Inspection Reports for
Claridge Court

The Plan of Correction addresses deficiencies related to written notice of transfer/discharge and bed hold policy, pressure reducing interventions with air mattresses, and safety of potentially hazardous kitchen equipment.

The facility was found deficient in multiple areas including failure to provide timely written transfer and bed hold notices, improper setting of pressure-reducing mattress for a resident, and unsecured hazardous kitchen equipment accessible to residents.

The facility failed to revise a resident's care plan to reflect restorative services, maintain proper mattress settings for pressure ulcer prevention, ensure safe wheelchair transport, complete yearly CNA performance evaluations, monitor pulse before administering carvedilol, document rationale for psychotropic medication use, and properly store food in a sanitary manner.

The Plan of Correction addresses multiple deficiencies related to care planning, pressure ulcer prevention, resident 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 Plan of Correction addresses multiple deficiencies related to baseline care plans, comprehensive care plans, resident preferences, catheter care, hydration, and infection control. The facility outlines corrective actions, education, audits, and monitoring to ensure compliance and prevent recurrence.

The inspection included a complaint investigation identified as #KS00165056.

The facility was found deficient in multiple areas including failure to complete baseline care plans, inaccurate care plan revisions, failure to honor resident preferences, improper catheter care, inadequate hydration support, improper dementia care resulting in injury, and infection prevention and control deficiencies.

The Plan of Correction addresses multiple deficiencies including inadequate supervision and assistive devices to prevent pressure ulcers, improper catheter tubing securing, insufficient nutritional interventions, failure to post daily nursing staffing information, and inadequate infection control practices.

The facility failed to provide adequate pressure ulcer prevention and treatment, failed to secure catheter tubing increasing risk of complications, lacked consistent documentation of meal intake for residents with weight loss, failed to post and maintain nurse staffing data, and failed to ensure proper infection control practices including hand hygiene and mask usage.

The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the COVID-19 Focused Infection Control survey.

The facility was found deficient in providing adequate supervision and assistive devices to prevent resident falls. The Plan of Correction outlines steps to review fall assessments, implement interventions, educate staff, and monitor compliance to prevent recurrence.

The investigation was triggered by multiple complaints (#KS00138693, #KS00138489, #KS00136142, #KS00136583, #KS00142476) alleging abuse by staff member M towards resident #39. The allegation was substantiated and immediate jeopardy was cited due to failure to suspend the staff member promptly.

The facility failed to suspend a staff member after an allegation of abuse, placing all residents in immediate jeopardy. The immediate jeopardy was removed after corrective actions including suspension and staff education. Additionally, the facility failed to identify and implement adequate fall prevention interventions for residents #1 and #24, placing them at risk for injury.

The facility addressed deficiencies related to RN coverage and food handling practices. Corrective actions include ensuring RN coverage for at least 8 hours daily, re-educating staff on food safety and hygiene, and ongoing monitoring through audits and QAPI meetings.

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

The visit was a complaint investigation combined with a health resurvey, 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 failed to ensure proper food labeling, use of hairnets and beard guards by staff, and proper hand hygiene during dining service, resulting in unsanitary conditions.

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

This Plan of Correction is related to a complaint investigation at Claridge Court dated 05/19/2016.

The plan addresses the use of physician-ordered chair alarms to prevent resident injury and outlines corrective actions including re-education of nursing staff, daily review of new orders, and maintenance of a master log of residents with alarms.

The investigation was based on complaints #98759 and #98189. The complaint was substantiated as the facility failed to implement the ordered chair alarm, leading to a fall and injury.

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 prior annual survey, the facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.

The report documents that the previously cited deficiency with regulation 26-40-303 (2)(a)(i)(ii)(iii) was corrected as of 06/04/2015. No other deficiencies are listed as corrected or uncorrected.

All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by the dates indicated.

The Plan of Correction addresses multiple deficiencies including mistreatment and abuse reporting, fall prevention and monitoring, resident environment safety, medication management, food handling, pharmacy services, infection control, and electronic door monitoring system functionality. The facility describes corrective actions, systemic changes, staff re-education, and monitoring plans to prevent recurrence and ensure sustained compliance.

The inspection was triggered by complaints regarding failure to report falls, inadequate care and supervision, medication management issues, and infection control concerns.

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 preparation and serving practices, and failed to properly clean resident rooms and wear gloves when exposed to body fluids.

The Plan of Correction addresses multiple deficiencies including policies on abuse prevention, resident care planning, qualified staff provision, fall prevention, nutritional assessments, medication parameters, immunization procedures, food safety, and pharmacist oversight. The facility outlines corrective actions, staff training, policy reviews, and monitoring plans to achieve substantial compliance by February 20, 2014.

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

The facility had multiple deficiencies including failure to implement abuse and neglect policies, failure to revise care plans, failure to ensure services by qualified persons, inadequate fall prevention and wanderguard monitoring, failure to maintain nutritional status, failure to ensure drug regimen free from unnecessary drugs, failure to provide immunization education and documentation, and failure to maintain sanitary food preparation and storage.

The report confirms that the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of the revisit date.

The facility acknowledged alleged violations and outlined corrective actions to ensure all incidents are thoroughly investigated and reported to the state department within required timeframes. The plan includes audits and quality assurance meetings to maintain compliance.

The complaint investigation #KS63822 was substantiated as the facility failed to report and properly investigate the misappropriation of property for one resident.

The facility failed to report misappropriation of property for one resident and did not perform a thorough investigation. The missing property was a gold ring belonging to a resident who had passed away, and the facility did not notify the State Agency as required.

The revisit confirmed that all previously reported deficiencies identified by regulation numbers F0225, F0280, F0323, F0329, and F0428 were corrected by 08/25/2011.

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 several residents, failed to provide adequate supervision to prevent falls, and failed to obtain parameters for holding blood pressure medication and notify the physician accordingly.