documentation.
Dietary Manager position vacancy and oversight of resident nutrition and dietary needs.
Expired foods found in kitchen and improper food storage practices.
Noncompliance with Water Management Program including infection control policies.
Failure to ensure nursing staff complete required 12 hours of annual in-service education.
Report Facts
Date for substantial compliance: Feb 18, 2025
Start date of new Dietary Manager: Feb 11, 2025
Required annual in-service education hours: 12
Frequency of dietary manager onsite visits: 2
Frequency of dietary refrigerator checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Maddie Lagree | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 8
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation for facility compliance with care standards and regulations.
Complaint Details
The visit was triggered by complaints #KS00190140 and #KS00190977, focusing on care plan adherence and resident safety.
Findings
The facility was found deficient in multiple areas including failure to follow residents' care plans leading to injuries, failure to monitor physician-ordered fluid restrictions, failure to conduct monthly pharmacist medication regimen reviews, lack of a full-time certified dietary manager, failure to maintain food safety standards, failure to implement a water management program for Legionella prevention, and failure to ensure nurse aides completed required annual in-service training.
Deficiencies (8)
Failure to follow Resident 128's care plan resulting in a tibia fracture and risk for further falls and injury.
Failure to follow Resident 4's care plan regarding use of paper chucks, resulting in a fall and risk for injury.
Failure to monitor Resident 4's physician-ordered 2000 ml per 24-hour fluid restriction, placing resident at risk of fluid overload.
Failure to ensure Consultant Pharmacist completed monthly medication regimen reviews and reported irregularities for Residents 4, 8, 9, 11, and 22.
Failure to employ a full-time certified dietary manager for the facility kitchen, risking inadequate nutrition for residents.
Failure to store, prepare, distribute, and serve food by professional standards for food service safety, including unlabeled and unsealed food items and maintenance issues in the kitchen.
Failure to implement a water management program to prevent growth and spread of Legionella and other waterborne pathogens.
Failure to ensure three of five Certified Nurse Aides completed their required 12-hour annual in-service training.
Report Facts
Census: 26
Fluid restriction: 2000
Annual in-service hours required: 12
Medication regimen review frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed regarding care plan adherence, medication regimen reviews, and fluid restriction monitoring |
| Dietary Staff BB | Dietary Staff | Observed in kitchen, verified lack of Certified Dietary Manager certification |
| Maintenance Staff U | Maintenance Staff | Interviewed regarding maintenance issues and lack of water management program |
| Certified Nurse Aide N | Certified Nurse Aide | Involved in fall incident with Resident 128 |
| Certified Medication Aide T | Certified Medication Aide | Interviewed regarding Resident 128's condition and care |
| Certified Medication Aide S | Certified Medication Aide | Interviewed regarding Resident 4's fluid restriction and medication documentation |
| Consultant GG | Consultant | Observed assisting Resident 4 with transfers |
| Consultant HH | Consultant | Observed assisting Resident 4 with transfers |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 13, 2023
Visit Reason
A revisit survey was conducted on 02/13/2023 and 02/14/2023 for all previous deficiencies cited on 01/04/2023.
Findings
All deficiencies have been corrected as of the compliance date of 02/02/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jan 4, 2023
Visit Reason
This document is a Plan of Correction submitted by Sterling Village in response to deficiencies cited during a prior inspection conducted on January 4, 2023.
Findings
The plan addresses multiple deficiencies related to resident care plans, bed hold policies, pressure ulcer interventions, oxygen administration, medication management, food storage, and staff education. Corrective actions include staff education, care plan revisions, audits, and monitoring to ensure compliance by February 2, 2023.
Deficiencies (8)
Failure to properly educate Social Service on bed hold and return agreement and provide written notices to residents/representatives.
Care plans for residents with falls and pressure ulcers were not adequately revised or implemented.
Care plans and treatment records for residents with pressure ulcers were deficient.
Care plans for residents using full body lift transfer slings were inadequate.
Oxygen cannulas and tubing were not properly changed and residents not properly educated on oxygen flow rates.
Pharmacy consultant policies and medication regimen reviews were not properly coordinated or documented.
Care plans for residents using blood pressure medications lacked proper vital sign frequency and parameters.
Expired foods were not properly disposed of and food storage practices were inadequate.
Report Facts
Deficiencies cited: 9
Compliance deadline: Feb 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Moore | Administrator | Administrator who submitted the Plan of Correction |
Inspection Report
Census: 36
Deficiencies: 8
Date: Jan 4, 2023
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #174989 and 175399.
Findings
The facility was found deficient in multiple areas including failure to provide bed hold notices upon resident hospitalization, failure to revise care plans after falls and pressure ulcers, improper use of mechanical lift slings resulting in resident injury, failure to maintain sanitary oxygen equipment and correct oxygen flow, failure to monitor and manage psychotropic medications properly, and failure to store and serve food in sanitary conditions.
Deficiencies (8)
Failure to provide bed hold notices for residents sent to hospital, risking loss of bed reservation.
Failure to review and revise care plans after falls and pressure ulcers, risking uncommunicated care needs.
Failure to use appropriate mechanical lift sling resulting in resident falling out of sling and sustaining head injury.
Failure to store oxygen cannulas and tubing in sanitary condition and failure to ensure correct oxygen flow setting.
Failure to ensure consultant pharmacist identified and reported lack of stop date for as needed antianxiety medication and lack of behavior monitoring for psychotropic medications.
Failure to obtain weekly vital signs as ordered to monitor efficacy of blood pressure medication.
Failure to ensure drug regimen free from unnecessary drugs due to lack of monitoring and documentation.
Failure to store, prepare, and serve food in sanitary condition, including expired and uncovered food items.
Report Facts
census: 36
deficiencies cited: 8
oxygen flow setting: 2
oxygen flow setting: 4
pressure ulcer size: 5
pressure ulcer size: 6.5
pressure ulcer size: 0.2
pressure ulcer size: 4
pressure ulcer size: 4.5
pressure ulcer size: 0
pressure ulcer size: 1.4
pressure ulcer size: 2.2
pressure ulcer size: 0.1
pressure ulcer size: 2.3
pressure ulcer size: 1.3
pressure ulcer size: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including failure to provide bed hold notices, oxygen equipment issues, lack of monitoring for psychotropic medications, and fall prevention. |
| Licensed Nurse G | Licensed Nurse | Observed resident vital signs and assisted with care; involved in mechanical lift transfer. |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted residents with transfers and care; involved in mechanical lift transfer. |
| Certified Medication Aide R | Certified Medication Aide | Administered medications and obtained vital signs for Resident 10. |
| Licensed Nurse J | Licensed Nurse | Verified blood pressure parameters and monitoring deficiencies for Resident 10. |
| Licensed Nurse I | Licensed Nurse | Reported oxygen setting responsibility and verified oxygen flow for Resident 13. |
| Dietary Staff BB | Dietary Staff | Removed expired food items from kitchen refrigerator. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 6, 2021
Visit Reason
An offsite revisit survey was conducted on 08/06/21 for all previous deficiencies cited on 06/08/21 to verify correction of deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 07/13/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 13, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report, addressing medication regimen review and medication storage issues.
Findings
The plan outlines corrective actions including audits of psychotropic medication and drug regimen reviews, staff education on medication policies, destruction of expired medications, and ongoing monitoring to ensure compliance by 7/13/2021.
Deficiencies (2)
Failure to complete timely drug regimen reviews and follow-up on lab orders for residents on psychotropic medications.
Improper storage and management of medications, including expired medications found in medication rooms.
Report Facts
Deficiency completion date: Jul 13, 2021
Lab completion date: Jun 16, 2021
Drug regimen review date: Jun 2, 2021
Medication room inspection date: Jun 3, 2021
Staff education date: Jun 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Dan Arice | Administrator | Submitted the Plan of Correction to KDADS |
| Melissa Miller | Added Plan of Correction | |
| Jessica Patterson | Modified Plan of Correction | |
| Director of Nursing | Director of Nursing | Conducted staff education and monitoring related to deficiencies |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 3
Date: Jun 8, 2021
Visit Reason
The inspection was a Health Resurvey to assess compliance with drug regimen review and medication storage regulations.
Findings
The facility failed to ensure timely follow-up on pharmacist recommendations for two residents regarding lab monitoring and medication adjustments. Additionally, expired medication vials were found in the medication storage area, indicating failure to remove outdated drugs.
Deficiencies (3)
Failure to ensure two residents had labs drawn to monitor Vitamin B-12 levels as recommended by the pharmacist.
Failure to act upon consultant pharmacist recommendations to discontinue or adjust certain medications for a resident.
Failure to remove expired vials of Tubersol from medication storage rooms.
Report Facts
Facility census: 35
Residents reviewed for unnecessary medications: 5
Residents with deficiencies: 2
Sample size for medication storage observation: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Interviewed regarding medication monitoring failures and expired medication storage |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
A complaint survey was conducted on 12/02/20 for complaint #KS00155295 to investigate allegations made in the complaint.
Complaint Details
Complaint #KS00155295 was investigated and the allegations were not substantiated.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility was in compliance with all regulations surveyed. Additionally, the facility was found to be in compliance with COVID-19 emergency preparedness and infection control requirements.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 29, 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 to prepare for COVID-19.
Findings
The facility was found to be in compliance with Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 15, 2019
Visit Reason
An offsite revisit survey was conducted on 11/15/19 for all previous deficiencies cited on 09/19/19.
Findings
All deficiencies have been corrected as of the compliance date of 10/18/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Sep 19, 2019
Visit Reason
This document is a Plan of Correction submitted by Sterling Village RS in response to deficiencies cited during a regulatory inspection conducted on 09/19/2019.
Findings
The Plan of Correction addresses multiple deficiencies related to resident dignity, grievance procedures, hospice care collaboration, MDS transmission and validation, care plan updates, staffing and supervision, behavioral monitoring, medication administration, food safety, medical records accessibility, and quality assurance processes. The facility outlines corrective actions, staff education, audits, and compliance deadlines.
Deficiencies (12)
Resident clothing preferences and dignity issues addressed with toileting diary and care plan updates.
Resident grievance/complaint procedures and staff education on filing grievances.
Significant change of status MDS and hospice services collaboration care plan updates.
MDS transmission and validation reports verified and audited.
Care plans updated to reflect current medications, black box warnings, and prevention interventions.
Staffing model reviewed to ensure adequate supervision and interventions for diversional activities.
Final staffing ratio discussed; nursing staff training on medication times and mechanical lift policy.
Care plans and eTAR updated for monitoring antipsychotropic medications and targeted behaviors.
Dietary department removed outdated foods and educated staff on food storage policies.
Resident medical records from previous owner maintained and audited for accessibility.
Hospice care collaboration plans developed and staff educated on hospice program policies.
QAPI program reviewed and staff trained on quality assurance processes and tools.
Report Facts
Compliance deadline: Oct 18, 2019
Nursing PPD (patients per day): 3.8
Nursing PPD (patients per day): 4.2
Education completion timeframe: 30
Medical records retention period: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Smith | Administrator | Administrator involved in staffing discussions, audits, and report submissions |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Annual Inspection
Census: 23
Deficiencies: 13
Date: Sep 17, 2019
Visit Reason
Annual health resurvey of Sterling Presbyterian Manor to assess compliance with federal regulations including resident rights, care planning, staffing, medication administration, food safety, and hospice services.
Findings
The facility was cited for multiple deficiencies including failure to treat a resident with dignity, inadequate grievance process awareness, incomplete significant change assessments, failure to transmit assessments to CMS, incomplete care plan revisions, inadequate supervision of wandering residents, insufficient staffing leading to delayed care and medication administration, failure of the pharmacist to report irregularities, unnecessary psychotropic medication use without behavior monitoring, unsanitary food storage, incomplete resident medical records after ownership change, lack of coordinated hospice care plan, and ineffective quality assurance program.
Deficiencies (13)
Failure to treat Resident 3 with dignity by exposing her in only a t-shirt and incontinence brief with door open.
Failure to ensure residents knew how to file grievances and that anonymous grievances were allowed.
Failure to complete significant change Minimum Data Set assessment for Resident 4's hospice admission.
Failure to transmit resident assessments to CMS and run validation reports to identify missing transmissions.
Failure to revise care plans for three residents regarding Wander Guard use, hospice care, urinary tract infections, behavior monitoring, and black box warnings.
Failure to provide adequate supervision to Resident 7 with wandering history who entered other resident rooms.
Failure to provide sufficient nursing staff to timely answer call lights, administer medications, and provide resident care.
Failure to notify physician and director of nursing of irregularities related to psychotropic medication use and lack of behavior monitoring for Residents 4 and 7.
Failure to monitor specific targeted behaviors for Residents 4 and 7 receiving psychotropic medications, resulting in unnecessary medication use.
Failure to store and serve food in a sanitary manner by keeping outdated food items in two snack refrigerators.
Failure to obtain, transfer, and maintain complete, accurate, and readily accessible medical records after change of ownership.
Failure to develop a coordinated hospice plan of care integrating facility and hospice services for Resident 4.
Failure to develop and implement effective quality assurance plans to address identified deficiencies and improve resident care.
Report Facts
Call lights not responded to within 10-14 minutes: 96
Call lights not responded to within 15-18 minutes: 34
Call lights not responded to within 19-23 minutes: 23
Call lights not responded to within 24-30 minutes: 7
Call lights not responded to 31 minutes or longer: 8
Medication administration opportunities outside accepted time frame: 106
Medication administration opportunities outside accepted time frame: 31
Medication administration opportunities outside accepted time frame: 159
Medication administration opportunities outside accepted time frame: 85
Medication administration opportunities outside accepted time frame: 236
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Interviewed regarding resident care plans, staffing, MDS transmission, hospice coordination, and medication administration |
| Certified Medication Aide A | Certified Medication Aide | Interviewed regarding staffing, medication administration, and resident care |
| Licensed Nurse O | Licensed Nurse | Interviewed regarding resident care, medication administration, and behavior monitoring |
| Certified Nurse Aide T | Certified Nurse Aide | Interviewed regarding resident behaviors, wandering, and care |
| Consultant Pharmacist X | Consultant Pharmacist | Interviewed regarding medication review and behavior monitoring |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding medication administration practices |
| Licensed Nurse C | Licensed Nurse | Interviewed regarding medication administration practices |
| Licensed Nurse U | Licensed Nurse | Interviewed regarding resident sleep and care |
| Administrative Staff I | Administrative Staff | Interviewed regarding food storage and medical records after ownership change |
| Nurse Consultant W | Nurse Consultant | Interviewed regarding behavior charting practices |
| Licensed Nurse B | Licensed Nurse | Interviewed regarding medication administration and staffing |
| Certified Nurse Aide J | Certified Nurse Aide | Interviewed regarding staffing and use of mechanical lift |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 25, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to allegations identified by complaint numbers KS 00125445 and KS 00125284.
Complaint Details
Complaint investigation KS 00125445 and KS 00125284 revealed allegations in complaints were not substantiated.
Findings
The survey resulted in no deficiency citations with allegations in the complaints found to be not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 25, 2018
Visit Reason
The document is a Plan of Correction submitted following a health survey and complaint investigations at the facility.
Complaint Details
Complaint investigations KS 00125445 and KS 00125284 were conducted and the allegations in the complaints were found not substantiated.
Findings
The health survey resulted in no deficiency citations under 42 CFR Part 483, Subpart B for long term care facilities. Complaint investigations KS 00125445 and KS 00125284 revealed that allegations in complaints were not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 15, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Sterling Presby dated 09/15/2016.
Findings
No deficiencies were cited in the referenced inspection report.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 15, 2016
Visit Reason
The health survey was conducted as a routine annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations, indicating full compliance with the regulatory requirements for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jul 2, 2015
Visit Reason
This document is a Plan of Correction submitted by Sterling Presbyterian Manor in response to alleged deficiencies identified during a regulatory inspection.
Findings
The plan addresses multiple alleged deficiencies including failure to notify physicians of medication administration issues, improper use of physical restraints, failure to maintain dignity and respect for residents, inadequate assistance with eating, and failure to ensure medication regimens were free of unnecessary drugs. Corrective actions include staff re-education, care plan revisions, monitoring by committees, and measures to prevent recurrence.
Deficiencies (5)
Failure to inform the physician for one resident who did not receive medications as ordered and scheduled.
Failure to ensure the resident's right to be free from physical restraints.
Failure to maintain an environment that promotes dignity by not assisting one resident.
Failure to provide assistance with eating for one resident.
Failure to ensure the medication regimen was free of unnecessary drugs for one resident.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Jul 2, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that all previously cited deficiencies, identified by their regulation numbers and prefix codes, were corrected as of the revisit date.
Deficiencies (5)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.13(a)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(l)
Report Facts
Deficiencies corrected: 5
Inspection Report
Enforcement
Deficiencies: 1
Date: Jun 3, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective July 2, 2015.
Deficiencies (1)
Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Rajewski | Administrator | Named as facility administrator in the report. |
| Irina Strakhova | Enforcement Coordinator | Author of the enforcement letter. |
| Sue Hine | Regional Manager | Copied on the letter. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Date: Jun 3, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #87362 to evaluate compliance with regulatory requirements related to medication administration, physical restraints, dignity, and care for residents.
Complaint Details
The visit was triggered by a complaint investigation #87362 regarding medication administration, physical restraints, dignity, and care issues for residents.
Findings
The facility failed to notify the physician when a resident did not receive scheduled medications, failed to ensure a resident's right to be free from physical restraints, failed to maintain dignity by not assisting a resident during meals, failed to provide necessary assistance with eating, and failed to ensure a resident's drug regimen was free from unnecessary drugs.
Deficiencies (5)
Failed to notify the physician for a resident who did not receive medications as ordered and scheduled.
Failed to ensure a resident's right to be free from physical restraints when the resident remained in a recliner with the lift control on the floor.
Failed to maintain an environment that promotes dignity by not assisting a resident who had drool and food on clothing protector at meal time.
Failed to provide assistance with eating for a resident who required extensive assistance.
Failed to ensure the medication regimen was free from unnecessary drugs for a resident, including failure to administer scheduled medications and failure to notify the physician of ongoing medication issues.
Report Facts
Census: 37
Sample size: 16
Medication doses held: 8
Medication doses held: 6
Medication doses held: 4
Medication doses held: 10
PRN Xanax doses administered: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Administrative Nurse | Verified staff failed to notify physician of resident not receiving scheduled medications and confirmed lift chair could be a restraint. |
| Nurse G | Licensed Nurse | Stated resident usually sleeps late and medications held due to sleeping; explained medication aides must notify nurse when medications are not given. |
| Nurse H | Nurse | Stated staff notified physician about resident not always receiving medications but did not inform ongoing issue; described resident's anxiety behaviors. |
| Nurse Aide F | Nurse Aide | Described resident's mood fluctuations and anxiety signs. |
| Nurse Aide E | Medication Aide | Observed not assisting resident adequately during meals. |
| Nurse C | Licensed Nurse | Stated resident required assistance with meals and could be resistive. |
| Nurse D | Nurse Aide | Assisted resident with meal when resident requested help. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 19, 2015
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 potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jun 19, 2015
Provider agreement termination date: Sep 19, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Rajewski | Administrator | Named as facility administrator |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Joe Ewert | Commissioner | Copied on the letter |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 25, 2014
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 had been corrected.
Findings
The revisit confirmed that the deficiencies identified under regulations 483.25 and 483.25(h) were corrected as of the revisit date.
Deficiencies (2)
Deficiency under regulation 483.25 (ID Prefix F0309)
Deficiency under regulation 483.25(h) (ID Prefix F0323)
Report Facts
Deficiencies corrected: 2
Inspection Report
Enforcement
Deficiencies: 1
Date: Mar 27, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective April 25, 2014.
Deficiencies (1)
Isolated 'D' level deficiencies 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
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Mar 27, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #73672 to assess compliance with care and safety regulations.
Complaint Details
The visit was triggered by a complaint investigation (#73672).
Findings
The facility failed to maintain the highest practicable physical, mental, and psychosocial well-being for one resident related to pain management and failed to provide adequate interventions to prevent accidents for another resident at risk of falls.
Deficiencies (2)
Failure to provide adequate pain control for Resident #47 in accordance with the comprehensive assessment and plan of care.
Failure to provide interventions to prevent accidents for Resident #32, who was cognitively impaired and at risk for falls.
Report Facts
Census: 36
Sample size: 11
Residents reviewed for accidents: 3
Fall risk score: 10
Pain medication dosage: 650
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 16, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report shows that all previously cited deficiencies were corrected as of the revisit date, with no uncorrected deficiencies noted.
Deficiencies (6)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(d)(1)-(2)
Deficiency related to regulation 483.35(i)
Report Facts
Deficiencies corrected: 6
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 16, 2013
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 had been corrected.
Findings
The revisit confirmed that all previously cited deficiencies related to various regulatory requirements were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Follow-up survey date: Original survey completed on 2013-02-14.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 16, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date 03/16/2013.
Report Facts
Deficiencies corrected: 6
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 16, 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 shows that all previously identified deficiencies were corrected by the revisit date of 03/16/2013, with corrections documented for multiple regulatory requirements.
Deficiencies (6)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(d)(1)-(2)
Deficiency related to regulation 483.35(i)
Report Facts
Deficiencies corrected: 6
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 6
Date: Feb 14, 2013
Visit Reason
The inspection was a Health Facility Resurvey to evaluate compliance with regulatory requirements and to verify correction of previously cited deficiencies.
Findings
The facility was found deficient in multiple areas including failure to revise admission care plans to prevent pressure ulcers, failure to provide adequate assistance with activities of daily living, failure to monitor blood pressure per physician orders before administering medication, failure to provide food at proper temperatures, and failure to maintain sanitary conditions in food preparation areas.
Deficiencies (6)
Failed to revise the admission care plan to prevent the development of a Stage II pressure ulcer for one resident.
Failed to provide assistance with eating for one resident, including failure to adapt care to changing needs.
Failed to prevent the development of a Stage II pressure ulcer for one resident.
Failed to monitor blood pressure per physician orders before administering Lasix to one resident.
Failed to provide food at the proper temperature for one of six residents receiving room trays.
Failed to ensure food was prepared and stored under sanitary conditions, including greasy lint on hood support beams and peanut butter residue on cupboard shelves.
Report Facts
Census: 36
Sample size: 22
Blood pressure readings: 13
Room trays served: 6
Temperature of sliced meat: 82
Temperature of carrots: 110
Temperature of potatoes: 104
Temperature of chocolate pudding: 74
Thickness of lint: 0.5
Peanut butter residue thickness: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse J | Verified resident was a two person transfer and confirmed delay in placing cushion on wheelchair | |
| Nurse L | Verified resident was a two person transfer and repositioned frequently | |
| Nurse B | Administrative Nurse | Verified resident required assistance during meals and staff should have adapted care |
| Nurse E | Verified resident's blood pressure monitoring and medication administration issues | |
| Nurse D | Verified staff did not check blood pressure before administering Lasix and communication issues | |
| Dietary Staff A | Verified food temperature issues and sanitary deficiencies in kitchen | |
| Dietary Staff M | Provided new meal tray after temperature issue |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N080003 POC KPYG11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to alleged deficiencies identified in a prior inspection related to maintaining residents' highest practicable well-being and accident prevention interventions.
Findings
The facility was found deficient in maintaining the highest practicable physical, mental, and psychosocial well-being for one resident and failing to provide interventions to prevent accidents for another resident. The plan outlines corrective actions including staff re-education, care plan updates, and ongoing monitoring by the Risk Committee.
Deficiencies (2)
Failure to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one resident.
Failure to provide interventions to prevent accidents for one resident.
Report Facts
Date of substantial compliance: Apr 25, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Rajewski | Executive Director | Submitted the Plan of Correction. |
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