Inspection Reports for Cumbernauld Village Inc
716 TWEED STREET, KS, 67156-1595
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 23, 2025, found the facility in compliance with all regulations and no new deficiencies. However, the prior inspection on December 31, 2024, cited deficiencies related to incomplete negotiated service agreements for residents at risk of falls, unclear medication administration responsibilities, unlabeled over-the-counter medications, and lack of quarterly emergency management plan reviews with staff. Earlier inspections identified issues with care planning, medication management, dining service hygiene, and resident safety, including a substantiated complaint investigation in March 2023 involving failure to report abuse incidents promptly, which was classified as immediate jeopardy. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed recent deficiencies promptly, showing improvement in compliance over time.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
8.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
13 residents
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Jan 23, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 12/31/24.
Findings
All deficiencies have been corrected as of the compliance date of 01/21/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 12/31/24, all corrected by 01/21/25
Inspection Report
Renewal
Census: 13
Deficiencies: 4
Dec 31, 2024
Visit Reason
The inspection was a licensure resurvey conducted on 12/30/24 and 12/31/24 to assess compliance with state regulations for the assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to base Negotiated Service Agreements (NSA) on Functional Capacity Screenings (FCS) for residents at risk of falls, failure to identify responsible parties for administration of selected medications in NSAs, failure to label over-the-counter medications with resident names, and failure to conduct quarterly reviews of the emergency management plan with all employees.
Severity Breakdown
SS=E: 2
SS=D: 1
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| The Administrator failed to ensure the Negotiated Service Agreements for residents 1, 2, and 3 were based on the Functional Capacity Screening and provided a description of services when residents were identified at risk for falls. | SS=E |
| The Administrator failed to ensure resident 2's Negotiated Service Agreement identified who was responsible for the administration of selected medications. | SS=D |
| The Administrator failed to ensure the Licensed Nurse or Licensed Pharmacist placed the full name of the resident on bottles of over-the-counter medications. | SS=E |
| The Administrator failed to ensure a review of the facility's emergency management plan was conducted with all employees at least quarterly. | SS=F |
Report Facts
Census: 13
Residents sampled: 3
Non-injury falls: 3
Dates of inspection: Inspection conducted on 12/30/24 and 12/31/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse C | Registered Nurse | Interviewed and confirmed deficiencies related to NSAs and emergency preparedness |
| Certified Medication Aide A | Certified Medication Aide | Interviewed regarding unlabeled over-the-counter medications |
| Licensed Nurse B | Licensed Nurse | Interviewed regarding unlabeled over-the-counter medications |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 30, 2024
Visit Reason
The document is a Plan of Correction addressing findings from the licensure resurvey conducted on December 30 and 31, 2024.
Findings
The Plan of Correction references citations found during the licensure resurvey of the facility on December 30 and 31, 2024. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 29, 2024
Visit Reason
An offsite revisit survey was conducted on 07/29/24 for all previous deficiencies cited on 06/05/24 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 07/10/24, 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: 5
Jun 5, 2024
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a regulatory inspection of Cumbernauld Village.
Findings
The Plan of Correction addresses multiple deficiencies including lack of non-pharmacological pain interventions in care plans, inadequate grooming care plans, improper preparation of pureed diets, failure to use hair restraints and proper handwashing in dining services, and failure to keep dumpster lids closed. Corrective actions include staff education, policy updates, audits, and monitoring by facility leadership.
Severity Breakdown
D: 3
F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Care plan lacking non-pharmacological interventions for pain for Resident R29 | D |
| Care plan lacking direction for ADL grooming care/shaving for Resident R30 | D |
| Improper preparation of pureed diets for three residents | D |
| Failure of dining services staff to wear hairnets and beard guards and follow proper handwashing procedures | F |
| Failure to keep dumpster lids closed after trash disposal | F |
Report Facts
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | Listed as contact for Plan of Correction assistance |
| Sarah Griggs | Executive Director | Submitted the Plan of Correction |
| Teresa Edwards | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 5
Jun 5, 2024
Visit Reason
The inspection was a Health Resurvey and investigation of complaint #187243 at Cumbernauld Village.
Findings
The facility was found deficient in multiple areas including failure to revise a resident's care plan to include non-pharmacological pain interventions, failure to provide grooming per resident preference, failure to prepare pureed diets with recipes to ensure nutritional value, failure to maintain sanitary food preparation conditions including hair and beard restraints and handwashing protocols, and failure to properly dispose of garbage to prevent pest harborage.
Complaint Details
The visit was triggered by complaint #187243 and included a health resurvey.
Severity Breakdown
SS=D: 3
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to review and revise one dependent resident's care plan to include non-pharmacological interventions for pain. | SS=D |
| Failed to ensure one resident received grooming per his usual preference. | SS=D |
| Failed to prepare food consistent with required recipes to ensure nutritional value and preservation of vitamins for three residents on pureed diets. | SS=D |
| Failed to prepare food under sanitary conditions related to hair restraints, beard restraints, and cross contamination following handwashing. | SS=F |
| Failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. | SS=F |
Report Facts
Census: 34
Residents sampled: 13
Residents reviewed for unnecessary medications: 5
Acetaminophen dosage: 325
Acetaminophen dosage: 500
Date of Admission MDS: Sep 22, 2023
Date of Quarterly MDS: Mar 8, 2024
Date of Care Plan revision: Jun 5, 2024
Date of Admission MDS: May 6, 2024
Date of Care Plan review: May 10, 2024
Date of dietary observations: Jun 4, 2024
Date of kitchen observations: Jun 3, 2024
Date of dumpster observation: Jun 3, 2024
Inspection Report
Renewal
Deficiencies: 0
Jun 29, 2023
Visit Reason
The licensure resurvey was conducted as a renewal inspection of the assisted living facility.
Findings
The inspection resulted in no deficiency citations being found at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 29, 2023
Visit Reason
The licensure resurvey was conducted on 06/29/23 at the assisted living facility to assess compliance and identify any deficiencies.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
May 2, 2023
Visit Reason
An onsite revisit survey was conducted on 05/02/23 for all previous deficiencies cited on 03/02/23 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 04/11/23 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies compliance date: Apr 11, 2023
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 9, 2023
Visit Reason
The document is a Plan of Correction submitted by the facility in response to deficiencies related to Abuse/Neglect/Exploitation (ANE) reporting and staff training.
Findings
The facility implemented corrective actions including posting signs, mandatory staff training on ANE policies, competency testing, and ongoing monitoring to prevent recurrence of failure to report ANE incidents.
Severity Breakdown
L: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately report Abuse/Neglect/Exploitation (ANE) incidents. | L |
Report Facts
Date corrective action completed: Mar 9, 2023
Date Quality Assurance Committee Meeting: Apr 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Linda Voth | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Mar 2, 2023
Visit Reason
A partial extended complaint survey was conducted due to allegations of abuse and mistreatment involving multiple residents and staff members at the facility.
Findings
The facility failed to ensure staff reported all alleged violations of abuse and mistreatment in a timely manner, resulting in immediate jeopardy to residents. Three incidents involving a Certified Nurse Aide abusing residents were witnessed but not reported promptly, allowing the abusive staff member to continue working for 14 days after the first incident.
Complaint Details
The complaint investigation revealed three abuse incidents involving CNA M and residents R1, R3, and R4 that were witnessed by other staff but not reported until 7 to 14 days later. This failure placed all residents at risk of ongoing abuse and mistreatment, constituting immediate jeopardy.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report alleged violations of abuse and mistreatment to administrative staff in a timely manner. | F |
Report Facts
Census: 35
Days abuse went unreported: 14
Days abuse went unreported: 7
Number of abuse incidents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named as the staff member who verbally and physically abused residents R1, R3, and R4 |
| CNA N | Certified Nurse Aide | Witnessed abuse incidents but failed to report them in a timely manner |
| CNA O | Certified Nurse Aide | Witnessed abuse incidents but failed to report them in a timely manner |
| Administrative Nurse B | Administrative Nurse | Provided Immediate Jeopardy template and explained reporting expectations |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 17, 2023
Visit Reason
An offsite revisit survey was conducted on 01/17/2023 for all previous deficiencies cited on 11/17/2022 to verify correction of cited deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 12/05/2022, 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: 34
Deficiencies: 3
Nov 17, 2022
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall care quality.
Findings
The facility failed to review and revise care plans for residents requiring wheelchair foot pedals, resulting in unsafe transport conditions. Additionally, inadequate oral hygiene care was provided to dependent residents. The facility also failed to ensure foot pedals were used on wheelchairs for several residents, increasing accident risk.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to review and revise care plans to include interventions for use of foot pedals on wheelchairs to ensure resident safety during transport. | SS=D |
| Failed to provide adequate oral hygiene care for dependent residents, resulting in poor oral health conditions. | SS=D |
| Failed to ensure resident environment was free of accident hazards by not providing foot pedals on wheelchairs for dependent residents, increasing risk of injury. | SS=D |
Report Facts
Residents reviewed: 16
Residents with foot pedal deficiency: 3
Residents reviewed for accidents: 5
Residents reviewed for ADL: 2
Census: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Attempted to attach foot pedals to wheelchair and noted left foot pedal did not attach completely |
| Certified Nurse Aide N | Certified Nurse Aide | Propelled resident in wheelchair without foot pedals; stated staff do not use foot pedals because resident propels herself |
| Certified Nurse Aide Q | Certified Nurse Aide | Propelled resident in wheelchair without foot pedals |
| Certified Nurse Aide NN | Certified Nurse Aide | Propelled resident in wheelchair without foot pedals; unaware of foot pedal location |
| Certified Nurse Aide MM | Certified Nurse Aide | Did not know why foot pedals were not attached; would notify maintenance |
| Administrative Nurse D | Administrative Nurse | Expected staff to apply foot pedals when resident could not hold feet off floor; stated foot pedals often refused by resident |
| Administrative Nurse E | Administrative Nurse | Responsible for updating care plans; stated use of foot pedals should be included on care plan |
| Licensed Nurse G | Licensed Nurse | Stated resident would propel herself at times; staff should probably place foot pedals when propelling |
| Certified Medication Aide R | Certified Medication Aide | Propelled resident in wheelchair without foot pedals; stated staff do not use foot pedals because resident propels herself |
| Certified Nurse Aide O | Certified Nurse Aide | Propelled resident in wheelchair without foot pedals; stated staff do not use foot pedals because resident propels herself |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 20, 2022
Visit Reason
A revisit survey was conducted on 01/19/2022 and 01/20/2022 for all previous deficiencies cited on 12/01/2021.
Findings
All deficiencies have been corrected as of the compliance date of 12/24/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 24, 2021
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection related to the use of Hoyer Lifts and resident mobility care plans.
Findings
The facility identified deficiencies in the care plans regarding the use of Hoyer Lifts for non-ambulatory, non-weight bearing residents. Corrective actions include revising care plans, staff training, policy updates, and ongoing monitoring to prevent recurrence.
Deficiencies (1)
| Description |
|---|
| Care Plan deficiencies related to proper use and documentation of Hoyer Lift for non-ambulatory, non-weight bearing residents |
Report Facts
Completion date: Dec 24, 2021
Training frequency: 2
Physician review interval: 60
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Dec 1, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#167397 and #167412) related to the facility's handling of accident hazards and supervision.
Findings
The facility failed to ensure staff transferred a resident (R1) using a mechanical lift as required by her care plan, resulting in the resident being lowered to the floor improperly and sustaining bilateral distal femur fractures requiring surgical intervention. Staff also failed to use the mechanical lift to move the resident off the floor.
Complaint Details
The visit was triggered by complaint investigations #167397 and #167412. The complaint involved improper transfer and supervision leading to resident injury.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff transferred resident with mechanical lift as care planned, resulting in injury. | SS=G |
Report Facts
Resident census: 38
Pain medication dosage: 650
Dates: Nov 19, 2021
Dates: Nov 20, 2021
Dates: Nov 22, 2021
Dates: Nov 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Assessed resident after fall, noted pain and assisted with transfer from floor |
| Certified Medication Aide R | Certified Medication Aide | Assisted with shower and transfer of resident, involved in lowering resident to floor |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted with shower and transfer of resident, involved in lowering resident to floor |
| Certified Nurse Aide N | Certified Nurse Aide | Assisted with shower and transfer of resident, involved in lowering resident to floor |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding staff actions and investigation |
| Administrative Staff A | Administrative Staff | Involved in investigation and provided statements |
| Consultant GG | Consultant | Provided expert opinion on injury and transfer appropriateness |
| Consultant Staff HH | Consultant Staff | Provided hospital admission and pain assessment information |
| Licensed Nurse H | Licensed Nurse | Confirmed transfer requirements for resident |
| Certified Medication Aide S | Certified Medication Aide | Confirmed resident transfer requirements |
Inspection Report
Follow-Up
Deficiencies: 0
May 19, 2021
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 03/17/21.
Findings
All deficiencies cited in the previous inspection have been corrected as of 04/20/21, 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: 32
Deficiencies: 1
Mar 17, 2021
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with medication administration regulations following previous findings.
Findings
The facility failed to administer the correct dosage of Albuterol sulfate medication to Resident 6 due to a mismatch between the medication on hand and the physician's order, resulting in the resident receiving an incorrect dosage.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to administer the correct dosage of Albuterol sulfate medication for Resident 6 due to medication mismatch. | SS=D |
Report Facts
Medication doses left: 40
Medication doses administered: 20
Census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Confirmed medication mismatch and notified pharmacy |
| Certified Medication Aide R | Certified Medication Aide | Prepared medication and identified mismatch |
| Consultant staff GG | Confirmed pharmacy medication shipment details | |
| Administrative Nurse D | Administrative Nurse | Provided expectations for medication verification |
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 17, 2021
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection related to medication administration orders.
Findings
The Plan of Correction addresses a deficiency involving verification of Albuterol Sulfate medication orders and outlines corrective actions including staff training, order verification procedures, and ongoing monitoring to prevent recurrence.
Deficiencies (1)
| Description |
|---|
| Failure to verify that the Albuterol Sulfate medication order matched the medication box label. |
Report Facts
Completion date: Apr 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction | |
| Janice Van Gotten | Modified Plan of Correction |
Inspection Report
Routine
Deficiencies: 0
Jul 13, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/13/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 16, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Kansas Department for Aging and Disability Services on June 15-16, 2020.
Findings
The facility was found to be in compliance with Centers for Medicare Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 16, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a COVID-19 survey conducted on 06/16/2020 at the facility.
Findings
The COVID-19 survey was deficiency free, indicating no deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 5, 2019
Visit Reason
The document is a Plan of Correction submitted in response to a Health Survey and complaint investigation #138204 for the facility.
Findings
The Health Survey and complaint investigation resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 5, 2019
Visit Reason
The inspection was conducted as a health survey and complaint investigation (#138204) at the facility.
Findings
The investigation resulted in no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Complaint Details
Complaint investigation #138204 resulted in no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 11, 2019
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with completion dates documented as 02/11/2019.
Inspection Report
Re-Inspection
Census: 17
Deficiencies: 9
Jan 8, 2019
Visit Reason
The inspection was a resurvey conducted on 1/2/19, 1/3/19, 1/7/19, and 1/8/19 to evaluate compliance with state regulations for the residential health care facility Cumbernauld Village.
Findings
The facility was found deficient in multiple areas including failure to provide written admission agreements detailing rates and resident obligations, incomplete functional capacity screenings, inadequate coordination of health care services by licensed nurses, improper delegation of glucometer testing to medication aides without proper authorization, failure to assess residents' ability to self-administer medications, incomplete negotiated service agreements regarding medication management, untimely signing of verbal medication orders, and lack of quarterly emergency management plan reviews with employees and residents.
Severity Breakdown
F: 2
E: 5
D: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure written admission agreements included rates, charges, and resident obligations prior to admission. | F |
| Licensed nurse failed to record functional capacity screening findings according to department definitions. | E |
| Licensed nurse failed to provide or coordinate necessary health care services in accordance with functional capacity screening and negotiated service agreement. | E |
| Health care services included personal care by unqualified sitters not under licensed nurse supervision. | E |
| Licensed nurse failed to delegate glucometer testing properly to certified medication aides as required by Kansas nurse practice act. | F |
| Licensed nurse failed to assess resident's ability to safely self-administer medications prior to and annually. | D |
| Negotiated service agreement did not reflect resident's self-administration of selected medications. | D |
| Licensed nurse failed to ensure verbal medication orders were signed by medical care provider within 7 days. | E |
| Failure to perform quarterly review of the facility's emergency management plan with employees and residents. | E |
Report Facts
Census: 17
Telephone order slips lacking signatures: 5
Telephone order slips lacking signatures: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Administrator | Named in multiple findings related to admission agreements, health care service coordination, and delegation failures. |
| Licensed Nurse C | Licensed Nurse | Involved in functional capacity screening, health care service plan reviews, and interviews confirming deficiencies. |
| Licensed Nurse D | Licensed Nurse | Signed health care service plans and negotiated service agreements related to medication administration and care. |
| Medical Records Director H | Medical Records Director | Interviewed regarding admission agreements and policy on verbal orders. |
| Certified Medication Aide E | Certified Medication Aide | Performed glucometer testing without proper delegation. |
| Certified Medication Aide F | Certified Medication Aide | Performed glucometer testing and assisted residents; interviewed regarding sitter duties. |
| Certified Medication Aide G | Certified Medication Aide | Assisted resident with mobility and meals. |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 21, 2018
Visit Reason
An offsite revisit survey was conducted on 09/21/2018 for all previous deficiencies cited on 08/29/2018.
Findings
All deficiencies have been corrected as of the compliance date of 09/10/2018, 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
Deficiencies: 1
Aug 29, 2018
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 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 2018-09-10.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact and signatory related to enforcement and compliance findings. |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 3
Aug 29, 2018
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with regulatory requirements for quality of life, catheter care, and food safety among other standards.
Findings
The facility failed to monitor neurochecks hourly for a resident after a fall with head injury, failed to properly secure catheter tubing for a resident with a suprapubic catheter to prevent trauma, and failed to maintain sanitary food handling and serving practices in the dietary department.
Severity Breakdown
SS=D: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to monitor neurochecks hourly for 72 hours as ordered by physician following a fall with head injury for resident #7. | SS=D |
| Failed to ensure proper securement of catheter tubing for resident #14 with suprapubic catheter, resulting in risk of trauma at insertion site. | SS=D |
| Failed to store, prepare, distribute, and serve food under sanitary conditions, including lack of covered step-on trash can and improper handling of clean plates by dietary staff. | SS=F |
Report Facts
Census: 42
Residents sampled: 12
Residents sampled: 13
Hours of neurocheck documentation: 8
Hours of neurocheck documentation: 6
Hours of neurocheck documentation: 6
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 10, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Cumbernauld Village NF.
Findings
No deficiencies were cited in the related inspection report, as indicated by the Plan of Correction.
Deficiencies (1)
| Description |
|---|
| No deficiencies cited |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 10, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Cumbernauld Village ALF dated 01/10/2017.
Findings
No deficiencies were cited in the referenced inspection report.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 10, 2017
Visit Reason
The document is a plan of correction related to a health survey conducted at the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Renewal
Deficiencies: 0
Jan 10, 2017
Visit Reason
The Health Licensure Resurvey of the facility was conducted as a renewal inspection to assess compliance with health licensure requirements.
Findings
The resurvey resulted in a finding of no deficiency citations, indicating full compliance with applicable regulations.
Inspection Report
Follow-Up
Deficiencies: 2
Nov 2, 2016
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 report indicates that the deficiencies previously cited under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h) have been corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.25(h) |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 2, 2016
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 the most serious deficiencies to be 'D' level deficiencies that constitute 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, resulting in a finding of substantial compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person regarding the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 1, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies related to elopement risk at the facility, addressing corrective actions to prevent residents at high risk of elopement from being admitted or transferred to the Health Care Unit.
Findings
The facility identified deficiencies regarding the admission and transfer of residents at risk for elopement. The Plan of Correction outlines policy revisions, screening procedures, and monitoring to ensure residents at high risk for elopement are not admitted to or transferred within the Health Care Unit.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Cumbernauld Village complaint 10312016.
Severity Breakdown
D: 2
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent admission or transfer of residents at high risk for elopement to the Health Care Unit. | D |
Report Facts
Corrective action completion date: Nov 2, 2016
Corrective action completion date: Nov 1, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Oct 31, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#106859) regarding allegations of failure to investigate and report incidents of a resident eloping from the facility without staff knowledge.
Findings
The facility failed to thoroughly investigate and report two occasions when a confused and mobile resident left the facility without staff knowledge. The resident was at high risk for elopement, and despite documented supervision orders, the facility did not notify the state agency or conduct a complete investigation. Additionally, the facility failed to ensure adequate supervision to prevent the resident from leaving the facility unsupervised.
Complaint Details
Complaint investigation #106859 focused on allegations that the facility failed to investigate and report incidents of a resident eloping without staff knowledge. The investigation found the allegations substantiated as the facility did not notify the state agency or conduct a thorough investigation for two elopement incidents on 9/30/16 and 10/2/16.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to investigate and report incidents of resident elopement to the state agency. | SS=D |
| Failure to ensure the safety of a confused and mobile resident from leaving the facility without staff knowledge. | SS=D |
Report Facts
Census: 39
Resident sample: 3
BIMS score: 5
Mood score: 10
Wandering days: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff C | Documented spouse's call reporting resident elopement and returned resident to facility. | |
| Administrative nursing staff B | Reported resident previously lived nearby with spouse and verified failure to investigate and report elopements. | |
| Administrative nursing staff G | Reported awareness of resident elopements and lack of new interventions. | |
| Administrative staff A | Verified incomplete investigation and described resident's purposeful elopement. | |
| Licensed nursing staff E | Verified resident was an elopement risk and facility's attempt to keep resident close to spouse. | |
| Direct care staff F | Reported unawareness of resident leaving dining room and facility on 10/12/16. | |
| Housekeeping staff D | Reported attempted intervention when resident tried to go outside without staff knowledge. |
Inspection Report
Follow-Up
Deficiencies: 2
Jun 11, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies.
Findings
The report documents that previously identified deficiencies under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) were corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Enforcement
Deficiencies: 1
Jun 5, 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 an 'E' level deficiency, pattern, 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 June 11, 2015.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be an 'E' level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 5, 2015
Visit Reason
The visit was an assisted living resurvey of the facility to determine compliance status.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 3
Jun 5, 2015
Visit Reason
The inspection was a health re-survey with complaint investigation #74314 focusing on the facility's failure to review and revise the plan of care for a resident with repeated falls and to ensure a safe environment free of accident hazards.
Findings
The facility failed to review and revise the care plan for resident #48 after multiple falls, did not implement appropriate interventions to prevent repeated falls, and failed to maintain a safe environment by leaving hazardous chemicals and biohazards unsecured. The resident experienced 7 falls between 2/26/15 and 5/26/15, with inadequate supervision and assistive devices.
Complaint Details
The complaint investigation #74314 focused on the facility's failure to adequately review and revise the care plan for resident #48 after multiple falls and failure to maintain a safe environment free of accident hazards.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to review and revise the plan of care for resident #48 after repeated falls with appropriate interventions. | SS=E |
| Failure to provide an environment free of accident hazards, including unsecured chemicals and biohazards accessible to residents. | SS=E |
| Failure to ensure adequate supervision and assistive devices to prevent repeated falls for resident #48. | SS=E |
Report Facts
Resident falls: 7
Census: 42
Residents reviewed: 13
Confused and mobile residents: 11
Fall risk assessment scores: 13
Fall risk assessment scores: 12
Fall risk assessment scores: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Reported involvement in reviewing falls and adding interventions to care plans | |
| Assistant Director of Nursing (ADON) | Acts in absence of DON and involved in care plan revisions | |
| Administrative nursing staff B | Assisted in reviewing falls but unaware of interventions not added to care plan | |
| Administrative staff A | Reported safety committee fully investigated falls and implemented interventions | |
| Licensed nursing staff E | Confirmed lack of appropriate interventions following each fall | |
| Direct care staff F | Assisted resident with cares and reported resident's abilities and use of alarms | |
| Direct care staff H | Reported resident needed to be kept busy and walked to meals | |
| Direct care staff J | Reported resident needed frequent monitoring and described fall interventions | |
| Activity staff D | Reported cabinets with chemicals should be locked | |
| Housekeeping staff C | Reported janitor closet door should be locked | |
| Licensed nursing staff G | Reported cleaning chemicals should be stored locked and biohazard room secured |
Inspection Report
Life Safety
Deficiencies: 1
Feb 17, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance 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 deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payment and termination of provider agreement were outlined if substantial compliance was not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Denial of payment effective date: May 17, 2015
Termination effective date: Aug 17, 2015
Plan of correction submission timeframe: 10
Fair hearing request timeframe: 60
IDR submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution and appeals related to deficiencies |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter and coordinated survey and certification |
Inspection Report
Follow-Up
Deficiencies: 7
Mar 26, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date, March 26, 2014.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(j) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.30(b) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Deficiencies: 3
Mar 24, 2014
Visit Reason
This is a revisit report to verify that previously cited deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiencies previously reported under regulations 26-41-101(k), 26-41-202(a), and 26-41-206(e)(1) were corrected as of 03/24/2014.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 26-41-101(k) |
| Deficiency under regulation 26-41-202(a) |
| Deficiency under regulation 26-41-206(e)(1) |
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 7
Feb 28, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements including catheter care, hydration, medication regimen, nursing coverage, food sanitation, pharmacy review, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate catheter care to prevent UTI and catheter dislodgement, inadequate hydration offered to a resident, failure to ensure drug regimens were free from unnecessary drugs, insufficient registered nurse coverage, unsanitary food preparation and storage conditions, failure of the pharmacy consultant to report medication monitoring issues, and ineffective infection control program lacking proper tracking and prevention measures.
Severity Breakdown
SS=D: 3
SS=F: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and services to reduce risk of urinary tract infections and catheter dislodgement for a resident with a suprapubic catheter. | SS=D |
| Failure to provide sufficient fluid intake to maintain proper hydration for a resident. | SS=D |
| Failure to ensure residents received only necessary medications, including inadequate bowel monitoring and inappropriate insulin administration. | SS=F |
| Failure to provide registered nurse coverage for at least 8 consecutive hours a day, 7 days a week. | SS=F |
| Failure to maintain a clean and sanitary dietary department for food storage, preparation, and service. | SS=D |
| Pharmacy consultant failed to monitor and report the need for improved behavior monitoring and excessive laxative use for a resident. | SS=F |
| Failure to implement an effective infection control program to prevent transmission of infections and to track infections properly. | SS=F |
Report Facts
Census: 41
Sample size: 12
Residents reviewed for unnecessary medications: 5
Days without RN coverage: 29
Residents with infections identified: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Provided information on catheter care, hydration, RN coverage, and infection control program |
| Staff D | Licensed Nursing Staff | Provided information on catheter care, hydration, medication administration, and insulin dosing |
| Staff F | Direct Care Staff | Reported lack of catheter care training and hydration offering |
| Staff O | Direct Care Staff | Reported documentation of bowel movements and hydration observations |
| Staff Y | Consulting Pharmacist | Reported failure to monitor and report medication and behavior monitoring issues |
| Staff S | Dietary Staff | Verified unsanitary food preparation equipment |
| Staff R | Licensed Nursing Staff | Reported on bowel management and resident behaviors |
| Administrative Staff A | Administrative Staff | Reported on RN coverage and facility costs |
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 7
Feb 28, 2014
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 provide appropriate catheter care to prevent urinary tract infections, inadequate hydration for a resident, improper medication management including unnecessary drug use and failure to notify physicians of critical lab values, insufficient registered nurse coverage, unsanitary food preparation and storage conditions, failure of the pharmacy consultant to report medication monitoring issues, and ineffective infection control program lacking proper tracking and trending of infections.
Severity Breakdown
SS=D: 3
SS=F: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and services to reduce the risk of urinary tract infections and catheter dislodgement for a resident with a suprapubic catheter. | SS=D |
| Failure to provide sufficient fluid intake to maintain proper hydration for a resident as per care plan. | SS=D |
| Failure to ensure drug regimen was free from unnecessary drugs, including inadequate bowel monitoring and inappropriate insulin administration. | SS=F |
| Failure to provide registered nurse coverage for at least 8 consecutive hours a day, 7 days a week. | SS=F |
| Failure to maintain a clean and sanitary dietary department for food storage, preparation, and service. | SS=D |
| Failure of the pharmacy consultant to monitor and report irregularities related to behavior monitoring and excessive laxative use. | SS=F |
| Failure to implement an effective infection control program to prevent transmission of infections and to track infections properly. | SS=F |
Report Facts
Census: 41
Sample size: 12
Residents reviewed for unnecessary medications: 5
Days without RN coverage: 29
Residents with infections identified: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Provided information on catheter care, hydration, RN coverage, and infection control program | |
| Licensed nursing staff D | Provided information on catheter care, insulin administration, and medication issues | |
| Direct care staff F | Reported lack of catheter care training and hydration offering | |
| Consulting staff Y | Reported pharmacy consultant review and monitoring deficiencies | |
| Dietary staff S | Verified unsanitary conditions in dietary department |
Inspection Report
Follow-Up
Deficiencies: 7
Apr 9, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited under various regulations were corrected as of the revisit date, with correction completion dates documented for each deficiency.
Deficiencies (7)
| Description |
|---|
| Deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency under regulation 483.20(b)(2)(ii) |
| Deficiency under regulation 483.20(d), 483.20(k)(1) |
| Deficiency under regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency under regulation 483.20(f) |
| Deficiency under regulation 483.25(h) |
| Deficiency under regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Deficiencies: 2
Apr 5, 2013
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 26-41-204 (b) and 26-41-204 (g)(h) were corrected as of 04/05/2013.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-204 (b) |
| Deficiency related to regulation 26-41-204 (g)(h) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Re-Inspection
Census: 18
Deficiencies: 3
Mar 7, 2013
Visit Reason
This inspection was a non-compliant revisit to assess correction of previously cited deficiencies related to health care service planning and physician orders.
Findings
The facility failed to develop appropriate health care service plans for 2 of 3 reviewed residents, including management of supplemental oxygen and constipation monitoring. Additionally, the facility failed to obtain timely physician admission orders for one resident and ensure documentation of bowel movement monitoring and medication effectiveness.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop a health care service plan for management of supplemental oxygen and application of T.E.D. hose for Resident #1. | SS=D |
| Failed to include management of constipation in the negotiated service agreement for Resident #3. | SS=D |
| Failed to obtain admission physician orders for Resident #2 for symptom and medication management. | SS=D |
Report Facts
Resident census: 18
Residents reviewed: 3
Days without bowel movement documentation: 6
Days without bowel movement documentation: 7
Time delay for physician order fax: 28
Medication administration start delay: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Verified lack of physician order for supplemental oxygen and confirmed need for T.E.D. hose order; reported on physician order fax and medication order delays for Resident #2 | |
| Direct care staff D | Reported resident needed supplemental oxygen and assisted with T.E.D. hose application for Resident #1 | |
| Direct care staff C | Reported resident wore supplemental oxygen almost constantly for Resident #1 | |
| Direct care staff B | Reported reminders for Resident #2 to dress for bed and perform 30-minute checks | |
| Administrative staff E | Provided facsimile to physician for admission orders for Resident #2 |
Inspection Report
Re-Inspection
Deficiencies: 1
Mar 7, 2013
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report indicates that the previously cited deficiency identified by regulation 26-41-206 (c) with ID prefix S3295 was corrected as of 03/07/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency identified under regulation 26-41-206 (c) with ID prefix S3295 |
Report Facts
Deficiencies corrected: 1
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 7
Mar 1, 2013
Visit Reason
The inspection was a health non-compliant revisit focused on allegations of neglect, resident to resident abuse, and compliance with care plan and assessment requirements.
Findings
The facility failed to thoroughly investigate and report allegations of neglect and resident to resident abuse for 2 residents, failed to complete significant change assessments, failed to develop individualized care plans for range of motion, failed to revise care plans for unnecessary medications, failed to timely transmit MDS assessments, and failed to ensure adequate supervision and interventions to prevent repeated falls for 2 residents. The quality assurance committee failed to adequately address and implement plans to correct these deficiencies.
Severity Breakdown
SS=D: 5
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate and report allegations of neglect and resident to resident abuse for 2 residents. | SS=D |
| Failed to complete a significant change comprehensive assessment for a resident who declined in ability to perform activities of daily living. | SS=D |
| Failed to develop individualized care plans for range of motion for 2 residents. | SS=D |
| Failed to review and revise plan of care for unnecessary medications for 1 resident. | SS=D |
| Failed to maintain a system to ensure timely transmission of Minimum Data Set assessments for 2 residents. | SS=D |
| Failed to ensure supervision and assistive devices to prevent repeated falls for 2 residents. | SS=F |
| Failed to maintain an effective quality assurance committee to address identified quality deficiencies. | SS=F |
Report Facts
Resident census: 39
Residents sampled: 10
Falls documented: 9
Falls documented: 4
Fall risk score: 43
Fall risk score: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Reported lack of reporting resident to resident incident and lack of staff statements in investigations | |
| Administrative nursing staff A | Reported failure to report incidents to state agency and use of paper care plans | |
| Administrative nursing staff C | Reported lack of MDS tracking system and incomplete MDS transmissions | |
| Direct care staff I | Reported restorative care practices and care plan updates | |
| Licensed nursing staff D | Reported documentation practices and resident condition | |
| Direct care staff F | Reported resident fall risk and care needs | |
| Direct care staff E | Reported resident fall risk and behaviors | |
| Licensed nursing staff J | Reported resident mobility and care needs |
Inspection Report
Follow-Up
Deficiencies: 6
Mar 1, 2013
Visit Reason
This is a post-certification revisit conducted 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 all previously identified deficiencies listed under various regulation numbers were corrected by the revisit date of 03/01/2013.
Deficiencies (6)
| Description |
|---|
| Deficiency under regulation 483.10(i)(1) |
| Deficiency under regulation 483.25(e)(2) |
| Deficiency under regulation 483.25(i) |
| Deficiency under regulation 483.25(l) |
| Deficiency under regulation 483.35(i) |
| Deficiency under regulation 483.60(c) |
Inspection Report
Plan of Correction
Deficiencies: 2
Jan 10, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to resident care agreements, specifically constipation management and medication care plans, as well as sanitary concerns in dietary services including cleaning procedures and food storage.
Severity Breakdown
D: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #3's occasional constipation added to service agreement; Resident #2's Coumadin medication care plan added. | D |
| Sanitary concerns in dietary services including cleaning procedures, covering of predipped food, and monitoring expiration dates. | F |
Report Facts
Plan of Correction completion date: Jan 10, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Submitted the Plan of Correction |
Inspection Report
Renewal
Census: 18
Deficiencies: 2
Jan 2, 2013
Visit Reason
The inspection was a licensure resurvey to assess compliance with regulatory requirements for an assisted living facility.
Findings
The facility failed to develop appropriate health care service plans for residents needing constipation and blood thinner medication monitoring, and failed to store, prepare, and serve food in a sanitary manner.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop a health care service plan for residents needing constipation monitoring and blood thinner medication monitoring. | SS=D |
| Failed to store, prepare, and serve foods to residents in a sanitary manner, including uncovered desserts, expired milk, unclean spice bottles, and unsanitary ice machines. | SS=F |
Report Facts
Census: 18
Protime laboratory test value: 24.7
INR laboratory test value: 2.3
Expired milk bottles: 4
Opened spice bottles: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff J | Reported on food storage and sanitation issues including uncovered desserts, expired milk, unclean spices, and ice machine maintenance. | |
| Direct care staff W | Acknowledged resident lacked ongoing planned orders or services for constipation. | |
| Licensed nursing staff K | Acknowledged resident lacked ongoing planned orders or services for constipation. |
Inspection Report
Routine
Census: 42
Deficiencies: 8
Dec 21, 2012
Visit Reason
The inspection was a routine health facility resurvey to assess compliance with federal regulations including resident rights, care plans, medication management, and safety.
Findings
The facility was found deficient in multiple areas including failure to deliver mail on Saturdays, inadequate investigation and reporting of a resident fall with fracture, incomplete individualized care plans, failure to provide restorative services, unsafe bed rails creating entrapment hazards, significant unplanned weight loss without timely interventions, and failure to monitor and act on medications with black box warnings.
Severity Breakdown
SS=B: 1
SS=D: 4
SS=E: 1
SS=F: 1
SS=G: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to deliver mail to residents on Saturdays. | SS=B |
| Failure to thoroughly investigate and report a fall resulting in a fractured hip. | SS=D |
| Failure to develop individualized care plans for sleep hygiene, antianxiety medication, and restorative services. | SS=D |
| Failure to provide restorative services to prevent decrease in range of motion for residents with impairments. | SS=D |
| Failure to maintain resident environment free of accident hazards due to loose and gapping bed side rails. | SS=D |
| Failure to ensure resident maintained acceptable nutritional status with significant unplanned weight loss and delayed interventions. | SS=G |
| Failure to monitor and act upon adverse consequences of medications with black box warnings, including failure to follow pharmacist recommendations for dose reduction and monitoring. | SS=E |
| Failure to store, prepare, and serve food under sanitary conditions including uncovered desserts, expired milk, greasy spice bottles, and unclean ice machines. | SS=F |
Report Facts
Resident census: 42
Residents reviewed: 24
Residents reviewed for accidents: 4
Residents reviewed for nutrition: 3
Residents reviewed for unnecessary medications: 10
Weight loss: 54
Weight loss percentage: 7.6
Expired milk bottles: 4
Opened spice bottles: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Reported care plan documentation practices for black box warnings and pharmacy recommendations | |
| Staff F | Consultant Pharmacist | Provided lists and summaries of medications with black box warnings to facility staff |
| Staff BB | Licensed Nursing Staff | Reported lack of knowledge about black box warnings |
| Staff CC | Administrative Staff | Reported lack of documentation and physician notification regarding pharmacist recommendation for Xanax dose reduction |
| Staff J | Dietary Staff | Reported food storage and sanitation issues in kitchen |
| Staff D | Reported medication unavailability and pharmacy communication | |
| Staff E | Licensed Nursing Staff | Reported medication unavailability and responsibility for medication notification |
| Staff G | Direct Care Staff | Reported loose bed rails and resident use |
| Staff U | Direct Care Staff | Reported bed rail use and loose rails |
| Staff L | Direct Care Staff | Reported restorative services and documentation |
Inspection Report
Follow-Up
Deficiencies: 5
Oct 17, 2011
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
All deficiencies previously cited under regulations 483.10(b)(11), 483.20(d)(3), 483.10(k)(2), 483.25(h), 483.35(c), and 483.35(i) were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency under regulation 483.10(b)(11) |
| Deficiency under regulations 483.20(d)(3) and 483.10(k)(2) |
| Deficiency under regulation 483.25(h) |
| Deficiency under regulation 483.35(c) |
| Deficiency under regulation 483.35(i) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 5
Sep 29, 2011
Visit Reason
The inspection was conducted as a health resurvey to assess compliance with federal regulations, including notification of changes, care planning, accident prevention, and food service standards.
Findings
The facility was found deficient in notifying the physician and responsible party of a resident injury, revising care plans after an accident, ensuring a safe environment free from accident hazards, and following proper food service sanitation and portion control procedures.
Severity Breakdown
SS=D: 3
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify physician and responsible party of injury after an accident for 1 of 7 sampled residents (#35). | SS=D |
| Failed to review and revise the care plan for 1 of 8 sampled residents (#35) after an accident. | SS=D |
| Failed to ensure resident environment remained free from accident hazards and failed to provide adequate supervision to prevent accidents for 1 of 4 residents (#35). | SS=D |
| Failed to follow planned menu and serve planned portion sizes to meet nutritional needs of all 41 residents. | SS=F |
| Failed to ensure sanitary food preparation and handling practices including proper sanitizing of food prep surfaces and equipment, proper glove use, and sanitary handling of dinnerware. | SS=F |
Report Facts
Facility census: 41
Residents sampled: 17
Residents sampled for care areas: 7
Residents sampled for care plan review: 8
Residents sampled for accident review: 4
Sanitizer concentration tested: 150
Portion size planned - regular meat: 3
Portion size planned - small meat: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Nurse | Confirmed report of resident injury and failure to notify physician |
| Administrative staff C | Administrative Nurse | Confirmed failure to notify physician and responsible party of injury and failure to consider incident a fall |
| Nurse D | Nurse | Notified responsible party about bruises and physician contact |
| Dietary Staff E | Dietary Staff | Reported portion sizes and sanitizer concentration, conferred with Dietary Staff G |
| Dietary Staff G | Dietary Staff | Observed serving incorrect portion sizes and improper sanitation and glove use |
| Nurse aide A | Nurse Aide | Reported noticing bruising and reporting to Nurse B |
| Administrative staff F | Administrative Staff | Interviewed regarding resident complaints and care |
Inspection Report
Plan of Correction
Deficiencies: 3
N018009 POC 3RLD11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 11/17/22.
Findings
The Plan of Correction addresses deficiencies related to wheelchair pedal storage and use, oral care practices, and resident safety. The facility outlines corrective actions, measures to prevent recurrence, and monitoring plans to ensure compliance.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to include proper storage and use of wheelchair pedals in resident care plans. | D |
| Deficient oral care practices affecting residents dependent on nursing staff. | D |
| Improper use and storage of wheelchair pedals posing safety risks to residents. | D |
Report Facts
Completion date: Dec 5, 2022
Plan of Correction submission date: Mar 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Linda Voth | Administrator | Submitted the Plan of Correction to KDADS |
| Lanae Workman | Added Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 7
N018009 POC 5BK311
Visit Reason
This document is a Plan of Correction submitted by Cumbernauld Village in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including urinary catheter care, hydration practices, insulin and medication administration, staffing coverage, kitchen utensil cleanliness, pharmacist training on EMR, and infection monitoring.
Severity Breakdown
D: 4
F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Staff training on urinary catheter care and monthly random checks of staff during catheter care. | D |
| Training on fluid hydration and ensuring water pitchers are within reach of residents. | D |
| Implementation of insulin/accu check schedule and monthly review of medication administration records. | D |
| Hiring of part-time RN to cover weekend/holiday shifts and ensuring RN coverage 8 hours per day, 7 days a week. | F |
| Discarding kitchen utensils and bakeware with baked-on build-up and monthly checks for cleanliness. | F |
| Training for consulting pharmacist on EMR and monthly review of behavior sheets and PRN medication documentation. | D |
| Infection monitoring through EMR infection log with monthly analysis and reporting to QA committee. | F |
Report Facts
Corrective action completion date: Mar 13, 2014
Corrective action completion date: Mar 20, 2014
Corrective action completion date: Mar 24, 2014
Corrective action completion date: Mar 25, 2014
Corrective action completion date: Mar 26, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 3
N018009 POC 5C7X11
Visit Reason
This document is a Plan of Correction submitted by Cumbernauld Village ALF in response to deficiencies identified in a prior inspection.
Findings
The plan addresses deficiencies including posting of Kansas Department on Aging contact information, communication and documentation of physician orders for residents, and cleanliness and maintenance of kitchen utensils and bakeware.
Deficiencies (3)
| Description |
|---|
| Failure to post Kansas Department on Aging and long-term care telephone numbers in visible locations. |
| Deficit practice in communication and documentation of new physician orders for Residential Care Residents. |
| Kitchen utensils and bakeware with baked-on build-up or discoloration not properly cleaned or discarded. |
Report Facts
Complete Date: Mar 25, 2014
Complete Date: Mar 6, 2014
Complete Date: Mar 10, 2014
Complete Date: Mar 24, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 3
N018009 POC O24811
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 08/29/2018.
Findings
The Plan of Correction addresses deficiencies related to inadequate documentation of 72-hour post-fall monitoring, improper securing of a suprapubic catheter, and unsafe handling of plates and trash can use in the dietary department. Corrective actions include policy changes, staff training, monitoring procedures, and documentation improvements.
Severity Breakdown
D: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to document hourly checks for 72 hours following a fall with potential head injury. | D |
| Suprapubic catheter not anchored to the thigh with a securement device at all times. | D |
| Improper handling of plates from the Cambro warming unit and improper trash can use in the dietary department. | F |
Report Facts
Deficiencies cited: 3
Completion dates: Sep 7, 2018
Completion date: Sep 10, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Linda Voth | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 9
N018009 POC QYF411
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction outlines specific corrective actions for multiple deficiencies including mail delivery, incident investigations, care plan interventions, restorative nursing services, bedrail safety, medication management including Black Box Warnings, dietary sanitation, and staff education. Each corrective action includes timelines and measures for substantial compliance.
Severity Breakdown
B: 1
D: 4
E: 2
F: 1
G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Deficit practice of not delivering Saturday mail until the following Monday. | B |
| Failure to investigate incidents and report injuries to the State Agency with proper documentation. | D |
| Lack of appropriate care plan interventions for residents related to medication and range of motion. | D |
| Inadequate restorative nursing interventions to prevent contractures. | D |
| Unsafe bedrail use and lack of proper monitoring and education on bedrail safety. | D |
| Inadequate management of weight loss and dietary intake for a resident with severe delirium and vascular dementia. | G |
| Failure to incorporate Black Box Warnings into residents' care plans and medication monitoring. | E |
| Sanitary concerns in dietary services including cleaning procedures and food storage monitoring. | F |
| Licensed nurses lacking inservice education on Black Box Warnings for medications. | E |
Report Facts
Corrective action completion dates: Multiple corrective actions with specific completion dates ranging from 12/21/2012 to 01/18/2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Submitted the Plan of Correction and responsible for oversight of corrective actions |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 7
N018009 POC QYF412
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report, outlining corrective actions and timelines to address identified issues.
Findings
The Plan of Correction details multiple policy revisions and systemic changes aimed at improving fall investigations, MDS completion, restorative services, careplan revisions, and communication protocols. It includes timelines for substantial compliance and ongoing monitoring measures.
Severity Breakdown
D: 6
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Falls are not thoroughly investigated including witness or no witness documentation; interventions and notifications are inadequate. | D |
| Improper development and completion of the MDS including Significant Change/Improvement and Careplan revision. | D |
| Restorative Services policies lack specific written instructions and individualized careplan incorporation. | D |
| Resident Careplans are not reviewed and revised timely when changes occur. | D |
| Failure to transmit completed MDS as required. | D |
| Falls with injury are not managed with standardized protocol interventions and proper documentation. | D |
| QA committee involvement and documentation in resident care plans and policies is insufficient. | F |
Report Facts
Complete Date for corrective actions: Mar 27, 2013
Complete Date for QA committee compliance: Mar 20, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 2
N018009 POC REHT11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction outlines corrective actions to address deficiencies related to careplan interventions, storage room door locking mechanisms, and fall prevention measures to ensure resident safety and compliance.
Severity Breakdown
Level D: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Careplan interventions documented and carried out inadequately, requiring policy revision and secondary review. | Level D |
| Storage rooms containing potential hazards lacked proper locking mechanisms, posing risk to residents with altered cognition. | Level E |
Report Facts
Corrective action completion date: Jun 11, 2015
Inspection Report
Plan of Correction
Deficiencies: 3
N018009 POC TDLM12
Visit Reason
The document provides the facility's plan of correction addressing deficiencies related to resident care practices, including management of TED hose use and constipation care, as well as physician order approvals for new admissions.
Findings
The plan of correction outlines actions taken to address identified deficiencies, such as resident-specific care plans, physician order verification for transfers, and ongoing compliance monitoring.
Deficiencies (3)
| Description |
|---|
| Resident #1 TED hose use discussed; resident and DPOA signed AMA regarding use. |
| Management of constipation added as a specific plan of care for Resident #4. |
| Physician orders for new admissions transferring from another facility were not always received timely. |
Report Facts
Plan of correction completion date: Apr 5, 2013
Plan of correction completion date: Mar 7, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for plan of correction assistance | |
| Linda Voth | Administrator | Submitted the plan of correction |
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