Inspection Reports for
Cumbernauld Village Inc
716 TWEED STREET, WINFIELD, KS, 67156-1595
Back to Facility ProfileDeficiencies (last 16 years)
Deficiencies (over 16 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
74% occupied
Based on a April 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 9, 2026
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a regulatory inspection of Cumbernauld Village RS.
Findings
The plan addresses deficiencies related to psychotropic medication orders lacking specific durations and inadequate infection control practices involving mechanical lifts.
Deficiencies (2)
F605-D: The assistant director of nursing will ensure psychotropic medication orders include a specific duration or rationale. An audit will identify orders lacking durations and staff will be educated on requirements.
F880-E: The facility assigned infection control education to nursing staff and implemented cleaning protocols for mechanical lifts after use. Monitoring will be conducted through weekly audits.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 2
Date: Apr 9, 2026
Visit Reason
A recertification survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in ensuring residents' rights to be free from chemical restraints without proper stop orders and in maintaining adequate infection prevention and control practices related to urinary catheter care, peri-hygiene, and shared mechanical lift sanitation.
Deficiencies (2)
F0605: The facility failed to ensure Resident 6 had a stop order for PRN antianxiety medication lorazepam, with physician declining a stop date despite recommendations.
F0880: The facility failed to maintain an infection prevention and control program, including inadequate glove use during peri-hygiene care, failure to don gowns during urinary catheter care, and lack of cleaning mechanical lifts between resident uses.
Report Facts
Sample size: 12
Medication dose: 1
Medication dose: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide | Reported Resident 6 was cooperative with medications and charge nurse administered PRN meds | |
| Administrative Nurse E | Responsible for monitoring psychotropic medication use and infection control; verified deficiencies | |
| Certified Nurse Aide M | Failed to change gloves and wash hands properly during peri-hygiene care for Resident 2 | |
| Licensed Nurse G | Verified infection control lapses during Resident 2 care | |
| Certified Nurse Aide N | Failed to don gown during urinary catheter care for Resident 3 | |
| Certified Nurse Aide O | Uncertain about cleaning schedule for mechanical lifts |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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.
Inspection Report
Renewal
Census: 13
Deficiencies: 4
Date: Dec 31, 2024
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance with regulatory requirements for the assisted living facility.
Findings
The inspection identified multiple deficiencies including failure to base negotiated service agreements on functional capacity screenings, lack of identification of responsible parties for medication administration, unlabeled over-the-counter medications, and inadequate emergency preparedness training documentation.
Deficiencies (4)
26-41-202 (a) Negotiated Service Agreement: The administrator failed to ensure negotiated service agreements for residents 1, 2, and 3 were based on functional capacity screenings and did not provide descriptions of services for fall risk.
26-41-205 (b) Administration of Selected Medications: The administrator failed to ensure resident 2's negotiated service agreement identified who was responsible for administration of selected medications.
26-41-205 (g) (3) Over the Counter Drugs: The administrator failed to ensure licensed nurse or pharmacist placed the full name of the resident on bottles of over-the-counter medications.
26-41-104 (d) Disaster and Emergency Preparedness: The administrator failed to ensure quarterly review of the facility's emergency management plan with all employees.
Report Facts
Census: 13
Non-injury falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse C | Registered Nurse | Interviewed regarding negotiated service agreements and emergency preparedness training |
| Certified Medication Aide A | Certified Medication Aide | Interviewed regarding medication cart and over-the-counter medications |
| LN B | Licensed Nurse | Interviewed regarding medication cart and over-the-counter medications |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
This document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on December 30 and 31, 2024.
Findings
The Plan of Correction addresses citations identified during the licensure resurvey of the facility on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 29, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-06-05.
Findings
All deficiencies have been corrected as of the compliance date of 2024-07-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 29, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-06-05.
Findings
All deficiencies have been corrected as of the compliance date of 2024-07-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2024-06-05 were corrected by 2024-07-10.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jun 18, 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 facility identified deficiencies related to care plans lacking non-pharmacological pain interventions, grooming care, preparation of pureed diets, dining services staff hygiene practices, and waste management. Corrective actions and monitoring plans were established for each deficiency.
Deficiencies (5)
F657-D: The care plan for Resident R29 lacked non-pharmacological interventions for pain. The facility will revise care plans and monitor compliance through audits.
F677-D: The care plan for Resident R30 lacked direction for ADL grooming care/shaving. The facility will revise care plans and monitor grooming care through audits and observations.
F804-D: Pureed diet recipes were not consistently followed for three residents. The facility updated policies and will monitor meal preparation.
F812-F: Dining services staff did not consistently wear hairnets and beard guards or follow handwashing procedures. The facility updated policies and will monitor staff compliance.
F814-F: Waste management policy was implemented to ensure dumpster lids remain closed. Staff were educated and monitoring will be conducted.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 5
Date: Jun 5, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to include non-pharmacological pain interventions in a resident's care plan, inadequate grooming assistance for a dependent resident, improper preparation of pureed diets without recipes, unsanitary food preparation practices related to hair and beard restraints and handwashing, and improper garbage disposal leading to pest risks.
Deficiencies (5)
F 0657: The facility failed to include non-medical interventions for pain in Resident 29's care plan despite documented pain and prescribed medications.
F 0677: The facility failed to ensure Resident 30 received grooming per his usual preference, despite decline in condition and resistive behaviors.
F 0804: The facility failed to prepare pureed diets consistent with required recipes for three residents, risking nutritional value and vitamin preservation.
F 0812: The facility failed to prepare food under sanitary conditions due to improper use of hair restraints, beard restraints, and cross contamination following handwashing.
F 0814: The facility failed to maintain and dispose of garbage properly, with open dumpster lids allowing potential pest harborage and contamination.
Report Facts
Residents present: 34
Residents sampled: 13
Residents reviewed for unnecessary medications: 5
Residents identified receiving pureed diets: 3
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 5
Date: Jun 5, 2024
Visit Reason
The inspection was conducted as a Health Resurvey and investigation of complaint #187243 at Cumbernauld Village.
Complaint Details
The visit was triggered by complaint #187243. The findings represent a Health Resurvey and complaint investigation.
Findings
The facility was found deficient in multiple areas including failure to revise a resident's care plan to include non-pharmacological pain interventions, inadequate grooming care for a dependent resident, failure to prepare pureed diets according to required recipes, unsanitary food preparation practices, and improper disposal of garbage leading to pest risks.
Deficiencies (5)
F 657 Care Plan Timing and Revision: The facility failed to review and revise Resident 29's care plan to include non-pharmacological interventions for pain.
F 677 ADL Care Provided for Dependent Residents: The facility failed to ensure Resident 30 received grooming per his usual preference, despite care plan instructions.
F 804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to prepare pureed diets consistent with required recipes to ensure nutritional value and vitamin preservation for three residents.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to prepare food under sanitary conditions, including improper use of hair and beard restraints and cross contamination following handwashing.
F 814 Dispose Garbage and Refuse Properly: The facility failed to maintain and dispose of garbage properly, with dumpster lids left open, risking pest harborage and contamination.
Report Facts
Resident census: 34
Residents sampled: 13
Residents reviewed for unnecessary medications: 5
Acetaminophen dosage: 325
Acetaminophen dosage: 500
Dates of assessments: Admission MDS 09/22/23, Quarterly MDS 03/08/24, Care Plan reviewed 05/10/24.
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The licensure resurvey was conducted as a renewal inspection of the assisted living facility on 06/29/2023.
Findings
The inspection resulted in no deficiency citations being found at the facility.
Inspection Report
Renewal
Deficiencies: 0
Date: 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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 2, 2023
Visit Reason
An onsite revisit survey was conducted to verify correction of all previous deficiencies cited on 03/02/23.
Findings
All deficiencies 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.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 9, 2023
Visit Reason
The document is a Plan of Correction submitted by the facility to address deficiencies related to Abuse/Neglect/Exploitation (ANE) reporting.
Findings
The facility implemented corrective actions including staff education on ANE reporting, mandatory inservice training, competency testing, and ongoing monitoring to prevent recurrence of failure to report ANE immediately.
Deficiencies (1)
F610: A sign was posted instructing direct care staff to stop and not clock in until they received information about ANE at the Nursing Station. Staff were required to read and sign an ANE information page prior to clocking in.
Report Facts
Employees spoken to weekly: 4
Residents spoken to weekly: 2
Employees spoken to biweekly: 4
Residents spoken to biweekly: 2
Employees spoken to monthly: 2
Residents spoken to monthly: 1
Employees spoken to monthly: 1
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Mar 2, 2023
Visit Reason
A partial extended complaint survey was conducted due to allegations of abuse and mistreatment involving multiple residents and staff.
Complaint Details
The complaint investigation revealed three abuse incidents witnessed by staff involving CNA M and residents R1, R3, and R4, which were not reported until 14 and 7 days after the incidents. The failure to report placed residents in immediate jeopardy.
Findings
The facility failed to ensure staff reported alleged abuse and mistreatment incidents in a timely manner, resulting in immediate jeopardy to residents. Three separate abuse incidents involving a certified nursing aide were witnessed but not reported promptly, allowing the abusive staff member to continue working for 14 days after the first incident.
Deficiencies (1)
F610: The facility failed to ensure all alleged violations of abuse and mistreatment were reported to administrative staff in a timely manner, placing residents at risk of ongoing abuse and mistreatment.
Report Facts
Resident census: 35
Days abuse not reported: 14
Days abuse not reported: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named as the staff member who committed abuse and mistreatment |
| CNA N | Certified Nurse Aide | Witnessed abuse incidents and failed to report in a timely manner |
| CNA O | Certified Nurse Aide | Witnessed abuse incidents and failed to report in a timely manner |
| CNA R | Certified Nurse Aide | Witnessed verbal abuse incident and did not report |
| Administrative Nurse B | Administrative Nurse | Provided Immediate Jeopardy template and explained reporting expectations |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 11/17/2022.
Findings
All deficiencies 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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 11/17/2022.
Findings
All deficiencies cited in the prior inspection have been corrected as of 12/05/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 3
Date: Nov 17, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with care planning, oral hygiene, accident prevention, and wheelchair safety standards at the nursing home.
Findings
The facility failed to adequately review and revise care plans for residents regarding wheelchair foot pedal use, failed to provide adequate oral hygiene care for dependent residents, and did not ensure foot pedals were used on wheelchairs to prevent accidents during transport.
Deficiencies (3)
F 0657: The facility failed to review and revise care plans to include interventions for foot pedal use on wheelchairs to ensure resident safety during transport.
F 0677: The facility failed to provide adequate oral hygiene care for two dependent residents, resulting in significant buildup and inflammation.
F 0689: The facility failed to ensure foot pedals were used on wheelchairs to prevent accidents while propelling three residents.
Report Facts
Census: 34
Residents selected for review: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Named in findings related to wheelchair transport and foot pedal use |
| Certified Nurse Aide N | Certified Nurse Aide | Named in findings related to wheelchair transport and oral hygiene care |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding care plan expectations and wheelchair transport policies |
| Administrative Nurse E | Administrative Nurse | Responsible for updating care plans and provided statements on foot pedal use |
| Certified Medication Aide R | Certified Medication Aide | Named in findings related to wheelchair transport and foot pedal use |
| Certified Nurse Aide O | Certified Nurse Aide | Named in findings related to wheelchair transport and foot pedal use |
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 3
Date: Nov 17, 2022
Visit Reason
The inspection was a health resurvey to assess compliance with previously identified deficiencies and overall resident care.
Findings
The facility failed to review and revise care plans to include interventions for wheelchair foot pedal use for three residents, resulting in potential foot/leg injury risks. Additionally, the facility failed to provide adequate oral hygiene care for two dependent residents and did not ensure safe wheelchair transport by not providing foot pedals for three residents.
Deficiencies (3)
F 657 Care Plan Timing and Revision: The facility failed to review and revise care plans for two residents to include interventions for foot pedal use on wheelchairs to prevent foot/leg injury during transport.
F 677 ADL Care Provided for Dependent Residents: The facility failed to provide adequate oral hygiene care for two dependent residents, resulting in poor oral health and hygiene.
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure foot pedals were provided and used on wheelchairs for three residents to prevent accidents and injury during transport.
Report Facts
Deficiency cited: 3
Residents sampled: 16
Residents reviewed for accidents: 5
Facility census: 34
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 20, 2022
Visit Reason
A revisit survey was conducted on 01/19/2022 and 01/20/2022 to verify correction of all previous deficiencies cited on 12/01/2021.
Findings
All deficiencies cited in the previous inspection have been corrected as 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
Date: Dec 24, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection related to the use of Hoyer lifts and resident care plans.
Findings
The facility identified issues with the care plans regarding the use of Hoyer lifts for non-ambulatory, non-weight bearing residents and has implemented corrective actions including care plan revisions, staff training, and monitoring procedures to prevent recurrence.
Deficiencies (1)
F689-G: Resident care plan was deficient in specifying Hoyer lift use and mobility status. The plan has been revised to clarify Hoyer lift use and mobility levels for affected residents.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Dec 1, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of improper resident transfer and injury.
Complaint Details
The investigation was triggered by complaint investigation #167397 and #167412. The complaint involved failure to use proper transfer devices and supervision leading to injury.
Findings
The facility failed to ensure staff transferred a resident using a mechanical lift as required, resulting in the resident being lowered to the floor and subsequently diagnosed with bilateral distal femur fractures requiring surgery.
Deficiencies (1)
F 689: The facility failed to ensure staff transferred the resident appropriately with a mechanical lift when standing her at a grab bar in the shower room, resulting in the resident being assisted to the floor and not using the mechanical lift to move her off the floor. The resident sustained bilateral distal femur fractures requiring surgical intervention.
Report Facts
Resident census: 38
Medication dosage: 325
Pain scale: 7
Pain scale: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Assessed resident after fall and noted pain and inability to move legs |
| Certified Medication Aide R | Certified Medication Aide | Involved in showering and transferring resident when fall occurred |
| Certified Nurse Aide N | Certified Nurse Aide | Assisted in transferring resident and lowering her to the floor |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted in showering and transferring resident |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding transfer procedures 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 | Provided hospital admission and pain assessment details |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 19, 2021
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2021-03-17.
Findings
All deficiencies have been corrected as of the compliance date of 2021-04-20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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 have been corrected as of the compliance date of 04/20/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 1
Date: Mar 17, 2021
Visit Reason
The visit was a health resurvey to assess compliance with medication administration regulations following prior findings.
Findings
The facility failed to administer the correct dosage of Albuterol sulfate medication to a resident due to a mismatch between the medication on hand and the physician's order. Staff did not verify the medication matched the order before administration, resulting in incorrect dosing.
Deficiencies (1)
F 757 Drug Regimen is Free from Unnecessary Drugs. The facility failed to administer the correct dosage of Albuterol sulfate to Resident 6 due to a medication mismatch and lack of verification before administration.
Report Facts
Resident census: 32
Medication doses administered: 20
Medication doses remaining: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Confirmed medication mismatch and notified pharmacy |
| CMA R | Certified Medication Aide | Prepared medication and identified mismatch |
| Consultant staff GG | Confirmed pharmacy sent incorrect medication | |
| Administrative Nurse D | Administrative Nurse | Provided expectation for medication verification |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
The visit was a special infection control survey for COVID-19 conducted at the facility.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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: 1
Date: Jun 16, 2020
Visit Reason
This document is a plan of correction submitted in response to a COVID-19 survey conducted at the facility.
Findings
The facility was found to be deficiency free in the COVID-19 survey conducted on 06/16/2020.
Deficiencies (1)
F0000: Deficiency free COVID-19 survey conducted on 06/16/2020.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 5, 2019
Visit Reason
The document is a plan of correction submitted in response to a health survey and complaint investigation #138204 for a long term care facility.
Findings
The health survey and complaint investigation resulted in no deficiency citations related to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 5, 2019
Visit Reason
The inspection was conducted as a health survey and complaint investigation for the facility.
Complaint Details
Complaint investigation #138204 was conducted and found no deficiencies.
Findings
The investigation resulted in no deficiency citations related to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 24, 2019
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection or deficiency report for the facility identified as State ID N018009.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a record of the Plan of Correction submission with no additional content provided.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 11, 2019
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
All previously cited deficiencies were corrected as of the revisit date. Each deficiency is identified by regulation number and marked as completed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 11, 2019
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 listed by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for each deficiency.
Inspection Report
Re-Inspection
Census: 17
Deficiencies: 9
Date: Jan 8, 2019
Visit Reason
The visit was a resurvey of the residential health care facility conducted on 1/2/19, 1/3/19, 1/7/19, and 1/8/19 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including admission policies, functional capacity screening, provision and coordination of health care services, delegation of nursing duties, medication self-administration and management, verbal order documentation, and emergency preparedness. Several residents' records lacked required documentation and assessments, and the facility failed to ensure proper delegation and oversight of medication administration.
Deficiencies (9)
KAR 26-39-102(a)(2)(3) Admission Policy: Administrator failed to ensure residents or their legal representatives were informed in writing of rates, charges, and obligations before admission and failed to execute a detailed written admission agreement.
KAR 26-41-201(a) Functional Capacity Screen on Admission: Licensed nurse failed to record findings on residents' functional capacity screening forms according to department specifications.
KAR 26-41-204(a) Health Care Services: Administrator failed to ensure licensed nurse provided or coordinated necessary health care services in accordance with functional capacity screening and negotiated service agreements for sampled residents.
KAR 26-41-204(c) Health Care Services: Administrator failed to ensure health care services provided or coordinated by licensed nurse only included authorized personal care and supervised nursing care.
KAR 26-41-204(e) Delegation of Duties: Administrator failed to ensure licensed nurse delegated glucometer testing to certified medication aides according to Kansas nurse practice act.
KAR 26-41-205(a)(1) Self Administration of Medication: Licensed nurse failed to assess and determine resident's ability to safely and accurately self-administer selected medications prior to and annually.
KAR 26-41-205(b) Administration of Selected Medications: Negotiated service agreement did not reflect resident stored and self-administered selected medications while remainder were managed by qualified staff.
KAR 26-41-205(e) Medication Verbal Orders and Standing Orders: Licensed nurse failed to ensure all verbal orders were signed by medical care provider within 7 days of receipt.
KAR 26-41-104(d)(3) Disaster and Emergency Preparedness: Administrator failed to ensure quarterly review of the facility's emergency management plan with employees and residents.
Report Facts
Census: 17
Telephone orders unsigned: 5
Telephone orders unsigned: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Named in multiple findings including admission policy failures, health care service coordination, and delegation issues. | |
| Licensed nurse C | Licensed Nurse | Interviewed regarding functional capacity screening, health care service plans, medication administration, and delegation. |
| Licensed nurse D | Licensed Nurse | Signed health care service plans and medication administration records. |
| Medical records director H | Medical Records Director | Interviewed about admission agreements and facility policies. |
| Certified medication aide F | Certified Medication Aide | Interviewed regarding resident care and glucometer testing. |
| Certified medication aide E | Certified Medication Aide | Interviewed regarding glucometer testing. |
| Certified medication aide G | Certified Medication Aide | Interviewed regarding resident mobility assistance. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 21, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-08-29.
Findings
All deficiencies cited in the prior inspection were corrected by the compliance date of 2018-09-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 21, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-08-29.
Findings
All deficiencies cited in the prior inspection were corrected by the compliance date of 2018-09-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Sep 7, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection report dated 08/29/2018.
Findings
The Plan of Correction outlines corrective actions for deficiencies related to fall incident monitoring, urinary catheter securement, and dietary department practices including trash can placement and plate handling procedures.
Deficiencies (3)
F675-D: Resident affected by a fall with head injury did not have hourly checks documented for 72 hours, though the resident recovered with no adverse outcome.
F690-D: Suprapubic catheter was not anchored to the thigh with a securement device at all times as required.
F812-F: Dietary staff improperly handled plates from the warming unit and used an inappropriate trash can by the handwashing sink.
Report Facts
Deficiencies cited: 3
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: 1
Date: Aug 29, 2018
Visit Reason
The visit 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.
Deficiencies (1)
The facility had a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 29, 2018
Visit Reason
The visit 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.
Deficiencies (1)
The facility had a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 3
Date: Aug 29, 2018
Visit Reason
Annual health resurvey conducted to assess compliance with quality of life, incontinence care, catheter care, and food safety regulations.
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, and failed to maintain sanitary food handling and serving practices.
Deficiencies (3)
F 675 Quality of life: The facility failed to monitor hourly neurochecks for a resident following a fall with head injury as ordered by the physician.
F 690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide proper securement of catheter tubing for a resident with a suprapubic catheter to prevent site trauma.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to store, prepare, and serve food under sanitary conditions, including lack of a step-on trash can lid and staff touching clean plates with bare hands.
Report Facts
Resident census: 42
Residents sampled: 12
Residents sampled: 13
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 10, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Cumbernauld Village Nursing Facility.
Findings
No deficiencies were cited in the referenced inspection report.
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 10, 2017
Visit Reason
The Health Licensure Resurvey was conducted as a renewal inspection of the facility's license.
Findings
The inspection resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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 related inspection report, so no corrective actions were required.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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 no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 2, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously cited deficiencies, including those under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h), were corrected as of the revisit date.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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, indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had "D" level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 2, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as indicated in the CMS-2567 and Plan of Correction.
Findings
The revisit confirmed that all previously cited deficiencies, including those under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h), were corrected as of the revisit date.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 2, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found 'D' level deficiencies indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signer of the report letter. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 1, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies related to elopement risks at the facility following a complaint investigation.
Findings
The facility identified deficiencies regarding the admission and management of residents at risk for elopement. The plan outlines corrective actions to prevent admission of residents with elopement risk to the Health Care Unit and procedures for monitoring and reporting any elopement incidents.
Deficiencies (2)
F225D: The facility will report any elopement immediately to the State Agency and will not admit residents at risk for elopement to the Health Care Unit, including those transferring from other care areas. Admission policies include notifying residents or their legal representatives about the facility's inability to care for high elopement risk residents due to physical layout.
F323D: The facility policy was revised to clarify that residents at high risk for elopement, regardless of prior residence area, will not be admitted to the Health Care Unit. Residents who develop elopement risk after admission will be assisted to transfer to a more appropriate facility.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: 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.
Complaint Details
Complaint investigation #106859 focused on allegations that the facility failed to investigate and report incidents of a resident eloping. The complaint was substantiated as the facility did not notify the state agency or conduct a thorough investigation of the resident's elopements on 9/30/16 and 10/2/16.
Findings
The facility failed to thoroughly investigate and report two occasions of a confused, mobile resident leaving the facility without staff knowledge. The facility also failed to ensure adequate supervision to prevent the resident from leaving unsupervised, despite the resident being identified as a high elopement risk.
Deficiencies (2)
F225: The facility failed to investigate and report to the state agency two incidents of a confused resident eloping without staff knowledge.
F323: The facility failed to provide adequate supervision and accident hazard prevention to stop a confused, mobile resident from leaving the facility without staff knowledge.
Report Facts
Resident census: 39
Resident sample for elopement: 3
BIMS score: 5
Mood score: 10
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 11, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report shows that previously reported deficiencies under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiency corrected as of 06/11/2015.
Regulation 483.25(h): Previously cited deficiency corrected as of 06/11/2015.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 11, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously reported under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) were corrected as of the revisit date.
Deficiencies (2)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jun 11, 2015
Visit Reason
The document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection related to careplan interventions, storage room security, and fall prevention.
Findings
The facility identified deficiencies in careplan intervention documentation and implementation, unsecured storage rooms posing hazards, and inadequate fall prevention measures. Corrective actions include policy revisions, locking mechanisms changes, staff assignments, and ongoing monitoring.
Deficiencies (3)
F280-D: Careplan interventions were not consistently documented and carried out. Policy was revised to include secondary review and monitoring of careplan changes.
F323-E: Storage rooms containing hazards were not properly secured. Locks were changed and monitoring procedures established to ensure proper locking.
Careplan interventions to protect residents from injury related to falls were not properly initiated or documented. Direct staff assignments and monitoring were implemented to ensure compliance.
Report Facts
Corrective action completion date: Jun 11, 2015
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 5, 2015
Visit Reason
The visit was an assisted living resurvey to assess compliance and verify correction of previous deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Enforcement
Deficiencies: 1
Date: Jun 5, 2015
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found 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.
Deficiencies (1)
The facility had an 'E' level deficiency pattern that constitutes no actual harm but has potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 2
Date: Jun 5, 2015
Visit Reason
Health re-survey with complaint investigation #74314 to assess compliance with care planning and accident prevention requirements.
Complaint Details
The inspection was a health re-survey with complaint investigation #74314.
Findings
The facility failed to review and revise the care plan for a resident with repeated falls and failed to provide an environment free of accident hazards for confused and mobile residents. Multiple unsecured chemicals and biohazards were found accessible. The facility also failed to implement adequate supervision and assistive devices to prevent repeated falls for a dependent resident who experienced seven falls.
Deficiencies (2)
F 280: The facility failed to review and revise the plan of care for resident #48 after repeated falls, missing interventions such as pressure sensitive floor mats and private sitters.
F 323: The facility failed to provide an environment free of accident hazards for 11 confused and mobile residents, with unsecured chemicals and biohazards accessible, and failed to ensure adequate supervision and assistive devices to prevent repeated falls for resident #48.
Report Facts
Resident census: 42
Residents reviewed: 13
Fall incidents: 7
Confused and mobile residents: 11
Sharps containers: 3
Fall risk scores: 13
Fall risk scores: 12
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 5, 2015
Visit Reason
This document is a plan of correction related to a prior deficiency report for Cumbernauld Village ALF.
Findings
No specific findings are detailed in this document; it serves as a plan of correction submission with no records found.
Inspection Report
Life Safety
Deficiencies: 1
Date: 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, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for 'F' level deficiencies related to Life Safety Code compliance that were widespread with no immediate jeopardy but potential for more than minimal harm.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Named as facility administrator in the report. |
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Kansas Department for Aging & Disability Services. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Life Safety
Deficiencies: 1
Date: 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, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 26, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the prior CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.25(d), 483.25(j), 483.25(l), 483.30(b), 483.35(i), 483.60(c), and 483.65 were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 24, 2014
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 26-41-101 (k), 26-41-202 (a), and 26-41-206 (e)(1) were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 7
Date: Feb 28, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including catheter care and prevention of urinary tract infections, hydration management, unnecessary drug use, registered nurse coverage, food sanitation, pharmacy consultant oversight, and infection control program implementation.
Deficiencies (7)
F 315: The facility failed to provide appropriate treatment and services to reduce the risk of urinary tract infections and catheter dislodgement for a resident with a suprapubic catheter.
F 327: The facility failed to offer hydration as planned and ensure a fresh water pitcher was available to a resident during waking hours.
F 329: The facility failed to ensure two residents received only necessary medications, including inadequate bowel monitoring and inappropriate insulin administration.
F 354: The facility failed to provide registered nurse coverage for at least 8 consecutive hours a day, 7 days a week.
F 371: The facility failed to maintain a clean and sanitary dietary department for food storage, preparation, and service.
F 428: The facility pharmacy consultant failed to monitor and report the need for improved behavior monitoring and excessive laxative use for a resident.
F 441: The facility failed to implement an effective infection control program to identify and track infections and prevent transmission to residents.
Report Facts
Resident census: 41
Sample size: 12
Residents reviewed for unnecessary medications: 5
Days lacking RN coverage: 29
Residents with infections identified in 3 months: 10
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 7
Date: Feb 28, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with previously identified deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including catheter care leading to UTI risk, hydration management, unnecessary drug use, insufficient RN coverage, unsanitary food preparation conditions, inadequate pharmacy oversight, and ineffective infection control program.
Deficiencies (7)
F 315: The facility failed to provide appropriate treatment and services to reduce the risk of urinary tract infections and catheter dislodgement for a resident with a suprapubic catheter.
F 327: The facility failed to offer hydration as planned and ensure water pitchers were available to a resident throughout the day.
F 329: The facility failed to ensure two residents received only necessary medications, including failure to notify physician of ineffective laxative use and improper insulin administration.
F 354: The facility failed to provide registered nurse coverage for at least 8 consecutive hours a day, 7 days a week.
F 371: The facility failed to maintain a clean and sanitary dietary department for food storage, preparation, and service.
F 428: The facility pharmacy consultant failed to monitor and report the need for improved behavior monitoring and excessive laxative use for a resident.
F 441: The facility failed to implement an effective infection control program to prevent transmission of infections and to track infections adequately.
Report Facts
Resident census: 41
Sample residents reviewed: 12
Residents reviewed for unnecessary medications: 5
Days lacking RN coverage: 28
Residents with infections identified in 3 months: 10
Inspection Report
Follow-Up
Deficiencies: 7
Date: Apr 9, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2012-12-21.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date 2013-04-09.
Deficiencies (7)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected by 2013-04-09.
Regulation 483.20(b)(2)(ii) deficiency was corrected by 2013-04-09.
Regulation 483.20(d), 483.20(k)(1) deficiency was corrected by 2013-04-09.
Regulation 483.20(d)(3), 483.10(k)(2) deficiency was corrected by 2013-04-09.
Regulation 483.20(f) deficiency was corrected by 2013-04-09.
Regulation 483.25(h) deficiency was corrected by 2013-04-09.
Regulation 483.75(o)(1) deficiency was corrected by 2013-04-09.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 5, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report confirms that the previously cited deficiencies under regulations 26-41-204 (b) and 26-41-204 (g)(h) were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-204 (b): Previously cited deficiency has been corrected as of 04/05/2013.
Regulation 26-41-204 (g)(h): Previously cited deficiency has been corrected as of 04/05/2013.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 12, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of an assisted living facility.
Findings
The plan addresses issues including resident refusal to wear TED hose, management of constipation, and ensuring physician approval for transfer orders before new admissions. Corrective actions include individualized care plans, weekly reviews, and administrator oversight of new admissions.
Deficiencies (2)
S3170-D: Resident #1 TED hose use was discussed; resident does not always want to wear them. Resident and DPOA signed AMA agreeing to wear them when chosen. Management of constipation was added as a specific plan of care for Resident #4.
S3456-D: Corrections were made with physician orders received the day after transfer from another facility. New admissions transferring from another facility are at risk without physician approval of transfer orders.
Report Facts
Plan of Correction completion date: Apr 5, 2013
Plan of Correction completion date: Mar 7, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 18
Deficiencies: 2
Date: Mar 7, 2013
Visit Reason
This inspection was a non-compliant revisit to verify 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 two residents, including management of supplemental oxygen and constipation. Additionally, the facility failed to obtain admission physician orders for one resident for symptom and medication management.
Deficiencies (2)
26-41-204 (b) Health Care Services: The facility failed to develop a health care service plan for two residents, including management of supplemental oxygen and application of T.E.D. hose, and constipation monitoring and management.
26-41-204 (g) (h) Health Care Services: The facility failed to obtain admission physician orders for one resident for symptom and medication management.
Report Facts
Resident census: 18
Residents reviewed: 3
Days without bowel movement documentation: 6
Days without bowel movement documentation: 7
Hours delay for physician order fax: 28.45
Hours delay for 30-minute checks documentation start: 23
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 7, 2013
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies from the initial survey conducted on 2013-01-02.
Findings
The report documents that the previously identified deficiency under regulation 26-41-206 (c) with ID prefix S3295 was corrected as of 2013-03-07.
Deficiencies (1)
Regulation 26-41-206 (c) deficiency previously cited was corrected by the revisit date of 2013-03-07.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 7, 2013
Visit Reason
This is a revisit inspection to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency under regulation 26-41-206 (c) was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-41-206 (c) deficiency was corrected as of 2013-03-07.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 7
Date: Mar 1, 2013
Visit Reason
Revisit inspection to evaluate compliance with previously cited deficiencies related to resident neglect, abuse investigations, care plan development, Minimum Data Set (MDS) assessments, and fall prevention.
Findings
The facility failed to thoroughly investigate and report allegations of neglect and resident-to-resident abuse, complete significant change assessments, develop individualized care plans, maintain timely MDS transmissions, and provide adequate supervision and interventions to prevent repeated falls for cognitively impaired residents. The quality assurance committee failed to implement effective plans to address these issues.
Deficiencies (7)
F225: Facility failed to thoroughly investigate and report allegations of neglect and resident-to-resident abuse for 2 residents with multiple falls and incidents.
F274: Facility failed to complete a comprehensive significant change assessment for a resident who declined in ability and entered palliative care.
F279: Facility failed to develop individualized comprehensive care plans with measurable objectives for 2 residents requiring range of motion interventions.
F280: Facility failed to review and revise the plan of care for a resident to discontinue unnecessary medications and lacked a policy for care plan revisions.
F287: Facility failed to maintain a system to ensure timely transmission of Minimum Data Set assessments for 2 residents.
F323: Facility failed to provide adequate supervision, assistive devices, and effective interventions to prevent multiple repeated falls for 2 cognitively impaired residents with a history of falls.
F520: Facility failed to maintain an effective quality assurance committee that developed and implemented plans to correct identified quality deficiencies related to resident care and behavior.
Report Facts
Resident census: 39
Resident falls: 9
Resident falls: 4
Fall risk assessment score: 43
Fall risk assessment score: 41
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 1, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously identified deficiencies were corrected by the date of the revisit.
Deficiencies (6)
Regulation 483.10(i)(1) deficiency was corrected by 03/01/2013.
Regulation 483.25(e)(2) deficiency was corrected by 03/01/2013.
Regulation 483.25(i) deficiency was corrected by 03/01/2013.
Regulation 483.25(l) deficiency was corrected by 03/01/2013.
Regulation 483.35(i) deficiency was corrected by 03/01/2013.
Regulation 483.60(c) deficiency was corrected by 03/01/2013.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 1, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies identified on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 29, 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 for constipation and medication management, and sanitary concerns in dietary services including cleaning procedures and food storage.
Deficiencies (2)
Tag S3156-D: Resident #3's occasional constipation and Resident #2's Coumadin medication have been added to their Negotiated Service Agreements. The Director of Nursing will review Service Agreements and Plans of Care quarterly and with any health status change.
Tag S3296-F: Corrective action includes education and policy enactment for dietary staff on cleaning procedures, food covering, and monitoring expiration dates. The ice machines will be cleaned by a contracted company with reports provided to the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Voth | Administrator | Named as submitting the Plan of Correction and responsible for oversight. |
Inspection Report
Renewal
Census: 18
Deficiencies: 2
Date: Jan 2, 2013
Visit Reason
The inspection was a licensure resurvey to assess compliance with health care service planning, dietary services, and sanitary conditions in the assisted living facility.
Findings
The facility failed to develop health care service plans for residents needing constipation and blood thinner medication monitoring. Additionally, the facility did not store, prepare, and serve food in a sanitary manner, including uncovered desserts, expired milk, unclean spice bottles, and unsanitary ice machines.
Deficiencies (2)
26-41-204 (b) Health Care Services: The facility failed to develop health care service plans for two residents, including management of constipation and monitoring of blood thinner medication.
26-41-206 (c) Dietary Services Menus: The facility failed to store, prepare, and serve food in a sanitary manner, including uncovered desserts, expired milk, unclean spice bottles, and unsanitary ice machines.
Report Facts
Resident census: 18
Expired milk bottles: 4
Opened spice bottles: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff J reported on food storage and sanitation issues | ||
| Direct care staff W and licensed nursing staff K acknowledged lack of planned orders for constipation management |
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 9
Date: Dec 21, 2012
Visit Reason
Re-survey of a health facility to assess compliance with previously cited deficiencies and review medication and care plan issues.
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, failure to develop individualized care plans, failure to provide restorative services, unsafe environment due to loose bed rails, failure to maintain nutritional status, and failure to monitor and act on medication-related black box warnings.
Deficiencies (9)
F170: The facility failed to deliver mail to residents on Saturdays as required, violating residents' right to privacy in written communications.
F225: The facility failed to thoroughly investigate and report a fall resulting in a fractured hip for a resident, and did not complete witness statements or timely report to the state agency.
F279: The facility failed to develop individualized care plans for residents related to sleep hygiene, anti-anxiety medication use, and restorative services.
F318: The facility failed to provide appropriate restorative services and range of motion exercises to prevent further decline in residents' physical function.
F323: The facility failed to maintain a safe environment free from entrapment hazards due to loose and gapping bed rails for a resident.
F325: The facility failed to ensure a resident maintained acceptable nutritional status, with significant unplanned weight loss and delayed implementation of physician-ordered nutritional interventions.
F329: The facility failed to monitor and act upon adverse consequences associated with medications containing black box warnings for multiple residents, including failure to follow pharmacist recommendations for dose reduction of unnecessary medications.
F371: The facility failed to store, prepare, and serve food under sanitary conditions, including uncovered desserts, expired milk, unclean spice bottles, and unsanitary ice machines.
F428: The facility failed to ensure monthly pharmacist drug regimen reviews were acted upon, including failure to monitor and address adverse effects of medications with black box warnings for multiple residents.
Report Facts
Resident census: 42
Weight loss: 54
Milk expiration: 4
Opened spice bottles: 48
Medication doses missed: 13
Inspection Report
Follow-Up
Deficiencies: 5
Date: Oct 17, 2011
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 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)
Regulation 483.10(b)(11): Previously cited deficiency corrected as of 10/17/2011.
Regulations 483.20(d)(3) and 483.10(k)(2): Previously cited deficiencies corrected as of 10/17/2011.
Regulation 483.25(h): Previously cited deficiency corrected as of 10/17/2011.
Regulation 483.35(c): Previously cited deficiency corrected as of 10/17/2011.
Regulation 483.35(i): Previously cited deficiency corrected as of 10/17/2011.
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 5
Date: Sep 29, 2011
Visit Reason
The visit was a health resurvey to assess compliance with federal regulations following a prior inspection.
Findings
The facility failed to notify the physician and responsible party of a resident injury, failed to revise the care plan after an accident, and did not ensure the resident's environment was free from accident hazards. Additionally, the facility failed to follow the planned menu portion sizes and did not maintain sanitary food preparation and handling practices.
Deficiencies (5)
483.10(b)(11) The facility failed to notify the physician and responsible party of an injury to resident #35 after an accident.
483.20(d)(3), 483.10(k)(2) The facility failed to review and revise the care plan for resident #35 after an accident to prevent future incidents.
483.25(h) The facility failed to ensure resident #35's environment was free from accident hazards and failed to investigate a fall to determine causal factors.
483.35(c) The facility failed to serve the planned portion sizes of food as per the dietician's menu, affecting all 41 residents.
483.35(i) The facility failed to maintain sanitary food preparation and handling practices, including improper sanitizing of surfaces and improper glove use, affecting all 41 residents.
Report Facts
Facility census: 41
Residents sampled: 17
Residents sampled for care areas requiring notification: 7
Residents sampled for care plan review: 8
Residents sampled for accident review: 4
Sanitizer concentration tested: 150
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018009 POC FJ1Z11
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for the facility identified as Aspen with State ID N018009.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N018009 POC JGA311
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection related to medication administration.
Findings
The Plan of Correction outlines corrective actions to ensure proper verification and administration of Albuterol Sulfate treatments, including staff training and monitoring procedures to prevent recurrence of the deficit practice.
Deficiencies (1)
F757-D: The facility failed to verify that the Albuterol Sulfate medication order matched the medication box label, risking incorrect medication administration.
Report Facts
Completion date: Apr 5, 2021
Quality Assurance Committee meeting date: Apr 20, 2021
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: 9
Date: 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 addresses multiple deficiencies including mail delivery delays, incident investigations, individualized care plans, restorative nursing interventions, bedrail safety, weight monitoring, incorporation of black box warnings into care plans, and dietary sanitation concerns.
Deficiencies (9)
F170-B: Saturday mail delivery was delayed until Monday, affecting residents receiving mail. The facility updated policy to ensure Saturday mail is delivered by the 6-2 charge nurse or designated staff.
F225-D: Incidents involving residents were not consistently investigated or reported to the State Agency. Training and procedures were implemented to ensure thorough investigations and timely reporting.
F279-D: Care plans lacked appropriate interventions for residents, including medication and range of motion (ROM) plans. Individualized care plans were developed and electronic tracking was initiated.
F318-D: Residents received restorative nursing interventions for contracture prevention. Assessments and monitoring of ROM services were established with administrative oversight.
F323-D: Loose bedrails posed injury risks. Bedrails were secured, monitored, and staff educated on proper use and reporting procedures.
F325-G: Resident with severe delirium and weight loss was monitored with dietary supplements and hospice care. Weekly weight tracking and intervention oversight were implemented.
F329-E: Black box warnings for medications were incorporated into care plans. Medication reviews and monitoring were established with pharmacist and administrative involvement.
F371-F: Dietary staff received education on sanitation including cleaning procedures and monitoring of food storage and expiration dates. Regular inspections were scheduled.
F428-E: Licensed nurses received inservice education on black box warnings. Monthly pharmacy reviews and care plan updates were instituted to monitor medication risks.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: 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.
Findings
The Plan of Correction outlines multiple policy revisions and systemic changes to address deficiencies related to fall investigations, MDS completion, restorative services, care plan revisions, and reporting protocols. The facility commits to achieving substantial compliance by specified dates in March 2013.
Deficiencies (7)
F225-D: Policy will be revised to ensure all falls are thoroughly investigated including documentation with or without witnesses. All incidents will be reported to the State Agency and corrective actions will be monitored weekly.
F274-D: Policy will be developed to assure proper development and completion of the MDS including Significant Change and Careplan revision. Compliance will be monitored weekly by the Administrator or DON.
F279-D: Policy will be revised for Restorative Services to include written therapist instructions and individualized care plans with defined responsibilities for restorative and direct care staff.
F280-D: Policy will be revised to include reviewing and revising Resident Careplans when changes occur. DON will be notified of medication or physician order changes and compliance will be monitored weekly.
F287-D: Policy will be developed to clarify MDS submittal regulations. The deficit practice could impact all residents and systemic changes include training and supervision of the MDS coordinator.
F323-D: All falls/incidents will be reported ASAP to DPOA and physician, followed by DON or Administrator review. Standard Protocol Interventions for falls will be developed and staff trained accordingly.
F520-F: QA committee suggestions and input will be documented and used to revise policies, careplans, and resident care procedures. Compliance will be measured by documentation.
Report Facts
Corrective action completion date: Mar 27, 2013
Corrective action completion date: Mar 20, 2013
Plan of Correction submission date: Mar 4, 2013
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N018009 POC 3RLD11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection report dated November 17, 2022.
Findings
The Plan of Correction addresses deficiencies related to wheelchair pedal storage and use, oral care practices, and resident dignity. The facility outlines corrective actions, education, monitoring, and completion dates to prevent recurrence of these issues.
Deficiencies (3)
F657: Resident careplans will be revised to include storage and proper use of wheelchair pedals to ensure safety and independence.
F677: Oral care practices will be improved through staff education, assignment of oral care teams, and monitoring to enhance resident dignity.
F689: Wheelchair pedals will be stored in bags and staff educated to ensure pedals are used properly to prevent injury during self-propelling.
Report Facts
Completion Date: Dec 5, 2022
Plan of Correction Committee Meeting Date: Dec 8, 2022
Random Observations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Linda Voth | Administrator | Submitted the Plan of Correction to KDADS. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018009 POC Z4LX11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified by State ID N018009 and Event ID Z4LX11.
Findings
No deficiencies or findings are listed in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: N018009 POC 5BK311
Visit Reason
This document is a Plan of Correction submitted by Cumbernauld Village in response to deficiencies identified 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.
Deficiencies (7)
F315-D: Staff will receive one-on-one training on urinary catheter care, with random monthly checks by the Director of Nursing to ensure compliance.
F327-D: Nursing staff will be trained on proper hydration practices and ensuring water is accessible to residents, with weekly room checks by the Director of Nursing.
F329-D: Medical Records added an Insulin/Accu check schedule; nurses will receive instruction and monthly MAR reviews will be conducted by the Director of Nursing.
F354-F: A part-time Registered Nurse was hired to cover weekend/holiday shifts; the Director and Assistant Director of Nursing will cover shifts as needed, with weekly schedule reviews by the Administrator.
F371-F: Kitchen utensils with baked-on build-up will be discarded; monthly checks by the Dietary Manager will ensure cleanliness or discard of cookware.
F428-D: Consulting Pharmacist will receive EMR training and review medication records monthly with assistance from Medical Records staff.
F441-F: Infection monitoring will be conducted monthly by the Director of Nursing with reports presented at QA meetings to identify infection trends and risks.
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
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N018009 POC 5C7X11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection report.
Findings
The plan outlines corrective actions for posting complaint reporting phone numbers, ensuring medical record updates are communicated and documented, and discarding unclean kitchen utensils and bakeware. Compliance will be monitored through monthly and weekly reviews by designated staff.
Deficiencies (3)
S3085-D: The Kansas Department on Aging and long-term care telephone numbers were not posted in highly visible areas for visitors and residents. Corrective actions include posting these numbers at the front entrance and other locations.
S3299-F: Deficit practice in communication of new physician orders to the Director of Nursing and updating resident care plans. A daily log and weekly reviews will be implemented to ensure accuracy.
S6050-C: Kitchen utensils and bakeware with baked-on build-up or discoloration will be discarded. Monthly checks will ensure cookware cleanliness and replacement as needed.
Report Facts
Corrective action completion dates: Mar 6, 2014
Corrective action completion dates: Mar 10, 2014
Corrective action completion dates: Mar 24, 2014
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018009 POC 5P0511
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified in a prior inspection of the facility.
Findings
The document does not provide specific findings but serves as a corrective action plan addressing previously cited deficiencies.
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