Inspection Reports for
Claridge Court

The Plan of Correction addresses multiple deficiencies related to care planning, pressure ulcer prevention, resident environment safety, staff performance reviews, medication management, antipsychotic medication use, and food service safety. The facility outlines corrective actions including care plan updates, staff education, audits, and monitoring schedules.

The facility was found deficient in multiple areas including failure to revise care plans to reflect restorative services, improper maintenance of pressure ulcer prevention equipment, failure to ensure accident-free environment due to wheelchair foot pedal use, lack of yearly CNA performance evaluations, inconsistent monitoring of medication effects, failure to document rationale for psychotropic medication use, and unsafe food storage practices.

The facility had multiple deficiencies related to baseline care plans, comprehensive care plans, resident preferences, catheter care, hydration, and infection control. The Plan of Correction details corrective actions including education, audits, and monitoring to ensure compliance and prevent recurrence.

The visit was triggered by a complaint investigation #KS00165056. Specific complaints included failure to complete baseline care plans, improper care plan revisions, neglect of resident preferences, improper catheter care, inadequate hydration support, and inappropriate dementia care leading to injury.

The facility was found deficient in multiple areas including failure to complete baseline care plans, revise care plans for hospice services, honor resident preferences affecting quality of life, maintain catheter care standards, ensure hydration accessibility, provide appropriate dementia care resulting in resident injury, and maintain infection control practices related to catheter and laundry handling.

The Plan of Correction addresses multiple deficiencies including pressure ulcer prevention, catheter care, nutritional status interventions, nursing staffing information posting, and infection control practices. The facility outlines corrective actions, systemic changes, education plans, and monitoring strategies to ensure compliance and prevent recurrence.

The facility was found deficient in multiple areas including failure to provide pressure ulcer prevention and treatment for Resident 28, failure to secure catheter tubing for Resident 7, inconsistent documentation of meal intake for Residents 28 and 12 with weight loss, failure to post and maintain nurse staffing data, and inadequate infection prevention and control practices including hand hygiene and mask usage.

The complaint investigation involved multiple complaint numbers (#KS00138693, #KS00138489, #KS00136142, #KS00136583, and #KS00142476) related to abuse allegations. The immediate jeopardy was removed after the alleged perpetrator was suspended and staff received abuse training.

The facility failed to prevent potential further abuse by not suspending the alleged perpetrator immediately, placing all residents in immediate jeopardy. Additionally, the facility failed to identify and implement adequate interventions to prevent falls for residents #1 and #24, both at high risk for falls.

The facility was found deficient in providing adequate supervision and assistive devices to prevent resident falls. The Plan of Correction outlines measures to review fall assessments, educate staff, audit residents at risk, and monitor interventions to prevent recurrence.

The revisit confirmed that the deficiencies identified under regulations 483.30(b) and 483.35(i) were corrected as of the revisit date.

The visit was triggered by a complaint investigation identified as #KS00104909.

The facility failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week on multiple dates. Additionally, the facility did not ensure proper food labeling, use of hairnets and beard guards by staff, and failed to maintain sanitary conditions during food service, including inadequate hand hygiene practices.

The survey found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.

The report indicates that the previously identified deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 06/05/2016. No other deficiencies or uncorrected issues are noted.

The complaint investigation found that the facility did not implement a physician ordered chair alarm for resident #3, who fell and sustained a head injury requiring hospital treatment. The fall occurred on 3/10/2016, and staff interviews confirmed no chair alarm was in use at the time.

The facility failed to implement a physician ordered chair alarm for a cognitively impaired resident, resulting in a fall with a head injury that required hospital treatment. Interviews and record reviews confirmed the absence of the chair alarm at the time of the fall.

The survey found the most serious deficiency at a 'G' level of actual harm that is not immediate jeopardy. Due to deficiencies cited and a history of noncompliance on the previous annual survey, the facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.

The plan references a complaint investigation at Claridge Court dated 05/19/2016.

The plan addresses the implementation and monitoring of physician-ordered chair alarms to prevent resident injury, including re-education of nursing staff and maintenance of a master log of residents with alarms.

The survey found the most serious deficiencies to be at an "F" level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

The report confirms that the deficiency identified by regulation 26-40-303 (2)(a)(i)(ii)(iii) with ID prefix S1174 was corrected as of 06/04/2015. No other deficiencies are noted.

The report documents that all previously identified deficiencies were corrected by 06/04/2015, with no uncorrected deficiencies remaining at the time of the revisit.

The Plan of Correction addresses multiple deficiencies including mistreatment and abuse reporting, fall prevention and monitoring, accident hazard prevention, unnecessary drug use, food handling, medication transcription accuracy, pharmacy review compliance, infection control, and electronic door monitoring system functionality. The facility outlines corrective actions, systemic changes, staff re-education, and monitoring plans to ensure compliance and prevent recurrence.

The inspection included complaint investigations #KS00080213, #KS00083744, and #KS00079725.

The facility failed to report unwitnessed injury falls with fractures, failed to perform neurological assessments after falls, failed to ensure a safe environment to prevent falls, failed to properly assess and monitor pain and anxiety medications, failed to follow pharmacy recommendations timely, failed to maintain sanitary food handling and infection control practices.

The survey found deficiencies at a level of actual harm that is not immediate jeopardy, with a history of noncompliance from a prior survey on January 23, 2014. Due to these deficiencies, enforcement remedies including denial of payment for new Medicare admissions were imposed effective June 5, 2015.

The report documents that all previously cited deficiencies identified by their regulation numbers and prefix codes were corrected by 02/20/2014, indicating compliance with required corrective actions.

The Plan of Correction details multiple areas of non-compliance including abuse policies, resident care planning, qualified staffing, fall prevention, nutritional assessments, medication parameters, immunization policies, food safety, and pharmacy oversight. The facility outlines specific corrective actions, training, audits, and monitoring to achieve substantial compliance by February 20, 2014.

The inspection was triggered by a complaint investigation KS#70617.

The facility was found deficient in multiple areas including failure to implement adequate abuse and neglect policies, failure to revise care plans timely, failure to ensure direct care staff were employed by the facility, inadequate fall prevention and monitoring of wanderguard systems, failure to meet nutritional needs resulting in significant weight loss, failure to provide parameters for medication administration, and failure to document immunization education.

The survey found the most serious deficiency in the facility to be a 'G' level. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions and possible termination of the provider agreement were recommended if substantial compliance is not achieved.

The revisit confirmed that the deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected on 02/25/2013.

The complaint investigation found that the facility did not report the missing ring of resident #1 to the State Agency and failed to conduct a thorough investigation, including obtaining witness statements and interviewing other residents. The facility involved the police and ombudsman but did not notify the State Agency as required.

The facility failed to report misappropriation of property for one resident and did not perform a thorough investigation, including lack of witness statements and failure to notify the State Agency.

This Plan of Correction is linked to a complaint investigation identified as Claridge Court 021913 Complaint.

The Plan of Correction outlines the facility's commitment to thoroughly investigate all alleged violations, report incidents to the state department within five working days, and conduct audits to ensure proper documentation and protocol compliance.

The report confirms that all previously cited deficiencies identified by regulation numbers F0225, F0280, F0323, F0329, and F0428 were corrected as of the revisit date.

The facility failed to investigate and report an injury of unknown origin for one resident, failed to revise care plans related to falls and skin issues for multiple residents, failed to provide adequate supervision to prevent falls, and failed to obtain parameters for holding blood pressure medication and notify the physician accordingly. The pharmacist also failed to identify missing parameters for medication management.

The Plan of Correction addresses deficiencies related to RN coverage and food handling practices, including staff re-education and monitoring plans to ensure compliance and prevent recurrence.