Inspection Reports for
Agewise Living Inc
204 W. WASHINGTON AVENUE, STERLING, KS, 67579-1614
Back to Facility ProfileDeficiencies (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/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
58% occupied
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
A revisit survey was conducted 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. It outlines corrective actions to address identified issues and 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. The facility has implemented corrective actions such as care plan revisions, staff re-education, audits, and hiring a new Dietary Manager.
Deficiencies (7)
F689-G: Revised care plans for residents to ensure adherence to fall prevention interventions including proper use of gait belts, motion sensors, and non-slip materials.
F692-D: Revised care plan for fluid restriction monitoring and re-education of nursing staff on documentation and resident education regarding fluid intake.
F756-E: Consultant Pharmacist reviewed medication regimens monthly; facility-wide audit and staff re-education conducted to ensure compliance.
F801-F: New Dietary Manager hired and enrolled in certification program; plan established for oversight of resident nutrition until certification.
F812-F: Expired foods disposed; staff educated on proper food storage and handling; regular audits implemented for refrigerator conditions.
F880-F: Water Management Program reviewed and reinforced; staff re-educated on infection control and water safety; monthly testing and audits ongoing.
F947-D: Human Resource Director to audit staff for required in-service education; nurse aides assigned education sessions until completion; ongoing audits planned.
Report Facts
Plan of Correction completion date: 2025
Dietary Manager start date: 2025
Dietary Manager certification enrollment date: 2025
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 7
Date: Jan 23, 2025
Visit Reason
The inspection was a health resurvey and complaint investigation for Sterling Village nursing facility.
Complaint Details
The inspection included a complaint investigation identified by complaint numbers #KS00190140 and #KS00190977.
Findings
The facility failed to follow care plans for two residents resulting in falls and injury, failed to monitor physician-ordered fluid restriction for a resident, failed to ensure monthly medication regimen reviews by the consultant pharmacist for multiple residents, failed to employ a full-time certified dietary manager, failed to maintain food safety standards in the kitchen, failed to implement a water management program to prevent Legionella, and failed to ensure required annual in-service training for nurse aides.
Deficiencies (7)
F689: The facility failed to follow care plans for residents R128 and R4, resulting in a tibia fracture and a fall from sliding off the bed, placing residents at risk for further falls and injury.
F692: The facility failed to monitor resident R4's physician-ordered 2000 ml per 24-hour fluid restriction, placing the resident at risk for fluid overload complications.
F756: The facility failed to ensure the consultant pharmacist completed monthly medication regimen reviews and reported irregularities for residents R4, R8, R9, R11, and R22, placing them at risk for unnecessary or inappropriate medications.
F801: The facility failed to employ a full-time certified dietary manager for 26 residents, placing them at risk for inadequate nutrition.
F812: The facility failed to store, prepare, distribute, and serve food by professional food safety standards, including unlabeled and unsealed food items and maintenance issues in the kitchen, placing residents at risk for foodborne illness.
F880: The facility failed to implement a water management program to prevent waterborne pathogens including Legionella, placing residents at risk for infectious disease.
F947: The facility failed to ensure three of five nurse aides completed their required 12-hour annual in-service training, placing residents at risk for unskilled care.
Report Facts
Resident census: 26
Fluid restriction: 2000
Missing fluid monitoring documentation days: 22
Annual in-service training hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed regarding failure to follow care plans, fluid restriction monitoring, and lack of consultant pharmacist medication reviews. |
| Dietary Staff BB | Dietary Staff | Observed in kitchen and verified lack of certified dietary manager and food safety issues. |
| Maintenance Staff U | Maintenance Staff | Interviewed regarding maintenance issues and lack of water management program. |
| Certified Nurse Aide N | Certified Nurse Aide | Named in fall investigation for failure to follow care plan for 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 fluid restriction monitoring for Resident 4. |
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 to verify correction of all previous deficiencies cited on 01/04/2023.
Findings
All deficiencies cited in the previous inspection 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
Complaint Investigation
Census: 36
Deficiencies: 9
Date: Jan 4, 2023
Visit Reason
Health Resurvey and Complaint Investigations #174989 and 175399 were conducted to assess compliance with regulatory requirements.
Complaint Details
The inspection was triggered by complaint investigations #174989 and 175399.
Findings
The facility was found deficient in providing bed hold notices for hospitalized residents, revising care plans after falls and pressure ulcers, using appropriate lift slings, maintaining sanitary oxygen equipment, ensuring proper medication monitoring, and storing food safely.
Deficiencies (9)
F625: The facility failed to provide bed hold notices for two residents when hospitalized, risking loss of their beds.
F657: The facility failed to review and revise care plans for residents after falls and pressure ulcer development, risking uncommunicated care needs.
F686: The facility failed to provide timely care for a resident's unstageable pressure ulcer, risking delayed healing and further injury.
F689: The facility failed to use an appropriate lift sling causing a resident to fall and sustain head injury, and failed to implement fall prevention interventions for another resident.
F695: The facility failed to store oxygen equipment in a sanitary manner and ensure correct oxygen flow settings for residents, risking infection and respiratory complications.
F756: The facility failed to ensure the consultant pharmacist identified and reported lack of stop dates for as needed psychotropic medications and lack of behavior monitoring, placing residents at risk for inappropriate medication use.
F757: The facility failed to obtain weekly vital signs as ordered to monitor efficacy of blood pressure medication, risking adverse medication effects.
F758: The facility failed to ensure psychotropic medications had required stop dates and behavior monitoring, and failed to attempt gradual dose reductions, risking adverse side effects.
F812: The facility failed to store, prepare, and serve food in sanitary conditions, including discarding expired items and uncovered food, risking foodborne illness.
Report Facts
Residents present: 36
Residents reviewed: 12
Expired food items: 3
Lift sling incident: 1
Psychotropic medication stop date missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including bed hold notices, oxygen equipment sanitation, medication monitoring, and fall prevention |
| Licensed Nurse G | Licensed Nurse | Observed resident care and verified oxygen and lift sling issues |
| Certified Nurse Aide M | Certified Nurse Aide | Involved in resident transfers and fall incident |
| Certified Medication Aide R | Certified Medication Aide | Administered medications and obtained vital signs |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jan 4, 2023
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on January 4, 2023.
Findings
The plan addresses multiple deficiencies related to resident care plans, pressure ulcer interventions, fall prevention, oxygen administration, medication management, food storage, and equipment availability. The facility outlines corrective actions including staff education, care plan revisions, audits, and monitoring to achieve compliance by February 2, 2023.
Deficiencies (8)
F625: Social Service will be educated on the bed hold and return agreement and ensure residents receive written notices at admission and transfer. The Administrator will monitor admission paperwork for compliance.
F657: Care plans for residents with falls and pressure ulcers have been revised and staff educated on care plan timing and revision. The DON will monitor care plans during risk meetings.
F686: Care plans and treatment records for residents with pressure ulcers were reviewed and revised. Staff will be educated on timely care and services after pressure ulcer development, with monitoring by the DON.
F689: Care plans for residents using full body lifts were reviewed and revised. Additional lift slings were ordered and staff educated on appropriate sling size. The DON will review care plans during risk meetings.
F695: Oxygen cannulas and tubing for residents were changed and staff educated on oxygen administration. The DON will perform random audits of oxygen supplies and flow rates.
F756: The consulting pharmacist was notified and will audit medication regimens for irregularities and unnecessary drugs. Staff will be educated on antipsychotic medication use and monitoring.
F757: Care plans for residents using blood pressure medication were reviewed and revised. Staff will be educated on vital sign monitoring and audits will be performed by the DON and pharmacist.
F812: Expired foods were disposed of and dietary staff educated on proper food storage and handling. Dietary team members will check refrigerator conditions regularly with audits by the CDM.
Report Facts
Plan of Correction completion date: 2023
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 6, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2021-06-08.
Findings
All deficiencies have been corrected as of the compliance date of 2021-07-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 2
Date: Jun 8, 2021
Visit Reason
This inspection was a Health Resurvey to evaluate compliance with drug regimen review and medication storage regulations.
Findings
The facility failed to ensure timely lab monitoring and follow-up on pharmacist recommendations for residents, and failed to remove expired medications from storage.
Deficiencies (2)
CFR 483.45(c) Drug Regimen Review. The facility failed to ensure two residents had labs drawn to monitor Vitamin B-12 as recommended by the pharmacist and failed to act on other pharmacist recommendations timely.
CFR 483.45(g)(h) Label/Store Drugs and Biologicals. The facility failed to remove two vials of Tubersol, one expired and one without an open date, from medication storage.
Report Facts
Facility census: 35
Residents reviewed for unnecessary medications: 5
Residents with lab monitoring failures: 2
Expired medication vials found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Interviewed regarding medication monitoring and storage failures |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 21, 2020
Visit Reason
This document is a Plan of Correction related to a prior inspection or deficiency report for Sterling Village facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
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 against the facility.
Complaint Details
Complaint #KS00155295 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparedness. The allegations in the complaint were not substantiated and no noncompliance was found.
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 for COVID-19 preparation.
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 to verify correction of all previous deficiencies cited on 2019-09-19.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2019-10-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Sep 19, 2019
Visit Reason
This document is a Plan of Correction submitted by Sterling Village RS in response to deficiencies identified during a regulatory inspection conducted on 2019-09-19.
Findings
The Plan of Correction addresses multiple deficiencies related to resident dignity, grievance procedures, hospice care collaboration, care plan updates, medication monitoring, staffing, food safety, medical records accessibility, and quality assurance processes. The facility outlines corrective actions, staff education, audits, and policy reviews to achieve compliance by 2019-10-18.
Deficiencies (13)
F550-D: Resident #3's clothing preferences and toileting needs were addressed to avoid dignity issues, with care plan updates and staff education planned.
F585-D: Residents were informed about the grievance/complaint procedures and forms, with staff education and ongoing audits planned.
F637-D: Hospice services for Resident #4 were incorporated into the care plan, with staff education and audits to ensure collaboration.
F640-F: All Minimum Data Set (MDS) submissions were verified and validated, with ongoing audits planned.
F657-D: Care plans for residents were updated to reflect current medications, including black box warnings and prevention interventions, with staff education and audits.
F689-D: Staffing model reviewed to ensure adequate supervision and interventions for diversional activities, with staff education and behavioral monitoring.
F725-F: Final staffing ratios discussed with plans for medication time reviews, mechanical lift training, and daily staffing audits.
F756-D: Care plans updated for monitoring targeted behaviors related to antipsychotropic medications, with staff education and audits.
F758-D: Targeted behavior monitoring placed on residents' electronic treatment records to ensure proper documentation and monitoring.
F812-F: Outdated foods removed from refrigerators, with staff education and weekly audits planned.
F842-F: Medical records from previous owner retained and maintained for six months to ensure accessibility, with audits planned.
F849-D: Collaborative care plans developed for residents on hospice services, with staff education and audits.
F867-F: QAPI program reviewed and improved with staff education and ongoing audits to identify and address broken processes.
Report Facts
Date compliance expected: Oct 18, 2019
Nursing PPD: 3.8
Nursing PPD: 4.2
Inspection Report
Annual Inspection
Census: 23
Deficiencies: 13
Date: Sep 17, 2019
Visit Reason
Annual health resurvey and inspection of Sterling Presbyterian Manor to assess compliance with regulatory requirements including resident care, medication administration, safety, and hospice services.
Findings
The facility had 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 causing delayed care and medication administration, failure to monitor psychotropic medication behaviors, storage of outdated food, incomplete medical records after ownership change, and lack of coordinated hospice care plans.
Deficiencies (13)
F550 Resident Rights: The facility failed to treat Resident 3 with dignity by leaving her exposed in a t-shirt and incontinence brief with her door open, exposing her to others.
F585 Grievances: The facility failed to ensure residents knew how to file grievances or that they could file anonymously; grievance forms and boxes were not properly identified or accessible.
F637 Comprehensive Assessment: The facility failed to complete a significant change Minimum Data Set assessment for Resident 4's admission to hospice on 02/12/19.
F640 Resident Assessments: The facility failed to transmit resident assessments to CMS and did not run validation reports to identify missing transmissions.
F657 Care Plan Revision: The facility failed to revise care plans for three residents regarding Wander Guard use, hospice care, urinary tract infections, behavior monitoring, and black box medication warnings.
F689 Accident Hazards: The facility failed to provide adequate supervision to Resident 7, who had a history of wandering and was observed wandering into other residents' rooms.
F725 Staffing: The facility failed to provide sufficient nursing staff to timely provide resident care, answer call lights, and administer medications, resulting in delayed medication administration and resident care.
F756 Drug Regimen Review: The consulting pharmacist failed to notify the physician or director of nursing about the facility's failure to monitor specific targeted behaviors for psychotropic medication use for Residents 4 and 7.
F758 Psychotropic Medications: The facility failed to ensure Residents 4 and 7 did not receive unnecessary psychotropic medications by failing to monitor specific targeted behaviors related to their use.
F812 Food Safety: The facility failed to store and serve food in a sanitary manner by failing to remove outdated foods from two snack refrigerators.
F842 Resident Records: The facility failed to obtain, transfer, and maintain complete, accurate, and readily accessible medical records for residents after a change of ownership, limiting access to records prior to 08/01/19.
F849 Hospice Services: The facility failed to develop a coordinated plan of care that integrated facility and hospice services for Resident 4 receiving hospice care.
F867 QAPI: The facility failed to develop and implement an effective Quality Assessment and Assurance program to ensure action plans were developed and implemented to address identified quality deficiencies.
Report Facts
Facility census: 23
Call lights not responded within 10-14 minutes: 96
Call lights not responded within 15-18 minutes: 34
Call lights not responded within 19-23 minutes: 23
Call lights not responded within 24-30 minutes: 7
Call lights not responded 31 minutes or longer: 8
Medication administration outside accepted time frame: 106
Medication administration outside accepted time frame: 31
Medication administration outside accepted time frame: 159
Medication administration outside accepted time frame: 85
Medication administration outside accepted time frame: 236
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 25, 2018
Visit Reason
The document is a plan of correction related to a health survey and complaint investigations at the facility.
Complaint Details
Complaint investigations KS 00125445 and KS 00125284 were conducted and the allegations were found not substantiated.
Findings
The health survey resulted in no deficiency citations under 42 CFR Part 483, Subpart B. Complaint investigations KS 00125445 and KS 00125284 revealed the allegations in complaints were not substantiated.
Deficiencies (1)
The health survey found no deficiency citations under 42 CFR Part 483, Subpart B for long term care facilities. Complaint investigations revealed allegations were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 25, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on allegations in complaints KS 00125445 and KS 00125284.
Complaint Details
Complaint investigation KS 00125445 and KS 00125284 revealed allegations in complaints were not substantiated.
Findings
The survey found no deficiency citations related to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities. The allegations in the 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 regulatory compliance purposes.
Findings
No deficiencies were cited in the referenced inspection report dated 09/15/2016.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 15, 2016
Visit Reason
The inspection was conducted as a health survey 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 applicable regulations 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 prior inspection.
Findings
The facility was found deficient in notifying physicians about medication administration deviations, use of physical restraints, maintaining dignity during care, providing assistance with eating, and ensuring medication regimens were free of unnecessary drugs. The provider outlines corrective actions, re-education of staff, and monitoring plans to address these issues.
Deficiencies (5)
F157-D: The facility failed to inform the physician when a resident did not receive medications as ordered and scheduled.
F221-D: The facility failed to ensure the resident's right to be free from physical restraints by using a full lift recliner that could act as a restraint.
F241-D: The facility failed to maintain an environment that promotes dignity by not assisting a resident appropriately.
F312-D: The facility failed to provide assistance with eating for a resident requiring help.
F329-D: The facility failed to ensure the medication regimen was free of unnecessary drugs for a resident.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 2, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Inspection Report
Enforcement
Deficiencies: 1
Date: Jun 3, 2015
Visit Reason
The visit 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 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)
The facility had isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy.
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 based on complaints received.
Complaint Details
The inspection was triggered by a complaint investigation (#87362) concerning medication administration, physical restraints, dignity in care, assistance with eating, and medication regimen issues for specific 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 and respect for 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)
F 157: The facility failed to notify the physician when Resident #18 did not receive medications as ordered and scheduled, including Buspirone and Sinemet.
F 221: The facility failed to ensure Resident #18 was free from physical restraints when the resident remained in a recliner with feet elevated and the remote control on the floor, without assessment or documentation.
F 241: The facility failed to maintain dignity and respect for Resident #22 by not assisting the resident who had drool and food on their clothing protector during meals.
F 312: The facility failed to provide necessary assistance with eating for Resident #22 who required and requested help during meals.
F 329: The facility failed to ensure Resident #18's drug regimen was free from unnecessary drugs by not consistently administering scheduled medications and failing to notify the physician of ongoing medication issues.
Report Facts
Resident census: 37
Sampled residents: 16
Medication doses held: 8
Medication doses held: 6
Medication doses held: 4
Medication doses held: 10
Xanax PRN administrations: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Administrative Nurse | Verified failure to notify physician of medication issues for Resident #18 |
| Nurse G | Licensed Nurse | Reported medication administration practices and resident sleeping patterns |
| Nurse H | Nurse | Reported resident behaviors and medication refusal, and notification to physician |
| Nurse Aide F | Nurse Aide | Reported resident mood fluctuations and anxiety |
| Nurse Aide B | Nurse Aide | Observed not assisting Resident #22 adequately during meals |
| Medication Aide E | Medication Aide | Observed not wiping Resident #22's face or removing soiled clothing protector |
| Nurse C | Licensed Nurse | Reported resident's need for assistance and resistiveness |
| Nurse D | Nurse Aide | Assisted Resident #22 with meal upon request |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 19, 2015
Visit Reason
A Life Safety Code survey was conducted 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, 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)
The facility was cited for 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Jun 19, 2015
Provider agreement termination date: Sep 19, 2015
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Joe Ewert | Commissioner | Copied on the report as Commissioner of KDADS. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 25, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously reported under regulations 483.25 and 483.25(h) were corrected as of the revisit date.
Deficiencies (2)
Regulation 483.25 deficiency was corrected as of 04/25/2014.
Regulation 483.25(h) deficiency was corrected as of 04/25/2014.
Inspection Report
Enforcement
Deficiencies: 1
Date: Mar 27, 2014
Visit Reason
The visit 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 isolated 'D' level deficiencies that constitute no actual harm but have the 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.
Deficiencies (1)
The facility had isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 35
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. The findings confirmed deficiencies in pain management and fall prevention.
Findings
The facility failed to maintain adequate pain management for one resident and failed to implement interventions to prevent falls for another resident, despite existing care plans and policies.
Deficiencies (2)
F 309: The facility failed to provide adequate pain control for Resident #47, who had impaired cognition and required assistance, despite standing orders for pain medication.
F 323: The facility failed to implement new interventions to prevent further falls for Resident #32, who was cognitively impaired and at risk for falls, despite care plans and fall prevention policies.
Report Facts
Resident census: 36
Resident census: 35
Sample size: 11
Residents reviewed for accidents: 3
Fall risk score: 10
Pain medication dosage: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Reported on pain management attempts and physician contact | |
| Administrative Nurse B | Provided expectations on physician contact and care plan updates | |
| Nurse B | Commented on care plan updates after falls |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 16, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All deficiencies previously reported were corrected as of the revisit date. The report lists multiple regulation citations with correction completion dates of 03/16/2013.
Deficiencies (6)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiency corrected as of 03/16/2013.
Regulation 483.25(a)(3): Previously cited deficiency corrected as of 03/16/2013.
Regulation 483.25(c): Previously cited deficiency corrected as of 03/16/2013.
Regulation 483.25(l): Previously cited deficiency corrected as of 03/16/2013.
Regulation 483.35(d)(1)-(2): Previously cited deficiency corrected as of 03/16/2013.
Regulation 483.35(i): Previously cited deficiency corrected as of 03/16/2013.
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 indicated in the plan of correction.
Findings
All deficiencies previously reported on the CMS-2567 were corrected by the revisit date of 03/16/2013 as documented by the correction completion dates.
Deficiencies (6)
Regulation 483.20(d)(3), 483.10(k)(2) deficiency was corrected by 03/16/2013.
Regulation 483.25(a)(3) deficiency was corrected by 03/16/2013.
Regulation 483.25(c) deficiency was corrected by 03/16/2013.
Regulation 483.25(l) deficiency was corrected by 03/16/2013.
Regulation 483.35(d)(1)-(2) deficiency was corrected by 03/16/2013.
Regulation 483.35(i) deficiency was corrected by 03/16/2013.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 16, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously cited in the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected.
Findings
The revisit confirmed that all previously identified deficiencies related to various regulatory requirements were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 16, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-02-14.
Findings
All previously cited deficiencies identified by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for each deficiency.
Deficiencies (6)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiency corrected as of 2013-03-16.
Regulation 483.25(a)(3): Previously cited deficiency corrected as of 2013-03-16.
Regulation 483.25(c): Previously cited deficiency corrected as of 2013-03-16.
Regulation 483.25(l): Previously cited deficiency corrected as of 2013-03-16.
Regulation 483.35(d)(1)-(2): Previously cited deficiency corrected as of 2013-03-16.
Regulation 483.35(i): Previously cited deficiency corrected as of 2013-03-16.
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 6
Date: Feb 14, 2013
Visit Reason
The inspection was a Health Facility Resurvey to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to revise care plans to prevent pressure ulcers, inadequate assistance with activities of daily living, failure to monitor blood pressure per physician orders, serving food at improper temperatures, and unsanitary food preparation and storage conditions.
Deficiencies (6)
F 280: The facility failed to revise the admission care plan to prevent the development of a Stage II pressure ulcer for one resident.
F 312: The facility failed to provide adequate assistance with eating and adapt care to accommodate changing needs for one resident.
F 314: The facility failed to prevent the development of a Stage II pressure ulcer for one resident despite known risk factors and treatment orders.
F 329: The facility failed to monitor and hold diuretic medication per physician orders based on resident's blood pressure for one resident.
F 364: The facility failed to provide food at the proper temperature for one of six residents receiving room trays.
F 371: The facility failed to ensure food was prepared and stored under sanitary conditions, including greasy lint on hood beams and peanut butter residue in cupboards.
Report Facts
Resident 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
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N080003 POC
Visit Reason
This document is a Plan of Correction related to a regulatory inspection event for the facility identified as State ID N080003.
Findings
No deficiencies or findings are listed in this Plan of Correction document. No records of deficiencies were found or linked.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N080003 POC I62Y11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to medication regimen reviews and storage of medications, including audits, staff education, and monitoring to ensure compliance by 7/13/2021.
Deficiencies (2)
F756-D: The facility failed to ensure timely drug regimen reviews and follow-up on psychotropic medications and lab orders. The plan includes audits, staff education, and ongoing monitoring to correct this.
F761-E: The facility failed to properly manage medication storage, including destruction of expired Tubersol vials and inspection of medication expiration dates. The plan includes staff education, audits, and monthly monitoring.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Dan Arice | Administrator | Submitted the Plan of Correction |
| Melissa Miller | Added the Plan of Correction | |
| Jessica Patterson | Modified the Plan of Correction |
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 report.
Findings
The facility was found to have failed to maintain the highest practicable physical, mental, and psychosocial well-being for one resident and failed to provide interventions to prevent accidents for another resident. The Plan of Correction outlines corrective actions, staff re-education, and monitoring measures to address these deficiencies.
Deficiencies (2)
F309-D: The community failed to maintain the highest practicable physical, mental, and psychosocial well-being for one resident according to the comprehensive assessment and plan of care.
F323-D: The community failed to provide interventions to prevent accidents for one resident, including updating care plans and reviewing fall risks.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N080003 POC SRIV11
Visit Reason
This document is a Plan of Correction related to a previous inspection or regulatory finding for the facility identified as State ID N080003.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N080003 POC YZ7H11
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for Sterling Village.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
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