Inspection Reports for Cheney Golden Age Home
724 N MAIN PO BOX 370, KS, 67025-
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 26, 2024, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed multiple deficiencies related mainly to resident dignity and privacy, care plan revisions, fall prevention, nurse aide performance reviews, staffing data accuracy, and infection control practices. Complaint investigations generally resulted in substantiated findings involving care planning, notification procedures, and infection control, but fines or license actions were not listed in the available reports. Earlier surveys identified issues with medication management, sanitary conditions, and respiratory care, including a substantiated immediate jeopardy finding in October 2020 related to COVID-19 infection control. The correction of all cited deficiencies by the latest inspection indicates improvement in compliance over time.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
36 residents
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 26, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-11-18.
Findings
All deficiencies have been corrected as of the compliance date of 2024-12-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 7
Nov 18, 2024
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with resident rights, care standards, and infection control.
Findings
The facility was found deficient in protecting resident dignity and privacy, providing proper notice before transfers, reviewing and revising care plans, ensuring fall prevention and investigation, conducting annual nurse aide performance reviews, submitting accurate staffing data, and maintaining infection prevention and control practices including sanitary storage of respiratory equipment and use of personal protective equipment.
Complaint Details
The visit was triggered by complaints regarding resident dignity violations, inadequate transfer notices, care plan deficiencies, fall management, nurse aide performance reviews, staffing data submission, and infection control practices.
Severity Breakdown
SS=D: 5
SS=F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to protect privacy and dignity of residents during care and transport. | SS=D |
| Failed to provide written notice before facility-initiated transfers to hospital for three residents. | SS=D |
| Failed to review and revise care plans with appropriate interventions for two residents related to fall prevention and CPAP equipment storage. | SS=D |
| Failed to identify a fall, investigate causal factors, and implement fall prevention interventions for a resident. | SS=D |
| Failed to conduct annual performance reviews for five certified nurse aides employed over a year. | SS=F |
| Failed to submit complete and accurate staffing information to CMS via Payroll-Based Journal. | SS=F |
| Failed to maintain infection prevention and control including sanitary storage of respiratory equipment, proper use of PPE, and cleaning of equipment between residents. | SS=F |
Report Facts
Residents sampled: 12
Residents census: 36
Deficiencies cited: 8
Nurse aides without annual review: 5
Dates without 24-hour licensed nursing coverage: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Interviewed regarding dignity expectations, CPAP equipment storage, and staffing documentation | |
| Administrative Staff A | Interviewed regarding transfer notices, staffing, fall definitions, and infection control policies | |
| Certified Nurse Aide I | Interviewed regarding resident dignity, PPE use, and equipment storage | |
| Certified Medication Aide C | Interviewed regarding CPAP and oxygen equipment handling | |
| Licensed Nurse O | Interviewed regarding transfer policies and infection control |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 28, 2023
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 02/02/2023.
Findings
All deficiencies have been corrected as of the compliance date of 02/15/2023, 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: 11
Feb 14, 2023
Visit Reason
This document is a Plan of Correction submitted by Cheney Golden Age Home addressing deficiencies cited during a prior survey.
Findings
The facility failed to comply with multiple regulatory requirements including timely provision of Beneficiary Protection Notification forms, accurate coding of MDS for wounds, revising care plans after falls, sanitary conditions during food preparation, and proper medication and respiratory care. Corrective actions and education were implemented to address these deficiencies.
Severity Breakdown
D: 10
F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to provide appropriate Beneficiary Protection Notification forms timely for 3 residents. | D |
| Facility failed to accurately code the MDS for resident related wounds. | D |
| Facility failed to revise the care plan with interventions after resident fall to prevent further falls. | D |
| Facility failed to review and revise residents' wishes on care plan regarding code status. | D |
| Facility failed to change gloves to provide a sanitary environment while performing peri care. | D |
| Facility failed to implement interventions after resident fall to prevent further falls. | D |
| Facility failed to provide necessary respiratory care and services on one resident requiring oxygen and nebulizer treatments. | D |
| Facility failed to ensure physician orders were followed for a total of 12 days, placing resident at risk for adverse medication effects. | D |
| Resident did not have 14 days stop on PRN antianxiety medication and facility/pharmacist failed to address this. | D |
| Facility failed to identify irregularities and monitor behavior related to psychotropic medication use for residents. | D |
| Facility failed to store, prepare, and serve food under sanitary conditions, creating potential for foodborne illness. | F |
Report Facts
Residents affected: 3
Days orders not followed: 12
Residents involved: 2
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 10
Feb 2, 2023
Visit Reason
The inspection was a Health Resurvey and complaint investigation KS00167199 conducted to assess compliance with Medicare/Medicaid regulations and investigate a complaint.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate Medicare Non-Coverage notices, inaccurate resident assessments, failure to revise care plans timely, inadequate ADL care, failure to implement fall prevention interventions, inadequate respiratory care, failure to follow physician medication orders timely, failure in drug regimen review and psychotropic medication monitoring, and unsanitary food procurement, storage, preparation, and serving practices.
Complaint Details
The inspection was triggered by complaint KS00167199 and included a Health Resurvey.
Severity Breakdown
SS=D: 9
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide appropriate Notice of Medicare Non-Coverage (NOMNC) to Medicare beneficiaries at least two days before the end of Medicare covered stay for three residents. | SS=D |
| Failed to complete an accurate comprehensive assessment for a resident regarding wounds present on admission. | SS=D |
| Failed to review and revise care plans timely for two residents related to fall prevention and DNR status. | SS=D |
| Failed to change gloves to provide sanitary environment while performing peri care to one resident following bowel movement. | SS=D |
| Failed to ensure fall prevention interventions were implemented after a resident's fall to prevent further falls. | SS=D |
| Failed to provide necessary respiratory care and services including timely changing of oxygen and nebulizer tubing for one resident. | SS=D |
| Failed to follow physician medication orders timely for one resident, resulting in risk for adverse medication effects. | SS=D |
| Consultant pharmacist failed to ensure psychotropic medication stop date or physician justification for continued use beyond 14 days for one resident. | SS=D |
| Failed to monitor behaviors every shift as ordered for one resident receiving psychotropic medications. | SS=D |
| Failed to store, prepare, and serve food under sanitary conditions, including unsealed and undated food items, dirty dishes, uncovered food in warmers, and damaged cutting boards. | SS=F |
Report Facts
Residents reviewed for Medicare services: 3
Residents sampled: 12
Residents receiving PRN Ativan: 59
Cutting boards with deep cuts or flakes: 4
Days staff lacked behavior monitoring: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Interviewed regarding Medicare Non-Coverage notices, MDS assessments, and care plan revisions. |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding care plan expectations, fall interventions, respiratory care, medication order processing, and behavior monitoring. |
| Certified Nurse Aide M | Certified Nurse Aide | Reported wounds present on admission for Resident R35. |
| Certified Medication Aide R | Certified Medication Aide | Reported on falls and medication administration for Resident R8. |
| Licensed Nurse G | Licensed Nurse | Reported on oxygen and nebulizer tubing change schedule and physician visit procedures. |
| Pharmacy Consultant HH | Pharmacy Consultant | Acknowledged oversight in not requesting stop date or physician certification for psychotropic medication. |
| Certified Nursing Assistant N | Certified Nursing Assistant | Observed failing to change gloves during peri care and reported on resident behaviors. |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 2, 2021
Visit Reason
The health survey was conducted as a routine annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 2, 2021
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Deficiencies (1)
| Description |
|---|
| No deficiency citations were found. |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 16, 2020
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 10/19/20.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 10/26/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies corrected: All deficiencies cited on 10/19/20 were corrected by 10/26/20
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Oct 19, 2020
Visit Reason
A Focused Infection Control/COVID-19 Survey was conducted due to concerns that the facility failed to follow guidance from the Sedgwick County Health Department regarding COVID-19 positive staff working while symptomatic and not wearing full PPE.
Findings
The facility failed to protect residents by allowing a Licensed Nurse (LN C) with a positive COVID-19 test and symptoms to work on the COVID-19 unit and in common areas without full PPE, contrary to local health department guidance. This placed all residents at immediate jeopardy. The facility presented an acceptable plan of removal of the immediate jeopardy.
Complaint Details
The investigation was complaint-driven based on failure to follow Sedgwick County Health Department guidance for COVID-19 positive staff working while symptomatic and without full PPE. The complaint was substantiated with findings of immediate jeopardy.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure nursing staff did not work while symptomatic with COVID-19 and failed to ensure full PPE use by COVID-19 positive staff. | Immediate Jeopardy |
Report Facts
Census: 38
Residents in COVID-19 unit: 29
Symptomatic days worked: 3
Shift length: 8
Date of positive test: Oct 8, 2020
Date of survey: Oct 15, 2020
Date of plan of removal: Oct 16, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Worked symptomatic with positive COVID-19 test and failed to wear full PPE |
| Administrative Staff A | Received surveyor notification and reported allowing LN C to work after consulting with Sedgwick County Health Department | |
| Administrative Nurse B | Administrative Nurse | Reported communication with Sedgwick County Health Department about staffing and LN C working |
| Consultant H | Consultant | Advised facility that asymptomatic COVID-19 staff could return to work but symptomatic staff should not |
| Certified Nursing Assistant D | Certified Nursing Assistant | Described screening and PPE practices on COVID-19 unit |
| Housekeeping Staff E | Housekeeping Staff | Described screening and PPE practices on COVID-19 unit |
| Licensed Nurse F | Licensed Nurse | Described screening and PPE practices and working on COVID-19 positive units |
| Administrative Nurse G | Administrative Nurse | Described screening and PPE practices and testing frequency |
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 15, 2020
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection, specifically addressing infection control and COVID-19 related issues.
Findings
The facility took corrective actions including revising staff scheduling to exclude symptomatic or COVID-positive staff, updating return-to-work policies in collaboration with the health department, providing infection control training, revising staff screening procedures, and assigning responsibility for compliance to the Director of Nursing.
Severity Breakdown
L: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies related to infection control and COVID-19 policies and procedures. | L |
Report Facts
Complete Date: Oct 26, 2020
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 8, 2020
Visit Reason
A complaint survey was conducted on 07/08/20 for complaint #151968 and 151531 to investigate allegations made in the complaints.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation. The allegations made in the complaints were not substantiated and no noncompliance was found.
Complaint Details
Complaints #151968 and 151531 were investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 8, 2020
Visit Reason
An offsite revisit survey was conducted on 01/08/20 for all previous deficiencies cited on 11/19/19.
Findings
All deficiencies have been corrected as of the compliance date of 12/04/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 2
Nov 19, 2019
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements.
Findings
The facility failed to remove two expired pain medications from the medication refrigerator and failed to ensure sanitary use of an indwelling urinary catheter by allowing a resident's catheter drainage bag to lay on the floor, risking contamination.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to remove two expired pain medications from a refrigerator in one medication room. | SS=D |
| Failed to ensure sanitary use of an indwelling urinary catheter by allowing the catheter drainage bag to lay on the floor with nothing underneath to prevent contamination. | SS=D |
Report Facts
Facility census: 44
Sample size: 12
Expired medications: 2
Resident affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN) A | Interviewed about expired medication checks | |
| Administration Nurse B | Interviewed about medication room checks and catheter care re-education | |
| Certified Nurse Aide (CNA) C | Reported resident behavior regarding catheter bag placement | |
| Licensed Nurse (LN) D | Reported catheter bag should be off the floor and discussed corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 19, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in the Cheney Golden Age Home inspection report dated 11-19-19.
Findings
The plan addresses deficiencies related to outdated medications found in the medication room and improper catheter bag placement. Corrective actions include removal of outdated medications, staff education, policy updates, and ongoing monitoring by the Director of Nursing and Nurse Consultant.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Outdated medication found in the medication room | D |
| Catheter bag was placed in a privacy bag instead of a basin or tied to the bed frame | D |
Report Facts
Corrective action completion date: Nov 22, 2019
Corrective action completion date: Nov 27, 2019
Quality assurance committee meeting date: Dec 4, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Achilles | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction on 01/30/2019 | |
| Lori Mouak | Modified Plan of Correction on 01/08/2020 |
Inspection Report
Deficiencies: 0
Jan 9, 2019
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
Plan of Correction
Deficiencies: 0
Jan 9, 2019
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 26, 2018
Visit Reason
An offsite revisit survey was conducted on 04/26/2018 to verify correction of all previous deficiencies cited on 01/16/2018.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 02/07/2018, 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
Jan 22, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a QIS survey of the facility.
Findings
The plan addresses deficiencies related to registry checks of nurse aides and improper storage of Albuterol medication, with corrective actions including staff education, audits, medication removal, and ongoing monitoring.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficiency related to registry checks of Nurse Aides. | D |
| Deficiency related to improper storage of Albuterol medication. | D |
Report Facts
Completion date: Jan 22, 2018
Completion date: Feb 7, 2018
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Jan 16, 2018
Visit Reason
The inspection was conducted as a health resurvey and complaint investigations related to allegations identified by investigation numbers #120768, 92373, and 101394.
Findings
The facility failed to verify one direct care staff's nurse aide registry certification prior to hire, resulting in a 22-day delay. Additionally, the facility failed to properly store Albuterol medication according to manufacturer recommendations on one of three medication carts reviewed.
Complaint Details
The visit included complaint investigations #120768, 92373, and 101394 as part of the health resurvey.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to verify 1 of 3 direct care staff for required new hire certification through the Kansas Nurse Aide Registry until 22 days after they began working. | SS=D |
| Failed to properly store Albuterol medication per manufacturer recommendation on 1 of 3 medication carts reviewed. | SS=D |
Report Facts
Direct care staff sample: 3
Days delayed: 22
Medication carts reviewed: 3
Facility census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Direct care staff | Named in finding for delayed nurse aide registry verification |
| Administrative Staff D | Verified lack of nurse aide registry verification prior to hire | |
| Administrative Nursing Staff E | Expected nurse aide registry to be checked prior to working | |
| Direct care Staff A | Certified to administer medications | Interviewed regarding improper storage of Albuterol |
| Administrative Nursing Staff B | Expected Albuterol to be stored in foil pouch as manufacturer directed |
Inspection Report
Routine
Deficiencies: 1
Jan 16, 2018
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 deficiency to be a 'D' level deficiency, isolated, 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 2018-02-07.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was a 'D' level deficiency, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Named as contact and signatory related to the survey findings and plan of correction acceptance. |
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 13
Feb 11, 2016
Visit Reason
Health resurvey inspection conducted to evaluate compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to obtain written consent for managing resident funds, inadequate individualized activity programs, poor housekeeping and maintenance services, uncomfortable sound levels due to noisy equipment, inaccurate resident assessments, incomplete care plans, failure to provide timely repositioning and toileting, improper food preparation and serving, unsanitary food storage and preparation conditions, and inadequate infection control practices.
Severity Breakdown
SS=D: 8
SS=E: 2
SS=F: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to obtain written consent to manage resident funds for 1 of 5 residents reviewed. | SS=D |
| Failed to provide individualized, ongoing activity program for 1 of 3 residents reviewed. | SS=D |
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in multiple resident rooms and facility areas. | SS=E |
| Failed to maintain comfortable sound levels in the dining room due to loud ice machine. | SS=E |
| Failed to accurately assess residents for range of motion impairment and constipation. | SS=D |
| Failed to develop comprehensive care plans with measurable objectives and timetables for residents with range of motion impairment and constipation. | SS=D |
| Failed to review and revise care plans to direct staff on timely repositioning and toileting for residents at risk. | SS=D |
| Failed to provide timely position changes for residents at risk for pressure ulcers, with delays up to 3 hours and 47 minutes. | SS=D |
| Failed to provide appropriate treatment and services to restore bladder function and timely toileting opportunities, and failed to provide adequate perineal hygiene after incontinence. | SS=D |
| Failed to provide range of motion and splinting services to prevent further decline in range of motion for a resident with contracted fingers. | SS=D |
| Failed to follow planned menu serving sizes for pureed diets, including omission of bread and serving less than planned amounts. | SS=E |
| Failed to prepare, store, and serve food under sanitary conditions, including unlabeled and damaged food packages, unclean pans, and lime and rust buildup on ice machine components. | SS=F |
| Failed to maintain an effective infection control program, including inadequate cleaning of shared equipment and resident care items, improper glove use, and lack of infection tracking and trending. | SS=F |
Report Facts
Resident census: 43
Residents reviewed for activities: 3
Residents reviewed for pressure ulcers: 4
Residents reviewed for urinary incontinence: 2
Residents requiring pureed diets: 7
Braden score: 16
BIMS score: 4
Position change interval: 2
Position change delay: 3.78
PRN constipation medication administrations: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Verified lack of written consent for resident funds and acknowledged facility maintenance and cleaning issues | |
| Direct care staff Y | Observed sitting with resident without interaction during meal | |
| Consultant staff Z | Reported lack of documentation of resident activity attendance | |
| Direct care staff D | Reported resident attended group activities and music events | |
| Licensed staff R | Assessed resident contractures and commented on resident engagement and care needs | |
| Maintenance staff E | Verified environmental maintenance issues and cleaning responsibilities | |
| Direct care staff S | Reported resident activity assistance and toileting needs | |
| Direct care staff V | Responsible for resident care but failed to provide timely repositioning and toileting | |
| Dietary staff C | Prepared pureed foods without following recipes and acknowledged food preparation deficiencies | |
| Consultant dietary staff J | Reported dietary staff should follow recipes for pureed foods | |
| Direct care staff K | Assisted resident with toileting but failed to clean wheelchair and toilet seat | |
| Direct care staff L | Provided perineal care without changing gloves appropriately | |
| Administrative nursing staff G | Reported infection control expectations and family preferences for restorative services | |
| Consultant staff CC | Reported lack of infection tracking and trending documentation |
Inspection Report
Follow-Up
Deficiencies: 2
Apr 5, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that deficiencies previously cited under regulations 483.20(k)(3)(i) and 483.25(c) were corrected by the revisit date of 04/05/2015.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(k)(3)(i) |
| Deficiency related to regulation 483.25(c) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Mar 25, 2015
Visit Reason
The inspection was conducted as a result of complaint investigations #84468, #84486, #84584, and #83809.
Findings
The facility failed to develop an adequate admission care plan for pressure ulcer care and failed to provide necessary pressure ulcer treatments and nutritional supplements to promote healing and prevent infection for a resident with multiple pressure ulcers.
Complaint Details
The findings represent the results of complaint investigations #84468, #84486, #84584, and #83809.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop an admission care plan sufficient to meet the needs of a resident for pressure ulcer care. | SS=D |
| Failed to provide necessary services of a nutritional supplement for wound healing and pressure ulcer treatments to promote healing and prevent infection for a resident with pressure ulcers. | SS=D |
Report Facts
Resident sample size: 5
Pressure ulcer measurements: 4
Pressure ulcer size: 4
Braden Scale score: 10
Albumin level: 1.8
Total protein level: 5.1
MAR missed treatments: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Administrative Nursing Staff | Responsible for developing care plans in resident #2's neighborhood; acknowledged deficiencies in admission care plan. |
| Staff D | Administrative Nursing Staff | Provided information about admission care plan purpose and wound care documentation. |
| Staff B | Direct Care Staff | Reported on resident #2's dietary supplement and repositioning. |
| Staff C | Licensed Nursing Staff | Reported on resident #2's pressure ulcers, treatments, and care. |
| Staff E | Physician | Provided medical opinion on resident #2's wounds and underlying conditions. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Mar 25, 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 Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies 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 effective April 5, 2015.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'D' level deficiencies indicating 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 questions concerning the survey information. |
Inspection Report
Follow-Up
Deficiencies: 4
Dec 10, 2014
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 documents that all previously cited deficiencies identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25, 483.25(d), and 483.60(a),(b) were corrected as of 11/12/2014.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.60(a),(b) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 5
Oct 24, 2014
Visit Reason
The inspection was a Health Resurvey of Cheney Golden Age Home to assess compliance with federal regulations including care planning, pain management, urinary incontinence, catheter use, and pharmaceutical services.
Findings
The facility failed to review and revise care plans for residents with changing conditions, failed to adequately manage pain related to an indwelling catheter, failed to justify and properly manage Foley catheter use resulting in complications, failed to assess and address decline in urinary continence, and failed to secure narcotic medications properly and ensure medication administration accuracy.
Severity Breakdown
SS=D: 2
SS=G: 2
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to review and revise care plan regarding complications from an indwelling urinary catheter including pain, bleeding, drainage, and decreased urinary output for resident #55 and failed to revise care plan for decline in urinary incontinence for resident #27. | SS=D |
| Failed to modify an ineffective pain management regimen for resident #55 with known inadequate pain relief related to an indwelling catheter. | SS=D |
| Failed to ensure medical justification for an indwelling urinary catheter which resulted in complications including severe pain, swelling, bleeding, and UTI requiring hospitalization for resident #55. | SS=G |
| Failed to thoroughly assess resident #27 with known decline in urinary incontinence resulting in failure to maintain or improve continence status. | SS=G |
| Failed to ensure narcotic medications were secured under double lock, failed to prepare medications for one resident at a time, and failed to conduct narcotic counts at least daily. | SS=F |
Report Facts
Census: 42
Sample size: 18
Pain medication administrations: 7
Pitting edema severity: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Licensed Nurse | Responsible for updating care plans and coding Quarterly MDS for bladder continence |
| Staff C | Licensed Nurse | Reported notifying physician of resident concerns and monitoring Foley catheter complications |
| Staff D | Licensed Nurse | Reported notifying physician for changes in resident condition and Foley catheter issues |
| Staff B | Administrative Nursing Staff | Reported expectations for physician notification and narcotic medication handling |
| Staff E | Direct Care Staff | Observed preparing multiple residents' medications at once and unsecured narcotics |
| Staff Q | Direct Care Staff | Reported daily medication cart preparation including multiple pill cups |
| Physician I | Physician | Provided orders and comments regarding resident #55's catheter and pain management |
Inspection Report
Enforcement
Deficiencies: 1
Oct 24, 2014
Visit Reason
A Health survey was conducted 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 deficiencies at a level of actual harm that is not immediate jeopardy, with a history of noncompliance from a prior abbreviated survey. Enforcement remedies including denial of payment for new Medicare admissions were imposed effective November 22, 2014.
Severity Breakdown
level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at a level of actual harm that is not immediate jeopardy as evidenced by the CMS-2567L. | level of actual harm |
Report Facts
months until recommended termination: 6
fine amount: 5000
effective date of denial of payment: Nov 22, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter and contact for questions concerning the instructions contained in the letter. |
| Sherriann Pater | Branch Manager, Division of Survey & Certification | Authorized the letter. |
Inspection Report
Follow-Up
Deficiencies: 3
Jun 5, 2014
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 revisit confirmed that the previously cited deficiencies under regulations 483.10(b)(11), 483.25, and 483.25(h) were corrected as of 04/18/2014.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 3
Apr 8, 2014
Visit Reason
The inspection was conducted as a complaint investigation based on complaints #3789, #3784, and #8987 regarding resident care and supervision.
Findings
The facility failed to immediately notify the physician of a significant change in a resident's condition, failed to assess and manage acute pain following a fall, and failed to provide adequate supervision to prevent falls, resulting in a fractured hip for one resident.
Complaint Details
The investigation was triggered by complaints #3789, #3784, and #8987 concerning failure to notify physician of condition changes, inadequate pain management, and insufficient supervision leading to falls.
Severity Breakdown
SS=D: 1
SS=G: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to immediately notify the physician of a significant change in resident #4's condition after a fall. | SS=D |
| Failed to assess and promptly respond to resident #4's acute pain related to a recent fall, resulting in decreased ambulation. | SS=G |
| Failed to provide sufficient supervision to resident #4, who experienced several falls including one resulting in a fractured hip. | SS=G |
Report Facts
Resident census: 45
Fall risk assessment score: 20
Number of falls: 3
Date of fall: Feb 26, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse F | Licensed Nurse | Reported resident's pain and changes but failed to notify physician |
| Nurse E | Licensed Nurse | Observed resident's pain and offered to notify physician; family requested call be delayed |
| Physician G | Physician | Received fax after hours; expected phone call for significant changes |
| Administrative Nurse Staff B | Administrative Nurse | Reported nurse should have called physician regarding resident's condition changes |
| Administrative Staff A | Administrative Staff | Reported supervision practices for resident #4 |
Inspection Report
Plan of Correction
Deficiencies: 3
Apr 8, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Cheney Golden Age facility.
Findings
The plan addresses deficiencies related to notification of residents' legal representatives and attending physicians regarding new onset of pain, pain management policies requiring daily monitoring, and fall policy updates including root cause analysis and individualized interventions.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Cheney Golden Age 040814 Complaint.
Severity Breakdown
D: 1
G: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to promptly notify physician and legal representative of new onset of pain or change of status. | D |
| Inadequate pain management policy and monitoring. | G |
| Fall policy deficiencies including lack of root cause analysis and individualized interventions. | G |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Achilles | Administrator | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Irina Strakhova | Added and modified the Plan of Correction. |
Inspection Report
Life Safety
Deficiencies: 1
Mar 17, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be isolated 'D' level deficiencies 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
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy | D |
Report Facts
Effective date for denial of payments: Jun 17, 2014
Provider agreement termination date: Sep 17, 2014
IDR request deadline: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Achilles | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Follow-Up
Deficiencies: 0
Jul 17, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-07-01.
Findings
All previously cited deficiencies identified by regulation numbers were corrected as of the revisit date 2013-07-17.
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 8
Jul 15, 2013
Visit Reason
This document is a Plan of Correction submitted by Cheney Golden Age Home addressing multiple deficiencies identified in a prior inspection.
Findings
The plan outlines corrective actions for various deficiencies including care plan updates, therapy screenings, nursing staff education on positioning, fall interventions, catheter care, nail care, and hazardous chemical storage. Substantial compliance will be monitored through random audits and checklists.
Severity Breakdown
D: 6
E: 1
F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Care plan reviewed and updated; therapy restorative program updated. | D |
| Care plan reviewed and updated; nursing staff to attend mandatory in-service on positioning; fall policy updated. | D |
| Nursing staff notified of resident positioning requirements; mandatory in-service on positioning. | D |
| Nail care deficiencies addressed; mandatory in-service on nail care; diabetic nail care checklist implemented. | D |
| Staff instructed on catheter care; mandatory in-service on catheter care; monitoring checklist implemented. | D |
| Physical therapy evaluation and restorative nursing program implemented. | D |
| Hazardous chemicals unsecured; keypad door locks bypass mechanism removed; staff counseled. | E |
| Multiple deficiencies addressed with mandatory in-services and updated policies. | F |
Report Facts
Corrective action completion dates: 2013
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 8
Jul 1, 2013
Visit Reason
Annual health resurvey inspection of Cheney Golden Age Home to assess compliance with federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to develop and revise comprehensive care plans, inadequate positioning and range of motion services, insufficient nail care, improper catheter care, unsecured hazardous chemicals, and inadequate fall investigations and interventions.
Severity Breakdown
SS=D: 6
SS=E: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for resident #44 to include contractures and restorative/range of motion services. | SS=D |
| Failed to revise comprehensive care plans to include positioning, fall interventions, and dietary orders for residents #8, #17, and #56. | SS=D |
| Failed to provide necessary care and services to maintain highest practicable physical well-being for resident #17 related to positioning and fall risk. | SS=D |
| Failed to provide necessary services to maintain good grooming regarding fingernail care for residents #44 and #23. | SS=D |
| Failed to properly care for indwelling catheters for residents #8 and #56, including improper catheter care technique and failure to maintain catheter drainage bag off the floor. | SS=D |
| Failed to ensure resident #44 with limited range of motion received appropriate treatment and services to increase or maintain range of motion. | SS=D |
| Failed to thoroughly investigate and implement interventions to reduce fall risk for resident #8 and failed to secure hazardous chemicals to prevent accidental exposure to cognitively impaired residents. | SS=E |
| Failed to develop and implement effective Quality Assessment and Assurance (QAA) plans to address identified deficiencies in care plans, positioning, nail care, catheter care, range of motion, and accident investigations. | SS=F |
Report Facts
Residents sampled: 23
Fall risk assessment score: 16
BIMS score: 8
BIMS score: 11
BIMS score: 10
BIMS score: 15
Foley catheter size: 16
Restorative program days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Direct Care Staff | Mentioned in relation to resident #44's contracture and care |
| Staff F | Direct Care Staff | Mentioned in relation to resident #44's care and therapy |
| Staff C | Direct Care Staff | Mentioned in relation to resident #44's restorative services |
| Staff E | Therapy Staff | Mentioned in relation to resident #44's restorative program initiation |
| Staff J | Licensed Nursing Staff | Mentioned in relation to resident #44's therapy and catheter care |
| Staff B | Administrative Nursing Staff | Mentioned in relation to resident #44's restorative services and overall facility expectations |
| Staff H | Direct Care Staff | Mentioned in relation to resident #8's fall risk and catheter care |
| Staff N | Licensed Nursing Staff | Mentioned in relation to resident #44's contracture and fall investigation |
| Staff O | Administrative Nurse | Mentioned in relation to fall investigation and care plan updates |
| Staff U | Direct Care Staff | Mentioned in relation to resident #44's nail care |
| Staff R | Direct Care Staff | Mentioned in relation to resident #44's nail care |
| Staff K | Direct Care Staff | Mentioned in relation to resident #44's morning care |
| Staff M | Licensed Nurse | Mentioned in relation to resident #17's positioning care |
| Staff L | Direct Care Staff | Mentioned in relation to resident #17's positioning care |
| Staff S | Activities Staff | Mentioned in relation to nail care provision |
Inspection Report
Plan of Correction
Deficiencies: 7
N087002 POC 3BSU11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey.
Findings
The facility acknowledged multiple deficiencies including failure to ensure resident rights and dignity, improper notice before transfer/discharge, incomplete care plans, unsafe environment, lack of staff performance reviews, inaccurate payroll based journal submissions, and infection prevention and control issues. Corrective actions including staff education, monitoring, and ongoing quality assurance have been implemented.
Severity Breakdown
D: 4
F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure all residents were treated with respect and dignity during care. | D |
| Failure to provide proper written notice to families regarding bed holds and transfers/discharges. | D |
| Failure to have care plans completed and up to date. | D |
| Failure to provide an accident-free environment. | D |
| Failure of not having staff performance reviews on file. | F |
| Failure of not submitting accurate staffing information for Payroll Based Journal (PBJ). | F |
| Failure to ensure potential of infection (infection prevention and control). | F |
Report Facts
Number of employees with up to date performance evaluations: 5
Date of QAPI meeting to review statement of deficiencies: QAPI meeting scheduled for 2024-12-19 to review statement of deficiencies.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Martin | Administrator | Submitted the Plan of Correction and involved in corrective actions. |
| Jessica Patterson | Added the Plan of Correction on 2024-12-02. | |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Plan of Correction
Deficiencies: 12
N087002 POC HQQO11
Visit Reason
This document is a Plan of Correction submitted by Cheney Golden Age Home in response to deficiencies identified in a prior inspection.
Findings
The Plan of Correction outlines specific corrective actions taken or planned to address various deficiencies including consent forms for resident funds, replacement of televisions, environmental cleanliness, ice machine replacement, therapy assessments, care plan updates, tissue tolerance testing, infection control, and food safety.
Severity Breakdown
D: 7
E: 3
F: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Resident consent forms for social security payments directly deposited to the facility. | D |
| Replacement of resident television and staff education on resident preferences. | D |
| Environmental cleanliness issues including cleaning of hair dryer hoods, walls, sinks, vents, and labeling towel bars. | E |
| Removal and replacement of ice machine in dining room. | E |
| Therapy assessments on admission and quarterly for range of motion and care plan updates. | D |
| Care plan updates for residents including tissue tolerance testing and constipation treatment. | D |
| Tissue tolerance testing and staff training on repositioning and pressure sore prevention. | D |
| Staff education and monitoring on toileting plans and incontinent care. | D |
| Family and resident education on contracture and pressure ulcer prevention. | D |
| Proper serving of planned menus with correct scoop sizes for pureed diets. | E |
| Food safety issues including unlabeled meat packages, cleaning of pans, and ice machine replacement. | F |
| Staff education on infection control including glove changing and sanitizing equipment. | F |
Report Facts
Complete Date: Feb 18, 2016
Complete Date: Feb 19, 2016
Complete Date: Mar 10, 2016
Complete Date: Mar 4, 2016
Complete Date: Mar 1, 2016
Complete Date: Mar 11, 2016
Complete Date: Feb 26, 2016
Complete Date: Mar 11, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Achilles | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Plan of Correction
Deficiencies: 4
N087002 POC KCOM11
Visit Reason
This document is a Plan of Correction submitted by Cheney Golden Age Home addressing deficiencies identified in a prior inspection report.
Findings
The Plan of Correction outlines corrective actions taken for multiple deficiencies including care plan updates, pain assessments, catheter care, and medication management, with timelines for completion and measures for compliance monitoring.
Severity Breakdown
D: 2
G: 1
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Care plan updates with mandatory in-service training for nurses. | D |
| Pain assessments to be completed at admission, annually, quarterly, and with significant changes. | D |
| Education on obtaining correct diagnosis and use of three-day voiding diary for catheter care. | G |
| Medications prepared just prior to administration; narcotics kept under double lock and reconciled each shift. | F |
Report Facts
Deficiency completion dates: Nov 12, 2014
Deficiency completion dates: Oct 27, 2014
Deficiency completion dates: Oct 23, 2014
Inspection Report
Plan of Correction
Deficiencies: 2
N087002 POC O2EE11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Cheney Golden Age Home.
Findings
The plan addresses deficiencies related to care planning and administration of treatments for residents with pressure ulcers, including corrective actions such as timely care plan documentation and quarterly chart reviews by the quality assurance nurse.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Cheney Golden Age Home.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficiency related to initial/admission care plan documentation and monitoring. | D |
| Deficiency related to administration and documentation of pressure ulcer treatments and nutritional supplements. | D |
Report Facts
Complete Date: Apr 2, 2015
Complete Date: Apr 5, 2015
Loading inspection reports...
