Inspection Reports for Cheyenne County Village, Inc
820 S. DENISON STREET, ST. FRANCIS, KS, 67756-0747
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 10, 2025, found the facility in compliance with all regulations and no new deficiencies. Prior inspections in late 2025 noted deficiencies related to failure to post survey reports publicly, incomplete negotiated service agreements, and unpaid licensing fees, but these issues were corrected by the December revisit. Earlier inspections identified recurring themes including care planning deficiencies, catheter and infection control issues, medication storage problems, and food safety concerns. Complaint investigations over the years included substantiated cases involving inadequate wound care leading to resident harm and delayed physician notifications, some resulting in immediate jeopardy findings and enforcement actions such as payment denials. The facility’s inspection history shows periods of significant deficiencies followed by corrective actions and improvements, with the most recent reports indicating resolution of prior issues.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
19.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
218% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
9 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 10, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-11-19.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 2025-12-09, 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: 0
Date: Nov 19, 2025
Visit Reason
The document is a Plan of Correction submitted following a resurvey conducted on 11/19/2025 at the facility.
Findings
The resurvey conducted on 11/19/2025 resulted in findings that required a Plan of Correction to be submitted and approved by the agency.
Inspection Report
Re-Inspection
Census: 9
Deficiencies: 4
Date: Nov 18, 2025
Visit Reason
The resurvey was conducted to evaluate compliance with licensure requirements including availability of survey reports, development and review of negotiated service agreements, and license renewal status.
Findings
The facility failed to post the most recent survey report and plans of correction in a public area, failed to develop and annually review negotiated service agreements for a sampled resident, and failed to file and pay annual renewal licensing fees for 2023, 2024, and 2025.
Deficiencies (4)
Failed to ensure that a copy of the most recent survey report and plan of correction is available in a public area to residents and others.
Failed to ensure development of an initial negotiated service agreement upon admission for Resident 3.
Failed to ensure review and revision of negotiated service agreement at least once every 365 days for Resident 3.
Failed to file and pay the 2023, 2024, and 2025 annual renewal licensing fees and post the license in a conspicuous place.
Report Facts
Census: 9
Sampled residents: 3
Annual renewal licensing fees missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Verified lack of survey report posting, inability to locate Resident 3's negotiated service agreement, and confirmed license renewal status | |
| License Nurse B | Licensed Nurse | Confirmed Resident 3's negotiated service agreement was not completed on admission or annually |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 4, 2025
Visit Reason
An off-site revisit survey was conducted to verify correction of all previous deficiencies cited on 06/18/25.
Findings
All deficiencies cited in the previous inspection have been corrected as of 07/30/25, 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: 21
Deficiencies: 5
Date: Jun 18, 2025
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to revise care plans for hospice residents, improper catheter care leading to infection risk, failure to label and store drugs and biologicals properly, unsanitary food storage and preparation practices, and inadequate infection prevention and control practices.
Deficiencies (5)
Failure to review or revise the care plan for a resident admitted to Hospice care, risking staff not honoring resident's wishes regarding CPR.
Failure to care for a resident's catheter in a manner to prevent infection, including catheter tubing dragging on the floor and failure to wear PPE.
Failure to label and store biologicals properly, including failure to place an open date on insulin vials and pens.
Failure to store food by professional standards for food service safety, including uncovered food in refrigerators and unsanitary kitchen surfaces.
Failure to use proper infection control practices, including failure to don PPE during catheter care and failure to change gloves between soiled and clean areas during incontinent care.
Report Facts
Census: 21
Resident sample size: 12
Deficiency count: 5
BIMS score: 99
BIMS score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Verified staff should have updated care plan for DNR, verified PPE use during catheter care, and confirmed glove change requirements during incontinent care. | |
| Certified Nurse Aide M | Observed wheeling resident with catheter tubing dragging on floor and failed to wear PPE during catheter care. | |
| Certified Nurse Aide N | Observed failing to change gloves between soiled and clean areas during incontinent care for Resident 5. | |
| Licensed Nurse G | Verified insulin vials and pens should be dated when opened. | |
| Certified Dietary Manager BB | Verified food storage and kitchen sanitation deficiencies and dishwasher temperature log issues. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jun 17, 2025
Visit Reason
This document is a Plan of Correction submitted by Cheyenne County Village Inc in response to deficiencies identified in a prior inspection.
Findings
The facility identified multiple deficiencies including lack of professional standards in hospice care plans, improper catheter care, medication labeling issues, food storage and sanitation problems, and infection control concerns. Corrective actions and staff education plans were outlined to address these issues.
Deficiencies (5)
Resident's care plan lacked professional standards for hospice services.
Residents with catheters had improper tubing placement and care.
Medications and biologicals were improperly labeled.
Improper food storage and sanitation issues including cracked light cover and missing dishwasher temperatures.
Infection control deficiencies related to catheter and perineal care.
Report Facts
Deficiency completion date: 2025
Date of resident care plan update: 2025
Date of cleaning and food disposal completion: 2025
Date of light fixture replacement: 2025
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 18, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 06/25/24.
Findings
All deficiencies have been corrected as of the compliance date of 07/15/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 06/25/24, all corrected by 07/15/24
Inspection Report
Renewal
Census: 7
Deficiencies: 7
Date: Jun 25, 2024
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance with state regulations for the assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to conduct annual functional capacity screenings for residents, incomplete negotiated service agreements lacking responsible party payment information and licensed nurse identification, improper medication storage, and non-compliance with tuberculosis screening guidelines for residents and staff.
Deficiencies (7)
Failure to conduct functional capacity screening at least once every 365 days for 2 of 3 sampled residents.
Negotiated Service Agreements lacked identification of party responsible for payment for outside services for 2 residents.
Failure to develop an initial negotiated service agreement upon admission for 1 resident.
Failure to review and revise negotiated service agreements at least once every 365 days for 2 residents.
Negotiated service agreements lacked name of licensed nurse responsible for implementation and supervision of health service plan for 2 residents.
Medications and biologicals were not securely and properly stored; specifically, Tylenol tablets were improperly stored in an open medication cup in a resident's locked drawer.
Failure to comply with tuberculosis screening guidelines; missing second step TB testing for 1 resident and 1 newly hired employee.
Report Facts
Residents in census: 7
Sampled residents: 3
Tylenol tablets refused: 16
Tylenol tablets counted: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Named in multiple findings including failure to ensure annual functional capacity screenings, negotiated service agreement deficiencies, medication storage issues, and tuberculosis screening compliance. |
| Certified Medication Aide C | Certified Medication Aide | Observed storing Tylenol tablets improperly in resident R2's medication drawer. |
| Certified Medication Aide D | Certified Medication Aide | Newly hired employee lacking second step tuberculosis testing upon hire. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 25, 2024
Visit Reason
The document is a plan of correction submitted in response to findings from the licensure resurvey conducted on 06/25/24 at the facility.
Findings
The plan of correction addresses citations identified during the licensure resurvey of the facility on 06/25/24. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 14, 2024
Visit Reason
A revisit survey was conducted on 05/14/24 to verify correction of all previous deficiencies cited on 04/03/24.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 04/18/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Apr 3, 2024
Visit Reason
The inspection was conducted as a partial extended survey and complaint investigation related to Resident 1's pressure ulcer and wound care.
Complaint Details
The complaint investigation was triggered by concerns about Resident 1's worsening pressure ulcer, inadequate wound care, and pain management. The facility was placed in Immediate Jeopardy due to failures in care that contributed to Resident 1's decline and death.
Findings
The facility failed to provide appropriate pressure reducing interventions, consistently monitor wounds, assess and address signs of infection, involve the physician when needed, and provide appropriate wound care services including ensuring availability of treatment supplies. Resident 1 developed a worsening Stage 4 pressure ulcer with exposed bone, sepsis, and ultimately died. The facility also failed to provide pain management for Resident 1 during dressing changes despite documented pain.
Deficiencies (2)
Failure to provide appropriate pressure reducing interventions and wound care resulting in worsening Stage 4 pressure ulcer with exposed bone and sepsis.
Failure to provide pain relieving measures prior to or after pressure ulcer dressing changes despite documented pain and signs of discomfort.
Report Facts
Resident census: 43
Pressure ulcer measurement: 4.1
Pressure ulcer measurement: 1.1
Pressure ulcer measurement: 1.6
Sinus tract measurement: 14
Sinus tract measurement: 4
Sinus tract measurement: 2.4
Sinus tract measurement: 2.8
Pain rating: 8
Pain rating: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Noted lack of wound documentation and pain medication administration failures |
| Licensed Nurse G | Licensed Nurse | Reported Resident 1 refused to lay down and denied pain during dressing changes |
| Certified Nurse Aide M | Certified Nurse Aide | Reported Resident 1 sat in recliner or wheelchair without cushion until wound worsened |
| Consultant GG | Wound Care Consultant | Ordered wound treatments and antibiotics, warned staff about wound care procedures |
| Consultant HH | Wound Care Consultant | Recommended nutritional supplements and was notified of wound worsening |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
An offsite revisit survey was conducted on 11/13/23 for all previous deficiencies cited on 09/28/23 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 10/25/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 24
Deficiencies: 9
Date: Sep 28, 2023
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including resident dignity, comprehensive care planning, professional standards of care, catheter and incontinence care, nursing staff competency, food safety, payroll-based journal reporting, quality assurance committee attendance, and infection prevention and control practices.
Deficiencies (9)
Failed to ensure Resident 22 was treated with dignity when staff failed to provide a privacy bag for his indwelling urinary catheter.
Failed to develop a comprehensive care plan for Resident 9's diabetes mellitus, placing the resident at risk for inappropriate care.
Failed to provide care meeting professional standards for Resident 9's treatment of hypoglycemia, including administering liquids orally while the resident had decreased consciousness.
Failed to provide appropriate care for Resident 20's suprapubic catheter, including tubing wrapped around walker and catheter bag dragging on floor, placing resident at risk for infection.
Failed to ensure nursing staff possessed skills to conduct thorough skin assessments for Resident 22, resulting in untreated skin conditions and risk for worsening skin breakdown.
Failed to prepare, store, and serve food in accordance with professional standards for food service safety, including unlabeled and undated food items and improper glove use by dietary staff.
Failed to submit complete and accurate Payroll Based Journal staffing information, with discrepancies between reported and actual licensed nurse coverage.
Failed to maintain evidence that required Quality Assessment and Assurance committee members attended quarterly meetings, risking decreased quality of care.
Failed to follow acceptable infection control standards when staff failed to change soiled gloves during personal cares and failed to perform hand hygiene after glove removal, placing residents at risk for infection.
Report Facts
Deficiency cited: 9
Resident census: 24
Dates with no licensed nurse coverage reported: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in infection control deficiency for failure to change gloves and perform hand hygiene during personal cares for residents R7 and R22. |
| Licensed Nurse G | Licensed Nurse | Verified observations related to Resident 22's catheter privacy bag and Resident 9's fluctuating blood sugar care. |
| Administrative Nurse D | Administrative Nurse | Verified multiple findings including catheter care, care planning, skin assessments, and infection control practices. |
| Certified Dietary Manager BB | Certified Dietary Manager | Verified food safety deficiencies including unlabeled food and improper glove use. |
| Dietary Staff CC | Dietary Staff | Observed using contaminated gloves improperly during food preparation. |
| Licensed Nurse H | Licensed Nurse | Performed skin assessment on Resident 22 and verified infection control practices. |
| Administrative Staff A | Administrative Staff | Verified Payroll Based Journal data inaccuracies and QAA committee attendance issues. |
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Sep 28, 2023
Visit Reason
This document is a Plan of Correction submitted by Cheyenne County Village in response to deficiencies cited during a regulatory inspection conducted on 09/28/2023.
Findings
The plan addresses multiple deficiencies related to catheter care, diabetes management, infection control, skin care, kitchen hygiene, staffing reports, and QAPI documentation. The facility outlines corrective actions including staff education, policy reviews, and ongoing monitoring to achieve compliance by specified dates in October 2023.
Deficiencies (9)
Residents with a catheter must have a privacy bag over their catheter bag; staff educated to ensure compliance.
Resident's EMR lacked a comprehensive care plan addressing diabetic needs; care plan updated.
Resident's EMR lacked professional standards for treatment of hypoglycemia; updated to ensure compliance.
Residents with suprapubic catheter must have tubing below bladder and urine bag clipped appropriately; staff educated.
Facility updated policies on skin observation, quality of life, and pressure injury prevention.
Kitchen staff educated on hygiene, sanitation, food prep, and storage; employee placed on Performance Improvement Plan.
Staffing report was incorrectly processed and submitted; administrator to verify LPN hours quarterly.
QAPI agendas lacked required signatures; administrator to ensure compliance and documentation.
Staff educated on glove use and infection control policies; ongoing monitoring planned.
Report Facts
Compliance deadline: Oct 25, 2023
Compliance deadline: Oct 17, 2023
Performance Improvement Plan duration: 30
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 27, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-01-25.
Findings
All deficiencies have been corrected as of the compliance date of 2023-02-26, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Original Licensing
Census: 9
Deficiencies: 4
Date: Jan 25, 2023
Visit Reason
The inspection was an initial survey conducted for the assisted living facility to assess compliance with regulatory requirements.
Findings
The facility was found deficient in disaster and emergency preparedness due to failure to conduct quarterly reviews of the emergency management plan with residents and staff. Additional deficiencies included failure to serve food at proper temperatures, improper food storage practices, and failure to comply with tuberculosis screening guidelines for residents.
Deficiencies (4)
Failure to ensure quarterly review of the facility's emergency management plan with residents and staff.
Failure to ensure facility staff served food at the proper temperature.
Failure to ensure facility staff stored all food under safe and sanitary conditions.
Failure to ensure compliance with tuberculosis screening guidelines, including lack of second step TB testing and annual TB questionnaires for residents.
Report Facts
Census: 9
Employee records reviewed: 5
Resident records reviewed: 3
Food temperature: 135
Food temperature: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Named in findings related to failure to ensure emergency preparedness, food safety, and tuberculosis screening compliance | |
| Operator Licensed Nurse B | Operator/Licensed Nurse | Interviewed regarding food temperature monitoring and food storage deficiencies |
| Operator Licensed Nurse A | Operator/Licensed Nurse | Interviewed regarding tuberculosis testing deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
The document is a plan of correction submitted in response to the findings of the initial survey conducted at the assisted living facility on January 25, 2023.
Findings
The plan of correction addresses the citations identified during the initial survey of the assisted living facility conducted on January 25, 2023.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 9, 2022
Visit Reason
An offsite revisit survey was conducted on 12/09/22 for all previous deficiencies cited on 10/13/22 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 11/25/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 14
Date: Oct 13, 2022
Visit Reason
Annual health resurvey of Cheyenne County Village Inc nursing facility to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including failure to notify physician of significant resident changes, failure to report and investigate abuse allegations, inadequate care planning, failure to prevent falls, inconsistent bathing and hygiene care, inappropriate use of psychotropic medications, failure to maintain infection control and antibiotic stewardship, and failure to provide competent nursing care.
Deficiencies (14)
Failed to notify Resident 28's physician of unintended urinary catheter removal and condition decline within 24 hours of death.
Failed to report resident to resident abuse to State Agency for Resident 15.
Failed to investigate an unwitnessed fall for cognitively impaired Resident 17.
Failed to develop a comprehensive care plan for Resident 3 with thrombocytopenia.
Failed to update care plans with interventions for Residents 15, 7, and 23 to address behaviors and fall risks.
Failed to provide consistent bathing services for Resident 3.
Failed to provide consistent bathing services for Resident 17.
Failed to identify and provide interventions for lack of bowel movements for Resident 23 with history of constipation.
Failed to implement meaningful, resident-centered fall prevention interventions for Residents 17 and 23.
Failed to provide appropriate treatment and services to prevent urinary tract infections for Resident 22 by allowing urinary catheter bag to contact contaminated surfaces.
Failed to ensure staff possessed skills and knowledge to accurately assess and respond to changes in Resident 28's condition including physician notification.
Failed to provide dementia care and services to maintain highest practicable well-being for Resident 15.
Failed to ensure appropriate diagnosis and stop date for psychotropic medications for Residents 7 and 17.
Failed to maintain an ongoing infection surveillance program including antibiotic stewardship.
Report Facts
Census: 27
Sample size: 12
Days without shower: 16
Days without shower: 10
Days without shower: 39
Days without shower: 10
Days without shower: 13
Days without bowel movement: 4
Days without bowel movement: 4
Days without bowel movement: 4
Days without bowel movement: 4
Days without bowel movement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including lack of physician notification, care plan omissions, and infection control failures. |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding fall interventions and catheter care. |
| Certified Nurse Aide N | Certified Nurse Aide | Provided observations on resident mobility and bathing refusals. |
| Certified Nurse Aide O | Certified Nurse Aide | Observed catheter care and fall risk interventions. |
| Certified Medication Aide M | Certified Medication Aide | Observed medication administration for Resident 17. |
| Social Service Designee X | Social Service Designee | Reported on mental health services for Resident 15. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 16, 2021
Visit Reason
An offsite revisit survey was conducted on 09/16/21 for all previous deficiencies cited on 07/28/21.
Findings
All deficiencies have been corrected as of the compliance date of 08/25/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Census: 28
Deficiencies: 5
Date: Jul 28, 2021
Visit Reason
The inspection was a Health Resurvey and Complaint Investigations #163711 and #163876 conducted to assess compliance with regulatory requirements.
Complaint Details
The inspection included complaint investigations #163711 and #163876. The facility failed to ensure complaint survey investigation results from the previous three years were available for public review, placing residents, staff, and visitors at risk for receiving inaccurate survey information.
Findings
The facility had multiple deficiencies including failure to ensure complaint survey results were available for public review, failure to revise care plans timely for residents at risk of falls, failure to prevent accidents for residents with cognitive impairments, failure to ensure appropriate diagnosis for psychotropic medication use, and failure to store food safely and maintain sanitary kitchen conditions.
Deficiencies (5)
Failed to ensure last three years complaint survey investigation results were available for public review.
Failed to revise fall care plans timely for residents R6, R11, and R15 after falls and changes in condition.
Failed to prevent accidents and provide adequate supervision and assistance devices to prevent falls for residents R6, R11, and R15.
Failed to ensure an appropriate diagnosis for Resident 24's antipsychotic medication Zyprexa.
Failed to store food in a safe and sanitary manner including undated opened food items, frost-covered freezer with ice buildup, and unclean light fixtures and stove hood in kitchen.
Report Facts
Census: 28
Sample size: 12
Fall Risk Assessment Score: 75
Fall Risk Assessment Score: 15
Fall Risk Assessment Score: 15
Fall Risk Assessment Score: 75
Fall Risk Assessment Score: 7
Number of hamburger patties: 5
Number of hard boiled eggs: 2
Number of frozen French toast pieces: 120
Number of frozen waffles: 8
Number of frozen hushpuppies: 20
Number of frozen cinnamon raisin biscuits: 120
Number of frozen sausage patties: 20
Number of frozen chicken strips with fries: 4
Number of frozen triangular hash brown patties: 4
AIMS Assessment Score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of timely interventions for falls and inappropriate diagnosis for psychotropic medication |
| Certified Nurse Aide M | Certified Nurse Aide | Provided information on resident cognition and fall risk |
| Licensed Nurse G | Licensed Nurse | Assisted resident transfers and provided information on alarms and resident cognition |
| Dietary Staff BB | Dietary Staff | Verified undated food items and unclean kitchen conditions |
| Certified Nurse Aide N | Certified Nurse Aide | Assisted resident ambulation and provided information on resident cognition decline |
| Administrative Staff A | Administrative Staff | Retrieved missing complaint survey results and added them to binder |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 23, 2020
Visit Reason
A complaint survey was conducted on 3/23/2020 for complaint #151302 and #151311 at Cheyenne County Village in St Francis, KS.
Complaint Details
The allegations made in the complaints were not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility was in compliance with all regulations surveyed. Additionally, a Targeted Infection Control Survey/COVID-19 Focused Survey found the facility in compliance with CMS and CDC recommended practices.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 23, 2020
Visit Reason
A complaint survey was conducted on 3/23/2020 for complaint #151302 and #151311 at Cheyenne County Village in St Francis, KS. Additionally, a Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by CMS on the same date.
Complaint Details
The allegations made in complaints #151302 and #151311 were not substantiated.
Findings
The allegations made in the complaints were not substantiated and no noncompliance was found. The facility was found to be in compliance with all regulations surveyed and with CMS and CDC recommended practices to prepare for COVID-19.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 9, 2019
Visit Reason
A revisit survey was conducted on 10/09/19 to verify correction of all previous deficiencies cited on 08/15/19.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 09/19/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 18
Date: Aug 15, 2019
Visit Reason
Annual health resurvey of Cheyenne County Village Inc nursing facility to assess compliance with Medicare/Medicaid regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare notices to residents, use of physical restraints, failure to conduct comprehensive assessments after significant changes, incomplete baseline and comprehensive care plans, inadequate restorative therapy services, unsafe environment hazards, inadequate nutrition management, insufficient nurse aide training, lack of infection control program and antibiotic stewardship, and failure to maintain effective quality assurance and performance improvement programs.
Deficiencies (18)
Failed to provide Advance Beneficiary Notice for skilled services to residents R17, R23, and R26.
Failed to ensure Resident 25 was free of physical restraints.
Failed to initiate a comprehensive assessment after significant change in status for Resident 25.
Failed to develop a baseline oxygen care plan for Resident 127.
Failed to develop and implement a comprehensive care plan including nutrition for Resident 1.
Failed to review and revise care plans for Residents 9 and 15.
Failed to provide consistent restorative program for Resident 15.
Failed to ensure environment free of accident hazards for Residents 9 and 127.
Failed to maintain adequate nutrition for Resident 1 with significant weight loss.
Failed to ensure five of eight nurse aides completed minimum 12 hours of in-service training per year and lacked effective tracking system.
Failed to ensure staff had training/competencies related to dementia and behavior care for five of eight staff reviewed.
Failed to prepare appropriate pureed foods for Residents 2, 5, and 25.
Failed to prepare, store, and serve food in a safe and sanitary manner.
Failed to provide physician ordered physical therapy for Resident 127.
Failed to develop and sustain an effective quality assurance and performance improvement program.
Failed to maintain a Quality Assessment and Assurance Committee that met quarterly with required membership attendance.
Failed to establish and maintain an infection prevention and control program including surveillance, policies, and procedures.
Failed to develop and implement an antibiotic stewardship program including antibiotic use protocols and monitoring system.
Report Facts
Resident census: 27
Weight loss percentage: 8.2
Nurse aide in-service hours: 12
Pureed servings: 3
Expired food items: 6
Restorative therapy missed sessions: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including lack of ABN forms, infection control program, restorative therapy monitoring, and antibiotic stewardship |
| Licensed Nurse G | Licensed Nurse | Designated infection control preventist, confirmed lack of infection control program and antibiotic stewardship |
| Dietary Staff BB | Dietary Staff | Reported on pureed food preparation issues and weight monitoring process |
| Certified Nurse Aide M | Certified Nurse Aide | Responsible for restorative therapy program, confirmed missed sessions due to surgery and staffing |
| Consultant HH | Dietary Consultant | Notified late of resident weight loss, confirmed lack of care plan update |
| Activity Staff Z | Activity Staff | Recently took over quality assessment and assurance program, reported lack of structured program |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Aug 15, 2019
Visit Reason
This document is a Plan of Correction submitted in response to a prior deficiency report for a healthcare facility, detailing corrective actions to address cited deficiencies.
Findings
The plan outlines multiple corrective actions addressing deficiencies related to liability notices, recliner assessments, significant change assessments, care plan accuracy, weight loss monitoring, fall investigations, restorative programs, oxygen therapy safety, staff training, infection prevention, and QAPI program improvements.
Deficiencies (10)
Failure to complete and provide liability notices (10055 and 10123) at discharge from therapy services.
Inadequate recliner assessments and failure to identify restraints restricting resident freedom.
Failure to complete significant change assessments and communicate changes to MDS coordinator.
Inaccurate or incomplete care plans related to oxygen therapy and other resident needs.
Failure to monitor and address resident weight loss appropriately.
Inadequate investigation and care planning for resident falls.
Failure to properly assess and update restorative programs on care plans.
Inadequate safety assessments related to oxygen equipment and environmental risks.
Failure to ensure staff complete required training including CNA training, dementia care, dietary procedures, and infection prevention.
Inadequate infection prevention program coordination and training.
Report Facts
Compliance date: Sep 19, 2019
Training hours: 12
Audit frequency: 5
Audit frequency: 2
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennie Klinge | Administrator | Administrator responsible for auditing training and compliance; submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Lanae Workman | Added Plan of Correction on 11/13/2018. | |
| Terry Riley | Modified Plan of Correction on 10/10/2019. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 3, 2019
Visit Reason
The document is a plan of correction related to deficiencies cited during a prior inspection, with an offsite visit conducted to verify correction of deficiencies.
Findings
Deficiencies cited on March 7, 2019, were addressed and placed back into compliance effective April 2, 2019.
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 3
Date: Mar 7, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#138900) regarding failure to timely report an incident involving a resident's injury.
Complaint Details
Complaint investigation #138900 focused on allegations of abuse, neglect, exploitation, or mistreatment related to failure to report an injury incident timely and failure to provide appropriate care.
Findings
The facility failed to timely report an incident involving a resident's laceration requiring emergency care, failed to update care plans for three residents after accidents and falls, and failed to provide wound care as ordered by the physician for one resident.
Deficiencies (3)
Failure to report an incident involving Resident #1's laceration to the state agency in a timely manner.
Failure to update and revise care plans for Residents #1, #2, and #3 after accidents and falls.
Failure to provide wound care as ordered by the physician for Resident #1.
Report Facts
Number of residents: 28
Number of sutures: 30
Length of laceration: 12
Days dressing not changed: 5
Days dressing not changed: 5
Fall date: 2019
Fall date: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Observed changing dressing on Resident #1's wound |
| Licensed Nurse H | Licensed Nurse | Verified care plan and dressing change deficiencies for Resident #1 and others |
| Administrative Staff A | Unaware of incident until 2 weeks later; acknowledged breakdown in reporting system | |
| Administrative Staff B | Unaware of incident until notified by resident's representative | |
| Administrative Nurse C | Administrative Nurse | Reported incident to state agency 24 days late; verified care plan and treatment deficiencies |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 7, 2019
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective April 2, 2019.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Mar 5, 2019
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection, addressing issues related to resident care plans, incident investigations, medication administration, and abuse/neglect reporting.
Findings
The plan outlines corrective actions including updating resident care plans, staff education on abuse and neglect policies, auditing medication administration and treatment orders, and ongoing monitoring through a Quality Assurance and Performance Improvement (QAPI) committee to ensure compliance and prevent recurrence of deficiencies.
Deficiencies (3)
Failure to properly update resident #1 care plan and report incident timely.
Inadequate review and revision of care plans for residents #1, #2, and #3.
Failure to ensure accuracy of physician orders and medication administration records, and proper wound care for resident #1.
Report Facts
Dates for compliance: Mar 29, 2019
Incident report date: Mar 5, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennie Klinge | Administrator | Submitted the Plan of Correction |
| Lacey Hunter | Added the Plan of Correction | |
| Caryl Gill | Modified the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 7, 2018
Visit Reason
An offsite revisit survey was conducted on 12/07/2018 for all previous deficiencies cited on 11/05/2018 to verify correction of deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 12/05/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: Nov 5, 2018
Compliance date: Dec 5, 2018
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 5, 2018
Visit Reason
A Health survey 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 the most serious deficiency to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-12-05.
Deficiencies (1)
Most serious deficiency found was a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Signed letter regarding plan of correction acceptance and enforcement |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Nov 5, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection of the facility.
Findings
The plan addresses multiple deficiencies including staff assistance at meals, safety hazards related to chemical storage, nursing staff competency, medication regimen reviews, dietary concerns with pureed diets, and infection control practices. Corrective actions include staff education, audits, policy reviews, and ongoing monitoring to ensure compliance.
Deficiencies (7)
Inadequate seating and assistance for residents at meals affecting dignity.
Unsafe storage of chemicals and hazardous appliances.
Lack of nursing staff competency and training.
Inadequate medication regimen review and follow-up.
Use of unnecessary medications without proper diagnoses.
Improper preparation and monitoring of pureed diets.
Infection control deficiencies including PPE use and cleaning protocols.
Report Facts
Compliance date: Dec 5, 2018
Resident numbers referenced: 125
Resident numbers referenced: 21
Resident number referenced: 15
Resident number referenced: 20
Resident numbers referenced: 10
Resident numbers referenced: 4
Resident numbers referenced: 1
Resident numbers referenced: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Valerie McGhee | Administrator | Administrator submitting the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 7
Date: Nov 5, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #133812 and #133728 to assess compliance with resident rights, safety, nursing competency, medication management, nutrition, and infection control.
Complaint Details
The visit was triggered by complaints #133812 and #133728 regarding resident dignity, safety hazards, medication management, and infection control.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity during dining, unsafe environment hazards, lack of nursing competency validation, failure to follow up on pharmacist recommendations for psychotropic medications, improper preparation of pureed diets, and inadequate infection prevention and control practices.
Deficiencies (7)
Failure to promote dignity during dining services for 3 residents by staff standing over residents while assisting with meals and yelling private information across the dining room.
Failure to provide a safe environment free of accident hazards for 3 cognitively impaired, independently mobile residents due to accessible operable stove and unlocked cabinet with disinfectant wipes.
Failure to ensure nursing staff competency validation process was implemented, placing residents at risk for improper care.
Failure to follow up on consultant pharmacist recommendations to obtain risk versus benefit rationale for continued use of Risperdal and Zoloft for one resident.
Failure to ensure one resident was free from unnecessary drug use with continued use of psychotropic medications without adequate rationale.
Failure to prepare pureed food by methods that conserve nutritive value for 2 residents with pureed diets.
Failure to maintain infection prevention and control program by not changing gloves during perineal care for 3 residents, improper cleaning of contact isolation room, and not wearing appropriate personal protective equipment while assisting a resident in isolation.
Report Facts
Residents sampled: 14
Residents with pureed diet: 2
Residents with infection control issues: 3
Residents with accident hazards: 3
Residents reviewed for unnecessary drug use: 5
Residents with medication issues: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified observations and statements regarding dignity, safety hazards, nursing competency, medication follow-up, and infection control deficiencies. |
| Dietary Staff BB | Dietary Staff | Verified observations regarding dining assistance and storage of disinfectant wipes. |
| Dietary Staff CC | Dietary Staff | Observed yelling across dining room about resident's toileting needs. |
| Nurse Aide N | Nurse Aide | Observed assisting residents with meals while standing, and improper glove use during perineal care. |
| Nurse Aide O | Nurse Aide | Observed not wearing protective gown in isolation room, improper glove use during perineal care. |
| Nurse M | Nurse | Reported resident agitation and medication refusal. |
| Dietary Manager EE | Dietary Manager | Reported no recipes available for pureed food preparation. |
| Housekeeping Staff U | Housekeeping Staff | Observed improper cleaning of contact isolation bathroom. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 15, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all cited deficiencies identified by regulation numbers 483.10(i)(2), 483.25(d)(1)(2)(n)(1)-(3), and 483.45(b)(2)(3)(g)(h) were corrected as of 06/15/2017.
Deficiencies (3)
Deficiency related to regulation 483.10(i)(2)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3)
Deficiency related to regulation 483.45(b)(2)(3)(g)(h)
Report Facts
Deficiencies corrected: 3
Inspection Report
Re-Inspection
Deficiencies: 1
Date: May 22, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 15, 2017.
Deficiencies (1)
Deficiencies cited at 'E' level, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date of substantial compliance: Jun 15, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance |
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 3
Date: May 22, 2017
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall facility conditions.
Findings
The facility failed to maintain a sanitary and comfortable environment due to persistent urine odor in a resident's room and hallway, failed to provide an environment free from accident hazards due to unsecured knives and screwdriver, and failed to ensure medications were properly labeled and not expired in the medication room.
Deficiencies (3)
Failed to provide necessary housekeeping and maintenance services to maintain a sanitary and comfortable interior for Resident #25 and the 24 residents on the south hall, evidenced by persistent urine odor.
Failed to provide an environment free from accident hazards, including unsecured knives and screwdriver accessible to residents.
Failed to ensure medications were not expired and properly labeled in the medication room, including expired nebulizer solutions and emergency medications.
Report Facts
Census: 29
Sample size: 9
Expired medication count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Provided statements regarding urine odor, accident hazards, medication monitoring, and facility policies. |
| Nurse Aide H | Nurse Aide | Reported resident's urine odor and toileting schedule. |
| Nurse J | Nurse | Reported resident's history of urinating on carpet and urine odor. |
| Nurse D | Nurse | Verified expired medications and reported to Director of Nursing. |
| Activity Staff A | Activity Staff | Verified knives should not be accessible and removed them. |
| Nurse Aide C | Nurse Aide | Verified screwdriver belonged to kitchen and removed it. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: May 22, 2017
Visit Reason
This document is a Plan of Correction submitted by Good Sam Cheyenne County in response to deficiencies cited in a prior inspection report dated 05/22/2017.
Findings
The plan addresses deficiencies related to housekeeping and maintenance services, accident hazards, and drug records management, including actions such as removal of hazardous items, improved toileting enforcement, odor control measures, and medication storage and monitoring improvements.
Deficiencies (3)
Housekeeping and Maintenance Services concerns including incontinence and associated odor in and outside of the room.
Free of Accident Hazards/Supervision/Devices - hazardous items like paring knives and screwdriver found unsecured.
Drug Records, Label/Store Drugs & Biologicals - expired nebulizer solutions found and medication record keeping issues.
Report Facts
Deficiency remedies monitoring start date: May 25, 2017
Date materials and supplies purchased: May 24, 2017
Date recliner replaced: May 28, 2017
Date hazardous items secured: Jun 1, 2017
Date expired nebulizer solutions removed: May 15, 2017
Date nursing staff refresher training due: Jun 15, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Submitted the Plan of Correction |
| DNS | Responsible person for multiple corrective actions | |
| Maintenance Supervisor | Responsible person for housekeeping and maintenance corrective actions | |
| Social Services | Responsible person for housekeeping and maintenance corrective actions | |
| Activities Director | Responsible person for securing hazardous items | |
| Charge Nurse | Removed expired nebulizer solutions | |
| Consulting Pharmacist | Responsible for medication monitoring | |
| Pharmacist | Responsible for medication monitoring |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 18, 2017
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy.
Report Facts
Effective date for denial of payments: Apr 18, 2017
Effective date for provider agreement termination: Jul 18, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in enforcement and certification context. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process regarding cited deficiencies. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 10, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25, 483.25(c), and 483.75(e)(5)-(7) were corrected as of 12/15/2016.
Report Facts
Deficiency correction dates: 5
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 23, 2016
Visit Reason
An abbreviated survey was conducted on November 23, 2016, by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from November 11 through November 23, 2016. Deficiencies cited included noncompliance with F309, "J", CFR 483.25, and the facility was determined to have substandard quality of care.
Deficiencies (1)
Noncompliance with F309, "J", CFR 483.25 constituting immediate jeopardy to resident health or safety
Report Facts
Denial of payment effective date: Dec 18, 2016
Provider agreement termination date: May 23, 2017
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to the findings and enforcement actions |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 4
Date: Nov 23, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#108073) and partial extended survey to assess compliance with care planning, treatment, and nursing aide registry verification requirements.
Complaint Details
The complaint investigation #108073 identified failures in care planning, assessment, treatment, and employee background check follow-up, including a resident death related to inadequate assessment and monitoring after hospital return.
Findings
The facility failed to update a resident's care plan to reflect physician orders for pressure reducing boots, failed to thoroughly assess and reassess a resident after a change of condition resulting in resident death, failed to provide necessary treatment and services to prevent pressure ulcers, and failed to follow up on background check results for several employees.
Deficiencies (4)
Failed to update care plan to include physician ordered blue pressure reducing boots for a resident.
Failed to complete thorough assessment and reassessment after a change of condition for a resident who returned from the emergency room with respiratory problems, resulting in resident death.
Failed to provide necessary treatment and services to prevent pressure ulcers, including failure to follow physician's order to use heel protectors and pressure reducing boots.
Failed to have a system in place to follow-up background check results for 4 of 5 employees reviewed.
Report Facts
Resident census: 26
Sample size: 3
Pressure ulcers: 5
Foreign body size: 3
Oxygen saturation: 87
Time without documented assessment: 3
Number of employees missing background check follow-up: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Nov 23, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Good Sam Cheyenne.
Complaint Details
This Plan of Correction is related to a complaint investigation at Good Sam Cheyenne dated 11/23/2016.
Findings
The plan outlines corrective actions addressing deficiencies related to care plan revisions, notification and assessment of residents with changes in condition, treatment of pressure sores, and nurse aide registry verification and retraining. Education and monitoring procedures are described to ensure compliance.
Deficiencies (4)
Right to Participate Planning Care - Care plans must be revised as resident needs change and communicated to staff.
Provide Care/Services for Highest Well-Being - Notification and assessment protocols for residents with change in condition, including vital sign monitoring and documentation.
Treatment/Services to Prevent/Heal Pressure Sores - Nursing staff must follow physician orders and care plans to treat and prevent pressure ulcers.
Nurse Aide Registry Verification, Retraining - Background checks and hiring checklists must be completed and documented for all employees.
Report Facts
Deficiency remedies monitoring start date: Dec 29, 2016
In-service education date: Nov 23, 2016
Individual education date: Dec 1, 2016
Background check completion date: Nov 18, 2016
Vital sign monitoring frequency: 1
Vital sign monitoring duration: 72
Vital sign notification frequency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Administrator responsible for submission of Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Jan 5, 2016
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report confirms that all previously identified deficiencies listed on the CMS-2567 have been corrected by the revisit date of 01/05/2016.
Deficiencies (6)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(f)(1)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.35(d)(1)-(2)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jan 5, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions for multiple deficiencies including notification of significant changes, activities for cognitively impaired residents, environmental hazards, food nutritive value and safety, and infection control procedures.
Deficiencies (6)
Notify of significant changes including thickened liquids policy and monitoring.
Activities meet interests/needs of each resident, especially cognitively impaired residents.
Environment free of hazards related to thickened liquids and water pitcher policy.
Food nutritive value, appearance, palatability, and temperature with monitoring of texture-altered diets.
Safe food handling practices including storage and hygiene training.
Infection control policy upgrade for oxygen tubing and accessory storage.
Report Facts
Date of corrective action completion: Jan 5, 2016
Monthly monitoring start date: Dec 30, 2015
Reserve supply quantity: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Certified Dietary Manager | Responsible for monitoring thickened liquids and food handling corrective actions. | |
| Activities Director | Responsible for activities plan corrections for cognitively impaired residents. | |
| DNS | Responsible for infection control policy implementation. | |
| Infection Preventionist | Responsible for infection control policy implementation. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 14, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
Deficiencies cited at 'E' level, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator in the report. |
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 6
Date: Dec 14, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to notify the physician of a resident not receiving nectar thickened liquids as ordered, failure to provide individualized activity programs, failure to ensure residents received correct liquids to prevent choking, failure to maintain food at proper temperatures and follow puree recipes, unsafe food handling and storage practices, and improper storage of reusable oxygen and respiratory equipment.
Deficiencies (6)
Failure to notify the physician regarding Resident #1 not consistently receiving nectar thickened liquids as ordered.
Failure to provide an individualized activity program to meet the needs of Resident #17 with moderately impaired cognition.
Failure to ensure Resident #1 received correct liquids to prevent choking and aspiration.
Failure to ensure food was served at proper temperature and follow puree recipes for 2 residents receiving pureed meals.
Failure to provide safe food handling practices including use of contaminated gloves and improper storage of food and supplies.
Failure to properly store reusable oxygen and respiratory equipment to prevent spread of infection for 7 residents.
Report Facts
Census: 29
Sample size: 12
Residents receiving oxygen therapy: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff H | Named in findings related to improper food preparation, handling, and glove contamination. | |
| Dietary Staff J | Verified thickener use and nursing staff responsibilities. | |
| Nurse B | Verified staff are to use thickener in resident's drinks. | |
| Administrative Nurse G | Reported resident's condition and failure to notify physician. | |
| Nurse Aide G | Observed transferring resident and noted missed group activities. | |
| Activity Staff F | Verified resident's cognitive impairment and missed activities. | |
| Nurse Aide A | Stated staff had not been instructed on proper storage of respiratory equipment. | |
| Nurse B | Confirmed improper storage of respiratory equipment. | |
| Nurse C | Provided information on oxygen therapy residents and policy. | |
| Dietary Staff I | Verified food temperature checks, recipe adherence, and safe food handling practices. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Oct 16, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Good Sam Cheyenne County.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as 'Good Sam Cheyenne Co 1st RV Complaint'.
Findings
The plan addresses three deficiencies related to nursing assessment, physician notification, and medication administration. Staff received refresher training on these topics, and policies and procedures were updated to ensure compliance.
Deficiencies (3)
Physician Notification (Change in Condition Evaluation).
Provide Care/Services for Highest Well Being.
Residents Free of Significant Medication Errors.
Report Facts
Deficiencies cited: 3
Training dates: Refresher trainings completed on Sept. 30 and Oct. 5, 2015.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Administrator submitting the Plan of Correction. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 14, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Jan 14, 2016
Provider agreement termination date: Apr 14, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for informal dispute resolution process. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 7, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report confirms that deficiencies previously cited under regulations 483.20(d), 483.20(k)(1), and 483.25(h) were corrected as of 08/27/2015.
Deficiencies (2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 2
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Oct 7, 2015
Visit Reason
The visit was a revisit conducted on October 7, 2015, following an abbreviated survey on August 27, 2015, to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Complaint Details
The action was based on deficiencies found on the current survey and a complaint survey conducted on September 20, 2015, indicating actual harm or above.
Findings
The revisit found the most serious deficiency to be a 'G' level deficiency, indicating actual harm or above. Due to these deficiencies and a complaint survey conducted on September 20, 2015, a denial of payment for new Medicare and Medicaid admissions was imposed effective September 20, 2015.
Deficiencies (1)
Most serious deficiency found was a 'G' level deficiency.
Report Facts
Denial of payment effective date: Sep 20, 2015
Provider agreement termination recommendation date: Feb 27, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named in relation to the complaint and enforcement action |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 7, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that deficiencies previously cited under regulations 483.20(d), 483.20(k)(1), and 483.25(h) were corrected by 08/27/2015.
Deficiencies (2)
Deficiency related to regulations 483.20(d) and 483.20(k)(1)
Deficiency related to regulation 483.25(h)
Report Facts
Correction completion date: Aug 27, 2015
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 3
Date: Oct 7, 2015
Visit Reason
The inspection was conducted as a Non-Compliance Revisit and Complaint #91506 to investigate allegations related to failure to notify the physician of a resident's change in condition and medication errors.
Complaint Details
Complaint #91506 involved failure to notify the physician of a resident's change in condition and medication administration errors, substantiated by findings of delayed physician notification and missed antibiotic doses leading to hospitalization.
Findings
The facility failed to notify the physician of a significant change in condition for Resident #1 related to a urinary tract infection (UTI), resulting in delayed treatment and hospitalization for sepsis. Additionally, the facility failed to administer prescribed antibiotics as ordered, missing 5 of 10 scheduled doses, constituting a significant medication error.
Deficiencies (3)
Failure to notify the physician of a change in Resident #1's condition related to a UTI for 6 days after physical decline.
Failure to provide necessary care and services to Resident #1, resulting in hospitalization for sepsis.
Failure to ensure Resident #1 was free from significant medication errors; missed 5 of 10 scheduled antibiotic doses.
Report Facts
Resident census: 30
Sample size: 3
Missed antibiotic doses: 5
Scheduled antibiotic doses: 10
White blood cell count: 15.25
Antibiotic dosage: 100
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Aug 27, 2015
Visit Reason
An Abbreviated survey was conducted on August 27, 2015, by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not to be in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety from July 12, 2015 through August 27, 2015, specifically related to F309, CFR 483.25 and F323, CFR 483.25(h).
Deficiencies (2)
Noncompliance with F309, CFR 483.25
Noncompliance with F323, CFR 483.25(h)
Report Facts
Denial of payment effective date: Sep 20, 2015
Recommended termination date: Feb 27, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffery Paulsen | Administrator | Facility administrator named in the report |
| Mary Jane Kennedy | Complaint Coordinator | Signed the report as Complaint Coordinator |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 4
Date: Aug 27, 2015
Visit Reason
Complaint Investigation #89746 and partial extended survey were conducted to investigate concerns related to resident care and supervision.
Complaint Details
Complaint Investigation #89746 was conducted due to concerns about resident care, including failure to notify physicians of significant changes, inadequate care planning, failure to provide necessary care, and inadequate supervision leading to elopement.
Findings
The facility failed to notify the physician about a resident's prolonged constipation leading to fecal impaction and subsequent death, failed to develop a comprehensive care plan for bowel management, failed to provide necessary care and services to maintain resident well-being, and failed to provide adequate supervision for a cognitively impaired resident who eloped from the facility while in a wheelchair.
Deficiencies (4)
Failed to notify the physician for a resident who did not have a bowel movement for 7 days on two occasions and developed fecal impaction.
Failed to develop a comprehensive care plan for bowel management for a resident with a history of constipation.
Failed to provide necessary care and services for bowel management for a resident who had no bowel movement for 7 days on two occasions, developed fecal impaction, and died.
Failed to ensure the resident environment was free of accident hazards and failed to provide adequate supervision for a cognitively impaired resident who eloped from the facility while seat belted in a wheelchair.
Report Facts
Resident census: 29
Days without bowel movement: 7
Temperature: 99.9
Distance from highway: 150
Speed limit: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician H | Physician | Notified that resident had no bowel movement for 7 days and disagreed with radiology report; stated facility should have been notified of resident's condition. |
| Administrative Nurse F | Administrative Nurse | Provided statements about facility policies, staff responsibilities, and confirmed failures in notification and supervision. |
| Nurse Aide A | Nurse Aide | Reported resident elopement and observations about resident behavior. |
| Nurse Aide B | Nurse Aide | Reported resident elopement and observations about resident behavior. |
| Nurse D | Nurse | Reported observations about resident's condition and computer alert system. |
| Nurse G | Nurse | Reported lack of physical assessment after resident vomited and limitations of computer alert system. |
| Nurse E | Nurse | Reported staff location during elopement and resident behavior. |
| Nurse Aide C | Nurse Aide | Reported resident's wandering behavior and complaints of stomach pain. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 13, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Good Sam Cheyenne, including an Elopement deficiency and Bowel Management deficiencies.
Complaint Details
The plan addresses deficiencies cited during a complaint investigation, specifically related to elopement risk and bowel management.
Findings
The plan outlines corrective actions including staff training for Licensed Nurses and CNAs, implementation of monitoring systems for bowel management and elopement prevention, and upgrades to door alarm systems. The facility commits to ongoing monitoring and reporting at monthly QAPI meetings.
Deficiencies (2)
Elopement deficiency cited on 08.13.2015
Bowel Management deficiencies
Report Facts
Deficiency remedy monitoring start date: Sep 24, 2015
Staff training completion date: Aug 13, 2015
Staff training completion date: Aug 27, 2015
Door alarm system upgrade approval date: Aug 31, 2015
Remote video/audio monitoring start date: Aug 20, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Named as responsible person and submitter of the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Nov 15, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date.
Deficiencies (8)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.25(m)(1)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 8
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 22, 2014
Visit Reason
A health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency rated as an 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective November 15, 2014.
Deficiencies (1)
Most serious deficiency rated as an 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as the Enforcement Coordinator issuing the report. |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Oct 22, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during an inspection on October 22, 2014, addressing compliance with Federal Medicare and Medicaid requirements.
Findings
The facility had multiple deficiencies including housekeeping and maintenance issues, care plan update failures, medication errors, infection control lapses, and failure to obtain weekly blood pressures for residents on anti-hypertensive medications. Corrective actions and staff education plans were outlined to address these issues.
Deficiencies (8)
Housekeeping & Maintenance Services issues including labeling towel bars, replacing discolored toilet seats, and cleaning light covers.
Failure to update resident care plans promptly after incidents, especially falls.
Failure to provide care/services for highest well-being including neuro checks after unwitnessed falls.
Treatment cart found unattended and unlocked in a public area accessible to residents.
Failure to obtain weekly blood pressures for 4 residents on anti-hypertensive medications.
Medication error: mis-transcription of Crestor on MAR, corrected during survey.
Consulting pharmacist failed to identify and notify facility of missing blood pressures and medication dosage error.
Infection control lapses including nasal cannula tubing not always stored in cloth bags and housekeeping cleaning deficiencies.
Report Facts
Deficiencies cited: 8
Residents missing weekly blood pressures: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Named as responsible person for multiple deficiencies and submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 7
Date: Oct 22, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements including housekeeping, care planning, medication administration, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to maintain a sanitary environment, inadequate care plan revisions after resident falls, failure to assess neurological status post-fall, unsafe medication administration practices, failure to obtain weekly blood pressures for residents on anti-hypertensive medications, and inadequate infection control practices including improper cleaning and storage of equipment.
Deficiencies (7)
Failure to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior.
Failure to review and revise the plan of care with interventions to prevent further falls for a resident.
Failure to assess/reassess neurological status for a resident after a fall.
Failure to ensure resident environment remained free of accident hazards and provide adequate supervision to prevent falls.
Failure to ensure residents received medications following physician orders and pharmacy recommendations, resulting in medication errors.
Failure of pharmacist to identify and report irregularities including missing blood pressure documentation and medication transcription errors.
Failure to establish and maintain an effective infection control program, including inadequate cleaning and sanitizing of resident rooms and bathrooms, improper infection control precautions during toileting, and improper storage of oxygen equipment.
Report Facts
Census: 34
Medication error rate: 8
Number of residents reviewed for medication errors: 8
Number of residents reviewed for unnecessary medications: 5
Number of residents reviewed for infection control: 10
Number of residents reviewed for falls: 2
Number of residents reviewed for accidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Verified resident fall and lack of care plan change | |
| Nurse H | Verified resident falls and care plan issues | |
| Administrative Nurse B | Provided statements on care plan reviews and blood pressure monitoring | |
| Maintenance Staff K | Acknowledged environmental concerns | |
| Activity Staff N | Lacked knowledge of food labeling and storage requirements | |
| Nurse A | Verified housekeeping and incontinence product storage issues | |
| Nurse C | Provided information on blood pressure monitoring and medication administration | |
| Nurse Aide D | Described blood pressure documentation process | |
| Nurse Aide O | Administered medications with errors | |
| Pharmacist Consultant P | Failed to identify medication irregularities and missing blood pressure documentation | |
| Housekeeping Staff F | Observed performing inadequate cleaning practices | |
| Housekeeping Supervisor E | Provided statements on cleaning procedures and lack of infection control training | |
| Administrative Staff A | Discussed infection control tracking and training deficiencies | |
| Nurse Aide Q | Observed performing toileting with infection control lapses | |
| Nurse Aide G | Observed assisting with toileting and acknowledged cleaning lapses | |
| Nurse H | Discussed blood pressure documentation and medication administration practices |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 13, 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 the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payments effective date: Aug 13, 2014
Provider agreement termination date: Nov 13, 2014
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffery Paulsen | Administrator | Named as facility administrator in the report. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Oct 22, 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
The report documents that all previously identified deficiencies were corrected by 09/13/2013, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (8)
Deficiency related to regulation 483.15(a)
Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)(3)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 8
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 22, 2013
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency with ID prefix S1136 related to regulation 26-40-303 was corrected as of 2013-09-13.
Deficiencies (1)
Deficiency with ID prefix S1136 related to regulation 26-40-303
Report Facts
Deficiency correction date: Sep 13, 2013
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 8
Date: Sep 4, 2013
Visit Reason
The inspection was a Health Resurvey and Extended Health Resurvey to assess compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and respect during dining, failure to revise care plans according to physician orders, inadequate assistance with activities of daily living, unsafe water temperatures posing burn hazards, use of unnecessary medications without proper assessment, improper disposal of garbage, failure of the consultant pharmacist to report medication irregularities, and inadequate infection control practices in laundry processing.
Deficiencies (8)
Failure to promote care in a manner that maintained and enhanced each resident's dignity and respect during dining for 2 of 15 sampled residents.
Failure to revise 1 of 15 sampled resident's nursing care plan related to nutritional supplements.
Failure to provide necessary assistance to maintain good nutrition for 2 of 2 residents reviewed for ADLs.
Failure to ensure residents' environment remained free of accident hazards when water temperatures in an unlocked bathroom adjacent to the dining room measured up to 159 degrees Fahrenheit.
Failure to ensure 1 of 5 sampled residents did not receive unnecessary medications without thorough assessment for insomnia.
Failure to dispose of garbage and refuse properly; dumpsters uncovered and lids open.
Failure to ensure the consultant pharmacist reported medication irregularities related to unnecessary drug use for 1 resident.
Failure to implement adequate infection control measures in the main laundry; use of a chemical not effective for sanitization in cold water for contaminated personal laundry and mechanical lift slings.
Report Facts
Residents sampled: 15
Water temperature: 159
Residents census: 30
Medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Direct care staff | Named in failure to assist resident #19 during dining |
| Staff K | Direct care staff | Named in failure to assist resident #19 and #29 during dining |
| Staff H | Direct care staff | Named in failure to assist resident #26 during dining |
| Licensed nurse G | Licensed nurse | Confirmed expectations for feeding assistance |
| Administrative staff B | Administrative staff | Confirmed staff feeding responsibilities |
| Direct care staff J | Direct care staff | Interviewed regarding feeding assistance and medication administration |
| Maintenance staff D | Maintenance staff | Responsible for water temperature monitoring |
| Housekeeping staff E | Housekeeping staff | Interviewed about dumpster lids |
| Laundry staff P | Laundry staff | Described laundry processing and chemical use |
| Consultant pharmacist R | Consultant pharmacist | Interviewed regarding medication regimen reviews |
| Administrative nurse B | Administrative nurse | Interviewed regarding resident #3's medication and care plan |
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Sep 4, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during an inspection on September 4, 2013, addressing compliance with Federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions for multiple deficiencies including dignity and respect in dietary care, timely care plan updates, ADL care, accident hazards related to water temperature, drug regimen management, infection control, waste disposal, and dietary equipment issues. Remedial in-services and monitoring plans are scheduled to address these issues.
Deficiencies (9)
Dignity and Respect of Individuality in dietary care
Right to Participate in Planning Care - Revise Care Plan
ADL Care Provided for Dependent Residents
Free of Accident Hazards/Supervision/Devices related to water temperature
Drug Regimen is Free From Unnecessary Drugs
Dispose Garbage & Refuse Properly
Drug Regimen Review, Report Irregular, Act On
Infection Control, Prevent Spread, Linens
Dietary Areas - Ice Maker, Open system drain
Report Facts
Date of cited deficiencies: Sep 4, 2013
Staff in-service date: Sep 11, 2013
Monitoring period: 6
Water temperature range: 98
Water temperature range: 120
Tylenol PM usage: 3
Tylenol PM usage period (months): 5
Date of Performance Improvement Plan: Sep 6, 2013
Date dumpster issue reported: Sep 4, 2013
Date dumpster ordered: Sep 9, 2013
Date ice maker ordered: Sep 4, 2013
Date ice maker received: Sep 10, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Named as responsible person for multiple deficiencies and submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Person who added and modified the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 7, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-05-07.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.25, 483.25(h), and 483.75(o)(1) were corrected as of 2013-08-07.
Deficiencies (3)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 3
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 7, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-05-07.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.25, 483.25(h), and 483.75(o)(1) were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 3
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 3
Date: Jul 3, 2013
Visit Reason
The inspection was conducted as a noncompliance revisit following a complaint investigation that identified deficiencies related to care and services, supervision, and quality assurance.
Complaint Details
The visit was triggered by a complaint investigation resulting in an Immediate Jeopardy deficiency and other harm level deficiencies identified on 5/7/13. The revisit found ongoing failures in care, supervision, and quality assurance.
Findings
The facility failed to provide necessary neurological assessments after falls for 3 sampled residents, failed to ensure adequate supervision and assistive devices to prevent falls, and failed to utilize the Quality Assessment and Assurance committee effectively to correct identified deficiencies.
Deficiencies (3)
Failure to provide neurological assessments including vital signs after falls for residents #10, #11, and #12.
Failure to ensure adequate supervision and assistive devices to prevent falls, including failure to place personal alarms and ensure resident safety while on the toilet for residents #10, #11, and #12.
Failure of the Quality Assessment and Assurance committee to meet requirements including physician attendance and failure to develop and implement appropriate plans of action to correct quality deficiencies.
Report Facts
Residents sampled: 3
Falls documented: 4
Neurological assessments missed: 9
QA meetings without physician attendance: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff B | Administrative Nursing Staff | Confirmed responsibility for ensuring neurological assessments and QA committee physician attendance; admitted failure to check neurological assessments. |
| Direct Care Staff C | Observed transferring and ambulating residents; confirmed leaving resident #10 unattended on toilet; unaware of personal alarm requirements for resident #11. | |
| Direct Care Staff D | Ambulated resident #12 with assistance of one staff; reported most staff do not feel safe ambulating resident #12 alone. | |
| Direct Care Staff E | Reported never trusting resident #10 alone on toilet; unaware of care plan details for resident #11; described resident #12 as tall, heavy, and unsteady. | |
| Administrative Staff A | Administrative Staff | Confirmed physician did not attend QA meetings and denied knowledge of physician attendance requirement. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 3, 2013
Visit Reason
This plan of correction addresses deficiencies cited on July 3, 2013, related to a complaint investigation at Good Sam Cheyenne County facility.
Complaint Details
The plan of correction is in response to deficiencies cited from a complaint investigation conducted on 07/03/2013.
Findings
The facility submitted a written allegation of substantial compliance with Federal Medicare and Medicaid requirements, detailing corrective actions including staff in-service training on neurological assessments, physician notification protocols, care plan communication, and QA committee meeting attendance improvements.
Deficiencies (3)
Failure to provide care/services for highest well-being including notification of change in resident status and neurological evaluation.
Failure to maintain free of accident hazards/supervision/devices, including proper use of alarms and communication of care plan changes.
Failure to conduct QA committee meetings with required attendance and documentation.
Report Facts
Deficiencies cited: 3
Training dates: Jul 9, 2013
QA meeting date: Jul 10, 2013
Planned training date: Jul 16, 2013
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 4
Date: May 7, 2013
Visit Reason
The inspection was conducted based on complaints #KS00064801 and #KS00064672 regarding failure to notify physicians of significant changes in resident conditions and inadequate care.
Complaint Details
The visit was complaint-related based on complaints #KS00064801 and #KS00064672 concerning failure to notify physicians of significant changes in resident conditions and inadequate care.
Findings
The facility failed to immediately notify physicians of significant changes in residents' conditions following unwitnessed falls, failed to perform neurological assessments, and failed to implement effective fall prevention strategies. These failures resulted in resident harm including a fatal subdural hematoma and a pelvic fracture. The facility's quality assessment and assurance committee also failed to develop and implement appropriate corrective plans.
Deficiencies (4)
Failed to immediately inform the physician of a significant change in condition for a resident following an unwitnessed fall resulting in injury and death.
Failed to provide necessary care and services including neurological assessments after unwitnessed falls for residents with cognitive impairment.
Failed to ensure residents received adequate supervision and effective fall prevention strategies, resulting in repeated falls and injury.
Failed to maintain a quality assessment and assurance committee that develops and implements appropriate plans of action to correct identified quality deficiencies.
Report Facts
Deficiencies cited: 4
Resident census: 31
Fall risk scores: 18
Fall risk scores: 28
Fall risk scores: 20
Fall risk scores: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician F | Physician | Confirmed resident conditions and failure to notify physician after changes in consciousness. |
| Administrative nurse B | Administrative Nurse | Confirmed failure to notify physician and lack of neurological assessments. |
| Licensed nurse C | Licensed Nurse | Administered Narcan and provided care after resident's fall and sedation. |
| Licensed nurse D | Licensed Nurse | Administered second dose of Narcan and secured immobilizer. |
| Licensed nurse H | Licensed Nurse | Described neurological assessment procedures and confirmed failures. |
| Direct care staff G | Direct Care Staff | Assisted resident #3 and described fall circumstances. |
| Licensed nurse I | Licensed Nurse | Assisted resident #2 with toileting. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: May 7, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited on May 7, 2013, related to a complaint investigation at Good Sam St Francis facility.
Complaint Details
This Plan of Correction is in response to a complaint investigation conducted on 05/07/2013 at Good Sam St Francis.
Findings
The plan addresses deficiencies related to notification of significant changes in resident condition, neurological assessments, and fall interventions. It includes corrective actions such as staff in-services, policy reviews, and ongoing monitoring through QA/CQI meetings.
Deficiencies (4)
Failure to ensure proper notification of significant changes in resident condition including neurological changes.
Failure to provide care and services for highest well-being including neurological evaluation and physician notification.
Failure to maintain a safe environment free of accident hazards and proper supervision/devices.
Failure of QA Committee to identify quality concerns and implement appropriate corrective actions.
Report Facts
Date of cited deficiencies: May 7, 2013
Date of Plan of Correction approval: May 23, 2013
Dates of staff in-services: May 6, 2013
Dates of staff in-services: May 7, 2013
Date of staff in-service: May 8, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Administrator responsible for submitting the Plan of Correction and mentioned as responsible person for QA meeting discussions |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Person who added the Plan of Correction on 05/08/2013 | |
| Mary Jane Kennedy | Person who modified the Plan of Correction on 08/23/2013 |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Mar 19, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.10(b)(11), 483.15(a), 483.25, and 483.25(h) were corrected as of 02/19/2013.
Deficiencies (4)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 4
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 4
Date: Feb 1, 2013
Visit Reason
The inspection was conducted based on complaints #KS00062977 and KS00062941 regarding resident care and notification of changes in condition.
Complaint Details
The investigation was triggered by complaints #KS00062977 and KS00062941 concerning failure to notify physician of resident condition changes and inadequate resident care.
Findings
The facility failed to immediately notify the physician of a significant change in resident #1's condition involving severe leg pain, failed to provide dignified care by not fully clothing residents #1 and #3 before taking them to public areas, failed to provide adequate pain management for resident #1, and failed to ensure safe transfers for resident #3 by not using assistive devices or adequate supervision.
Deficiencies (4)
Failed to immediately inform the physician of a significant change in resident #1's physical condition (new onset of severe leg pain).
Failed to provide care in a manner that enhanced residents' dignity when staff failed to fully clothe residents #1 and #3 prior to taking them into public areas.
Failed to provide resident #1 with necessary care and services including timely physician notification and effective pain management measures.
Failed to ensure resident #3 received adequate supervision and assistive devices to prevent accidents during transfers.
Report Facts
Resident census: 31
Residents sampled: 4
Whiskey doses administered: 6
Pain rating: 8
Medication doses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Reported physician directed staff to wait until Monday for xray and confirmed lack of physician notification over weekend |
| Direct Care Staff B | Direct Care Staff | Reported resident #1 was in severe pain and confirmed failure to dress residents #1 and #3 before dining room visits; also reported unsafe transfers of resident #3 without gait belt |
| Direct Care Staff C | Direct Care Staff | Removed blanket from resident #1's lower body prior to transfer |
| Direct Care Staff E | Direct Care Staff | Assisted with transfers of resident #3 and held wheelchair steady during unsafe transfers |
| Licensed Nurse D | Licensed Nurse | Denied knowledge of residents being undressed in public and stated staff should use mechanical lift for resident #3 |
| Physician F | Physician | Reported staff failed to notify him/her or PA of resident #1's condition changes over weekend and that immediate hospital transfer would have been warranted |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Feb 1, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited on 02.01.2013 during a complaint investigation at Good Sam St Francis.
Complaint Details
This Plan of Correction is in response to deficiencies cited during a complaint investigation conducted on 02.01.2013.
Findings
The plan outlines corrective actions addressing deficiencies related to pain management, notification of changes in resident status, resident dignity, and safe bed-to-chair transfer techniques. Staff training and ongoing audits are scheduled to ensure compliance.
Deficiencies (4)
Failure to properly notify physician and family of significant changes in resident condition including pain management.
Failure to maintain resident dignity and respect individuality.
Failure to provide care/services for highest well-being including notification of condition changes.
Failure to ensure free of accident hazards and proper supervision/devices during bed-to-chair transfers.
Report Facts
Deficiencies cited: 4
Staff in-service dates: 3
QA/CQI meetings: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 26, 2012
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
The report shows that all previously cited deficiencies identified by regulation numbers 483.10(b)(11), 483.25(i), 483.35(i), and 483.75(o)(1) were corrected by 06/07/2012.
Deficiencies (4)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: May 22, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during an inspection on 05/22/2012. It outlines corrective actions to address issues related to resident status notification, weight monitoring, nutrition status maintenance, food handling, and QA committee meetings.
Findings
The plan addresses deficiencies including failure to notify physicians and families of significant resident changes, inadequate monitoring of resident weight and nutritional supplements, improper food handling and glove use, and documentation of QA committee meetings.
Deficiencies (4)
Failure to notify of changes in resident condition including significant weight loss
Failure to maintain nutrition status unless unavoidable
Unsanitary food procurement, storage, preparation, and serving practices
QA committee members not meeting quarterly as required
Report Facts
Deficiency citation date: May 22, 2012
QA/CQI meeting dates: 4
Staff in-service date: Jun 7, 2012
Nutritional supplement compliance monitoring: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Paulsen | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 4
Date: May 22, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies.
Findings
The facility failed to immediately notify the physician of a resident's severe weight loss, failed to maintain acceptable nutritional status for the resident, failed to store, prepare, and serve food under sanitary conditions, and failed to ensure a physician attended the quality assessment and assurance committee meetings quarterly.
Deficiencies (4)
Failed to immediately consult with resident #30's physician related to severe weight loss.
Failed to maintain acceptable parameters of nutritional status for resident #30, who experienced severe weight loss and did not receive ordered high protein diet with nutritional supplements.
Failed to store, prepare, and serve food under sanitary conditions in the kitchen, dining room, and activity room kitchenette, including improper glove use and unlabeled food items.
Failed to ensure a physician designated by the facility attended the quality assessment and assurance committee meetings at least quarterly.
Report Facts
Resident census: 27
Weight loss percentage: 15.43
Weight loss percentage: 12.91
Weight loss percentage: 10.29
Resident sample size: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician K | Physician | Reported lack of awareness of resident #30's weight loss and confirmed staff failed to notify physician. |
| Administrative Nursing Staff A | Administrative Nursing Staff | Reported lack of awareness of resident #30's weight loss. |
| Dietary Staff C | Dietary Staff | Reported awareness of diet order but failure to provide nutritional supplements and failure to alert dietitian consultant. |
| Direct Care Staff F | Direct Care Staff | Reported no physician order for nutritional supplements and described weight measurement procedures. |
| Consultant Staff J | Consultant Staff | Reported lack of awareness of resident #30's severe weight loss. |
| Dietary Staff D | Dietary Staff | Observed touching food and serving without proper glove changes. |
| Licensed Nursing Staff B | Licensed Nursing Staff | Reported staff failed to clean hands and remove contaminated gloves prior to assisting residents to eat. |
| Administrative Staff N | Administrative Staff | Reported failure to reschedule QA&A meetings and failure to invite physician quarterly. |
Inspection Report
Plan of Correction
Deficiencies: 14
Date: N012001 POC 8POT11
Visit Reason
This document is a Plan of Correction submitted by Cheyenne County Village RS to address deficiencies identified in a prior inspection.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies related to resident care, notification procedures, care plan updates, fall investigations, catheter care, and staff education to ensure compliance with regulatory standards.
Deficiencies (14)
Failure to notify provider of resident changes
Inadequate care planning for aggressive resident behavior
Incomplete fall investigations and root-cause analysis
Care plans not updated with current diagnoses and precautions
Care plans not updated with interventions for falls and behaviors
Discharge plans and goals not consistently updated in care plans
Inadequate documentation and follow-up on resident bathing refusals
Care plans lacking interventions for constipation
Care plans lacking interventions for high fall risk residents
Inadequate catheter care competencies and monitoring
Nursing staff competencies and education deficiencies
Lack of dementia care critical element pathway completion
Psychotropic medication orders lacking proper diagnosis verification
Inadequate antibiotic monitoring and stewardship
Report Facts
Completion dates: 11
Number of nurses reviewing antibiotic stewardship policy: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Daphne McTague | Administrator | Submitted the Plan of Correction to KDADS |
| Felicia Majewski | Added and modified the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: N012001 POC CEQ711
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in prior inspections, detailing corrective actions to address those deficiencies.
Findings
The plan outlines corrective actions for multiple deficiencies including updating survey binders, fall interventions for residents, oxygen tubing adjustments, psychotropic medication diagnosis corrections, and food labeling and kitchen maintenance improvements.
Deficiencies (5)
Survey binder updated with complaint and annual survey results and policy for posting survey results.
Care plans of residents 6, 11, and 15 updated to include recent fall interventions; systemic changes to fall protocol and nurse education.
Implementation of fall interventions for residents 6, 11, and 15; oxygen tubing changed to 7 foot canals; nursing staff education on oxygen tank use and incident review.
Prescribing physician to change Zyprexa diagnosis to appropriate diagnosis; review of psychotropic orders and diagnoses; monthly pharmacy review follow-up.
Food labeling procedures improved; monthly freezer defrost checks initiated; cleaning of fluorescent lighting and vent hood added to weekly kitchen cleaning; staff education on procedures.
Report Facts
Deficiency completion dates: Aug 3, 2021
Deficiency completion dates: Aug 13, 2021
Deficiency completion dates: Aug 25, 2021
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N012001 POC P7DJ11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report for Cheyenne Co Village.
Findings
The plan addresses deficiencies related to pressure ulcers and skin breakdown, noting that Resident #1 was discharged and deceased, and that staff education on the issue was completed on 4/2/24 and 4/18/24 with substantial compliance verified.
Deficiencies (1)
Deficiencies related to pressure ulcers/skin breakdown
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle English | Verified substantial compliance on 4/2/24 | |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Daphne McTague | Administrator submitting the Plan of Correction | |
| Felicia Majewski | Administrator modifying and adding to the Plan of Correction |
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