Inspection Report Summary
The most recent inspection on June 4, 2025, found deficiencies related to neglect when staff transferred a resident without using the required mechanical lift, resulting in injury. Earlier inspections showed a pattern of deficiencies involving resident care, food safety, staffing documentation, and supervision, with substantiated complaints about medication errors, elopement risks, and infection control. Main themes of deficiencies included failure to follow care plans, inadequate supervision to prevent accidents and elopements, unsanitary food handling, and incomplete or inaccurate staffing and medication management. Several enforcement actions were noted historically, including denial of payment for new Medicare admissions due to 'F' level deficiencies, but no fines or license suspensions were listed in the available reports. The facility has shown some improvement at times with corrected deficiencies verified on re-inspections, though recent findings indicate ongoing challenges in resident safety and care plan adherence.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
19.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
227% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
39 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Jun 4, 2025
Visit Reason
The inspection was conducted as an abbreviated survey and complaint investigation related to allegations of neglect involving Resident 1 (R1) who was injured during a transfer without the use of a mechanical lift as required by her care plan.
Findings
The facility failed to ensure R1 remained free from neglect when Certified Nurse Aides (CNAs) transferred R1 without using the required full-body mechanical lift, resulting in R1 being lowered to the floor and sustaining fractures to her left femur and right fibula. The incident was not immediately reported to nursing or administrative staff, delaying appropriate follow-up care. Corrective actions included staff suspensions, terminations, education, pain assessments, mechanical lift audits, and a QAPI meeting.
Complaint Details
The complaint investigation revealed that on 05/18/25, CNAs M and N lowered Resident 1 to the floor without using the mechanical lift and did not report the incident. Resident 1 sustained fractures to the left femur and right fibula. The facility failed to immediately notify nursing and administrative staff, placing the resident in immediate jeopardy. CNAs involved were suspended or terminated, and staff education was conducted.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to use the full-body mechanical lift as required by Resident 1's care plan during transfer, resulting in injury and neglect. | J |
Report Facts
Census: 39
Residents sampled for abuse and neglect: 5
Suspension duration: 3
Pain assessment duration: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Involved in improper transfer of Resident 1 leading to injury; suspended and terminated |
| CNA N | Certified Nurse Aide | Involved in improper transfer of Resident 1 leading to injury; suspended and received final written warning |
| CNA O | Certified Nurse Aide | Involved in improper transfer of Resident 1 leading to injury; suspended and received final written warning |
| LN G | Licensed Nurse | Assessed Resident 1 after incident; documented findings and communicated with physician |
| LN H | Licensed Nurse | Assessed Resident 1 and reported incident to physician; involved in follow-up care |
| Administrative Nurse D | Administrative Nurse | Received delayed incident report; coordinated follow-up care and investigation |
| Administrative Nurse E | Administrative Nurse | Received report from CNA O; assisted in investigation and communication |
| Administrative Staff A | Administrative Staff | Informed of incident; participated in investigation and corrective action |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 20, 2025
Visit Reason
An offsite revisit survey was conducted on 02/20/25 to verify correction of all previous deficiencies cited on 12/23/24.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 02/01/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Dec 19, 2024
Visit Reason
The inspection was conducted as a Health Resurvey and investigation of complaint #192384 regarding food safety and staffing issues at the facility.
Findings
The facility failed to prepare, store, and serve food in a sanitary manner, with multiple instances of expired and undated food items, unsanitary kitchen and storage conditions, and improper maintenance of resident snack refrigerators. Additionally, the facility failed to electronically submit complete and accurate direct care staffing information, omitting hours worked by an administrative nurse providing direct care during weekends, resulting in inaccurate Payroll Based Journal (PBJ) reports.
Complaint Details
The visit was triggered by complaint #192384. The complaint was substantiated as evidenced by the findings of unsanitary food handling and inaccurate staffing reports.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to prepare, store, and serve food in a sanitary manner, including expired and undated food items and unsanitary kitchen conditions. | SS=F |
| Failed to electronically submit complete and accurate direct care staffing information, omitting hours of an administrative nurse providing direct care during weekends. | SS=F |
Report Facts
Census: 40
Deficiencies cited: 2
PBJ reporting quarters: 2
Direct care staffing hours: 3.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided direct care during weekends but hours were not included in PBJ reports. |
| Dietary Staff BB | Dietary Staff | Interviewed regarding food safety and management of resident snack areas. |
| Consulting Staff GG | Dietary Consultant | Confirmed food safety and sanitation issues in the kitchen. |
| Licensed Nurse G | Licensed Nurse | Interviewed about maintenance responsibilities of refrigerators and resident snacks. |
| Licensed Nurse H | Licensed Nurse | Interviewed about management of resident snack areas. |
| Certified Nurse Aide M | Certified Nurse Aide | Interviewed about management of resident snack area and ice packs. |
| Administrative Staff B | Administrative Staff | Confirmed inability to submit Administrative Nurse D's direct care hours due to bookkeeping system limitations. |
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 19, 2024
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited during a prior inspection.
Findings
The plan addresses deficiencies related to unlabeled and undated food items, cleaning issues in the kitchen, and accurate reporting of Administrative Nurse/DON direct care hours in PBJ submissions.
Deficiencies (2)
| Description |
|---|
| Unlabeled/undated food items removed and disposed of; cleaning of kitchen equipment and repair of drainpipe. |
| Administrative Nurse/DON hours to be reflected accurately in direct care hours and PBJ reporting. |
Report Facts
Audit frequency: 3
Audit frequency: 2
Plan approval date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Morey | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
May 21, 2023
Visit Reason
An offsite revisit survey was conducted on 05/21/2023 for all previous deficiencies cited on 03/21/2023.
Findings
All deficiencies have been corrected as of the compliance date of 05/04/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Census: 41
Deficiencies: 9
Mar 21, 2023
Visit Reason
The inspection was a Health Resurvey and complaint investigations related to resident care, grievances, abuse investigations, and compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs such as call light accessibility, failure to file and follow up on grievances, inadequate investigation of resident-to-resident altercations and abuse, failure to notify the Ombudsman of hospital transfers, inadequate hygiene care for residents, failure to prevent repeated skin injuries, improper catheter tubing securing, improper garbage disposal, and infection control breaches including hand hygiene and equipment sanitation.
Severity Breakdown
SS=D: 5
SS=E: 3
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure call light was within reach for residents R17 and R13 to alert staff of needs. | SS=D |
| Failure to file grievance reports and follow up with resident concerns voiced during resident council meetings. | SS=E |
| Failure to thoroughly investigate allegations of resident-to-resident altercation/abuse and sexual abuse, including inadequate resident interviews. | SS=E |
| Failure to notify the Ombudsman office of resident hospital transfers for R12 and R6. | SS=D |
| Failure to provide appropriate hygiene and grooming cares to Resident R33, including inadequate fingernail care. | SS=D |
| Failure to identify contributing causes of multiple skin injuries of unknown origin for Resident R24 and failure to implement immediate interventions to prevent further injuries. | SS=D |
| Failure to ensure urinary catheter tubing for Resident R18 was appropriately secured to prevent urethral trauma. | — |
| Failure to maintain and dispose of garbage and refuse properly, with dumpster lids open and trash exposed, risking pest harborage. | SS=F |
| Failure to follow infection prevention and control standards including hand hygiene, glove use, sanitizing shared equipment, and sanitary administration of eye drops, increasing risk of infection transmission. | SS=E |
Report Facts
Residents selected for review: 17
Resident census: 41
Skin injuries on R24: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Provided statements and verified findings related to investigations, catheter care, infection control, and grievance processes. | |
| Certified Nurse Aide Q | CNA | Observed providing peri care with infection control breaches. |
| Certified Medication Aide S | CMA | Reported on skin injury reporting and infection control procedures. |
| Certified Medication Aide LL | CMA | Observed administering eye drops and using blood pressure cuff without proper sanitation. |
| Certified Nurse Aide O | CNA | Observed providing peri care with infection control breaches. |
| Certified Nurse Aide M | CNA | Reported on fingernail care practices. |
| Certified Nurse Aide N | CNA | Reported on shower and fingernail care schedule. |
| Social Service Staff X | Reported on grievance and Ombudsman notification processes. | |
| Administrative Staff A | Provided statements on grievance and Ombudsman notification expectations. |
Inspection Report
Plan of Correction
Deficiencies: 10
Mar 21, 2023
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited during a survey conducted on March 21, 2023.
Findings
The plan addresses multiple deficiencies including call light accessibility, resident grievances, resident-to-resident investigations, Ombudsman notifications, resident care issues such as fingernail care, bruising assessments, catheter securement, sanitation concerns, and staff skills check-offs. Corrective actions include staff education, audits, monitoring, and updates to care plans and policies.
Deficiencies (10)
| Description |
|---|
| Resident 17 call light was immediately moved to a reachable position; Resident 13 CNA educated on call light use. |
| Previous resident concerns reviewed during resident council to verify improvement and grievance process education provided. |
| New questionnaire pertaining to investigation of resident-to-resident incidents; audit found 5 residents with staff-related questions. |
| Ombudsman notified of residents transferred or discharged for missing months; audits and education on notification requirements conducted. |
| Resident 33 fingernails were clean and filed; fingernail care added to TAR and care plan updated. |
| Audit of 9 diabetic residents' nail care placed on TAR and care plan updated; staff education and monitoring planned. |
| Audit found 16 residents with bruising lacking risk assessment; investigations, care plan updates, and staff education planned. |
| Resident 18 catheter securement added to TAR and care plan; audits and staff education planned with ongoing monitoring. |
| Dumpster lid replaced; daily audits by maintenance and housekeeping staff to ensure lids are present and closed. |
| Skills check-offs to be completed by DON/Designee for staff including peri care, medication pass, and hand hygiene. |
Report Facts
Residents audited for diabetic nail care: 9
Residents with bruising lacking risk assessment: 16
Residents with staff-related questions in resident-to-resident investigation: 5
Residents transferred or discharged missing Ombudsman notification months: 5
Residents affected by catheter securement audit: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Morey | Administrator | Administrator who submitted the Plan of Correction and provided education to staff. |
| Evelyn Lacey | Person who added and modified the Plan of Correction. |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 25, 2021
Visit Reason
An offsite revisit survey was conducted on 10/25/2021 for all previous deficiencies cited on 08/26/2021.
Findings
All deficiencies have been corrected as of the compliance date of 09/24/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 4
Aug 26, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation #153890.
Findings
The facility failed to review and revise care plans for residents following falls, failed to follow care plan interventions to prevent falls, failed to manage a urinary catheter properly to prevent infections and trauma, and failed to appropriately label and store medications including expired drugs and undated opened medications.
Complaint Details
The visit was triggered by complaint investigation #153890.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to review and revise care plans for residents following falls to prevent further falls. | SS=D |
| Failed to follow care plan interventions to prevent falls for residents. | SS=D |
| Failed to appropriately manage urinary catheter to prevent urinary tract infections and urethral trauma. | SS=D |
| Failed to appropriately label and store drugs; included expired medications and undated opened medications. | SS=E |
Report Facts
Resident census: 41
Sample size: 12
Falls for Resident 35: 6
Expired medication date: 2020
Expired medication date: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Provided statements regarding expectations for care plan interventions and catheter management. | |
| Licensed Nurse I | Provided statements regarding catheter care and resident behavior. | |
| Certified Nursing Assistant Q | Observed assisting resident to recliner and noted failure to provide planned interventions. | |
| Certified Nurse Aide M | Provided statements about fall risk interventions and care plan communication. | |
| Licensed Nurse H | Observed medication cart and noted undated insulin pens. |
Inspection Report
Plan of Correction
Deficiencies: 4
Aug 26, 2021
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited during a survey conducted on August 26, 2021.
Findings
The plan addresses multiple deficiencies related to care plan updates for fall interventions and catheter care, medication management including removal of expired medications, and staff education and audits to ensure compliance with care standards.
Severity Breakdown
D: 3
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Residents 6 and 31 care plan updated by IDT for fall interventions and catheter care | D |
| Residents 6 and 35 care plan updated by IDT to indicate current interventions, environmental assessment completed | D |
| Resident 31 catheter anchored and tubing placed appropriately; care plan updated to include catheter care | D |
| Expired medications removed from medication cart; undated insulin pens removed | E |
Report Facts
Date of survey: Aug 26, 2021
Plan of Correction approval date: Sep 24, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Morey | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction on January 7, 2020 | |
| Lori Mouak | Modified Plan of Correction on November 4, 2021 |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 16, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by Kansas Department for Aging and Disability Services (KDADS) on 06/16/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 16, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a COVID-19 survey conducted on 06/16/2020.
Findings
The facility was found to be deficiency free during the COVID-19 survey conducted on 06/16/2020.
Deficiencies (1)
| Description |
|---|
| DEFICIENCY FREE COVID 19 SURVEY. |
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 2, 2020
Visit Reason
The health survey was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 9, 2019
Visit Reason
An offsite revisit was conducted on 08/09/19 to verify correction of all previous deficiencies cited on 07/01/19.
Findings
All deficiencies have been corrected as of the compliance date of 07/25/19, 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
Jul 25, 2019
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited in a prior complaint-related inspection.
Findings
The plan outlines corrective actions including notification of physician, director of nursing, and resident; monitoring for side effects; medication administration audits; staff education; and ongoing audits and trend reviews by the QAPI committee.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficiency related to medication administration and following physician orders (F755-D) | D |
| Deficiency related to medication administration and following physician orders (F760-D) | D |
Report Facts
Plan of Correction completion date: Jul 25, 2019
Monitoring period: 72
Audit frequency: 4
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Jul 1, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#142931) regarding medication administration errors at the facility.
Findings
The facility failed to follow physician's orders and administered medications intended for a different resident to resident #01, resulting in significant medication errors. The resident was monitored and no negative outcomes were noted.
Complaint Details
The complaint investigation #142931 found that on 6/28/19, licensed nurse B administered medications intended for another resident to resident #01. The resident was alert, notified, and monitored with no adverse effects noted. The error was confirmed by staff involved.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to follow physician's orders to ensure resident #01 received medications as ordered, administering medications intended for a different resident. | Level D |
| Failed to ensure resident #01 remained free of significant medication errors when wrong medications were administered. | Level D |
Report Facts
Census: 44
Medication error incident date: Jun 28, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Prepared and administered wrong medications to resident #01 |
| Certified Medication Aide C | Certified Medication Aide | Set up medications for a different resident leading to medication error |
| Administrative Nursing Staff A | Administrative Nursing Staff | Provided expectations regarding medication administration procedures |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 5, 2019
Visit Reason
An offsite revisit survey was conducted on 03/05/2019 for all previous deficiencies cited on 01/07/2019.
Findings
All deficiencies have been corrected as of the compliance date of 01/31/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 1
Jan 7, 2019
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2019-01-31.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a "F" level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 4
Jan 7, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation covering multiple complaint numbers (#135358, #135312, #131980, #131908, #131920, #131888, and #136422).
Findings
The facility failed to maintain a safe, clean, and comfortable environment, with housekeeping and maintenance deficiencies observed in multiple hallways. Additionally, the facility failed to provide timely treatment for a resident's pressure ulcer, ensure proper labeling and storage of insulin pens, and maintain sanitary food procurement, storage, preparation, and service conditions.
Complaint Details
The visit was complaint-related, involving multiple complaint investigations as referenced by complaint numbers #135358, #135312, #131980, #131908, #131920, #131888, and #136422.
Severity Breakdown
E: 1
D: 2
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services to maintain an orderly, sanitary, and comfortable environment in 2 of 2 hallways, including rust, hair buildup, soiled linens, missing towel bars, and peeling paint. | E |
| Failed to provide newly ordered treatment for a resident's pressure ulcer for 13 days, delaying healing and infection prevention. | D |
| Failed to ensure proper labeling of insulin pens for safe storage and correct dosage administration. | D |
| Failed to store, prepare, distribute, and serve food under sanitary conditions, including greasy walls, peeling paint, deep cuts in cutting boards, and flaking non-stick skillets. | F |
Report Facts
Resident census: 45
Sample size: 18
Delay in treatment: 13
Pressure ulcer size: 2.5
Pressure ulcer size: 1.9
Pressure ulcer size: 0.5
Pressure ulcer size: 1.7
Pressure ulcer size: 1.2
Pressure ulcer size: 0.5
Inspection Report
Plan of Correction
Deficiencies: 4
Jan 7, 2019
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited during a survey conducted on January 7, 2019.
Findings
The plan addresses multiple deficiencies including maintenance and cleanliness issues, wound care order accuracy, insulin pen labeling, and dietary equipment condition. Corrective actions include cleaning, repairs, staff education, audits, and ongoing monitoring by facility leadership.
Severity Breakdown
E: 1
D: 2
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Beauty Shop chairs, cabinets and carts cleaned and repaired; personal care equipment replaced and labeled; paint repaired; carpet cleaned; bed linens changed; towel bars repaired; towels covered; mattresses cleaned; urinal replaced and resident educated on proper placement. | E |
| Orders received on 12/20/18 were updated on 1/2/19; wound care notified of error; wound care orders audited for accuracy; education provided to nursing staff on verifying orders; audits to verify new orders during clinical meetings. | D |
| Insulin pens labeled with name and directions; audit identified 3 concerns; pharmacy notified; education provided to nurses and medication aides; monthly audits to verify labeling. | D |
| Pipes above sink cleaned and painted; cutting boards and skillets replaced; bids to repair/replace kitchen walls; cleaning schedule developed; dietary equipment audited; education provided to dietary staff. | F |
Report Facts
Deficiencies cited: 4
Date of survey: Jan 7, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Morey | Administrator | Administrator who submitted the plan of correction |
| Shirley Boltz | Contact for plan of correction assistance | |
| Lanae Workman | Person who added the plan of correction | |
| Lacey Hunter | Person who modified the plan of correction |
Inspection Report
Follow-Up
Deficiencies: 0
Dec 19, 2017
Visit Reason
An offsite visit was completed on 12/19/17 to verify correction of previous deficiencies cited on 11/16/17.
Findings
The deficiencies previously cited have been corrected and no new non-compliance was found. The facility is in compliance with all regulations surveyed effective 12/15/17.
Inspection Report
Plan of Correction
Deficiencies: 5
Dec 15, 2017
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited during a prior inspection, outlining corrective actions to address the cited issues.
Findings
The plan details corrective actions including cleaning and repairs of resident rooms and equipment, audits by maintenance and nursing staff, staff education sessions, and ongoing monitoring and reporting to the Quality Assurance Committee to address deficiencies related to facility maintenance, resident care equipment, kitchen sanitation, and infection control.
Severity Breakdown
E: 1
D: 2
F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Room was cleaned, carpet shampooed, mattress replaced, tile in shower room repaired, shower chair removed, carpet replaced, resident room painted, arm rest on wheelchair replaced. | E |
| Foot pedals placed on Resident #1 wheelchair when deemed appropriate; care plan updated; audits and staff education provided. | D |
| Foot pedals placed on Resident #1 wheelchair when deemed appropriate; care plan updated; audits and staff education provided. | D |
| Caulking replaced; kitchen audit completed to identify areas needing replacement; staff education and weekly audits conducted. | F |
| Resident #46 feces emptied from commode and flushed in toilet; infection control cleaning per policy; staff education and weekly audits conducted. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Morey | Administrator | Administrator who submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Deficiencies: 1
Nov 16, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective 12/15/2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency at level "F", widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 5
Nov 16, 2017
Visit Reason
The inspection was conducted as a Health Facility Resurvey and complaint investigations #107740, #101610 and #111274.
Findings
The facility failed to maintain sanitary housekeeping and maintenance services, failed to review and revise a resident's care plan regarding wheelchair foot rest, failed to provide adequate supervision and assistive devices to prevent accidents, failed to prepare food under sanitary conditions, and failed to maintain an effective infection control program related to disposal of contaminated bowel movement material infected with C-diff.
Complaint Details
The inspection included complaint investigations #107740, #101610 and #111274.
Severity Breakdown
SS=D: 2
SS=F: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide maintenance and housekeeping services in 4 resident rooms and 1 common bathing room, resulting in foul odors and uncleanable surfaces. | SS=D |
| Failed to review and revise resident #1's care plan to include foot rest on wheelchair. | SS=D |
| Failed to ensure resident #1 received adequate assistive devices to prevent accidents with a foot rest on wheelchair while being propelled. | SS=F |
| Failed to prepare and serve food in a sanitary manner; stove hood above cook stove had peeling rust-like debris. | SS=F |
| Failed to maintain an effective infection control program with failure to properly and timely dispose of contaminated bowel movement material infected with C-diff for resident #46. | SS=F |
Report Facts
Census: 42
Residents sampled: 21
Fall risk score: 20
Fall risk score: 17
BIMS score: 9
BIMS score: 7
BIMS score: 4
Antibiotic treatment duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Confirmed urine odor in resident room and noted resident had urinary tract infection | |
| Staff J | Housekeeping staff | Confirmed urine odor and stated carpets need shampooing every 2 weeks |
| Staff D | Licensed nursing staff | Confirmed urine odor and urinary tract infection for resident #38 |
| Staff A | Administrative staff | Provided information about odor and carpet cleaning |
| Staff H | Maintenance staff | Described maintenance of wheelchairs and painting rooms |
| Staff L | Direct care staff | Propelled resident wheelchair without foot rest |
| Staff M | Direct care staff | Discussed foot rest location and resident wheelchair use |
| Staff O | Direct care staff | Reviewed Kardex and discussed foot rest absence |
| Staff N | Direct care staff | Discussed resident removing foot rest when moving in room |
| Staff E | Therapy staff | Discussed resident wheelchair foot rest use and encouragement |
| Staff C | Licensed nursing staff | Discussed resident mobility and foot rest use |
| Staff K | Therapy staff | Discussed difficulty getting resident to self propel wheelchair and foot rest use |
| Staff B | Administrative nursing staff | Discussed resident wheelchair foot rest use and staff encouragement |
| Staff I | Dietary staff | Confirmed stove hood rust-like debris and fire safety code restrictions |
| Staff Q | Housekeeping staff | Described handling of contaminated linens and commode cleaning |
| Staff P | Direct care staff | Described handling of contaminated bowel movement material in red bags |
| Staff J | Administrative staff | Confirmed storage and disposal procedures for contaminated waste |
Inspection Report
Follow-Up
Deficiencies: 3
Nov 10, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report indicates that all previously cited deficiencies identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25(c), and 483.25(d) were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(d) |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Oct 28, 2016
Visit Reason
The inspection was conducted as a result of complaint investigations #106530, 106524, and 107026 to assess compliance with care planning, pressure sore prevention, and urinary incontinence management.
Findings
The facility failed to review and revise individualized care plans for toileting needs for residents #5 and #2, failed to provide consistent pressure relieving interventions and timely repositioning for residents #2, #3, #4, and #5, and failed to develop individualized toileting plans to maintain normal bladder function for residents #5 and #2.
Complaint Details
The inspection was triggered by complaints #106530, 106524, and 107026 regarding care planning, pressure sore prevention, and urinary incontinence management.
Severity Breakdown
Level 2: 2
Level 3: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to review and revise care plans for toileting needs for residents #5 and #2. | Level 2 |
| Failure to provide consistent pressure relieving interventions and timely repositioning for residents #2, #3, #4, and #5, resulting in pressure ulcers. | Level 3 |
| Failure to develop individualized toileting plans to maintain normal bladder function for residents #5 and #2. | Level 2 |
Report Facts
Residents reviewed for care planning: 5
Residents with pressure ulcers reviewed: 5
Residents reviewed for urinary incontinence: 5
Resident census: 40
Pressure ulcer size: 10
Pressure ulcer size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Reported on toileting assistance and care for resident #5 | |
| Licensed nurse D | Assisted with toileting and wound care for resident #5 | |
| Direct care staff M | Reported on toileting and pressure ulcer care for residents | |
| Licensed nursing staff F | Reported on toileting and pressure ulcer care for residents | |
| Administrative nursing staff B | Reported on resident repositioning and wound care | |
| Administrative nursing staff C | Reported on care plan updates for resident #5 |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Oct 28, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective November 10, 2016.
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314, Pressure Ulcers, including failure to prevent avoidable pressure ulcers and provide appropriate care to prevent increased complexity of existing pressure ulcers. | level deficiencies |
Report Facts
Effective date of substantial compliance: Nov 10, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 3
Oct 28, 2016
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited during an inspection triggered by an operator complaint dated 10/28/2016.
Findings
The plan addresses deficiencies related to individualized toileting care plans, skin assessments and pressure ulcer interventions, and urinary assessments to maintain bladder function. The facility outlines corrective actions including audits, re-education of staff, and ongoing monitoring by the interdisciplinary team and Quality Assurance committee.
Complaint Details
Inspection was triggered by an operator complaint dated 10/28/2016.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident care plans were not adequately reflecting individual toileting needs to restore normal bladder function. | D |
| Inconsistent skin assessments and pressure relieving interventions for residents with pressure ulcers. | E |
| Incomplete urinary assessments and individualized toileting care plans to maintain bladder function. | D |
Report Facts
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Morey | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Jun 29, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the previously cited deficiency related to regulation 483.25(h) was corrected as of 06/29/2016. No uncorrected deficiencies were noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiency correction date: Jun 29, 2016
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Jun 15, 2016
Visit Reason
The inspection was conducted as an investigation of complaints #101581 and #101635 regarding resident safety during facility van transport.
Findings
The facility failed to provide proper wheelchair securement and resident safety during transport in the facility van, resulting in a resident falling from the wheelchair and sustaining abrasions, bruises, a skin tear, and loss of a toenail. The van driver was not adequately trained and failed to use the required safety devices.
Complaint Details
The investigation findings relate to complaints #101581 and #101635. The resident fell during transport due to failure to secure the wheelchair and resident properly. The fall caused injuries including a skin tear, missing toenail, and abrasions. The van driver was not the routine driver and had no formal training prior to the incident.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide wheelchair securement during transport for a resident, resulting in a fall and injury. | SS=D |
Report Facts
Resident census: 37
Date of resident re-admission: May 25, 2016
Date of admission MDS: Jun 1, 2016
Date of incident: Jun 4, 2016
Skin tear size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff C | Substitute van driver | Failed to secure resident and wheelchair during transport, causing resident fall |
| Licensed nursing staff E | Licensed nursing staff | Completed performance correction notice for direct care staff C |
| Administrative staff A | Interviewed regarding incident and acknowledged lack of training for staff C | |
| Licensed staff B | Licensed staff | Examined resident for injuries after fall and provided wound care |
| Routine van driver D | Facility transportation staff member | Properly secured resident and wheelchair during observed transport |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 15, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency, indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to the survey findings and correspondence. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 7, 2016
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited in a prior complaint investigation.
Findings
The plan addresses corrective actions including suspension of staff, completion of van training by a transportation aide, resident and family interviews with no issues noted, staff training on transportation procedures, and ongoing monitoring and reporting to the Quality Assurance committee.
Complaint Details
Related to Arma complaint dated 06/15/2016; the plan of correction responds to findings from this complaint.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency related to transportation and staff training | D |
Report Facts
Dates related to plan of correction: Plan submitted 06/07/2016; corrective actions to be completed by 06/29/2016; QA committee review on July 12, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Morey | Administrator | Submitted the plan of correction |
Inspection Report
Follow-Up
Deficiencies: 1
Apr 29, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report indicates that all previously cited deficiencies were corrected as of the revisit date, with corrections completed and documented.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID Prefix F0323 related to regulation 483.25(h) |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 29, 2016
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited in a prior complaint investigation related to an elopement incident.
Findings
The plan outlines corrective actions including resident assessment upon return, auditing elopement books, placing the resident on one-on-one supervision, scheduling care plan meetings with family, and ongoing review of elopement assessments and trends by the Quality Assurance committee.
Complaint Details
This plan of correction is linked to an Arma Operator complaint dated 04/28/2016.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency related to resident elopement risk assessment and supervision | D |
Report Facts
Complete Date: Apr 29, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Morey | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Apr 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#99420) regarding the facility's failure to provide adequate supervision and/or assistive devices to prevent a resident's elopement.
Findings
The facility failed to ensure adequate supervision for one resident with dementia and wandering behavior, who eloped from the facility without staff knowledge. The resident was found off-site after being picked up by a delivery driver. The facility's policies and staff interviews revealed gaps in monitoring and response to elopement risks.
Complaint Details
The complaint investigation (#99420) substantiated that the facility did not provide adequate supervision to prevent a confused resident from eloping without staff knowledge.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and/or assistive devices to prevent resident elopement. | SS=D |
Report Facts
Resident census: 38
Residents reviewed for elopement: 3
BIMS score: 7
BIMS score: 10
Elopement incident date: Apr 12, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Reported details of the resident's elopement and subsequent recovery. | |
| Direct care staff B | Described resident checks and elopement risk monitoring procedures. | |
| Direct care staff C | Provided information about the timing of the resident's elopement. | |
| Direct care staff D | Explained staff notification and response to elopement alarms. | |
| Licensed nursing staff E | Described placement of residents at risk for elopement in a nurse's station book. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 28, 2016
Visit Reason
An Abbreviated Survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory of the report letter. |
Inspection Report
Follow-Up
Deficiencies: 10
Apr 7, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were marked as corrected and completed as of the revisit date.
Deficiencies (10)
| Description |
|---|
| Deficiency with regulation 483.10(b)(11) |
| Deficiency with regulation 483.15(h)(2) |
| Deficiency with regulation 483.25 |
| Deficiency with regulation 483.25(h) |
| Deficiency with regulation 483.25(l) |
| Deficiency with regulation 483.40(a) |
| Deficiency with regulation 483.55(b) |
| Deficiency with regulation 483.60(c) |
| Deficiency with regulation 483.65 |
| Deficiency with regulation 483.70(h) |
Report Facts
Deficiencies corrected: 10
Inspection Report
Plan of Correction
Deficiencies: 10
Apr 7, 2016
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited during a prior inspection, outlining corrective actions to address identified issues.
Findings
The plan addresses multiple deficiencies including resident bowel movement monitoring, maintenance repairs, documentation of bruising, chemical storage security, monitoring of blood sugar and blood pressure parameters, hospice physician orders, dental service refusals, infection control documentation, and facility maintenance issues. Corrective actions include audits, staff re-education, monitoring, and reporting to the Quality Assurance/Assessment Committee.
Severity Breakdown
D: 6
E: 2
F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Resident #3 has history of loose stool bowel movements; nursing staff monitoring and physician notified. | D |
| Carpet cleaned, paper towel dispenser cleaned, therapy room and resident bathroom walls repaired, vent cleaned, and other maintenance repairs completed. | E |
| Resident #10 bruising to face documented; nursing staff re-educated on monitoring and documentation. | D |
| Cabinet containing chemicals is locked; staff re-educated on verifying cabinet remains locked. | E |
| Resident #39 bowel movement monitoring in place; audits completed for blood glucose and blood pressure parameters. | D |
| Physician order in place for Resident #30; audits completed to verify orders for hospice residents. | D |
| Resident #16 refuses and declines dental services; letters sent to responsible parties and social service re-educated. | D |
| Pharmacist completed audit to ensure parameters and bowel movement monitoring in place; facility expectations reviewed. | D |
| Infection Control logs contain culture results; nursing re-educated on documenting culture results. | F |
| Laundry room and kitchen repairs completed; light fixtures cleaned and repaired; maintenance audits and staff re-education conducted. | F |
Report Facts
Compliance date: Apr 7, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Morey | Administrator | Administrator who submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Person who added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 10
Mar 8, 2016
Visit Reason
The inspection was conducted as a Licensure Resurvey and complaint investigation #97676.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant resident condition changes, inadequate housekeeping and maintenance, failure to provide necessary care and monitoring, unsafe environment hazards, failure to ensure drug regimens were free from unnecessary drugs, lack of physician supervision for resident care, failure to provide necessary dental services, inadequate pharmacist drug regimen review, failure to maintain an infection control program, and unsafe and unsanitary conditions in laundry and kitchen areas.
Complaint Details
The visit was triggered by complaint investigation #97676.
Severity Breakdown
Level D: 6
Level E: 2
Level F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to notify physician regarding a resident's significant change in condition related to several consecutive days of diarrhea. | Level E |
| Failed to maintain a clean and sanitary environment including soiled carpets, damaged walls, and unclean bathroom areas. | Level D |
| Failed to accurately monitor a resident's extensive facial bruising following a fall. | Level E |
| Failed to keep hazardous chemicals inaccessible and maintain safe assistive devices in shared shower/bathrooms. | Level D |
| Failed to ensure drug regimen was free from unnecessary drugs due to inadequate monitoring of blood sugar, bowel movements, and blood pressure. | Level D |
| Failed to provide care and treatment under physician's orders due to lack of signed admitting physician orders. | Level D |
| Failed to ensure resident received necessary dental services including replacement of lost dentures. | Level D |
| Pharmacist failed to identify irregularities in monitoring blood sugar, bowel movements, and blood pressure for residents. | Level D |
| Failed to establish and maintain an infection control program including lack of infection tracking and organism identification. | Level F |
| Failed to provide maintenance and housekeeping services in laundry and kitchen to ensure a safe and sanitary environment. | Level F |
Report Facts
Residents reviewed for sample: 15
Residents with identified cognitive impairment: 6
Days resident #39 lacked bowel movement: 33
Blood sugar readings over 300: 12
Blood pressure monitoring instances: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Direct Care Staff | Reported resident diarrhea problems and lack of PRN medication use. |
| Staff B | Administrative Nursing Staff | Reported failure to notify physician of resident diarrhea and lack of monitoring of facial bruising. |
| Staff J | Maintenance Staff | Reported maintenance issues including holes in walls, toilet replacement, and dryer cleaning. |
| Staff K | Licensed Nursing Staff | Reported lack of monitoring of resident facial bruising and physician notification requirements. |
| Staff M | Consultant Staff | Reviewed blood sugar readings and commented on monitoring deficiencies. |
| Staff A | Administrative Staff | Reported on facility maintenance and infection control practices. |
| Staff E | Social Services Staff | Reported on dental services and admission paperwork. |
| Staff O | Laundry Staff | Reported cleaning practices and demonstrated dryer cleaning. |
| Staff W | Dietary Staff | Reported kitchen maintenance issues including leaking faucets. |
Inspection Report
Re-Inspection
Deficiencies: 1
Mar 8, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter accepting plan of correction and substantial compliance determination. |
Inspection Report
Follow-Up
Deficiencies: 2
Jan 1, 2016
Visit Reason
This report documents a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as of the revisit date.
Findings
The revisit confirmed that the deficiencies previously reported under regulations 483.15(a) and 483.25 were corrected by the revisit date of January 1, 2016.
Deficiencies (2)
| Description |
|---|
| Deficiency under regulation 483.15(a) |
| Deficiency under regulation 483.25 |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 9, 2015
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited in a complaint survey.
Findings
The plan addresses two deficiencies: one involving resident dignity related to dressing and mattress placement, and another involving lab order transcription and audit processes. Corrective actions include audits, staff education, and ongoing monitoring through Quality Assurance meetings.
Complaint Details
This Plan of Correction is in response to a complaint survey identified as Event ID ZU4D11.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #4 affected by dignity-related deficient practice; mattress placement and dressing concerns. | D |
| Deficient practice related to lab order transcription and audit processes. | D |
Report Facts
Complete Date for F0000: Plan of Correction submission date 12/09/2015
Corrective Action Completion Date for F241-D: Corrective actions to be accomplished by 01/01/2016
Corrective Action Completion Date for F309-D: Corrective actions accomplished by 12/04/2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Morey | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction | |
| Director of Nursing | Director of Nursing | Provided in-service education on lab process |
| Director of Medical Records | Director of Medical Records | Conducted audits and reporting related to lab orders |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Dec 2, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be D level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
D level: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| D level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy | D level |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 2
Dec 2, 2015
Visit Reason
The inspection was conducted as a complaint investigation for complaint numbers #93623 and #94158.
Findings
The facility failed to maintain resident dignity by placing a cognitively impaired resident on a mattress on the floor in a common area, frequently dressed in a hospital gown and undressing in public. Additionally, the facility failed to obtain ordered laboratory tests for another resident, resulting in delayed treatment for anemia.
Complaint Details
The visit was triggered by complaint investigations #93623 and #94158. The dignity deficiency was substantiated with severity level SS=D. The lab testing deficiency was also identified during the complaint investigation.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain dignity and respect for resident #4 by placing the resident on a mattress on the floor in a common area, frequently dressed in a hospital gown and undressing in public. | SS=D |
| Failure to obtain laboratory tests as ordered for resident #1, resulting in delayed treatment for anemia. | — |
Report Facts
Census: 26
Residents sampled for dignity: 3
Residents sampled for care: 3
Falls with injury: 2
Falls without injury: 2
Hemoglobin level: 5.5
Blood transfusion frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff C | Reported resident #4 stripped clothes frequently and was placed on mattress on floor. | |
| Administrative Nursing Staff B | Confirmed resident #4 was placed on mattress on floor for safety; responsible for admission and lab order entry. | |
| Direct Care Staff D | Stated residents should be dressed appropriately and resident #4 required 1:1 supervision. | |
| Direct Care Staff E | Reported resident #4 had behaviors and was placed on mattress on floor for ease of supervision. | |
| Licensed Nursing Staff F | Stated expectation that residents be dressed appropriately and dignity maintained; described resident #4's condition. | |
| Administrative Nursing Staff B | Reported failure to enter lab orders on calendar resulting in missed lab work for resident #1. |
Inspection Report
Life Safety
Deficiencies: 1
Nov 2, 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 at 'F' level, indicating no harm but with 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Feb 2, 2016
Provider agreement termination date: May 2, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Oct 2, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that the deficiency identified under regulation 483.75(g) with ID prefix F0499 was corrected as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.75(g) previously cited and corrected |
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 2, 2015
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited in a complaint-related inspection.
Findings
The plan outlines corrective actions including termination of an administrative staff member, verification of nursing licenses, staff education on licensing policies, maintenance of a nursing license register, and ongoing review of identified trends by the Quality Assurance/Assessment Committee.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Arma Health And Rehab 092915 Complaint.
Deficiencies (1)
| Description |
|---|
| Failure to ensure nursing staff held current nursing licenses as required. |
Report Facts
Complete Date: Oct 2, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Alicia Weide | RVP | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 29, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Sep 29, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#91706) regarding the facility's failure to employ qualified licensed nursing staff to carry out nursing care.
Findings
The facility failed to provide licensed professional staff to administer IV antibiotic treatments and TB skin tests. An administrative staff member with a lapsed RN license since 12/1/2013 performed IV antibiotic administration for two residents and administered and read TB tests for eight staff members, violating nursing practice standards.
Complaint Details
Complaint investigation #91706 confirmed that an administrative staff member with a lapsed RN license performed nursing duties including IV antibiotic administration and TB skin test administration and reading.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to employ qualified licensed nursing staff; unlicensed staff with lapsed RN license administered IV antibiotics and TB tests. | SS=F |
Report Facts
Census: 25
Number of residents receiving IV antibiotics from unlicensed staff: 2
Number of staff with TB tests administered/read by unlicensed staff: 8
Date RN license lapsed: Dec 1, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Administrator | Performed IV antibiotic administration and TB skin test duties with lapsed RN license |
| Licensed Nursing Staff E | Licensed Nursing Staff | Reported observations of unlicensed staff administering IV antibiotics |
| Licensed Staff C | Licensed Nursing Staff | Normally performed IV antibiotics but was on vacation during incidents |
| Licensed Nursing Staff K | Licensed Practical Nurse | IV certified LPN who observed unlicensed staff administering IV antibiotics |
Inspection Report
Follow-Up
Deficiencies: 1
Sep 9, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.60(a),(b) with ID prefix F0425 was corrected as of 09/09/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.60(a),(b) previously cited |
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 9, 2015
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited in a complaint-related inspection.
Findings
The plan addresses deficiencies related to the inventory and availability of OTC/floor stock medications, including audits of physician orders, education of staff, and ongoing monitoring of medication inventory.
Complaint Details
This plan of correction is linked to a complaint investigation as indicated by the reference to 'Complaint' and the Event ID N5DI11.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency related to inventory and availability of OTC/floor stock medications. | D |
Report Facts
Complete Date: Sep 9, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethanie Popejoy | Administrator | Submitted the plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 10, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective September 9, 2015.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Aug 10, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#89915) to assess the facility's compliance with pharmaceutical service requirements, specifically regarding the availability of medications for residents.
Findings
The facility failed to ensure the availability of medications for administration to three residents. Medications such as a ProAir inhaler and Calcium supplements were not available or delayed, resulting in missed doses and a resident being sent to the hospital due to symptoms related to lack of medication.
Complaint Details
The visit was triggered by complaint investigation #89915. The complaint was substantiated as the facility failed to provide medications timely and adequately to residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure availability of medications for administration to three residents (#1, 4, & 5), including delayed delivery of ProAir inhaler and lack of Calcium medication. | SS=D |
Report Facts
Resident census: 25
Number of residents affected: 3
Dates of medication orders: Resident #1 ProAir inhaler ordered 4/7/15; Resident #5 Calcium 500 mg ordered 3/29/15; Resident #4 Calcium 600 mg ordered 4/14/15
Medication delivery delay: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported medication ordering and delivery details, including faxing pharmacy and medication receipt | |
| Licensed staff B | Confirmed Calcium medication was not in stock and explained medication ordering process | |
| Direct care staff C | Reported over the counter medication shortages and communication with DON and administrator |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 12, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report indicates that the previously cited deficiency with regulation number 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 12, 2015
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited in a complaint-related inspection.
Findings
The plan addresses concerns related to resident elopement risk assessments, implementation of wanderguard bracelets for at-risk residents, staff education on elopement policies, and ongoing monitoring and auditing of interventions.
Complaint Details
This plan of correction is related to a complaint investigation identified by Event ID JBW311 and linked to Deficiency Report (2567).
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident (#1) evaluated for risk of elopement; new assessment completed showing no current risk due to health condition and mobility. | D |
Report Facts
Complete Date: Jul 12, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethanie Popejoy | Administrator | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 12, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Jun 12, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#87235) regarding the facility's failure to provide adequate supervision to prevent the elopement of a resident.
Findings
The facility failed to provide adequate supervision for one resident who eloped from the facility without staff knowledge. The resident, diagnosed with vascular dementia and cognitive impairment, was found outside the facility after leaving through a door opened by a visitor. Staff had discontinued the use of a wanderguard bracelet prior to the incident and did not consider the resident an elopement risk at the time.
Complaint Details
Complaint investigation #87235 found the facility failed to prevent elopement of a resident with vascular dementia and cognitive impairment. The resident eloped on 5/16/15 after a visitor opened the front door, and staff were unaware until after the resident was found outside. The facility had discontinued the wanderguard bracelet and did not consider the resident an elopement risk at the time.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent the elopement of one resident. | SS=D |
Report Facts
Resident census: 29
Residents sampled for elopement: 3
Date of elopement incident: May 16, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Direct Care Staff | Reported the resident eloped on 5/16/15 and described the circumstances of the elopement |
| Staff B | Administrative Nursing Staff | Reported on 6/9/15 about the resident's elopement risk and history |
Inspection Report
Follow-Up
Deficiencies: 1
Jun 5, 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 report confirms that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of 06/05/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(h) previously cited |
Report Facts
Deficiency correction date: Jun 5, 2015
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
May 13, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#86867) regarding a resident elopement incident.
Findings
The facility failed to ensure adequate supervision and safety measures for a resident who left the facility without staff knowledge, walked 1.5 blocks, fell, and sustained injuries. The facility lacked a sign-in/out system and did not complete safety assessments to determine the resident's ability to leave safely.
Complaint Details
The complaint investigation found that the resident left the facility without staff knowledge, fell approximately 1.5 blocks away, and sustained bruising and abrasions. The facility did not report the incident to the state agency and lacked proper monitoring procedures.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the resident environment remained free of accident hazards and provide adequate supervision, resulting in a resident leaving the facility unnoticed, falling, and sustaining injuries. | SS=D |
Report Facts
Resident census: 27
Distance walked by resident: 1.5
Bruise size: 7
Bruise size: 4.5
Abrasion size: 1
Abrasion size: 1.5
BIMS score: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Acknowledged the incident was not reported to the state agency and described facility policies. |
| Ancillary staff C | Reported finding the resident after the elopement incident. | |
| Social service staff E | Reported the resident frequently walked outside and returned. | |
| Certified nursing staff F | Certified Nursing Staff | Reported the resident would wave or notify staff when leaving the facility. |
| Certified nursing staff G | Certified Nursing Staff | Reported the resident would wave or notify staff when leaving the facility. |
Inspection Report
Plan of Correction
Deficiencies: 1
May 13, 2015
Visit Reason
This document is a Plan of Correction submitted by Arma Health and Rehab in response to deficiencies cited in the survey report dated May 13, 2015.
Findings
The plan addresses deficiencies related to resident supervision when exiting community grounds, including transferring a resident to a locked unit, establishing a sign in/out procedure, staff re-education on assessments, and monitoring compliance to ensure resident safety.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident #1 was not adequately supervised when exiting community grounds, requiring corrective actions including transfer to a locked unit and implementation of a sign in/out procedure. | D |
Report Facts
Plan of Correction completion date: Jun 5, 2015
QA Committee meeting date: Jun 20, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethanie Popejoy | Administrator | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 11, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency, indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and compliance information. |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 13, 2015
Visit Reason
This document is a Plan of Correction submitted by Arma Care Center in response to deficiencies cited in a prior survey, outlining corrective actions to address the findings.
Findings
The facility dietary manager was enrolled in a Certified Dietary Manager course and was required to complete certification to comply with state regulations requiring a full-time certified dietary manager to supervise the dietary department.
Severity Breakdown
C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to employ a full-time certified dietary manager as required to supervise the facility dietary department. | C |
Report Facts
Lessons remaining in course: 3
Completion date: Feb 13, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethanie Popejoy | Administrator | Submitted the Plan of Correction and responsible for oversight of corrective actions. |
Inspection Report
Re-Inspection
Census: 24
Deficiencies: 1
Jan 15, 2015
Visit Reason
The visit was a non-compliant revisit to assess compliance with dietary services regulations, specifically regarding staffing and supervision in the dietary department.
Findings
The facility failed to retain the services of a certified dietary manager to oversee dietary staff and maintain a clean and sanitary dietary department for food storage, preparation, and service to residents.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to retain the services of a certified dietary manager to perform managerial duties overseeing dietary staff and maintaining a clean and sanitary dietary department. | SS=C |
Report Facts
Census: 24
Classes remaining for certification: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| dietary staff B | Reported not being a certified dietary manager and needing 4 more classes | |
| administrative staff A | Stated dietary manager had a few more classes before certification |
Inspection Report
Re-Inspection
Deficiencies: 2
Jan 15, 2015
Visit Reason
This report is a revisit conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiencies identified in the prior survey were corrected by the dates indicated, specifically on 12/21/2014 for the cited regulations 28-39-153(e) and 28-39-153(f).
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 28-39-153(e) |
| Deficiency related to regulation 28-39-153(f) |
Report Facts
Correction completion date: Dec 21, 2014
Inspection Report
Follow-Up
Deficiencies: 16
Jan 15, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from an earlier survey had been corrected.
Findings
The report documents that all previously identified deficiencies were corrected by 12/21/2014, as evidenced by the correction completion dates listed for each deficiency.
Deficiencies (16)
| Description |
|---|
| Deficiency related to regulation 483.15(b) |
| Deficiency related to regulation 483.15(f)(1) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.15(h)(3) |
| Deficiency related to regulation 483.15(h)(6) |
| Deficiency related to regulation 483.20(b)(2)(ii) |
| 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(d) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(n) |
| Deficiency related to regulation 483.35(c) |
| Deficiency related to regulation 483.35(d)(1)-(2) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(h) |
Report Facts
Deficiencies corrected: 16
Inspection Report
Plan of Correction
Deficiencies: 17
Dec 21, 2014
Visit Reason
This document is a Plan of Correction submitted by Arma Care Center in response to deficiencies cited during a prior inspection, outlining corrective actions to address those deficiencies.
Findings
The plan details corrective actions taken or planned for multiple deficiencies including opening and monitoring an indoor smoke room, updating resident activity assessments and care plans, maintaining facility cleanliness and repairs, ensuring availability of hand towels, completing significant change assessments, and improving dietary and infection control practices.
Severity Breakdown
E: 5
D: 8
F: 4
Deficiencies (17)
| Description | Severity |
|---|---|
| Indoor facility smoke room opened and monitored for cleanliness and safety. | E |
| Updated activity assessments and care plans for residents; Activity Director role clarified. | D |
| Facility maintenance and housekeeping improvements including painting, cleaning, and repairs. | E |
| Hand towel availability ensured in resident bathrooms. | E |
| Significant change MDS completed for hospice residents and monitored. | D |
| Updated activity assessments and care plans following resident accidents. | D |
| Podiatry appointments scheduled and monitored for residents needing nail care. | D |
| Three day voiding pattern assessments completed and care plans revised accordingly. | D |
| Resident safety regarding filing cabinet use addressed with care plan revisions and education. | D |
| Pneumonia vaccine administration and consent auditing improved. | D |
| Menus modified to include daily specials; dining audits implemented. | F |
| Pureed diet preparation and dietary staff training enhanced. | D |
| Kitchen cleaning and food storage audits conducted. | F |
| Proper handwashing practices audited and staff educated. | D |
| Exterior building maintenance and repairs conducted and monitored. | E |
| Activity Director and Social Services Designee roles clarified and hours adjusted. | F |
| Dietary manager enrolled in certification course and supervised accordingly. | F |
Report Facts
Compliance completion date: Dec 21, 2014
Certified Dietary Manager course lessons remaining: 7
Certified Dietary Manager course total lessons: 24
Certified Dietary Manager course enrollment date: 201407
Certified Dietary Manager course anticipated completion: 201502
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 26
Deficiencies: 16
Nov 21, 2014
Visit Reason
The inspection was a health resurvey to evaluate compliance with regulatory requirements including resident rights, activities, housekeeping, infection control, and care planning.
Findings
The facility was found deficient in multiple areas including failure to provide a smoke-free environment for smokers during inclement weather, inadequate activity programming for residents, housekeeping and maintenance deficiencies, failure to provide clean linens, uncomfortable temperature levels in the dining area, incomplete comprehensive assessments after significant changes, failure to revise care plans after falls, inadequate ADL care including toenail hygiene, failure to prevent urinary tract infections through proper toileting programs, unsafe resident environment hazards, failure to provide pneumococcal immunizations, failure to follow planned menus, failure to provide palatable pureed diets, unsanitary food preparation and storage, improper infection control practices, and unsafe and unsanitary environment maintenance.
Severity Breakdown
SS=E: 4
SS=D: 7
SS=F: 3
Deficiencies (16)
| Description | Severity |
|---|---|
| Facility failed to allow 4 residents who smoke to smoke free in an environment free of inclement weather and failed to reopen the remodeled smoking room timely. | SS=E |
| Facility failed to provide an activity program to meet the needs of 2 residents, including failure to provide individualized activities and encouragement to participate. | SS=D |
| Facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior including dining room wall repairs, carpet stains, and damaged resident room doors. | SS=E |
| Facility failed to provide clean bed and bath linens in good condition, including lack of hand towels and washcloths in resident rooms. | SS=E |
| Facility failed to maintain comfortable temperature levels in the dining room when smokers opened patio doors allowing cold air in. | SS=D |
| Facility failed to complete a comprehensive assessment within 14 days after resident's admission to hospice. | SS=D |
| Facility failed to review and revise care plans for residents related to activities and falls, including failure to update fall interventions after a fall. | SS=D |
| Facility failed to provide adequate toenail hygiene care for one resident, resulting in extremely long toenails. | SS=D |
| Facility failed to assess and implement effective interventions to maintain normal bladder function for a cognitively impaired resident with urinary incontinence. | SS=D |
| Facility failed to ensure resident environment remained free of accident hazards and failed to provide new interventions after a fall. | SS=D |
| Facility failed to ensure residents received pneumococcal immunizations or the opportunity to refuse them. | SS=F |
| Facility failed to follow planned menus and provide residents the option of selecting the daily planned menu to meet nutritional needs. | SS=D |
| Facility failed to provide a palatable and appealing pureed diet to a resident. | SS=F |
| Facility failed to prepare, serve, and store foods under sanitary conditions including dirty kitchen equipment, unclean refrigerator, and dusty storage shelves. | SS=D |
| Facility failed to follow infection control practices including improper glove use and hand hygiene during incontinent care. | SS=E |
| Facility failed to maintain a safe, functional, sanitary, and comfortable environment including broken kitchen floor tiles and unmaintained exterior building areas. | SS=F |
Report Facts
Residents who smoke: 4
Residents sampled: 12
Residents census: 26
Fall risk score: 13
Fall date: 2014
Pneumonia vaccine refusal: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Maintenance Staff | Reported indoor smoke room closed and exhaust issues. |
| Staff D | Activity/Social Services Staff | Reported activity attendance and resident refusals. |
| Staff H | Licensed Nurse | Verified failure to complete significant change MDS and care plan updates. |
| Staff B | Administrative Nursing Staff | Discussed fall interventions and pneumonia vaccine procedures. |
| Staff C | Dietary Staff | Reported on menu options and kitchen sanitation concerns. |
| Staff M | Direct Care Staff | Reported resident activity and assisted with incontinent care. |
| Staff L | Direct Care Staff | Observed improper glove use during incontinent care. |
Inspection Report
Enforcement
Deficiencies: 1
Nov 21, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at an 'F' level, resulting in enforcement remedies including denial of payment for new Medicare admissions effective February 21, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level severity | F |
Report Facts
Denial of payment effective date: Feb 21, 2015
Compliance deadline: May 21, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethane Popejoy | Administrator | Named as facility administrator in the report header |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Life Safety
Deficiencies: 1
May 12, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F level: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found during the Life Safety Code survey | F level |
Report Facts
Effective date for denial of payments: Aug 12, 2014
Effective date for provider agreement termination: Nov 12, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethane Popejoy | Administrator | Named as facility administrator in relation to the survey |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 6, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the prior survey were corrected.
Findings
The report documents that all previously identified deficiencies were corrected by the facility as of 09/20/2013, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Correction completion date: Sep 20, 2013
Follow-up survey completion date: Aug 23, 2013
Inspection Report
Plan of Correction
Deficiencies: 15
Sep 20, 2013
Visit Reason
This document is a Plan of Correction submitted by Arma Care Center in response to deficiencies cited during a prior inspection, addressing corrective actions for various identified issues.
Findings
The plan outlines corrective actions for multiple deficiencies including proper completion of liability/appeal notices, resident trust account management, fall investigations, facility maintenance and sanitation, care plan updates for infections and accidents, medication monitoring, staffing adequacy, dietary sanitation, infection control, environmental repairs, and ventilation system improvements.
Severity Breakdown
B: 1
D: 7
E: 5
F: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Incomplete liability/appeal notices and lack of toll free number for appeals/questions. | E |
| Resident trust account management issues including availability of funds during non-business hours. | E |
| Failure to report resident fall resulting in pelvic fracture to state agency. | D |
| Facility maintenance and sanitation issues including discolored floors, damaged surfaces, and cleaning deficiencies. | E |
| Incomplete significant change Minimum Data Set (MDS) assessments for residents. | D |
| Lack of comprehensive care plans for residents with infections. | D |
| Care plans for residents involved in accidents not reviewed or revised appropriately. | D |
| Inadequate supervision and assistive devices to prevent repeated accidents. | D |
| Lack of monitoring and care planning for medications with black box warnings. | D |
| Insufficient qualified nursing staff and inadequate call light response times. | F |
| Food storage and preparation areas not maintained in sanitary conditions. | F |
| Infection control issues including improper storage of urine and inadequate nursing staff education. | E |
| Unsafe and unsanitary kitchen environment including damaged dishwasher area. | E |
| Beauty shop temporarily closed due to inadequate ventilation system. | B |
| Incomplete medical records for residents with incidents or bruises. | D |
Report Facts
Resident trust account refund: 2
Fall incident date: Jul 16, 2013
Compliance met date: Sep 20, 2013
Audit frequency: 4
Chart review percentage: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethanie Popejoy | Administrator | Administrator submitting the Plan of Correction and involved in oversight of corrective actions. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 17
Aug 23, 2013
Visit Reason
Annual health resurvey of ARMA CARE CENTER LLC to assess compliance with federal regulations including resident rights, personal funds management, abuse investigations, housekeeping, care planning, medication monitoring, infection control, staffing, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide complete liability and appeal notices, inadequate management of resident personal funds, incomplete abuse investigations, insufficient housekeeping and maintenance, failure to conduct significant change assessments, incomplete care plans, inadequate monitoring of dialysis patients, poor personal hygiene care, improper wound care techniques, insufficient supervision to prevent falls, failure to monitor adverse drug effects, inadequate staffing levels, unsanitary food storage and preparation, lack of ventilation in the beauty shop, incomplete clinical records, and failure to maintain infection control during medication administration and laundry handling.
Severity Breakdown
SS=E: 7
SS=D: 6
SS=F: 2
SS=B: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to provide complete liability and appeal notices to residents including missing toll free numbers and signatures. | SS=E |
| Failed to maintain a system assuring full and separate accounting of resident personal funds, including failure to obtain authorization, ensure availability of funds, and provide appropriate interest. | SS=E |
| Failed to thoroughly investigate and report a resident fall with injury to the state agency. | SS=D |
| Failed to provide adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior. | SS=E |
| Failed to conduct a comprehensive assessment within 14 days after significant change in resident's condition. | SS=D |
| Failed to develop and revise comprehensive care plans including measurable objectives and timetables for residents with infections and accidents. | SS=D |
| Failed to provide necessary care and services to attain or maintain highest practicable well-being including monitoring dialysis patients post-treatment. | SS=D |
| Failed to provide adequate personal hygiene for a bed bound resident including hair care. | SS=D |
| Failed to provide appropriate wound care treatment technique to prevent infection and spread of infection for residents with pressure ulcers. | SS=D |
| Failed to ensure resident environment free of accident hazards and provide adequate supervision and assistive devices to prevent repeated accidents. | SS=D |
| Failed to ensure drug regimen free from unnecessary drugs by not monitoring adverse consequences of medications with black box warnings and failing to obtain timely lab tests. | SS=D |
| Failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain highest practicable well-being. | SS=F |
| Failed to store and prepare food under sanitary conditions including expired food, melted plastic on plate warmers, and inadequate air gap on ice machine drain. | SS=F |
| Failed to maintain an infection control program to prevent development and transmission of infections during medication administration, laundry handling, and in medication room snack refrigerator. | SS=E |
| Failed to provide a safe, functional, sanitary, and comfortable environment in the kitchen area including deteriorated metal backsplash, open wall voids, and cracked floor tiles. | SS=E |
| Failed to provide adequate outside ventilation in the beauty shop. | SS=B |
| Failed to maintain complete and accurate clinical records including documentation of resident accidents and bruises. | SS=D |
Report Facts
Census: 31
Deficiency count: 16
Fall risk score: 14
Fall risk score: 10
Fall risk score: 10
Bruise size: 3
Bruise size: 2.5
Bruise size: 4
Pressure ulcer size: 4
Pressure ulcer size: 5
Medication dose: 5
Medication dose: 25
Lab recheck interval: 14
Call light response time: 19
Call light response time: 22
Call light response time: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff T | Licensed Nursing Staff | Named in wound care treatment and personal funds findings |
| Staff B | Administrative Nursing Staff | Named in multiple findings including wound care, personal funds, complaint investigation, and medication monitoring |
| Staff R | Direct Care Staff | Named in supervision and fall prevention findings |
| Staff O | Direct Care Staff | Named in personal funds and fall prevention findings |
| Staff Z | Business Office Staff | Named in personal funds accounting findings |
| Staff Q | Direct Care Staff | Named in supervision and fall prevention findings |
| Staff E | Activity Staff | Named in personal funds findings |
| Staff G | Housekeeping/Maintenance Staff | Named in housekeeping and laundry findings |
| Staff I | Licensed Nursing Staff | Named in infection control and medication monitoring findings |
| Staff K | Direct Care Staff | Named in infection control and call light response findings |
| Staff M | Direct Care Staff | Named in wound care and staffing findings |
| Staff L | Direct Care Staff | Named in wound care findings |
| Staff F | Dietary Staff | Named in kitchen sanitation and staffing findings |
| Staff N | Laundry/Housekeeping Staff | Named in laundry handling and linen sanitation findings |
| Staff C | Administrative Nursing Staff | Named in complaint investigation, supervision, and fall prevention findings |
| Staff J | Consultant Staff | Named in medication monitoring findings |
| Staff V | Consultant Staff | Named in supervision and fall prevention findings |
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 3, 2012
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were completed.
Findings
The report confirms that the previously cited deficiency identified by regulation 28-39-162(a) with prefix code S1000 was corrected as of 06/02/2012.
Deficiencies (1)
| Description |
|---|
| Deficiency previously cited under regulation 28-39-162(a) with prefix S1000 |
Report Facts
Deficiency correction date: Jun 2, 2012
Inspection Report
Follow-Up
Deficiencies: 0
Jul 3, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report documents that all previously cited deficiencies were corrected by 06/02/2012 as verified during this revisit.
Report Facts
Deficiencies corrected: 16
Inspection Report
Plan of Correction
Deficiencies: 16
Jun 2, 2012
Visit Reason
This document is a Plan of Correction submitted by Arma Care Center in response to deficiencies cited during a prior inspection, outlining corrective actions to address those deficiencies.
Findings
The plan details corrective actions taken for multiple deficiencies including financial account handling after resident death, grievance procedures, facility maintenance and cleanliness, care plan revisions for residents, medication monitoring, and equipment storage. All corrective actions were accomplished by June 2, 2012.
Severity Breakdown
D: 7
E: 7
G: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Monies ($8.05) regarding account in question was submitted to the State Recovery Unit; policy reviewed for conveyance of funds upon resident's death. | D |
| Pink sweatpants for resident (#9) replaced; policy and procedure implemented regarding grievances/complaints/missing items. | D |
| West nurses desk painted, cork board removed, repairs and cleaning done throughout facility including bathrooms, ceilings, floors, and therapy room. | E |
| Care plans revised for multiple residents to include PT evaluation, pain management, pressure relief cushions, toileting plans, behavior monitoring, and hospice services. | E |
| Plan of care revised for resident #34 to prevent unsupervised courtyard entry; staff educated on care plan updates. | D |
| Pressure relieving cushion provided to resident #49; skin and weights program implemented with nurse education on Braden Skin assessment. | D |
| Toileting plan updated for resident #6 after evaluating 3 day voiding pattern; nursing staff educated on completion. | D |
| Resident #6 evaluated by Occupational therapy for splint; restorative nursing program developed and monitored. | D |
| Care plans revised to encourage residents to wear protective clothing; charge nurse to investigate injuries of unknown origin. | D |
| Dietician recommendations implemented for resident #34; policy for supplementing meal intake when less than 75% consumed. | G |
| Policy and procedure developed and implemented for medications with Black Box Warnings (BBW); staff educated. | E |
| New policy and procedure reviewed with pharmacy consultant. | E |
| Nebulizer/tubing removed; nurses inserviced on storage policy; Director of Nursing to monitor compliance. | D |
| Call light system bulbs replaced; contractors contacted for repairs; maintenance director to inspect weekly. | E |
| Contractors contacted to repair laundry/maintenance facility; building maintained for functional and sanitary environment. | E |
| Call light system bulbs replaced and system repaired/replaced to ensure full function; maintenance director to monitor. | E |
Report Facts
Monetary amount: 8.05
Date: Jun 2, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethanie Popejoy | Administrator | Administrator responsible for presenting plan of correction and verifying compliance |
Inspection Report
Census: 32
Deficiencies: 1
May 3, 2012
Visit Reason
The inspection was conducted to evaluate the facility's compliance with physical environment regulations, specifically the functionality of the call light system in soiled utility rooms.
Findings
The facility failed to maintain a fully functioning call light system in 2 of 2 soiled utility rooms, as the call light indicators did not sound or light, which could prevent alerting staff when residents require assistance.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide a fully functioning call light system in 2 of 2 soiled utility rooms. | SS=E |
Report Facts
Census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff H | Reported checking call lights weekly and awareness of call lights not lighting in the panel at the desk |
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