Inspection Reports for
Cheney Golden Age Home
724 N MAIN PO BOX 370, CHENEY, KS, 67025-
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
10.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
90% occupied
Based on a November 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: 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.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 7
Date: Nov 18, 2024
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for Cheney Golden Age Home.
Complaint Details
The inspection was triggered by a complaint investigation KS00182143.
Findings
The facility failed to protect residents' dignity and privacy, failed to provide written notice for transfers, failed to review and revise care plans appropriately, failed to identify and prevent falls, failed to conduct annual nurse aide performance reviews, failed to submit accurate staffing data, and failed to maintain infection prevention and control standards including proper storage of respiratory equipment and use of personal protective equipment.
Deficiencies (7)
F 550 Resident Rights: The facility failed to protect the privacy and dignity of three residents during care and transport, exposing them inappropriately and failing to explain procedures.
F 623 Notice Requirements: The facility failed to provide written notice to residents or representatives for facility-initiated transfers to hospitals for three residents.
F 657 Care Plan Timing and Revision: The facility failed to review and revise care plans with appropriate interventions for two residents related to fall prevention and CPAP equipment storage.
F 689 Free of Accident Hazards: The facility failed to identify a fall, investigate causes, and implement fall prevention interventions for a resident, risking further injury.
F 730 Nurse Aide Performance Review: The facility failed to conduct annual performance reviews for five certified nurse aides employed over a year.
F 851 Payroll Based Journal: The facility failed to submit complete and accurate staffing information to CMS, missing licensed nursing coverage on multiple dates.
F 880 Infection Prevention & Control: The facility failed to ensure sanitary storage of respiratory equipment, proper use of personal protective equipment, and cleaning of mechanical lifts, risking infection spread.
Report Facts
Resident census: 36
Residents sampled: 12
Certified Nurse Aides missing annual review: 5
Dates with missing licensed nursing coverage: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Named in findings related to dignity, infection control, and CPAP equipment storage. |
| Administrative Staff A | Administrative Staff | Named in findings related to transfer notices, fall prevention, and infection control. |
| Certified Nurse Aide I | CNA | Named in findings related to dignity, infection control, and PPE use. |
| Certified Medication Aide C | CMA | Named in findings related to CPAP and oxygen equipment handling. |
| Licensed Nurse O | LN | Named in findings related to dignity and infection control. |
Inspection Report
Routine
Census: 36
Deficiencies: 7
Date: Nov 18, 2024
Visit Reason
Routine inspection of Cheney Golden Age Home to assess compliance with regulatory requirements including resident dignity, care planning, notification procedures, fall prevention, staffing, infection control, and equipment storage.
Findings
The facility failed to protect residents' dignity during transfers and care, failed to provide written discharge notifications, failed to revise care plans after falls, failed to conduct annual performance reviews for CNAs, failed to submit accurate staffing data, and failed to ensure proper infection control practices including PPE use and sanitary storage of respiratory equipment.
Deficiencies (7)
F 0550: The facility failed to protect residents' dignity when transporting residents with exposed body parts and failing to explain care procedures, potentially causing negative psychosocial effects.
F 0623: The facility failed to provide timely written notification to residents or representatives for facility-initiated transfers or discharges to hospitals.
F 0657: The facility failed to review and revise care plans with appropriate interventions for residents after falls and failed to include interventions for CPAP equipment storage.
F 0689: The facility failed to identify a fall, investigate causes, and implement fall prevention interventions for a resident, risking further injury.
F 0730: The facility failed to conduct annual performance reviews for five Certified Nurse Aides employed over a year.
F 0851: The facility failed to submit complete and accurate staffing information to CMS through Payroll-Based Journal for nursing personnel.
F 0880: The facility failed to implement infection prevention and control by not ensuring proper PPE use during catheter care, failing to clean mechanical lifts between residents, and failing to store respiratory equipment in sanitary conditions, risking cross contamination and infection.
Report Facts
Residents sampled: 12
Census: 36
Dates with missing licensed nursing coverage: 8
Certified Nurse Aides without annual performance reviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed expectations on resident dignity, bed hold procedures, staffing coverage, and annual performance reviews | |
| Administrative Nurse B | Provided documentation on staffing coverage, educated residents on CPAP mask storage, confirmed infection control concerns | |
| Certified Nurse Aide I | CNA | Observed transporting resident with exposed buttocks, stated facility policies on transfers and PPE use |
| Certified Medication Aide C | CMA | Responsible for changing CPAP and oxygen equipment, unsure about proper storage |
| Licensed Nurse O | LN | Stated expectations on transfers, PPE use, and oxygen equipment storage |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 7
Date: Nov 18, 2024
Visit Reason
The inspection was conducted as an annual survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility failed to protect residents' dignity during transfers and care, failed to provide timely written discharge notifications, did not review and revise care plans appropriately, failed to identify and prevent falls, did not conduct annual performance reviews for nurse aides, failed to submit accurate staffing data, and failed to maintain infection control practices including proper use of PPE and sanitary storage of respiratory equipment.
Deficiencies (7)
F 0550: The facility failed to protect residents' dignity when transporting a resident with exposed buttocks, failing to explain care procedures, and leaving a resident partially exposed during medication administration with the door open.
F 0623: The facility failed to provide written notification to residents or their representatives for facility-initiated transfers to the hospital.
F 0657: The facility failed to review and revise care plans with appropriate interventions for two residents related to fall prevention and CPAP equipment storage.
F 0689: The facility failed to identify a fall, investigate causal factors, and implement fall prevention interventions for a resident to prevent further falls.
F 0730: The facility failed to conduct annual performance reviews for five Certified Nurse Aides employed over a year.
F 0851: The facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journal (PBJ).
F 0880: The facility failed to implement infection prevention and control practices including proper use of PPE during catheter care, cleaning of mechanical lifts between residents, and sanitary storage of respiratory equipment and oxygen tubing.
Report Facts
Residents sampled: 12
Dates with inadequate licensed nursing coverage: 8
Certified Nurse Aides without annual performance reviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed expectations on resident dignity, bed hold procedures, and staffing data issues | |
| Administrative Nurse B | Provided documentation on nursing coverage, educated residents on CPAP mask storage, and confirmed infection control concerns | |
| Certified Nurse Aide I | CNA | Observed transporting resident with exposed buttocks and discussed PPE use and CPAP equipment storage |
| Certified Medication Aide C | CMA | Responsible for changing CPAP and oxygen equipment and discussed storage practices |
| Licensed Nurse O | LN | Discussed resident dignity expectations and PPE use |
| Certified Nurse Aide P | CNA | Defined falls and discussed care plan changes |
| Certified Nurse Aide J | CNA | Discussed assisting residents with CPAP equipment and PPE use |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2023-02-02.
Findings
All deficiencies have been corrected as of the compliance date of 2023-02-15, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 10
Date: Feb 2, 2023
Visit Reason
The inspection was a Health Resurvey and complaint investigation KS00167199 at Cheney Golden Age Home.
Complaint Details
The inspection was triggered by a complaint KS00167199 and included a Health Resurvey.
Findings
The facility failed to provide appropriate Medicare Non-Coverage notices, complete accurate assessments, revise care plans timely, provide sanitary ADL care, implement fall prevention interventions, provide necessary respiratory care, follow physician medication orders timely, ensure proper drug regimen review, monitor psychotropic medication use, and maintain sanitary food preparation and storage.
Deficiencies (10)
F582: The facility failed to provide Notice of Medicare Non-Coverage (NOMNC) forms to three Medicare beneficiaries at least two days before the end of their Medicare covered stay.
F641: The facility failed to complete an accurate comprehensive assessment for one resident regarding wounds present on admission.
F657: The facility failed to review and revise care plans timely for two residents related to fall prevention and DNR status.
F677: The facility failed to change gloves to provide sanitary peri care to one resident following a bowel movement.
F689: The facility failed to implement fall prevention interventions after a resident's fall to prevent further falls.
F695: The facility failed to provide necessary respiratory care and services for one resident requiring oxygen and nebulizer treatments, including timely tubing changes.
F755: The facility failed to follow physician medication orders timely for one resident, placing the resident at risk for adverse medication effects.
F756: The facility's consultant pharmacist failed to ensure a psychotropic medication stop date or justification for long-term use for one resident.
F758: The facility failed to monitor behaviors as ordered for one resident and failed to ensure psychotropic medication stop dates and monitoring for another resident.
F812: The facility failed to maintain sanitary food preparation, storage, and serving conditions, including unsealed and undated food items, dirty dishes, uncovered food, and damaged cutting boards.
Report Facts
Resident census: 38
Residents sampled: 12
Ativan PRN administrations: 59
Behavior monitoring missed occasions: 18
Cutting boards with deep cuts: 4
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Feb 2, 2023
Visit Reason
This document is a Plan of Correction submitted by Cheney Golden Age Home to address 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 MDS coding for wounds, updating care plans after resident falls, sanitary food preparation, and proper medication administration and monitoring.
Deficiencies (11)
F582-D: Facility failed to provide timely Beneficiary Protection Notification forms for 3 residents to ensure their right to appeal service discontinuation.
F641-D: Facility failed to accurately code the MDS for resident-related wounds.
F657-D: Facility failed to revise the care plan with interventions after a resident fall to prevent further falls.
Facility failed to review and revise residents' wishes on care plans regarding code status, risking unwanted medical procedures.
F677-D: Facility failed to change gloves to maintain sanitary conditions during peri care for one resident.
F689-D: Facility failed to implement interventions after a resident fall to prevent further falls.
F695-D: Facility failed to provide necessary respiratory care and services including proper dating of oxygen tubing and components.
F755-D: Facility failed to follow physician orders for 12 days, placing a resident at risk for adverse medication effects.
F756-D: Resident did not have 14-day stop on PRN antianxiety medication and facility failed to address this with physician.
F758-D: Facility failed to identify irregularities and monitor behavior for residents receiving psychotropic medications beyond 14 days without evaluation.
F812-F: Facility failed to store, prepare, and serve food under sanitary conditions, risking foodborne illness.
Report Facts
Residents involved: 3
Days medication orders not followed: 12
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 10
Date: Feb 2, 2023
Visit Reason
Annual inspection of Cheney Golden Age Home to assess compliance with Medicare/Medicaid regulations including resident care, medication management, safety, and food service.
Findings
The facility had multiple deficiencies including failure to provide appropriate Medicare Non-Coverage notices, inaccurate resident assessments, incomplete care plan revisions, inadequate infection control during peri care, insufficient fall prevention interventions, improper respiratory care, delayed medication order processing, lack of pharmacist oversight on psychotropic medication stop dates, failure to monitor resident behaviors related to psychotropic medications, and unsanitary food storage and preparation practices.
Deficiencies (10)
F 0582: The facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) form to three Medicare beneficiaries at least two days before the end of their Medicare covered stay.
F 0641: The facility failed to complete an accurate comprehensive assessment for Resident 35 regarding wounds present on admission.
F 0657: The facility failed to review and revise care plans for Residents 8 and 35 related to fall prevention and DNR orders respectively.
F 0677: The facility failed to change gloves to provide a sanitary environment while performing peri care to Resident 5 following a bowel movement.
F 0689: The facility failed to ensure fall prevention interventions were implemented to prevent further falls for Resident 8 after a fall.
F 0695: The facility failed to provide necessary respiratory care and services for Resident 5, including timely changing and dating of oxygen and nebulizer tubing.
F 0755: The facility failed to follow physician orders in a timely manner for Resident 8, resulting in a 12-day delay in medication changes.
F 0756: The facility's consultant pharmacist failed to ensure a 14-day stop date or physician justification for PRN psychotropic medication for Resident 6, who received Ativan on 59 occasions without proper evaluation.
F 0758: The facility failed to monitor Resident 25's behaviors as ordered and ensure gradual dose reductions and appropriate use of psychotropic medications.
F 0812: The facility 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.
Report Facts
Resident census: 38
Residents sampled: 12
PRN Ativan administrations: 59
Days medication order delayed: 12
Cutting boards with deep cuts: 4
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 2, 2021
Visit Reason
The inspection was conducted as a health survey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 2, 2021
Visit Reason
The document is a Plan of Correction submitted in response to a health survey inspection 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
Annual Inspection
Deficiencies: 0
Date: Aug 2, 2021
Visit Reason
Annual inspection of Cheney Golden Age Home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2020-10-19.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2020-10-26, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Abbreviated Survey
Census: 38
Deficiencies: 1
Date: Oct 19, 2020
Visit Reason
A focused Infection Control/COVID-19 survey was conducted due to concerns about the facility's adherence to COVID-19 infection prevention guidance, specifically regarding staff with COVID-19 symptoms working in the facility.
Findings
The facility failed to prevent a Licensed Nurse (LN) with symptomatic COVID-19 from working on the COVID-19 unit and in common areas without full PPE, exposing other staff and residents. The facility did not ensure proper isolation and PPE use as directed by the local health department, constituting immediate jeopardy to all residents.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program by allowing a symptomatic COVID-19 positive Licensed Nurse to work without full PPE and proper isolation, exposing residents and staff to infection.
Report Facts
Resident census: 38
Resident census: 29
Dates symptomatic Licensed Nurse worked: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Symptomatic COVID-19 positive nurse who worked on COVID-19 unit and in common areas without full PPE |
| Administrative Staff A | Provided information about facility's plan and communication with health department | |
| Administrative Nurse B | Reported communication with health department and staff screening | |
| Consultant H | Health department consultant who advised on staff return to work criteria | |
| Certified Nursing Assistant D | Certified Nursing Assistant | Described PPE use and screening procedures |
| Housekeeping Staff E | Housekeeping Staff | Described PPE use and screening procedures |
| Licensed Nurse F | Licensed Nurse | Described screening and PPE procedures, worked near LN C |
| Administrative Nurse G | Administrative Nurse | Described screening and testing procedures |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 15, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection.
Findings
The facility reviewed and revised policies related to staff scheduling, return to work guidelines, and infection control in response to COVID-19. Corrective actions include staff training, policy updates, and enhanced screening procedures.
Deficiencies (2)
F0000 The statement of deficiencies was presented to the facility's Quality assurance/assessment committee on October 15, 2020.
F880-L The statement of deficiencies was presented to the facility's Quality assurance/assessment committee on October 15, 2020, with corrective actions addressing staff scheduling, return to work policies, and infection control training.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 8, 2020
Visit Reason
A complaint survey was conducted on July 8, 2020, for complaints #151968 and #151531. The visit also included a Targeted Infection Control Survey/COVID-19 Focused Survey.
Complaint Details
The allegations made in complaints #151968 and #151531 were not substantiated.
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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 8, 2020
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-11-19.
Findings
All deficiencies have been corrected as of the compliance date of 2019-12-04, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 2
Date: Nov 19, 2019
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements following a prior survey.
Findings
The facility failed to remove expired medications from storage and did not ensure sanitary use of an indwelling urinary catheter by allowing the catheter drainage bag to lay on the floor, risking contamination.
Deficiencies (2)
F761 Label/Store Drugs and Biologicals: The facility failed to remove two expired pain medications from a refrigerator in one medication room reviewed for expired medications.
F880 Infection Prevention & Control: The facility failed to ensure sanitary use of an indwelling urinary catheter by allowing a resident's catheter drainage bag to lay on the floor with nothing underneath to prevent contamination.
Report Facts
Facility census: 44
Expired medications: 2
Residents sampled: 12
Resident affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN) A | Interviewed about monthly 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
Date: Nov 19, 2019
Visit Reason
This document is a plan of correction submitted by Cheney Golden Age Home in response to deficiencies cited during a prior inspection on November 19, 2019.
Findings
The plan addresses medication management issues related to outdated medications and catheter care practices that posed risks to residents. Corrective actions include removal of outdated medications, policy updates, staff education, and ongoing monitoring by the Director of Nursing and Nurse Consultant.
Deficiencies (2)
F761-D: No resident was identified and the outdated medication was removed from the medication room. The Director of Nursing will conduct weekly and then monthly checks of medication storage, with quarterly random checks by a Nurse Consultant.
F880-D: For the affected resident, the catheter bag was placed in a privacy bag and will be placed in a basin on the floor or tied to the bed frame. Policy was updated and staff educated on proper catheter care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Achilles | Administrator | Submitted the plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 9, 2019
Visit Reason
The inspection was conducted as a health survey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The survey resulted in no deficiency citations, indicating full compliance with the regulatory requirements for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: Apr 23, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-01-16.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2018-02-07, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: 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. No residents were found to be affected by the deficient practices, but potential risks were acknowledged.
Deficiencies (2)
F606-D: No residents were found to be affected by the deficient practice regarding registry checks of nurse aides. Staff were educated and audits of employee records will be conducted quarterly to ensure compliance.
F761-D: No residents were found to be affected by improper storage of Albuterol medication. The improperly stored medication was removed and disposed of, staff were educated, and ongoing inspections will be conducted to ensure proper medication storage.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 16, 2018
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a single isolated 'D' level deficiency that constituted no actual harm but had potential for more than minimal harm without 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.
Deficiencies (1)
A 'D' level deficiency was cited, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Jan 16, 2018
Visit Reason
The inspection was conducted as a health resurvey and complaint investigations for cases #120768, 92373, and 101394.
Complaint Details
The inspection included complaint investigations for cases #120768, 92373, and 101394.
Findings
The facility failed to verify one direct care staff's certification through the Kansas Nurse Aide Registry until 22 days after employment. Additionally, the facility failed to properly store Albuterol medication per manufacturer recommendations on one of three medication carts reviewed.
Deficiencies (2)
483.12(a)(3)(4) The facility failed to verify one direct care staff's nurse aide registry certification until 22 days after the staff began working.
483.45(g)(h)(1)(2) The facility failed to properly store Albuterol medication in a foil pouch away from light as per manufacturer instructions on one of three medication carts.
Report Facts
Deficiencies cited: 2
Direct care staff sample: 3
Medication carts reviewed: 3
Days delayed for registry verification: 22
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 13
Date: Feb 11, 2016
Visit Reason
The inspection was a health resurvey to assess compliance with federal regulations and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including management of resident funds, individualized activity programs, housekeeping and maintenance, sound level control, assessment accuracy, care planning, pressure ulcer prevention, urinary incontinence care, range of motion services, dietary menu adherence, food sanitation, and infection control practices.
Deficiencies (13)
F159: The facility failed to obtain written consent to manage personal funds for one resident.
F248: The facility failed to provide an individualized, ongoing activity program for one resident.
F253: The facility failed to provide adequate housekeeping and maintenance services to maintain a sanitary environment.
F258: The facility failed to maintain comfortable sound levels in the dining room due to a noisy ice machine.
F278: The facility failed to accurately assess two residents for range of motion impairment and constipation.
F279: The facility failed to develop comprehensive care plans addressing contracture management and constipation interventions for residents.
F280: The facility failed to review and revise care plans to direct timely repositioning and constipation management for residents.
F314: The facility failed to provide timely position changes for two residents at risk for pressure ulcers.
F315: The facility failed to provide timely toileting opportunities and adequate perineal hygiene care to prevent urinary tract infections for one resident.
F318: The facility failed to provide range of motion and splinting services to prevent further decline in range of motion for one resident.
F363: The facility failed to follow the planned menu serving sizes and omitted bread for seven residents on pureed diets.
F371: The facility failed to prepare, store, and serve food under sanitary conditions, including unlabeled meat and unclean pans.
F441: The facility failed to maintain an effective infection control program, including inadequate cleaning of equipment, improper glove use, and incomplete infection tracking.
Report Facts
Resident census: 43
Residents reviewed: 17
Residents on pureed diet: 7
Duration without position change: 227
Duration without position change: 155
Duration without toileting opportunity: 155
Duration without toileting opportunity: 185
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 5, 2015
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that deficiencies identified in prior surveys under regulations 483.20(k)(3)(i) and 483.25(c) were corrected by the revisit date of 04/05/2015.
Deficiencies (2)
Regulation 483.20(k)(3)(i) deficiency was corrected as of 04/05/2015.
Regulation 483.25(c) deficiency was corrected as of 04/05/2015.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 25, 2015
Visit Reason
An abbreviated 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 '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 based on the credible allegation of compliance.
Deficiencies (1)
The facility had 'D' level deficiencies indicating no actual harm but potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Signed letter regarding survey results and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Mar 25, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint investigations #84468, #84486, #84584, and #83809.
Complaint Details
The findings represent the results 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.
Deficiencies (2)
483.20(k)(3)(i) The facility failed to develop an admission care plan sufficient to meet the needs of a resident for pressure ulcer care, lacking location and treatment details for pressure ulcers.
483.25(c) The facility failed to provide necessary nutritional supplements and pressure ulcer treatments to promote healing and prevent infection for a resident with pressure ulcers.
Report Facts
Resident census: 43
Nutritional supplement administration failures: 17
Braden Scale score: 10
Albumin level: 1.8
Total protein level: 5.1
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 10, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies related to regulations 483.20(d)(3), 483.10(k)(2), 483.25, 483.25(d), and 483.60(a),(b) were corrected by 11/12/2014.
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 4
Date: Oct 24, 2014
Visit Reason
The visit was a health resurvey to assess compliance with previously identified deficiencies and overall regulatory compliance at Cheney Golden Age Home.
Findings
The facility failed to review and revise care plans for residents with changing conditions, failed to manage pain effectively for a resident with an indwelling catheter, failed to justify and manage catheter use properly resulting in complications, failed to assess and address decline in urinary continence, and failed to secure narcotic medications properly and ensure safe medication administration practices.
Deficiencies (4)
F280: The facility failed to review and revise the care plan for resident #55 regarding complications from an indwelling urinary catheter including pain, bleeding, drainage, and decreased urinary output, and failed to revise the care plan for resident #27 with a decline in urinary incontinence.
F309: The facility failed to modify an ineffective pain management regimen for resident #55 with known inadequate pain relief related to an indwelling catheter, including failure to administer pain medication prior to catheter changes.
F315: The facility failed to ensure medical justification for an indwelling urinary catheter for resident #55, resulting in complications including severe pain, swelling, bleeding, UTI, and hospitalization; and failed to assess and address decline in urinary continence for resident #27.
F425: The facility failed to keep narcotic medications under double lock, failed to prepare medications for one resident at a time to ensure correct administration, and failed to conduct narcotic counts at least daily.
Report Facts
Facility census: 42
Sample size: 18
PRN pain medication administrations: 7
BIMS score: 14
BIMS score: 3
Inspection Report
Enforcement
Deficiencies: 0
Date: Oct 24, 2014
Visit Reason
The inspection 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. Due to the facility's history of noncompliance, no opportunity to correct deficiencies was given before enforcement remedies were imposed, including denial of payment for all new Medicare admissions effective November 22, 2014.
Report Facts
Enforcement effective date: Nov 22, 2014
Noncompliance correction deadline: Apr 24, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
| Teresa Achilles | Administrator | Facility administrator named in report header |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 5, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that deficiencies previously cited under regulations 483.10(b)(11), 483.25, and 483.25(h) were corrected as of 04/18/2014.
Report Facts
Deficiency correction dates: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 18, 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.
Complaint Details
This Plan of Correction is in response to deficiencies cited during a complaint investigation at Cheney Golden Age.
Findings
The plan addresses deficiencies related to notification of residents' legal representatives and attending physicians about new onset of pain, pain management monitoring each shift, and fall policy updates including root cause analysis and individualized interventions.
Deficiencies (3)
F157-D: The resident associated with this deficiency no longer resides in the facility. The policy for notification of resident's legal representative and attending physician has been revised to include new onset of pain, with nursing staff educated on prompt notification.
F309-G: The resident associated with this deficiency no longer resides in the facility. The pain management policy has been revised to require daily monitoring each shift, with nursing staff educated to monitor and document pain and report new onset immediately.
F323-G: The resident associated with this deficiency no longer resides in the facility. The fall policy was updated to include one-on-one activity and root cause analysis for falls, with nursing staff educated to add individualized interventions to care plans.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 3
Date: 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.
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.
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 after a fall, and failed to provide adequate supervision to prevent falls, resulting in a fractured hip for one resident.
Deficiencies (3)
F 157: The facility failed to immediately notify the physician of a significant change in resident #4's condition after a fall, including signs of pain and decreased ambulation.
F 309: The facility failed to assess and manage resident #4's acute pain related to a fall, resulting in decreased ambulation and no timely interventions for pain relief.
F 323: The facility failed to provide adequate supervision and fall prevention interventions for resident #4, who experienced multiple falls including one resulting in a fractured hip.
Report Facts
Resident census: 45
Fall risk assessment score: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse F | Licensed Nurse Staff | Reported resident's pain and changes but failed to notify physician. |
| Nurse E | Licensed Nurse Staff | Observed resident's pain and external rotation but delayed physician notification. |
| Physician G | Physician | Received fax after hours and expected phone call for significant changes. |
| Staff B | Administrative Nurse Staff | Reported nursing staff should have called physician regarding resident's condition changes. |
| Staff A | Administrative Staff | Reported supervision practices for restless resident. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 17, 2014
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 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 to address these deficiencies.
Deficiencies (1)
The facility was cited for 'D' level deficiencies related to Life Safety Code compliance, indicating isolated issues with no immediate jeopardy but potential for more than minimal harm.
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 | Named as facility administrator in the report header |
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Kansas Department for Aging and Disability Services |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 17, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers were corrected by the revisit date of 07/17/2013, as documented in the report.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jul 15, 2013
Visit Reason
This document is a Plan of Correction submitted by Cheney Golden Age Home in response to deficiencies identified during a prior inspection.
Findings
The plan outlines corrective actions for multiple deficiencies related to resident care plans, positioning, nail care, catheter care, hazardous chemical storage, and therapy programs. It includes staff education, updated policies, and monitoring procedures to ensure compliance.
Deficiencies (8)
F279-D: The resident identified has had the care plan reviewed and updated, including restorative therapy program adjustments. Therapy department screens all residents' MDS to update care plans accordingly.
F280-D: Residents identified have had care plans reviewed and updated. Nursing staff will attend mandatory in-service on positioning and updated fall policy interventions will be implemented immediately.
F309-D: The resident identified has had nursing staff notified of positioning requirements. All nursing staff will attend mandatory in-service on positioning.
F312-D: Residents identified have had nails trimmed and chipped polish removed. Nursing staff will attend mandatory in-service on nail care and use checklists for diabetic nail care weekly.
F315-D: Staff instructed on catheter care for two residents. Nursing staff will attend mandatory in-service and use checklists to monitor catheter care each shift.
F318-D: Resident identified has had physical therapy evaluation and restorative nursing program implemented. Therapy coordinator will screen residents quarterly to update programs.
F323-E: Staff counseled on securing hazardous chemicals. Keypad door locks modified to prevent unlocking. Maintenance and nursing staff will perform regular checks.
F520-F: QA committee members listed. Nursing staff will attend mandatory in-services on deficiencies including positioning, fall policy, and physician order updates. Random audits will be conducted.
Report Facts
Corrective action completion dates: Jul 12, 2013
Corrective action completion dates: Jul 15, 2013
Corrective action completion dates: Jul 17, 2013
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 8
Date: Jul 1, 2013
Visit Reason
Annual survey inspection to assess compliance with regulatory requirements for nursing home care.
Findings
The facility had multiple deficiencies 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.
Deficiencies (8)
F279: The facility failed to develop a comprehensive care plan for resident #44 to include upper extremity contractures and restorative/range of motion services.
F280: The facility failed to revise comprehensive care plans to reflect current care needs including positioning, fall interventions, and dietary orders for residents #8, #17, and #56.
F309: The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for resident #17 by not repositioning him when slumped or leaned to the side.
F312: The facility failed to provide necessary services to maintain good grooming for residents #44 and #23 regarding fingernail care.
F315: The facility failed to properly care for indwelling catheters for residents #8 and #56, including failure to use clean washcloths during catheter care and failure to maintain catheter drainage bags off the floor.
F318: The facility failed to ensure resident #44 with limited range of motion received appropriate treatment and services to increase or maintain range of motion.
F323: The facility failed to thoroughly investigate falls and implement interventions to reduce fall risk for resident #8 and failed to secure hazardous chemicals from cognitively impaired residents.
F520: The facility failed to develop and implement an effective Quality Assessment and Assurance program to address deficiencies in care plans, positioning, nail care, catheter care, range of motion, and accident investigations.
Report Facts
Residents sampled: 23
Fall risk score: 16
BIMS score: 8
BIMS score: 11
BIMS score: 10
BIMS score: 7
BIMS score: 15
Foley catheter size: 16
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087002 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as State ID N087002.
Findings
No deficiencies or findings are detailed in this document. It serves as a placeholder or record for a Plan of Correction with no records found.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: N087002 POC 3BSU11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The facility acknowledged multiple deficiencies including failure to ensure resident dignity and rights, inadequate notice before transfer/discharge, incomplete care plans, unsafe environment, lack of staff performance reviews, inaccurate Payroll Based Journal submissions, and infection prevention control issues. Corrective actions include staff education, monitoring, and ongoing quality assurance through QAPI meetings.
Deficiencies (7)
F550: The facility failed to ensure all residents were treated with respect and dignity during care, including privacy during care and transport.
F623: The facility failed to provide proper written notice to families regarding bed holds and transfers/discharges.
F657: The facility failed to have care plans completed and up to date, including proper documentation of medical equipment use and incident reporting.
F689: The facility failed to provide an accident-free environment, lacking proper policies and documentation related to falls and incidents.
F730: The facility failed to have staff performance reviews on file, with corrective actions to update personnel files and conduct evaluations.
F851: The facility failed to submit accurate staffing information for the Payroll Based Journal, with corrective measures to review and verify reports before submission.
F880: The facility failed to ensure infection prevention and control, including education on equipment cleaning and storage.
Inspection Report
Plan of Correction
Deficiencies: 13
Date: N087002 POC HQQO11
Visit Reason
This document is a Plan of Correction submitted by Cheney Golden Age Home in response to deficiencies identified during a prior inspection.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including consent forms for resident funds, replacement of televisions, cleaning and maintenance issues, ice machine replacement, therapy assessments, tissue tolerance testing, diet preparation, infection control, and food safety.
Deficiencies (13)
F159-D: The resident identified now has a signed consent form for social security payments deposited to the facility. All residents with funds deposited will have consent forms signed prior to posting amounts.
F248-D: The resident television was replaced with a digital TV. Staff were educated on resident preferences and attendance at activities will be monitored.
F253-E: Cleaning and repairs were completed on hair dryer hoods, walls, sinks, wheelchair cushions, vents, and other environmental items. Weekly checks will be conducted to prevent recurrence.
F258-E: The ice machine will be removed and replaced with a residential refrigerator dispensing ice and water. Resident council will monitor this change.
F278-D: Therapy assessments on admission and quarterly will address range of motion and constipation treatment, with oversight by the DON.
F279-D: Care plans updated with therapy assessments; MDS coordinator will check completion and report discrepancies.
F280-D: Tissue tolerance testing is ongoing for identified residents and new admits; care plans will be developed accordingly with quarterly reviews.
F314-D: Tissue tolerance testing continues with staff training and biweekly DON spot checks for repositioning compliance.
F315-D: Staff educated on toileting plans; skills checkoffs and frequent checks by charge nurses and DON will monitor incontinent care.
F318-D: Family and resident educated on contracture and pressure ulcer risks; therapy assessments and care plans updated accordingly.
F363-E: Residents on pureed diets now served planned menus with proper scoop sizes; dietitian approved recipes and staff training scheduled.
F371-F: Food safety issues addressed by removing unlabeled or damaged food packages and cleaning equipment; ice machine to be replaced due to noise and rust.
F441-F: Staff educated on glove changing, cleaning of wheelchair cushions and toilet seats; infection control training and monitoring implemented.
Report Facts
Plan of Correction completion dates: 2016
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N087002 POC KCOM11
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 corrective actions for deficiencies related to care plan updates, pain assessments, catheter care, and medication management, including narcotics handling.
Deficiencies (4)
F280-D: The resident identified on this deficiency has been discharged. All staff nurses will attend mandatory in-service on updating care plans by November 12, 2014.
F309-D: Pain assessments will be completed on residents at admission, annually, quarterly, and with significant changes. All current residents have a pain assessment completed.
F315-G: Resident #55 discharged; Resident #27 had a bladder diary/assessment completed. Staff will be educated on correct diagnosis and three-day voiding diaries will be completed for new admissions and significant changes.
F425-F: Medications are prepared just prior to administration. Narcotics are kept under double lock and reconciled each shift for all residents.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087002 POC LCY111
Visit Reason
This document is a Plan of Correction related to a previously issued deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a corrective action plan reference linked to a prior deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N087002 POC O2EE11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during 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 ensuring timely care plans and proper medication administration monitoring.
Deficiencies (2)
F281-D: The resident identified on this deficiency no longer resides in the facility. The initial/admission care plan will be on chart within eight hours of admission and checked by a second nurse within twenty four hours. The quality assurance nurse will review three charts each quarter to monitor completeness and promptness of initial care plan.
F314-D: The resident identified on this deficiency no longer resides in the facility. Night shift nurse to check that any new pressure ulcer orders/treatments and/or nutritional supplements are correctly administered and documented on the MAR. The quality assurance nurse will review three charts each quarter to monitor administration of medications and treatments.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087002 POC Y05711
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
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