Inspection Reports for
Chapman Valley Manor
1009 N MARSHALL PO BOX 219, CHAPMAN, KS, 67431
Back to Facility ProfileDeficiencies (last 13 years)
Deficiencies (over 13 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
89% occupied
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 18, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-09-18.
Findings
All deficiencies have been corrected as of the compliance date of 2024-09-24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Sep 24, 2024
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited in a prior survey conducted on 09/18/2024.
Findings
The plan addresses multiple deficiencies related to incorrect form usage, medication management including fentanyl patch placement and psychotropic medication stop dates, dietary policy adherence, hospice care coordination, and water management concerns. The facility outlines corrective actions, staff in-services, audits, and monitoring plans to achieve substantial compliance.
Deficiencies (8)
F582-D: The facility used the wrong CMS 10055 form for skilled residents. Social Services staff were in-serviced and audits will be conducted to ensure correct form usage.
F726-D: Hospice CNA removed a fentanyl patch improperly. The facility audited fentanyl patch orders and in-serviced Hospice CNA and charge nurses on patch placement and disposal policies.
F756-D: PRN Psychotropic Medications lacked proper 14 day stop dates. Audits were completed and staff were in-serviced on medication renewal policies.
F758-D: PRN Psychotropic Medication stop dates were audited and staff were in-serviced on psychotropic drug policies to ensure compliance.
F760-D: Medication for a resident with a PEG tube was changed to ensure no long-acting or enteric-coated meds were given via tube. Audits and staff notifications were conducted.
F804-D: The Cook was in-serviced on modified diet policies and weekly audits of diet preparation were implemented.
F849-D: Hospice care plans were updated to reflect coordination between the facility and hospice providers. Staff were in-serviced on hospice coordination policies.
F880-F: The Maintenance Director identified water management concerns. A Legionella Weekly and Monthly Assessment was developed to identify and prevent risk areas.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 8
Date: Sep 18, 2024
Visit Reason
Health resurvey to assess compliance with Medicare/Medicaid regulations including beneficiary liability notices, nursing staff competency, drug regimen review, psychotropic medication use, medication administration, nutrition, hospice services, and infection control.
Findings
The facility failed to provide correct Medicare ABN forms to residents, ensure nursing staff competency in medication disposal, identify and report medication irregularities, ensure psychotropic medication orders had required stop dates, prevent medication errors with extended-release drugs, prepare pureed diets correctly, coordinate hospice care plans, and implement a water management program to mitigate Legionella risk.
Deficiencies (8)
F582: Facility failed to provide correct CMS Form 10055 Advanced Beneficiary Notice to residents R28 and R137, risking uninformed decisions on skilled services.
F726: Facility failed to ensure staff competency in safely monitoring and disposing of R29's fentanyl patch, risking inadequate care.
F756: Consultant pharmacist failed to identify and report that R26's PRN Haldol medication lacked a 14-day stop date, risking unnecessary psychotropic medication use.
F758: Facility failed to obtain required 14-day stop date for R26's PRN antipsychotic medication, risking unnecessary medication and complications.
F760: Facility failed to prevent medication error when staff crushed extended-release Wellbutrin XL for R19, risking adverse medication reactions.
F804: Facility failed to prepare three pureed diets correctly, risking impaired nutrition and decreased quality of life.
F849: Facility failed to coordinate hospice care plans with hospice providers for residents R19 and R29, risking inappropriate end-of-life care.
F880: Facility failed to conduct risk assessment and implement water management program to mitigate Legionella risk, placing residents at risk of infection.
Report Facts
Resident census: 31
Residents reviewed: 12
Residents reviewed for medication: 5
PRN Haldol administration dates: 3
Pureed diet liquid thickener: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified medication and hospice care plan deficiencies, and water management program absence |
| Licensed Nurse G | Licensed Nurse | Observed medication administration error with crushed extended-release medication |
| Maintenance Staff U | Maintenance Staff | Reported lack of routine water management checks |
| Social Services X | Social Services | Acknowledged providing incorrect Medicare ABN forms |
Inspection Report
Routine
Census: 31
Deficiencies: 8
Date: Sep 18, 2024
Visit Reason
Routine inspection of Chapman Valley Manor to assess compliance with healthcare regulations including medication management, infection control, hospice coordination, and dietary services.
Findings
The facility had multiple deficiencies including failure to provide correct Medicare ABN forms, inadequate staff competency in medication patch disposal, lack of pharmacist oversight on medication stop dates, medication administration errors, improper food preparation, poor coordination of hospice care plans, and failure to implement a water management program to mitigate Legionella risk.
Deficiencies (8)
F 0582: The facility failed to provide the correct CMS Form 10055 Advanced Beneficiary Notice to residents R28 and R137, risking uninformed decisions about skilled services.
F 0726: Staff failed to safely monitor and dispose of R29's fentanyl patch, risking inadequate care.
F 0756: The Consultant Pharmacist did not identify or report that Resident R26's PRN Haldol medication lacked a required 14-day stop date, risking unnecessary psychotropic medication use.
F 0758: The facility failed to implement gradual dose reductions and limit PRN psychotropic medication use for R26, who lacked a 14-day stop date on Haldol, risking unnecessary medication complications.
F 0760: Staff crushed an extended-release medication for R19, contrary to medication administration policy, risking adverse medication reactions.
F 0804: The facility failed to prepare pureed diets correctly for three residents, risking impaired nutrition and decreased quality of life.
F 0849: The facility failed to coordinate care plans with hospice providers for residents R19 and R29, risking inappropriate end-of-life care.
F 0880: The facility failed to conduct a risk assessment and implement a water management program to mitigate Legionella risk, placing residents at risk for infectious disease.
Report Facts
Resident census: 31
Sample size: 12
Medication administration dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified medication errors and hospice care coordination deficiencies |
| Licensed Nurse H | Licensed Nurse | Involved in fentanyl patch disposal observation |
| Licensed Nurse G | Licensed Nurse | Observed medication administration and fentanyl patch handling |
| Certified Medication Aide R | Certified Medication Aide | Administered medication to R26 |
| Dietary Staff BB | Dietary Staff | Prepared pureed diets incorrectly |
| Maintenance Staff U | Maintenance Staff | Reported lack of routine water management checks |
| Social Services X | Social Services | Acknowledged providing incorrect Medicare ABN forms |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 16, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-01-17.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2024-01-24. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 17, 2024
Visit Reason
This document is a plan of correction submitted by Chapman Valley Manor in response to deficiencies cited related to medication errors identified during a prior inspection.
Findings
The facility conducted audits and education related to a medication error involving resident R 2, notified the PCP and consulting pharmacist, and implemented ongoing medication competency testing and audits to ensure compliance.
Deficiencies (1)
F760: The facility identified a medication error involving resident R 2 and took corrective actions including audits, education of medication aides, and notification of the PCP and pharmacist.
Report Facts
Date of medication error audit: Nov 27, 2023
Date resident seen by PCP: Dec 6, 2023
Plan of correction completion date: Jan 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Jeardoe | Administrator | Submitted the plan of correction |
| Felicia Majewski | Added and modified the plan of correction | |
| Shirley Boltz | Contact for plan of correction assistance |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Date: Jan 17, 2024
Visit Reason
The inspection was conducted following complaints related to falls and medication errors involving residents at the facility.
Complaint Details
The investigation was complaint-driven, focusing on falls and medication errors. Resident 1's fall was substantiated with actual harm, and Resident 2's medication error was substantiated with minimal harm or potential for harm.
Findings
The facility failed to follow fall prevention interventions for Resident 1, resulting in a fall and a broken nasal bone. The facility also failed to prevent a significant medication error for Resident 2, administering the wrong medication which placed the resident at risk for adverse effects.
Deficiencies (2)
F 0689: The facility failed to follow Resident 1's fall interventions, resulting in a fall from bed and a broken nasal bone. Staff did not replace the fall mat next to the bed as required by the care plan.
F 0760: The facility failed to prevent a significant medication error when staff administered amlodipine instead of amiodarone to Resident 2. This placed the resident at risk for health complications.
Report Facts
Residents reviewed for falls and accidents: 3
Residents reviewed for medication errors: 3
Fall mat hematoma size: 5
Fall mat hematoma size: 3.5
Medication dosage: 200
Medication dosage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Notified primary care physician of medication error and stated expectations for staff to follow medication administration rights and fall care plans. |
| Licensed Nurse G | Licensed Nurse | Documented events surrounding Resident 1's fall and admitted to moving the fall mat without replacing it. |
| Certified Medication Aide M | Certified Medication Aide | Found Resident 1 on the floor after the fall and reported the incident. |
| Certified Medication Aide N | Certified Medication Aide | Stated Resident 1's fall interventions and sensor alarm procedures. |
Inspection Report
Abbreviated Survey
Census: 28
Deficiencies: 2
Date: Jan 17, 2024
Visit Reason
The inspection was conducted as an abbreviated survey combined with complaint investigations KS00185063, KS00184799, and KS00183046.
Complaint Details
The visit included complaint investigations KS00185063, KS00184799, and KS00183046.
Findings
The facility failed to follow fall prevention interventions for Resident 1, resulting in a fall with a broken nasal bone and facial bruising. The facility also failed to prevent a significant medication error for Resident 2, administering amlodipine instead of amiodarone, placing the resident at risk for adverse effects.
Deficiencies (2)
F 689: The facility failed to follow Resident 1's fall interventions, resulting in a fall from bed causing a broken nasal bone and facial bruising. Staff did not replace the fall mat as required, placing the resident at risk for injury and pain.
F 760: The facility failed to prevent a significant medication error when staff administered amlodipine instead of amiodarone to Resident 2, placing the resident at risk for health complications and medication-related adverse effects.
Report Facts
Resident census: 28
Medication error duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA M | Certified Medication Aide | Found Resident 1 on the floor after fall |
| LN G | Licensed Nurse | Documented fall incident and failed to replace fall mat |
| CMA N | Certified Medication Aide | Described Resident 1's fall interventions |
| Administrative Nurse D | Administrative Nurse | Oversaw staff expectations and notified physician of medication error |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-03-07.
Findings
All deficiencies have been corrected as of the compliance date of 2023-03-27, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 21, 2023
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited in a prior inspection report dated 03/07/23.
Findings
The facility identified multiple deficiencies related to resident care plans, estimated cost notifications, discharge summaries, gastrostomy tube care, monitoring of antipsychotics, and infection control procedures. The facility implemented corrective actions including audits, staff in-service training, policy updates, and ongoing monitoring.
Deficiencies (6)
F582: The facility failed to ensure all skilled residents were informed of the estimated cost as required by CMS form 10055.
F656: The facility did not update R16’s comprehensive care plan to reflect appropriate gastrostomy tube care.
F661: The facility failed to complete a summary of stay and discharge planning review for resident R27.
F693: The facility did not monitor the amount of intake of feeding fluids for resident R16’s gastrostomy orders.
F758: The facility did not ensure proper usage monitoring of Seroquel for resident R22.
F880: The facility failed to demonstrate proper infection control procedures related to perineal care competency and surveillance audits.
Report Facts
Deficiencies cited: 6
Monitoring period: 6
QAPI review period: 3
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 6
Date: Mar 7, 2023
Visit Reason
Health resurvey conducted at the facility to assess compliance with Medicare and Medicaid regulations.
Findings
The facility was found deficient in multiple areas including failure to provide Medicaid beneficiary liability notices, incomplete comprehensive care plans, lack of discharge summaries, inadequate monitoring of tube feeding, inappropriate psychotropic medication use, and deficient infection control practices.
Deficiencies (6)
F582 The facility failed to provide Medicaid beneficiaries R7 and R24 with estimated costs for skilled services on CMS form 10055, risking uninformed decisions.
F656 The facility failed to develop a comprehensive care plan for Resident R16's gastrostomy tube, placing the resident at risk for inappropriate care.
F661 The facility failed to develop a discharge summary for Resident R27 that included a recapitulation of the stay and post-discharge plan, risking inadequate care.
F693 The facility failed to monitor the amount of feeding and fluids administered through Resident R16's gastrostomy tube, risking malnutrition, dehydration, and fluid overload.
F758 The facility failed to ensure an appropriate indication for use of antipsychotic medication for Resident R22, risking unnecessary psychotropic medication.
F880 The facility failed to provide adequate hand hygiene and glove changing when caring for Residents R9 and R22 during incontinent care, placing residents at risk for infection.
Report Facts
Resident census: 27
Residents reviewed: 12
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of documentation for CMS form 10055 and care plan deficiencies; verified expectations for documentation and hand hygiene. |
| Licensed Nurse G | Licensed Nurse | Administered gastrostomy tube feeding and verified documentation expectations. |
| Administrative Nurse E | Administrative Nurse | Verified staff expectations for glove changing and hand hygiene during incontinent care. |
| Certified Nurse Aide M | Certified Nurse Aide | Observed providing incontinent care to Resident R9 without proper hand hygiene after glove removal. |
| Certified Nurse Aide N | Certified Nurse Aide | Observed providing incontinent care to Resident R9 without proper hand hygiene after glove removal. |
| Certified Nurse Aide O | Certified Nurse Aide | Observed providing incontinent care to Resident R22 without changing gloves or hand hygiene. |
Inspection Report
Routine
Census: 27
Deficiencies: 6
Date: Mar 7, 2023
Visit Reason
Routine inspection of Chapman Valley Manor nursing home to assess compliance with Medicare and Medicaid regulations, including care planning, medication use, infection control, and resident notification requirements.
Findings
The facility had multiple deficiencies including failure to provide Medicare beneficiary liability notices with estimated costs, incomplete care plans for gastrostomy tube feeding, lack of discharge summaries, inappropriate psychotropic medication indications, and inadequate infection control practices such as improper glove use and hand hygiene.
Deficiencies (6)
F 0582: The facility failed to provide residents R7 and R24 with Medicare beneficiary liability notices including estimated costs for skilled services, risking uninformed decisions.
F 0656: The facility failed to develop a comprehensive care plan for Resident R16's gastrostomy tube, risking inappropriate care.
F 0661: The facility failed to develop a discharge summary for Resident R27 that included a recapitulation of the resident's stay and post-discharge plan, risking inadequate care.
F 0693: The facility failed to monitor the amount of feeding and fluids administered through Resident R16's gastrostomy tube, risking malnutrition, dehydration, and fluid overload.
F 0758: The facility failed to ensure appropriate indications for psychotropic medication use for Resident R22, risking unnecessary medication and complications.
F 0880: The facility failed to provide adequate hand hygiene and glove changing when caring for Residents R9 and R22 during incontinent care, risking infection.
Report Facts
Residents present: 27
Residents reviewed: 12
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified failures in providing CMS form 10055, care plan documentation, discharge summary, medication indication, and infection control practices. |
| Licensed Nurse G | Licensed Nurse | Administered feeding and verified documentation practices for gastrostomy tube feeding. |
| Certified Nurse Aide M | Certified Nurse Aide | Observed providing incontinent care without proper glove changing or hand hygiene. |
| Certified Nurse Aide N | Certified Nurse Aide | Observed providing incontinent care without proper glove changing or hand hygiene. |
| Certified Nurse Aide O | Certified Nurse Aide | Observed providing incontinent care without proper glove changing or hand hygiene. |
| Administrative Nurse E | Administrative Nurse | Verified expectations for glove changing and hand hygiene during incontinent care. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 13, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-05-10.
Findings
All deficiencies cited in the prior inspection were corrected by the compliance date of 2022-05-19. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: May 10, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the facility's nursing staff competency and resident safety, specifically regarding the accuracy of the Elopement Risk Assessment for a resident at risk of elopement.
Complaint Details
The complaint investigation KS00171507 found that the facility inaccurately documented a resident's elopement risk as zero despite evidence of behaviors indicating risk. The resident eloped on 05/09/22, exited through a malfunctioning alarm door, and sustained injuries requiring hospital evaluation.
Findings
The facility failed to ensure the Elopement Risk Assessment was completed accurately for a resident with dementia and behavioral disturbances, which placed the resident at risk for injuries related to accidents and hazards. The resident eloped from the facility, resulting in injury, and the facility's door alarm system was found to be malfunctioning.
Deficiencies (1)
F 726 Competent Nursing Staff: The facility failed to ensure the Elopement Risk Assessment was completed accurately and updated, placing a resident at risk for injuries related to accidents and hazards.
Report Facts
Resident census: 31
Date of elopement incident: May 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided information about the door alarm malfunction and resident's prior elopement history | |
| Administrative Nurse D | Performed the inaccurate Elopement Assessment and acknowledged documentation errors | |
| Certified Nurses Aide M | CNA | Witnessed resident elopement and answered call light during incident |
| Licensed Nurse G | LN | Present during resident elopement incident |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 10, 2022
Visit Reason
The plan of correction was submitted in response to deficiencies cited in a prior survey related to elopement risk assessment and resident safety.
Findings
The facility failed to ensure the elopement risk assessment was completed accurately, placing a resident at risk. Corrective actions included re-assessment of all residents, staff re-education, repair of a door alarm, and ongoing monitoring by facility leadership.
Deficiencies (1)
F726D The facility failed to ensure the elopement risk assessment was completed accurately, placing the resident at risk. Corrective actions included medication review, re-assessment of all residents, staff re-education, and repair of the north door alarm.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 30, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 09/02/21.
Findings
All deficiencies cited in the prior inspection were corrected by the compliance date of 09/14/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Sep 14, 2021
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited during a prior inspection.
Findings
The facility failed to investigate skin tears, update care plans for safe transfers, follow accident procedures, monitor blood glucose, and ensure medication availability and monitoring for adverse reactions. Corrective actions include staff re-education, care plan updates, policy revisions, and ongoing monitoring through QAPI meetings.
Deficiencies (5)
F610-D The facility failed to investigate skin tears of unknown injury for one resident, placing the resident at risk for future injuries.
F657-D The facility failed to update a resident's care plan to reflect the need for assistance of two staff members for safe transfers.
F689-D The facility failed to follow 'Accident or Incident Procedures' when a resident received a skin tear during transfers.
F756-D The facility's consultant pharmacist failed to identify and report a resident's lack of blood glucose monitoring.
F757-D The facility failed to ensure a resident's medication was available and failed to monitor the resident for adverse reactions.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 5
Date: Sep 2, 2021
Visit Reason
The inspection was conducted based on complaints and observations regarding the facility's failure to investigate skin tears, update care plans, provide adequate supervision to prevent accidents, and monitor medication for residents.
Complaint Details
The investigation was complaint-driven, focusing on allegations of failure to investigate skin tears, update care plans, provide adequate supervision, and monitor medication for residents. The complaint was substantiated with findings of minimal harm.
Findings
The facility failed to investigate skin tears for Resident 15, did not update the care plan after changes in transfer status, failed to provide adequate nursing care and supervision to prevent accidents, and failed to monitor blood glucose and ensure insulin availability for Resident 16.
Deficiencies (5)
F 0610: The facility failed to investigate Resident 15's skin tears of unknown origin, lacking investigation or incident reports for skin tears dated 08/13/21 and 08/23/21.
F 0657: The facility failed to update Resident 15's care plan after a change in transfer status, placing the resident at risk for further injury and accidents.
F 0689: The facility failed to provide adequate nursing care and supervision to prevent accidents for Resident 15, who received skin tears during transfers.
F 0756: The facility's Consultant Pharmacist failed to identify and report the lack of blood glucose monitoring and insulin unavailability for Resident 16, placing the resident at risk for hypoglycemia/hyperglycemia.
F 0757: The facility failed to monitor Resident 16's blood glucose and ensure insulin medication availability, placing him at risk for hypoglycemia/hyperglycemia.
Report Facts
Resident census: 29
Skin tear measurements: 2.3
Skin tear measurements: 1.5
Skin tear measurements: 2
Skin tear measurements: 4
Skin tear measurements: 1.3
Skin tear measurements: 1.5
Blood glucose level: 278
Insulin units: 3
Dates insulin unavailable: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of investigation for skin tears, lack of care plan update, and failure to monitor blood glucose and insulin availability |
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 5
Date: Sep 2, 2021
Visit Reason
The inspection was a health resurvey to evaluate compliance with prior deficiencies and regulatory requirements.
Findings
The facility failed to investigate skin tears for Resident 15, failed to update and revise the care plan for Resident 15 after changes in condition, and failed to provide adequate supervision to prevent accidents. Additionally, the facility's consultant pharmacist failed to identify and report lack of blood glucose monitoring and insulin unavailability for Resident 16, placing the resident at risk for hypoglycemia/hyperglycemia.
Deficiencies (5)
F610: The facility failed to investigate Resident 15's skin tears of unknown origin and did not complete required incident reports or investigations.
F657: The facility failed to update and revise Resident 15's care plan after a change in transfer status, placing the resident at risk for injury.
F689: The facility failed to provide adequate nursing care and supervision to prevent accidents for Resident 15, who sustained skin tears during transfers.
F756: The consultant pharmacist failed to identify and report the lack of blood glucose monitoring and insulin unavailability for Resident 16 receiving insulin injections.
F757: The facility failed to monitor Resident 16's blood glucose and failed to have insulin medication available, placing the resident at risk for hypoglycemia/hyperglycemia.
Report Facts
Census: 29
Sampled residents: 12
Skin tears: 3
Blood glucose level: 278
Days insulin unavailable: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of investigation and care plan updates for Resident 15 and insulin monitoring issues for Resident 16 |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 7, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 07/07/2020 to assess compliance with COVID-19 preparation practices.
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.
Deficiencies (1)
F0000: A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted on 07/07/2020. The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
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
Re-Inspection
Deficiencies: 0
Date: Aug 14, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-07-02.
Findings
All deficiencies have been corrected as of the compliance date of 2019-07-31, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 2
Date: Jun 26, 2019
Visit Reason
The visit was a Health Resurvey to assess compliance with regulatory requirements following a prior inspection.
Findings
The facility failed to discard expired medications in the emergency medication kit and failed to store food in a safe and sanitary manner in the activity refrigerator/freezer, placing residents at risk for ineffective medication use and foodborne illness.
Deficiencies (2)
F 761 Label/Store Drugs and Biologicals: The facility failed to discard expired medications in the emergency medication kit, including Amoxicillin and Coumadin, placing residents at risk for use of ineffective medication.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to store food safely and sanitarily in the activity refrigerator/freezer, with undated and unlabeled items and unsanitary conditions, risking foodborne illness for residents.
Report Facts
Resident census: 34
Expired Amoxicillin tablets: 8
Expired Coumadin tablets: 3
Undated soda bottles: 6
Bottles of water: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide M | Verified expired medications in emergency medication kit and contacted pharmacy for replacement | |
| Administrative Nurse D | Verified expired medications and contacted pharmacy for replacement | |
| Activity Director Z | Verified lack of cleaning schedule for refrigerator/freezer | |
| Administrative Nurse DD | Reported staff assigned to clean refrigerator was on leave and cleaning was not routine |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 8, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-09-24.
Findings
All deficiencies have been corrected as of the compliance date of 2018-10-22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 24, 2018
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-10-22.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Signed letter regarding survey results and plan of correction acceptance. |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 6
Date: Sep 24, 2018
Visit Reason
The inspection was a health resurvey to assess compliance with Medicare and Medicaid regulations at Chapman Valley Manor nursing facility.
Findings
The facility was found deficient in multiple areas including failure to provide Advanced Beneficiary Notices to residents, inadequate hydration and nutrition monitoring, failure to document medication-related vital signs, unsanitary food storage and preparation conditions, and failure to maintain a safe and sanitary environment in resident areas.
Deficiencies (6)
F 582: The facility failed to provide Advanced Beneficiary Notices (ABN) to 2 of 3 reviewed residents when skilled nursing services ended, risking uninformed decisions about skilled services.
F 692: The facility failed to provide adequate fluids, monitor hydration status, and ensure fluid availability for 1 resident, placing the resident at risk for dehydration.
F 756: The pharmacist consultant failed to identify and report lack of daily pulse documentation for 1 resident, risking undetected bradycardia or heart failure.
F 757: The facility failed to document daily pulses for 1 resident receiving Tenormin, placing the resident at risk for bradycardia or heart failure.
F 812: The facility failed to store, prepare, and serve food in a sanitary manner, including issues with ice buildup, unlabeled food, rust, dust, and poor kitchen hygiene, risking foodborne illness.
F 921: The facility failed to maintain a clean, sanitary environment on 2 of 3 residential halls, including ceiling damage, water stains, poor drainage, and air unit maintenance issues, risking air quality problems.
Report Facts
Resident census: 35
Pulse documentation missing days: 8
Pulse documentation missing days: 7
Pulse documentation missing days: 7
Fluid intake observation: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Verified facility had not provided CMS form 10055 to residents or representatives |
| Licensed Nurse G | Licensed Nurse | Provided information on staff competency and fluid administration practices |
| Administrative Nurse D | Administrative Nurse | Verified lack of pulse documentation and hydration monitoring issues |
| Medication Aide M | Medication Aide | Reported staff had not monitored fluid intake with medication administration |
| Dietary Staff CC | Dietary Staff | Verified kitchen sanitation deficiencies |
| Dietary Staff BB | Dietary Staff | Verified freezer defrost schedule and kitchen sanitation issues |
| Maintenance Staff U | Maintenance Staff | Verified environmental sanitation and maintenance deficiencies |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 29, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory requirements.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 6
Date: Mar 20, 2017
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation #113172 to evaluate compliance with resident rights and other regulatory requirements.
Complaint Details
The visit was triggered by a complaint investigation #113172 focusing on resident rights and safety concerns.
Findings
The facility failed to ensure an effective system to respond to residents' missing personal property, failed to secure chemicals safely, failed to administer medications as ordered, failed to dispose of expired food, failed to identify medication irregularities, and failed to implement proper infection control precautions.
Deficiencies (6)
F166: The facility failed to ensure an effective system to respond to residents' missing personal property for 1 of 3 residents reviewed.
F323: The facility failed to secure chemicals safely, leaving hazardous chemicals unlocked on housekeeping carts accessible to residents.
F329: The facility failed to administer medications as ordered for Resident #28, giving 30 mL of milk of magnesia every other day instead of the ordered 15 mL.
F371: The facility failed to dispose of expired food items found in the kitchen, including vinegar and soy sauce past their best by dates.
F428: The facility's pharmacy consultant failed to identify excessive medication doses for Resident #28, missing the 30 mL milk of magnesia dose given instead of the ordered 15 mL.
F441: The facility failed to prevent infection transmission when housekeeping staff did not change gloves between resident rooms and allowed toilet brush water to drip on floors.
Report Facts
Resident census: 39
Medication administration count: 51
Cognitive impairment count: 19
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 20, 2017
Visit Reason
The visit was a Health survey conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The survey identified 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the letter and referenced in relation to the plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 20, 2017
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor following deficiencies identified in a prior inspection conducted on 03/20/2017.
Findings
The plan addresses multiple deficiencies including proper disposal of resident property after discharge, secure chemical storage, medication administration as ordered, disposal of expired food, monthly drug regimen reviews, and infection control precautions to prevent transmission.
Deficiencies (6)
F166-D The facility will develop a policy to ensure resident property is disposed of properly within 24 hours of discharge or death. Staff will be trained and inventory sheets used to document property pickup.
F323-E The facility will keep chemicals in view and/or secure at all times. Housekeeping staff will remove chemical caddies when not in use and receive in-service training on proper chemical storage.
F329-D Medication will be administered as ordered per physician. Staff will be trained not to change medication amounts on electronic charts without nurse authorization.
F371-F The facility will dispose of expired food in the kitchen. Weekly visual inspections and staff training will ensure compliance with food expiration policies.
F428-D Licensed pharmacist will perform monthly drug regimen reviews on every resident and provide documentation of any irregularities to the facility and physicians.
F441-F Appropriate precautions will be used to prevent transmission of infection. Housekeeping staff will change gloves between rooms and use proper procedures for handling toilet brushes.
Report Facts
Deficiency tags: 6
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 11, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at 'E' level, indicating no harm with potential for more than minimal harm and no immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for deficiencies at the 'E' severity level under the Life Safety Code survey. These deficiencies indicate no harm with potential for more than minimal harm and no immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 31, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the previously reported deficiencies identified by regulation numbers 483.10(e), 483.75(l)(4), 483.15(e)(2), and 483.20(d), 483.20(k)(1) were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.10(e), 483.75(l)(4): Previously cited deficiency corrected as of 08/31/2015.
Regulation 483.15(e)(2): Previously cited deficiency corrected as of 08/31/2015.
Regulation 483.20(d), 483.20(k)(1): Previously cited deficiency corrected as of 08/31/2015.
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 3
Date: Aug 27, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements following a prior inspection.
Findings
The facility was found deficient in maintaining resident privacy during toileting, providing notice before room or roommate changes, and developing comprehensive care plans for residents, including care plans for behavioral medications and individualized activities.
Deficiencies (3)
F 164: The facility failed to ensure privacy for resident #39 during toileting as staff did not close window blinds exposing the resident to outside view.
F 247: The facility failed to document notification to a resident and/or family regarding a room change on 2/26/15.
F 279: The facility failed to develop comprehensive care plans for 2 of 11 residents, including lack of care plan for Clonazepam medication and missing individualized activity plans.
Report Facts
Census: 43
Sample size: 11
Residents with deficient care plans: 2
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Aug 27, 2015
Visit Reason
The document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The facility identified deficiencies related to resident privacy, documentation of room changes, and comprehensive care planning including behavior sheets and individualized activity plans.
Deficiencies (3)
F164-D: The facility will ensure privacy for all dependent residents by closing blinds and curtains during direct care and toileting. Monitoring will be conducted by the DON and Charge Nurses.
F247-D: The facility will document notification of room changes in the residents' medical records, ensuring residents and families are informed. The DON will monitor documentation compliance.
F279-D: The facility will have a comprehensive care plan for all residents, including behavior sheets for residents on anti-anxiety medication and individualized activity plans. Monitoring will be quarterly or as needed.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 27, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid. The visit was a follow-up related to deficiencies cited in a prior survey.
Findings
The survey found isolated 'D' level deficiencies constituting no actual harm but with potential for more than minimal harm, not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had isolated 'D' level deficiencies that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter. |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 13, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting 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.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm. These deficiencies relate to noncompliance with Life Safety Code requirements.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Aug 13, 2015
Provider agreement termination date: Nov 13, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: May 13, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies at Chapman Valley Manor.
Findings
The report shows that all previously identified deficiencies were corrected as of the revisit date, with corrections completed on 05/13/2014.
Deficiencies (4)
Regulation 483.15(a) deficiency was corrected by 05/13/2014.
Regulations 483.20(d) and 483.20(k)(1) deficiencies were corrected by 05/13/2014.
Regulation 483.20(k)(3)(i) deficiency was corrected by 05/13/2014.
Regulation 483.65 deficiency was corrected by 05/13/2014.
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 4
Date: May 8, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously identified deficiencies.
Findings
The facility failed to promote dignity and respect by leaving incontinent pads on recliners not in use, did not develop a comprehensive care plan for a resident's use of side rails, failed to provide follow-up assessments for as needed medications, and failed to maintain infection control measures including improper cleaning of resident rooms and glucometer disinfection.
Deficiencies (4)
F 241: The facility failed to promote dignity and respect by leaving incontinent pads on recliners not in use on multiple days.
F 279: The facility failed to develop a comprehensive care plan for a resident's use of bilateral side rails as requested by the resident.
F 281: The facility failed to provide follow-up assessments by licensed nurses after administration of as needed medications for one resident.
F 441: The facility failed to maintain infection control by improper cleaning of resident rooms and failure to disinfect the glucometer between uses.
Report Facts
Resident census: 45
Sample size: 15
Diabetic residents using glucometer: 3
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 13, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
All previously reported deficiencies identified by regulation numbers F0157, F0241, F0309, F0329, F0425, F0428, and F0441 were corrected by the revisit date of 05/13/2013.
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 1, 2013
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited during a prior inspection.
Findings
The facility identified multiple deficiencies related to physician notification, resident dignity during care, skin care, medication management, infection control, and sanitary environment. Corrective actions and staff training plans were outlined to address these issues.
Deficiencies (7)
F157-D: The facility will notify the physician and legal representative promptly when incidents occur that may require physician intervention. Nurses have been instructed on skin assessment and notification procedures.
F241-D: Staff will assist residents needing eating help and ensure insulin and treatments are administered in private areas to promote dignity.
F309-D: The facility will provide necessary care including thorough reassessments and physician-ordered treatments to maintain resident skin condition. Weekly skin assessments will be conducted by the wound nurse.
F329-D: The facility will ensure residents' drug regimens are free from unnecessary drugs and monitor medication administration monthly with pharmacist review.
F425-D: Staff will administer medications as ordered, assess pain levels before PRN narcotics, and ensure proper medication labeling.
F428-D: The pharmacy consultant will report drug irregularities to the primary care physician or DON and provide monthly reports.
F441-D: The facility will maintain a sanitary environment by revising policies on oxygen tubing handling, glucometer disinfection, biohazard disposal, and hand hygiene practices.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 7
Date: Apr 22, 2013
Visit Reason
Annual health facility survey conducted to assess compliance with federal regulations and standards for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify a resident's physician of a skin condition change, lack of dignity during meal assistance, inadequate monitoring of blood pressure medication, improper medication labeling and administration, failure to report drug irregularities, and infection control deficiencies related to equipment sanitation and resident care.
Deficiencies (7)
F 157: The facility failed to notify Resident #45's physician regarding a worsening skin condition characterized by psoriasis with red, flaky skin and bleeding due to scratching.
F 241: The facility failed to promote dignity during meal assistance for Resident #42 and failed to provide privacy during insulin administration.
F 309: The facility failed to provide necessary care and reassessments for Resident #45's psoriasis, resulting in untreated worsening skin condition.
F 329: The facility failed to adequately monitor Resident #42's blood pressure while on Lisinopril, and failed to ensure drug regimen was free from unnecessary drugs.
F 425: The facility failed to ensure medications were properly labeled and administered as ordered, including mislabeled 'Pain Pill' blister packs and improper dosing of Oxycodone.
F 428: The facility's pharmacist failed to report drug irregularities regarding lack of blood pressure monitoring for Resident #42 to the physician and director of nursing.
F 441: The facility failed to maintain infection control by not properly disinfecting glucometers between residents, improper storage of oxygen tubing, inadequate disposal of biohazardous trash, and failure to promote hand hygiene and nail care for Resident #45 with psoriasis.
Report Facts
Resident census: 42
Sample residents reviewed: 18
Residents reviewed for unnecessary drug use: 10
Blood pressure last recorded: 11256
Insulin units: 65
Tylenol dose: 500
Oxycodone dose: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Verified improper medication labeling and administration, and lack of blood pressure monitoring | |
| Nurse A | Administrative Nurse | Verified skin assessments, dignity issues, and blood pressure monitoring deficiencies |
| Nurse D | Verified worsening skin condition and lack of physician notification | |
| Wound Nurse C | Verified skin documentation and lack of treatment for psoriasis | |
| Medication Aide G | Administered medications improperly including Oxycodone dosing | |
| Nurse C | Observed glucometer use and cleaning practices | |
| Nurse Aide E | Verified resident scratching behavior and reporting requirements |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 7, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.
Findings
The facility identified issues with the call light system and plans to conduct monthly maintenance checks and update the call light policy to ensure proper functioning.
Deficiencies (1)
F463: The facility will take the statement of deficiencies to the QA committee by 04/10/2012. The maintenance supervisor will conduct monthly maintenance call light checks to ensure the call light system is in proper working condition.
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 1
Date: Feb 28, 2012
Visit Reason
The inspection was a health facility resurvey to assess compliance with regulatory requirements, specifically focusing on the resident call system.
Findings
The facility failed to ensure the nurse call system worked effectively and efficiently on 2 of the 3 halls. Observations and interviews revealed that call lights in resident rooms and bathrooms failed to signal properly and the facility had no routine system to check the call lights.
Deficiencies (1)
483.70(f) Resident call system was not functioning properly on 2 of 3 halls, with call lights failing to signal at the nurse's station and on staff pagers. The facility lacked a routine system to regularly check and maintain the call light system.
Report Facts
Census: 47
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N021001 POC 1KUW11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as 1KUW11 for the facility with State ID N021001.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N021001 POC 4DOT11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions for multiple deficiencies including skilled nursing discharge procedures, hydration assistance for dependent residents, medication administration documentation, kitchen sanitation, and facility maintenance issues.
Deficiencies (6)
F582_E: All residents ending skilled nursing services will receive CMS ABN form 10055. MDS coordinators will control skilled nursing discharges and provide the form to residents or representatives. Nursing administration and facility administrator will monitor compliance.
F692_D: Facility charge nurse will continue competency checklists to ensure staff offer and assist dependent residents with fluids at meals and during cares. All nursing staff will be re-educated and a Performance Improvement Plan will be formed.
F756_D: Physician orders for resident #6 reviewed by Director of Nurses and Charge Nurse. Medication administration instructions updated with reminders to document daily pulse. Nursing staff educated on documentation procedures.
F757_D: Physician orders for resident #6 reviewed and updated with reminders for pulse documentation. Nursing staff educated on documentation. Director of Nurses and Charge Nurse will monitor compliance.
F812_F: Kitchen freezers defrosted and cleaned. Unlabeled food discarded. Ceiling vents repainted. Staff re-educated on hairnet use. New dietary cleaning policy implemented and monitored by Dietary Manager and Administrator.
F921_E: Ceiling panels replaced above exit doors. Drain pipes extended away from building. Damaged ceiling above resident rooms repaired and repainted. Air unit vent cleaned. Preventative maintenance policy to be implemented and monitored.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N021001 POC V7YL11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to incontinent pads left on living room furniture, development of care plans for residents using bilateral side rails, proper administration and monitoring of PRN narcotic medications, and maintaining a sanitary environment including disinfecting glucometers.
Deficiencies (4)
F241-D: Incontinent pads will not be left on living room furniture. Staff will monitor to ensure pads are removed when not in use and review this at monthly nursing meetings.
F279-D: The facility will develop and review comprehensive care plans for residents using bilateral side rails upon admission and quarterly thereafter.
F281-D: Licensed nurses will assess residents before and after administration of PRN narcotic medications, with staff reviewing medication administration policies regularly.
F441-E: The facility will maintain a sanitary environment by proper cleaning of resident rooms and disinfecting glucometers according to manufacturer guidelines, with staff training and monitoring.
Report Facts
Plan of Correction completion dates: May 12, 2014
Plan of Correction completion date: May 13, 2014
Plan of Correction committee review date: May 28, 2014
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N021001 POC XHWI11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The facility replaced expired medications in the emergency medication kit and implemented monthly checks by the Consultant Pharmacist and nursing staff. The facility also cleaned refrigerators and freezers, discarded undated or unlabeled food, and added cleaning schedules to ensure ongoing compliance.
Deficiencies (2)
F761: The facility had expired medicines Amoxicillin 250 mg and Coumadin 5 mg in the emergency medication kit which have now been replaced. Monthly checks by the Consultant Pharmacist and nursing staff will ensure medications are not outdated.
F812: The Activity/Family room refrigerator and freezer were cleaned and undated or unlabeled food discarded. The north dining room resident and staff refrigerator was added to the weekly cleaning schedule to maintain compliance.
Report Facts
Complete Date for corrective actions: Jul 31, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cassidy | Administrator | Submitted the Plan of Correction. |
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