Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 11
Feb 6, 2017
Visit Reason
Resurvey with complaint investigations conducted on multiple dates from 2017-01-26 to 2017-02-06 at Grace Gardens of Leawood Assisted Living Inc.
Findings
The inspection found multiple deficiencies including failure to report allegations of abuse or neglect timely, failure to conduct functional capacity screenings annually, failure to review and revise negotiated service agreements annually, failure to ensure all involved individuals signed service agreements, failure to provide or coordinate necessary health care services, improper medication storage and disposal, inadequate dietary services supervision and preparation, unsafe food preparation and temperature monitoring, and unsecured hazardous materials accessible to cognitively impaired residents.
Complaint Details
The visit was a resurvey with complaint investigations 109293 and 108796.
Severity Breakdown
SS=E: 7
SS=D: 3
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to report allegations of abuse or neglect to the department within 24 hours and submit complaint investigation reports within five working days. | SS=E |
| Failure to conduct functional capacity screenings at least every 365 days for residents. | SS=E |
| Failure to review and revise negotiated service agreements at least once every 365 days. | SS=E |
| Failure to ensure each individual involved in the development of the negotiated service agreement signed the agreement. | SS=E |
| Failure to ensure licensed nurse provided or coordinated necessary health care services to meet residents' needs, including skin care and risk management. | SS=E |
| Failure to properly store medications, including lack of date opened on Tuberculin PPD injection solution and failure to discard after 30 days. | SS=D |
| Failure to maintain records of receipt and disposition of all medications for accurate reconciliation. | SS=D |
| Failure to maintain employee records with evidence of licensure for licensed staff. | SS=D |
| Failure to ensure therapeutic and mechanically altered diets were prepared according to medical or dietitian instructions and lack of supervision of dietary services. | SS=E |
| Failure to prepare and serve food using safe methods that conserve nutritive value, flavor, appearance, and proper temperature; lack of food temperature documentation and staff knowledge. | SS=F |
| Failure to maintain facility to protect health and safety of cognitively impaired residents and public due to unsecured hazardous chemicals and cleaning supplies accessible to residents. | SS=E |
Report Facts
Residents sampled: 6
Residents census: 64
Employees reviewed: 5
Medication packets: 143
Medication bottles: 19
Suppository packages: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff F | Licensed Staff | Employee record lacked evidence of licensure. |
| Administrative Nurse C | Administrator/Nurse | Interviewed multiple times confirming failures in reporting, documentation, and oversight. |
| Administrative Staff A | Administrator | Interviewed confirming unsecured hazardous materials and other deficiencies. |
| Certified Staff J | Certified Staff | Observed providing care to resident with skin impairment and reporting lack of instructions. |
| Dietary Staff D | Dietary Staff | Interviewed regarding food temperature logs and dietary service supervision. |
| Dietary Manager | Dietary Manager | Interviewed confirming lack of oversight and outdated resident diet lists. |
| Certified Staff K | Certified Staff | Observed preparing mechanically altered diets without written instructions. |
Inspection Report
Follow-Up
Deficiencies: 5
Feb 16, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-203(d), 26-41-204(a), 26-41-206(a)(b), 26-41-206(d), and 26-41-206(e)(1) were corrected as of 02/16/2015.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-203(d) |
| Deficiency related to regulation 26-41-204(a) |
| Deficiency related to regulation 26-41-206(a)(b) |
| Deficiency related to regulation 26-41-206(d) |
| Deficiency related to regulation 26-41-206(e)(1) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 16, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection visit on 2015-02-16.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a record of the Plan of Correction related to the inspection event identified as OPCC12.
Report Facts
Plan of Correction added date: Feb 18, 2015
Plan of Correction modified date: Jul 29, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patty Brown | User who added and modified the Plan of Correction | |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 5
Jan 27, 2015
Visit Reason
The inspection was a resurvey conducted on 1-22-15, 1-26-15, and 1-27-15 to assess compliance with previously cited deficiencies at Grace Gardens of Leawood Assisted Living Inc.
Findings
The facility was found deficient in multiple areas including failure to obtain a medical care provider's written order for admission to the special care unit and failure to inform the resident's legal representative in writing about available services. Additionally, licensed nursing staff failed to provide or coordinate necessary health care services according to residents' needs and negotiated service agreements. Dietary services were deficient in preparing therapeutic and mechanically altered diets according to medical or dietitian instructions, failure to monitor and record food temperatures, and improper food storage including storing cleaning supplies in food storage areas.
Severity Breakdown
SS=D: 1
SS=E: 3
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to obtain a written order from a medical care provider for admission to the special care unit and failure to inform the resident's legal representative in writing of available services specific to the resident's needs. | SS=D |
| Failure to ensure a licensed nurse provided or coordinated necessary health care services that met residents' needs and were in accordance with functional capacity screening and negotiated service agreements. | SS=E |
| Failure to prepare therapeutic and mechanically altered diets according to instructions from a medical care provider or licensed dietitian. | SS=E |
| Failure to prepare food using safe methods that conserve nutritive value, flavor, and appearance and failure to serve food at the proper temperature with documentation. | SS=E |
| Failure to store all food under safe and sanitary conditions; containers of poisonous compounds and cleaning supplies were stored in food storage areas. | SS=F |
Report Facts
Census: 64
Residents in special care unit: 14
Sample size: 6
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff B | Signed nurse's notes and confirmed lack of physician's order for transfer to special care unit | |
| administrative staff A | Accompanied surveyor during facility tour and confirmed findings related to special care unit and food storage | |
| licensed staff A | Confirmed lack of instructions in negotiated service agreement for resident care | |
| certified staff K | Interviewed regarding toileting frequency of resident | |
| certified staff G | Confirmed lack of written instructions on how to prepare pureed food | |
| dietary staff C | Confirmed taking but not recording food temperatures | |
| dietary staff D | Unable to provide food temperature log records | |
| dietary staff E | Confirmed no written instructions for preparation of therapeutic or mechanically altered diets | |
| dietary staff F | Confirmed no written instructions for preparation of therapeutic or mechanically altered diets |
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