Inspection Reports for Alderbrook Village
402 E Windsor Rd, Arkansas City, KS 67005, United States, KS, 67005
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 26, 2025, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed recurring issues with documentation, medication management, emergency preparedness, and nurse identification on service agreements. Complaint investigations in 2023 and 2019 included substantiated neglect related to resident elopement and inadequate incident reporting, but enforcement actions such as fines or license suspensions were not listed in the available reports. Earlier deficiencies involved incomplete functional capacity screenings, missing criminal background checks, and unsafe storage practices, which were addressed over time. The facility’s recent clean inspection suggests improvement following a period of mixed compliance findings.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
36 residents
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-02-06.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 2025-02-26, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 36
Deficiencies: 6
Date: Feb 6, 2025
Visit Reason
The inspection was a licensure resurvey conducted on 02/05/2025 and 02/06/2025 to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in multiple areas including failure to ensure all individuals involved in the development of negotiated service agreements signed the agreements, lack of nurse identification responsible for health care services in agreements, failure to perform required assessments for residents self-administering medication, incomplete documentation of medication administration responsibilities, missing criminal background checks for newly hired staff, and failure to conduct quarterly reviews of the emergency preparedness plan with residents.
Deficiencies (6)
Failure to ensure each individual involved in the development of Resident 1's Negotiated Service Agreement signed the agreement.
Negotiated Service Agreement lacked the name of the nurse responsible for implementation and supervision of the health service plan for Resident 1.
Failure to ensure a licensed nurse performed an assessment for Residents 1 and 3 to determine ability to self-inject insulin safely and accurately.
Negotiated Service Agreement for Resident 3 lacked identification of who was responsible for administration and management of insulin and select medications.
Failure to ensure supporting documentation for criminal background checks of newly hired staff including Certified Medication Aide A, Certified Nurse Aides B and C, and housekeeping staff E.
Failure to ensure the facility's emergency preparedness plan was reviewed quarterly with all residents.
Report Facts
Census: 36
Number of residents sampled: 3
Number of newly hired employees reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator E | Interviewed and confirmed multiple deficiencies including missing signatures, missing nurse identification, lack of assessments, missing medication administration documentation, missing criminal background checks, and emergency preparedness plan review failures. | |
| Certified Medication Aide A | Certified Medication Aide | Personnel record lacked documentation of criminal background check. |
| Certified Nurse Aide B | Certified Nurse Aide | Personnel record lacked documentation of criminal background check. |
| Certified Nurse Aide C | Certified Nurse Aide | Personnel record lacked documentation of criminal background check. |
| Housekeeping Staff E | Housekeeping Staff | Personnel record lacked documentation of criminal background check. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey conducted on February 5 and 6, 2025.
Findings
The plan of correction addresses citations identified during the licensure resurvey of the facility conducted on February 5 and 6, 2025.
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 8
Date: Oct 4, 2023
Visit Reason
The inspection was an abbreviated survey conducted in response to complaints regarding resident elopement and staff neglect at Alderbrook Village LLC.
Complaint Details
The complaint investigation was triggered by an incident on 09/16/2023 when resident R1 eloped from the facility and was found 0.2 miles away at a local restaurant. The restaurant staff called the police. The facility failed to report the elopement timely, failed to investigate, and failed to implement interventions to prevent further elopements.
Findings
The facility failed to prevent a resident (R1) from eloping, failed to report the elopement timely, failed to investigate the incident properly, and failed to implement adequate interventions for exit-seeking behaviors. Additional deficiencies included incomplete functional capacity screening documentation, unsigned negotiated service agreements, lack of coordinated health care services for wandering residents, expired insulin pens without proper dating, incomplete incident documentation, and failure to post required electronic monitoring notices.
Deficiencies (8)
Failure to ensure resident R1 was not neglected when staff failed to recognize and intervene on exit seeking behaviors, resulting in elopement.
Failure to report elopement incident within 24 hours, open investigation, and maintain written records.
Failure to record functional capacity screening findings on the department specified form for resident R3.
Failure to ensure all individuals involved in the development of the negotiated service agreement signed the agreement for resident R2.
Failure to ensure licensed nurse provided or coordinated necessary health care services for residents R1 and R3 related to wandering and exit seeking behaviors.
Failure to ensure insulin pens were dated and discarded according to manufacturer or pharmacy provider recommendations.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, actions taken, and results for resident R1's elopement.
Failure to post conspicuous notice at the entrance and resident rooms regarding electronic monitoring.
Report Facts
Census: 24
Elopement distance: 0.2
Speed limit: 45
Temperature: 69.8
Insulin pen expiration days: 28
Insulin pen expiration days (Levemir): 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Executive Director | Named in findings related to failure to report elopement, failure to investigate, and failure to implement interventions for resident R1 |
| CMA D | Certified Medication Aide | Named in witness statements and interviews regarding resident R1 elopement incident |
| Licensed Nurse Consultant B | Licensed Nurse Consultant | Interviewed regarding failure to implement interventions and documentation for residents R1 and R3 |
| Police Lieutenant CC | Interviewed regarding police response to resident R1 elopement | |
| Patrol Sergeant DD | Provided email report regarding police response to resident R1 elopement | |
| Licensed Nurse C | Licensed Nurse | Interviewed regarding undated insulin pens found in medication cart |
Inspection Report
Re-Inspection
Census: 24
Deficiencies: 10
Date: Oct 4, 2023
Visit Reason
Revisit for correction order 23-SCCC-217 conducted on 10/03/23 and 10/04/23 to verify compliance with previously cited deficiencies.
Findings
The facility failed to conduct required functional capacity screenings and develop or revise negotiated service agreements for residents exhibiting significant changes. Deficiencies included lack of licensed nurse identification on service plans, incomplete training and competency for medication aides, improper labeling of over-the-counter medications, inadequate emergency preparedness training, unsafe food storage practices, failure to comply with tuberculosis screening guidelines for residents and employees, and unsecured chemicals and oxygen cylinders compromising resident safety.
Deficiencies (10)
Failure to conduct functional capacity screening for residents exhibiting exit seeking/wandering behaviors.
Failure to develop initial negotiated service agreements based on functional capacity screens.
Failure to review and revise negotiated service agreements following significant change in condition.
Failure to include the name of the licensed nurse responsible for implementation and supervision of health service plans.
Failure to ensure certified medication aides were trained and completed competencies for delegated insulin pen preparation.
Failure to ensure licensed pharmacist or nurse placed the full name of the resident on bottles of over-the-counter medications.
Failure to perform quarterly emergency preparedness training with staff and residents.
Failure to store food items under safe and sanitary conditions; foods were not properly dated, labeled, or closed.
Failure to comply with tuberculosis screening guidelines for residents and newly hired employees.
Failure to secure chemicals and oxygen cylinders to maintain resident safety.
Report Facts
Census: 24
Deficiencies cited: 10
Dates of inspection: 2023-10-03 to 2023-10-04
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Interviewed regarding multiple deficiencies including functional capacity screening, negotiated service agreements, emergency preparedness, and tuberculosis testing. | |
| Nursing Consultant B | Nursing Consultant | Interviewed regarding functional capacity screening and negotiated service agreements. |
| Registered Nurse DD | Consulting Registered Nurse | Provided consulting visit report noting follow-up for insulin administration competencies and tuberculosis testing. |
| Licensed Nurse C | Licensed Nurse | Observed during medication cart audit; confirmed OTC medication labeling deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The document is a plan of correction related to an abbreviated survey conducted for complaints #183163 at the facility on 10/03/23 and 10/04/23.
Complaint Details
The visit was complaint-related, referencing complaints #183163.
Findings
The plan of correction addresses findings from an abbreviated survey triggered by complaints at the facility conducted on the specified dates.
Inspection Report
Re-Inspection
Census: 23
Deficiencies: 14
Date: Sep 11, 2023
Visit Reason
The inspection was a resurvey with complaints #181812, 181837, 181946, 182136, and 182552 at an assisted living facility conducted on 09/07/23 and 09/11/23.
Complaint Details
The inspection was a resurvey with complaints #181812, 181837, 181946, 182136, and 182552.
Findings
The facility was found deficient in multiple areas including failure to make the most recent survey report available to residents, incomplete functional capacity screenings, missing negotiated service agreements and revisions, lack of updated nurse assignments in service agreements, inadequate training and competencies for medication aides, improper labeling of medications, incomplete employee records, deficient emergency preparedness plans, unsafe food storage practices, infection control noncompliance, failure to comply with tuberculosis screening guidelines, and unsecured chemicals posing safety risks.
Deficiencies (14)
Failed to ensure a copy of the most recent survey report was available in a public area for residents and others.
Failed to complete Functional Capacity Screen for resident after significant change.
Failed to develop initial Negotiated Service Agreement at admission for a resident.
Failed to revise Negotiated Service Agreement following significant change in condition.
Negotiated Service Agreements did not identify current licensed nurse responsible for care plan implementation and supervision.
Failed to ensure all Certified Medication Aides were trained and competent in delegated insulin pen preparation.
Failed to ensure over-the-counter medications were labeled with resident's full name by pharmacist or nurse.
Failed to ensure prescription medication containers had labels provided by dispensing pharmacist.
Failed to ensure timely verification of nurse aide registry and criminal background checks for newly hired employees.
Emergency management plan did not include all required items such as natural gas leaks, explosions, lack of water, severe weather, and missing persons.
Failed to ensure quarterly review of emergency management plan with employees and residents was completed.
Failed to ensure food items were stored under safe and sanitary conditions; items were not properly dated or labeled.
Failed to comply with tuberculosis guidelines for adult care homes; missing two-step TB skin tests and symptom screening for residents and employees.
Failed to secure chemicals properly to maintain resident safety; chemicals stored in unlocked rooms and cabinets.
Report Facts
Census: 23
Number of sampled residents: 3
Number of sampled Certified Medication Aides: 5
Number of newly hired employees reviewed: 5
Number of residents with unlabeled OTC medications: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Interviewed regarding multiple deficiencies including survey report availability, functional capacity screening, negotiated service agreements, medication aide competencies, emergency plan reviews, and tuberculosis screening. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
This document is a Plan of Correction addressing findings from a resurvey with complaints #181812, 181837, 181946, 182136, and 182552 conducted at the assisted living facility on 09/07/23 and 09/11/23.
Complaint Details
The visit was complaint-related involving multiple complaints (#181812, 181837, 181946, 182136, and 182552).
Findings
The Plan of Correction corresponds to deficiencies identified during the resurvey related to multiple complaints at the assisted living facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-09-07.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2022-09-20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2022-09-07 and corrected by 2022-09-20
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 6, 2022
Visit Reason
The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on 09/06/22 at the facility.
Findings
The Plan of Correction addresses citations identified during the licensure resurvey of the facility on 09/06/22.
Report Facts
Inspection date: Sep 6, 2022
Plan of Correction completion date: Sep 21, 2022
Inspection Report
Renewal
Census: 22
Deficiencies: 3
Date: Sep 6, 2022
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance with regulatory requirements for the facility.
Findings
The facility was found deficient in multiple areas including failure to include the licensed nurse's name on residents' negotiated service agreements, failure to provide quarterly emergency management plan reviews to staff and residents, and failure to maintain compliance with tuberculosis testing guidelines for residents and newly hired employees.
Deficiencies (3)
The negotiated service agreement lacked the name of the licensed nurse responsible for implementation and supervision of the Health Care Service Plan for residents 112, 117, and 119.
Failure to ensure residents and staff received quarterly reviews of the facility's emergency management plan.
Failure to maintain compliance with tuberculosis guidelines for adult care homes for two newly admitted residents and four newly hired employees.
Report Facts
Census: 22
Residents sampled: 3
Newly hired employees sampled: 5
Emergency drills: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Confirmed deficiencies related to negotiated service agreements and tuberculosis testing compliance |
| Certified Nurse Aide D | Certified Nurse Aide | Reviewed for tuberculosis testing compliance |
| Certified Nurse Aide E | Certified Nurse Aide | Reviewed for tuberculosis testing compliance |
| Certified Nurse Aide F | Certified Nurse Aide | Reviewed for tuberculosis testing compliance |
| Maintenance Staff A | Maintenance Staff | Interviewed regarding emergency management plan training |
Inspection Report
Re-Inspection
Deficiencies: 8
Date: Feb 8, 2021
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
All previously cited deficiencies were corrected as of the revisit date, with completion dates documented for each regulation cited.
Deficiencies (8)
Deficiency related to regulation 26-41-101 (j)
Deficiency related to regulation 26-41-205 (a) (2)
Deficiency related to regulation 26-41-205 (d) (4)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-206 (a) (b)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Deficiency related to regulation 28-39-254
Inspection Report
Re-Inspection
Census: 17
Deficiencies: 8
Date: Dec 31, 2020
Visit Reason
Licensure resurvey with complaint #158614 and #150666 conducted over four days from 12/28/2020 to 12/31/2020.
Complaint Details
The inspection was conducted as a licensure resurvey with complaints #158614 and #150666.
Findings
The facility was found deficient in multiple areas including failure to post emergency phone numbers, lack of annual self-administration medication assessments for residents, inadequate delegation and documentation of medication administration tasks, improper labeling of over-the-counter medications, failure to provide disaster and emergency preparedness training quarterly, failure to provide therapeutic diets as ordered, incomplete infection control policies compliance, and unsecured chemicals posing safety risks.
Deficiencies (8)
Failure to post names and telephone numbers of persons or places commonly required in emergencies adjacent to the phone for employees and residents.
Failure to provide annual evaluation for residents #115 and #317 for functional ability to safely and accurately self-administer prefilled insulin pen for diabetes management.
Failure to ensure licensed nurse oriented and instructed 2 of 3 sampled certified medication aides in blood sugar testing and failed to document competency demonstration.
Failure to ensure licensed pharmacist or nurse placed full resident names on over-the-counter medication bottles affecting residents #519 and #620.
Failure to provide disaster and emergency preparedness training quarterly to all residents and staff.
Failure to provide therapeutic diets as ordered for residents #115 and #317.
Failure to ensure infection control policies compliance including tuberculosis screening for newly hired employees.
Failure to ensure facility was equipped and maintained to protect health and safety regarding unlocked chemicals accessible to residents.
Report Facts
Residents: 17
Sampled residents: 3
Sampled employees: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Interviewed and confirmed multiple deficiencies including emergency phone postings, medication administration delegation, disaster preparedness training, therapeutic diet orders, and chemical safety. | |
| Licensed Nurse C | Licensed Nurse | Interviewed and confirmed deficiencies related to medication assessments, delegation, medication labeling, therapeutic diets, infection control, and chemical safety. |
| Certified Medication Aide A | Certified Medication Aide | Sampled CMA involved in blood sugar testing without documented competency and lacking tuberculosis screening. |
| Certified Medication Aide D | Certified Medication Aide | Sampled CMA involved in blood sugar testing without documented competency. |
| Cook E | Cook | Interviewed regarding therapeutic diets and infection control compliance; lacked tuberculosis screening. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 7-9-2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 1
Date: Mar 20, 2019
Visit Reason
The visit was a revisit for notice of assessment 19-31 of the assisted living facility conducted on 3/19/19 and 3/20/19.
Findings
The facility failed to ensure that resident #10's record contained documentation of all incidents, symptoms, and other indications of illness or injury including the date, time of occurrence, action taken, and results of the action. Multiple incidents involving the resident were not documented in the record as required.
Deficiencies (1)
Failure to ensure resident's record contained documentation of all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results.
Report Facts
Census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Named in failure to ensure proper documentation of resident incidents | |
| Licensed nurse C | Licensed Nurse | Named in failure to document wellness notes and assessments for resident #10 |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Mar 20, 2019
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit inspection found that the previously cited deficiencies identified by regulation numbers 26-41-101 (f)(1) and 26-41-101 (f)(3) were corrected as of 03/19/2019.
Deficiencies (2)
Deficiency related to regulation 26-41-101 (f)(1)
Deficiency related to regulation 26-41-101 (f)(3)
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Date: Feb 6, 2019
Visit Reason
The inspection was an abbreviated/complaint survey conducted due to complaints #137688 and #137691 at the facility on 1/31/19, 2/4/19, 2/5/19, and 2/6/19.
Complaint Details
The complaint investigation involved allegations of neglect related to resident #2 eloping and being found outside in cold weather without proper clothing and no timely nurse assessment. The neglect was substantiated with findings of immediate jeopardy.
Findings
The facility was found to have neglected resident #2 who was found outside in cold weather, wedged under an air conditioner unit with inadequate clothing and a low body temperature. The licensed nurse failed to assess the resident timely. The administrator failed to report the neglect allegation timely, start and complete an investigation, and submit required reports. Documentation of incidents for resident #2 was incomplete.
Deficiencies (3)
Failure to ensure no resident was subjected to neglect when resident #2 was found outside in cold weather with inadequate clothing and no timely nurse assessment.
Failure to report allegation of neglect to the department within 24 hours, start and complete investigation timely, and maintain written records of investigation.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, actions taken, and results for resident #2.
Report Facts
Census: 32
Temperature: 32
Resident body temperature: 95.8
Incident time: 6.45
Incident date: Dec 22, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Named in findings related to failure to assess resident #2 timely and failure to document incident |
| Administrator B | Administrator | Named in findings related to failure to report neglect allegation timely and failure to investigate |
| Certified Staff C | Named in observations and interviews related to resident #2 elopement and discovery | |
| Certified Staff E | Named in incident report and investigation related to resident #2 elopement | |
| Certified Staff F | Named in incident report and investigation related to resident #2 elopement | |
| Certified Staff G | Named in interviews related to resident #2 elopement | |
| Resident #4 | Resident who reported hearing knocking on window related to resident #2 elopement |
Inspection Report
Re-Inspection
Deficiencies: 10
Date: Sep 4, 2018
Visit Reason
This revisit report documents the correction of previously cited deficiencies at the facility following an earlier survey.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (10)
Deficiency with regulation 26-39-102 (a)
Deficiency with regulation 26-41-202 (a)
Deficiency with regulation 26-41-202 (j)
Deficiency with regulation 26-41-204 (a)
Deficiency with regulation 26-41-204 (d)
Deficiency with regulation 26-41-204 (i)
Deficiency with regulation 26-41-205 (a) (3)
Deficiency with regulation 26-41-205 (d) (1-2)
Deficiency with regulation 26-41-102 (c)
Deficiency with regulation 26-41-105 (f) (11)
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 10
Date: Aug 8, 2018
Visit Reason
The inspection was a resurvey with investigation of complaints #115371, #119360, #124270, and #131841 at an assisted living facility.
Complaint Details
The visit was a resurvey with investigation of complaints #115371, #119360, #124270, and #131841.
Findings
The facility was found deficient in multiple areas including failure to provide proper admission agreements, incomplete negotiated service agreements, inadequate monitoring of outside services, failure to provide necessary health care services according to plans, lack of documentation for self-administration of medications, improper medication administration practices, lack of RN supervision for LPN, and incomplete documentation of incidents.
Deficiencies (10)
Failure to inform prospective resident or legal representative in writing of rates, charges, and refund policy, and failure to execute a proper written admission agreement.
Failure to develop a written negotiated service agreement including description of services, provider identification, and payment responsibility.
Failure to monitor services provided by outside resources and act as an advocate for the resident.
Failure to ensure licensed nurse provides or coordinates necessary health care services in accordance with functional capacity screening and negotiated service agreement.
Negotiated service agreements lacked specification of the licensed nurse responsible for implementation and supervision of the health care service plan.
Failure to provide health care services by qualified staff in accordance with acceptable standards of practice, including failure to provide requested medication and inadequate oxygen therapy monitoring.
Failure to document assessment of resident's ability to safely self-administer and manage selected medications.
Failure to ensure medications were administered according to medical orders, professional standards, and manufacturer recommendations, including unlabeled insulin pens and delayed medication administration.
Failure to ensure registered professional nurse supervision of licensed practical nurse as required by law.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
Report Facts
Census: 31
Deficiencies cited: 10
Medication dosage: 37.5
Medication dosage: 25
Insulin dosage: 25
Insulin dosage: 40
Medication administration delay: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse C | Licensed Practical Nurse | Named in multiple findings including failure to document assessments, failure to monitor outside services, failure to provide health care services, and failure to ensure medication administration. |
| Operator B | Named in findings related to admission policies, service agreements, and medication administration. | |
| Certified staff F | Certified Medication Aide | Observed handling insulin pens not labeled properly. |
| Certified staff G | Certified Staff | Confirmed medication delivery and availability. |
| Licensed nurse E | Registered Nurse | Previous supervising RN no longer available. |
| Administrative staff D | Provided information about RN supervision status. |
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Sep 21, 2016
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers have been corrected as of the revisit date.
Deficiencies (5)
Deficiency related to regulation 26-41-205 (d) (1-2)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-102 (d)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-206 (c) (1)
Inspection Report
Re-Inspection
Census: 24
Deficiencies: 5
Date: Jul 19, 2016
Visit Reason
The inspection was a resurvey with complaint #101770 conducted on 7-12-16, 7-13-16, 7-18-16, and 7-19-16 to assess compliance with medication administration, staff qualifications, emergency preparedness, dietary services, and other regulatory requirements.
Complaint Details
The visit was a resurvey following complaint #101770.
Findings
The facility failed to administer medications according to medical orders, specifically missing 11 doses of escitalopram for one resident. Several over-the-counter medications lacked residents' full names on containers. Employee records for three certified staff lacked required criminal background checks. The emergency management plan was not reviewed quarterly with residents, and weekly menu plans were not made available to residents.
Deficiencies (5)
Failure to ensure all medications were administered according to medical care provider's orders, resulting in missed doses of escitalopram for resident #111.
Licensed nurse failed to place residents' full names on over-the-counter medication containers, tubes, or bottles for multiple residents.
Employee records lacked supporting documentation for criminal background checks for three certified staff.
Failure to ensure quarterly review of the emergency management plan with residents.
Failure to ensure weekly menu plans were available to each resident.
Report Facts
Census: 24
Residents sampled: 3
Focus review residents: 4
Missed medication doses: 11
Employees lacking criminal background checks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff C | Licensed Nurse | Named in medication administration deficiency and refill order communication. |
| Certified staff E | Certified Staff | Named in employee records lacking criminal background check. |
| Certified staff F | Certified Staff | Named in employee records lacking criminal background check. |
| Certified staff G | Certified Staff | Named in employee records lacking criminal background check. |
| Certified staff B | Certified Staff | Interviewed regarding over-the-counter medication labeling. |
| Dietary service director | Dietary Service Director | Interviewed regarding weekly menu availability. |
| Management staff | Management Staff | Interviewed regarding employee records and emergency management plan review. |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 12, 2015
Visit Reason
The licensure resurvey of the assisted living facility was conducted on 2/11/15 and 2/12/15 to assess compliance for license renewal.
Findings
The inspection resulted in no deficiency citations being found at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 20, 2013
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID BGD211 and State ID N018010.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a record of the Plan of Correction status and related administrative data.
Report Facts
POC added date: 01/03/2012 12:46:02 PM
POC modified date: 03/22/2013 09:23:14 AM
Inspection start date: 03/20/2013
Inspection exit date: 03/20/2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patty Brown | User who added and modified the Plan of Correction | |
| Shirley Boltz | Contact for Plan of Correction assistance |
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