Inspection Reports for El Dorado Operator LLC
900 COUNTRY CLUB LANE, EL DORADO, KS, 67042
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 27, 2018 found no deficiencies and confirmed the facility was in compliance with all regulations surveyed. Prior inspections showed a pattern of deficiencies primarily related to resident care planning, timely reporting and investigation of incidents, and ensuring resident safety, including an elopement event. Complaint investigations substantiated issues such as inadequate nursing assessments, medication administration errors, and lapses in supervision, with one enforcement action involving a denial of payment due to pressure ulcer care deficiencies. Fines, immediate jeopardy findings, or license suspensions were not listed in the available reports. The facility’s inspection history shows improvement over time, with earlier significant deficiencies addressed and the most recent survey confirming compliance.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
25.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
323% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
45 residents
Based on a September 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 27, 2018
Visit Reason
An offsite revisit survey was conducted on 11/27/2018 for all previous deficiencies cited on 09/27/2018.
Findings
All deficiencies have been corrected as of the compliance date of 10/27/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 27, 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 a most serious deficiency at an "E" level, 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 reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-10-27.
Deficiencies (1)
Deficiency at an "E" level, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Named as contact and signatory related to the plan of correction acceptance and enforcement. |
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 7
Date: Sep 27, 2018
Visit Reason
The inspection was a Health Resurvey conducted to evaluate the facility's compliance with regulations following prior deficiencies.
Findings
The facility was found deficient in multiple areas including failure to report alleged violations timely, incomplete investigations of alleged theft, failure to develop and implement baseline and comprehensive care plans timely, failure to revise care plans after incidents, and failure to ensure resident safety resulting in an elopement incident and delayed fall interventions.
Deficiencies (7)
Failure to report alleged theft of $280 from resident #24 to local police and state agency within required timeframe.
Failure to complete a comprehensive investigation into the alleged theft of $280 from resident #24's room.
Failure to develop and implement baseline care plans within 72 hours of admission for residents #4 and #7.
Failure to develop and implement a comprehensive care plan for resident #8, including failure to review and update multiple care plan focus areas by target dates.
Failure to revise resident #39's care plan with interventions after a fall and failure to ensure interdisciplinary team and resident/responsible party review of care plans for residents #4, #7, and #8.
Failure to ensure resident #8's safety resulting in elopement from the facility without staff knowledge and failure to assess resident as at risk for elopement.
Failure to timely evaluate and analyze resident #8's fall and revise fall interventions, resulting in delayed response to fall and injury.
Report Facts
Resident census: 45
Amount missing: 280
Number of sampled residents: 22
Number of residents in fall sample: 14
BIMS score: 15
BIMS score: 9
BIMS score: 13
Bruise size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator Q | Administrator | Notified of missing money incident and investigation for resident #24 |
| Social Services Director | Social Services Director | Confirmed failure to develop baseline care plans within 72 hours and failure to ensure care plan interdisciplinary review |
| Resident Assessment Coordinator | Resident Assessment Coordinator | Confirmed facility policy and failure to develop and review care plans timely |
| Staff Q | Reported searching resident #24's room for missing money | |
| Staff Y | Assisted in searching resident #24's room for missing money | |
| Direct care staff OO | Observed resident #8 elopement and knew resident had fall history | |
| Licensed nursing staff EE | Cared for resident #8 during fall incident and provided interview about fall | |
| Administrative nursing staff JJ | Entered fall intervention for resident #39 |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Sep 24, 2018
Visit Reason
The plan of correction addresses deficiencies identified in a prior inspection related to a report of missing money from resident #24 and care plan reviews for residents #4, #7, #8, and #39.
Findings
The report details corrective actions including re-education of staff on reporting abuse and neglect, resident safety regarding valuables, and care plan review and updates for multiple residents. The facility implemented monitoring and re-education plans to ensure compliance and resident safety.
Deficiencies (3)
Report of resident #24 missing money and related staff re-education on abuse and neglect reporting.
Care plan reviews and updates for residents #4, #7, #8, and #39 with re-education of staff on care plan procedures.
Resident #39 care plan reviewed and revised; education on fall precautions and care plan interventions.
Report Facts
Re-education completion date: Oct 12, 2018
Resident interviews: 3
Care plan review frequency: 3
Care plan review update dates: Oct 5, 2018
Care plan review update date: Oct 10, 2018
Inspection Report
Follow-Up
Deficiencies: 13
Date: Apr 5, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each deficiency fully identified by regulation number and marked as completed.
Deficiencies (13)
Deficiency identified by regulation 483.10(f)(5)(iv)(A)(B)
Deficiency identified by regulation 483.10(i)(2)
Deficiency identified by regulation 483.20(d);483.21(b)(1)
Deficiency identified by regulation 483.25(e)(1)-(3)
Deficiency identified by regulation 483.25(c)(2)(3)
Deficiency identified by regulation 483.45(d)(e)(1)-(2)
Deficiency identified by regulation 483.60(i)(1)-(3)
Deficiency identified by regulation 483.45(a)(b)(1)
Deficiency identified by regulation 483.45(c)(1)(3)-(5)
Deficiency identified by regulation 483.45(b)(2)(3)(g)(h)
Deficiency identified by regulation 483.80(a)(1)(2)(4)(e)(f)
Deficiency identified by regulation 483.90(i)(5)
Deficiency identified by regulation 483.90(i)(2)
Report Facts
Deficiencies corrected: 13
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 8, 2017
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 'F' level, 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 April 5, 2017.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date of substantial compliance: Apr 5, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to enforcement and compliance |
Inspection Report
Routine
Census: 39
Deficiencies: 13
Date: Mar 8, 2017
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements related to resident grievances, housekeeping, maintenance, care planning, medication administration, infection control, and environmental safety.
Findings
The facility failed to act on resident council grievances regarding housekeeping and supplies, maintain sanitary and comfortable living conditions, develop comprehensive care plans for urinary catheter care, provide necessary restorative services, monitor medications with black box warnings, ensure proper medication administration, maintain sanitary food service and storage, and uphold infection control and environmental safety standards.
Deficiencies (13)
Failed to act upon resident council grievances regarding housekeeping and needed supplies in resident rooms/areas.
Failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 20 of 38 resident rooms and the beauty shop.
Failed to develop a comprehensive care plan for urinary indwelling catheter treatment and services for one resident.
Failed to ensure necessary treatment and services for urinary catheter care including tubing off the floor and adequate anchoring to prevent urethral trauma.
Failed to provide appropriate treatment and services to prevent further decrease in range of motion following therapy discharge for one resident.
Failed to monitor for unnecessary medications including failure to monitor black box warnings, bowel movements, and pulse prior to antihypertensive medication administration for three residents.
Failed to store, prepare, distribute and serve food under sanitary conditions in the kitchen.
Failed to ensure correct administration of inhaler and eye drops for two residents.
Failed to conduct monthly drug regimen review to identify irregularities related to unnecessary medications and black box warnings.
Failed to ensure appropriate storage of medications off the floor and failed to monitor for expired medications, including expired medications found in the medication refrigerator.
Failed to maintain an effective infection control program including proper storage of urine specimen equipment, changing gloves during dressing changes, adequate room cleaning, and keeping linens off the floor.
Failed to provide a safe, functional, sanitary, and comfortable environment in laundry, nursing storage rooms, janitor closets, central supply room, clean linen room, resident water container room, and kitchen.
Failed to maintain a functioning outside exhaust ventilation system in the beauty shop.
Report Facts
Residents present: 39
Resident rooms inspected: 38
Residents sampled: 13
Deficiencies cited: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Activities Staff | Named in relation to resident council grievance handling |
| Staff F | Licensed Nursing Staff | Observed urinary catheter care deficiencies |
| Staff H | Licensed Nursing Staff | Observed failing to change gloves during dressing change |
| Staff J | Direct Care Staff | Observed incorrect inhaler and eye drop administration |
| Staff K | Licensed Nursing Staff | Verified expired medications and medication administration practices |
| Staff M | Dietary Staff | Provided kitchen cleaning schedule and verified kitchen sanitation issues |
| Staff N | Maintenance Staff | Verified environmental and ventilation deficiencies |
| Staff R | Housekeeping Staff | Observed inadequate cleaning and linen handling |
| Staff S | Direct Care Staff | Observed linen handling practices |
| Staff U | Direct Care Staff | Reported urinary catheter tubing should not be on floor |
| Administrative Staff A | Administrative Staff | Verified laundry and environmental concerns |
| Administrative Staff B | Administrative Licensed Nursing Staff | Verified medication and infection control deficiencies |
| Administrative Staff C | Administrative Licensed Nursing Staff | Verified medication and infection control deficiencies |
| Consultant Staff T | Consultant | Provided expert opinion on medication administration and black box warnings |
| OT Staff V | Occupational Therapist | Reported therapy discharge and restorative service recommendations |
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Mar 8, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection on 03/08/2017. It outlines corrective actions taken and planned to address cited deficiencies and ensure compliance with regulatory requirements.
Findings
The plan details multiple deficiencies related to housekeeping, environmental cleanliness, catheter care, medication administration, restorative programming, dietary sanitation, and medication storage. The facility has implemented corrective actions including staff re-education, environmental cleaning, equipment repair, audits, and ongoing monitoring to prevent recurrence and ensure resident safety and quality of care.
Deficiencies (9)
Deficiency related to housekeeping and laundry services affecting quality of living conditions.
Deficiency related to catheter care and care planning for residents with indwelling catheters.
Deficiency related to restorative programming for residents.
Deficiency related to medication administration and management of black box warnings.
Deficiency related to dietary sanitation and food storage.
Deficiency related to medication storage and expired medications.
Deficiency related to room cleaning and linen management.
Deficiency related to cleanliness and maintenance of laundry rooms, storage rooms, and janitor closets.
Deficiency related to ventilation system in the facility beauty shop.
Report Facts
Dates of corrective actions and verifications: Multiple dates ranging from 2017-02-09 to 2017-04-05 for corrective actions and monitoring
Frequency of audits and monitoring: Examples include daily audits x 2 weeks, weekly audits x 4 weeks, monthly audits x 3-4 months
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | CEO | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 20, 2017
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.24 and 483.25(k)(l) have been corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.24, 483.25(k)(l)
Deficiency related to regulation 483.24(a)(2)
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 24, 2017
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 deficiency to be a "D" level deficiency indicating 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 February 20, 2017.
Deficiencies (1)
Most serious deficiency found was a "D" level deficiency constituting 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 and author of the report letter. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jan 24, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Complaint Details
This Plan of Correction is in response to deficiencies cited following a complaint investigation (El Dorado complaint 01242017).
Findings
The facility recognized deficiencies related to resident care including assessment and documentation of change of condition, oral hygiene and denture care, bathing preferences and hygiene care. The Plan of Correction outlines re-education of staff, monitoring, and ongoing quality assurance interventions to address these issues.
Deficiencies (3)
Concerns regarding assessment and documentation of resident change of conditions, notification to PCP, and follow-up clinical documentation.
Issues with oral hygiene care and denture care for residents.
Deficiencies in bathing care and respecting resident bathing preferences.
Report Facts
Plan of Correction completion dates: Feb 10, 2017
Plan of Correction completion date: Feb 20, 2017
QAPI monitoring frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | CEO | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: Jan 24, 2017
Visit Reason
Complaint investigation #109884 was conducted to assess the facility's compliance with care and services provided to residents, focusing on pain management, dialysis, and quality of life.
Complaint Details
The visit was triggered by complaint investigation #109884, which found deficiencies related to inadequate nursing assessments during illness, failure to monitor and document acute illnesses, and failure to provide adequate bathing and personal hygiene services.
Findings
The facility failed to ensure adequate nursing assessments during periods of illness for three residents, failed to monitor and document acute illnesses properly, and did not provide bathing and personal hygiene services as expected for two residents. There were issues with documentation, follow-up with physicians, and resident care, including neglect of oral care and hygiene.
Deficiencies (2)
Failure to ensure adequate nursing assessments during periods of illness for three residents.
Failure to provide bathing and personal hygiene services to maintain personal hygiene for two residents.
Report Facts
Residents reviewed: 3
Census: 37
Baths provided: 1
Baths provided: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff D | Reported resident #1 was fine when left alone but combative during cares | |
| Direct care staff H | Reported resident #1 sometimes needed 2 person transfer and was combative during cares | |
| Licensed nursing staff F | Reported resident #1 was combative and aggressive during cares and confirmed lack of assessments | |
| Administrative nursing staff B | Reported expectations for documentation and bathing sheets, and confirmed deficiencies | |
| Direct care staff G | Assisted resident #3 with cares and reported no cleansing of face, hands, or mouth care provided | |
| Direct care staff E | Reported resident #1 and #3 needs and behaviors during cares |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 20, 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 confirms that the deficiencies previously cited have been corrected as of the revisit date.
Report Facts
Provider / Supplier Identification Number: 175324
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 3, 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 deficiency to be F323, a 'D' level deficiency indicating 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 effective November 20, 2016.
Deficiencies (1)
Deficiency F323, 'D' level deficiency indicating 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 the contact person and complaint coordinator related to the survey findings. |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Nov 3, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #107564, #106315, and #107512.
Complaint Details
The findings represent the results of complaint investigations #107564, #106315, and #107512. The resident left the facility without staff knowledge, indicating a failure in supervision and accident hazard prevention.
Findings
The facility failed to ensure adequate supervision to prevent accidents, as evidenced by a resident with severe cognitive impairment who left the facility unobserved in a wheelchair and traveled approximately 1/4 mile away without staff knowledge. The resident was found safe with no injury, but the incident revealed a deficiency in supervision and elopement risk management.
Deficiencies (1)
Resident #01, not identified as an elopement risk, left the facility without staff knowledge, traveling approximately 1/4 mile in a wheelchair.
Report Facts
Census: 36
Samples reviewed: 3
Elopement risk residents: 2
Distance traveled: 0.25
BIMS score: 6
BIMS score: 12
Temperature: 74
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 30, 2016
Visit Reason
The document is a Plan of Correction submitted in response to a complaint investigation related to an incident involving Resident #01 leaving the premises without notifying facility staff on 10/29/2016.
Complaint Details
Complaint investigation related to an incident on 10/29/2016 involving Resident #01 leaving the facility without notifying staff. The deficiency was substantiated and corrective actions were implemented.
Findings
The facility acknowledged a deficiency related to resident safety and implemented corrective actions including counseling the resident, establishing outdoor privileges based on BIMS scores, and initiating monitoring programs to ensure compliance and resident safety.
Deficiencies (1)
Failure to ensure resident safety related to Resident #01 leaving the premises without notifying staff.
Report Facts
BIMS score thresholds: 13
BIMS score thresholds: 10
BIMS score thresholds: 10
Monitoring period: 2
Plan completion date: Nov 10, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Chief Executive Officer | Met with Resident #01 on 10/30/2016 and submitted the Plan of Correction. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 8, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. A plan of correction was required, and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
Deficiencies found at 'F' level in Life Safety Code compliance
Report Facts
Effective date for denial of payments: Dec 8, 2016
Provider agreement termination date: Mar 8, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 31, 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 had been corrected.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.20(k)(3)(i) and 483.60(b),(d),(e) were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.20(k)(3)(i)
Deficiency related to regulation 483.60(b), (d), (e)
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 13, 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 'E' 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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
Deficiencies cited at 'E' level constituting 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 signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Jul 12, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#102403) regarding medication administration and storage practices at the facility.
Complaint Details
The complaint investigation (#102403) substantiated that medication administration and storage practices did not meet professional standards and regulatory requirements.
Findings
The facility failed to follow professional standards in medication preparation and administration by licensed nursing staff, and failed to maintain medications, including narcotics, in locked compartments as required by policy and law.
Deficiencies (2)
Two licensed nursing staff failed to follow professional standards related to preparation and administration of medications for one resident, including leaving medications unattended and improper administration.
Facility failed to ensure medications, including narcotics, were maintained in locked compartments in accordance with facility policy and state/federal laws.
Report Facts
Census: 35
Medication pills: 5
Medication carts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Licensed Nurse | Administered medications without preparing or setting them up, lacked knowledge of medications administered |
| Nurse C | Registered Nurse | Prepared and set up medications but left them unattended in resident's room |
| Nurse A | Administrative Nurse | Provided medication administration policy and competency checklist |
| Staff E | Certified Medication Aide | Left medication cart unlocked while administering medications |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 12, 2016
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey conducted on or before 07/12/2016.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as GLC El Dorado complaint dated 07/13/2016.
Findings
Deficiencies involved medication administration and securement, with potential to affect all residents. The facility implemented staff in-service training and ongoing medication pass observations to ensure compliance with policies and regulations.
Deficiencies (2)
Deficiency related to medication administration and adherence to the 5 rights of medication administration.
Deficiency related to securement and handling of medication according to facility policy and State/Federal guidelines.
Report Facts
Dates for corrective actions completion: Jul 31, 2016
Dates for staff in-service: Jul 12, 2017
Dates for staff in-service: Jul 18, 2017
Dates for medication cart audits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 31, 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 confirms that the deficiencies previously cited, including one identified by regulation 483.25(h), were corrected as of 03/10/2016.
Deficiencies (1)
Deficiency related to regulation 483.25(h)
Report Facts
Date correction completed: Mar 10, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 3, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to cited deficiencies from a prior inspection, outlining corrective actions to address the issues.
Findings
The facility acknowledged deficiencies related to resident care, specifically involving resident #1, and described multiple corrective actions including reassessment, care plan updates, staff in-services, and implementation of a 'Stop and Watch' program to monitor resident condition changes.
Deficiencies (1)
Deficiency cited related to resident care and safety, including the need for reassessment and care plan interventions for resident #1.
Report Facts
Plan of Correction completion date: Mar 10, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 2, 2016
Visit Reason
An abbreviated survey 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 deficiency to be at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the facility's history of noncompliance on a prior resurvey, no opportunity to correct deficiencies before remedies are imposed was given.
Deficiencies (1)
Deficiencies constituting a level of actual harm that is not immediate jeopardy were found.
Report Facts
Denial of payment effective date: Mar 27, 2016
Noncompliance reference date: Aug 27, 2015
Termination recommendation date: Sep 2, 2016
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named in relation to instructions for Informal Dispute Resolution and contact for questions |
| Darla McCloskey | Branch Manager, Division of Survey & Certification | Authorized the letter |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 8, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the previously cited deficiency with ID Prefix F0314 related to regulation 483.25(c) was corrected as of 12/08/2015. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Deficiency with ID Prefix F0314 related to regulation 483.25(c)
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 8, 2015
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.
Findings
The report confirms that the previously cited deficiency with regulation number 28-39-158(a) has been corrected as of 12/08/2015. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency previously cited under regulation 28-39-158(a) corrected
Inspection Report
Follow-Up
Deficiencies: 9
Date: Nov 4, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the prior survey on 2015-08-27 were corrected.
Findings
The revisit confirmed that all previously identified deficiencies were corrected as of 2015-11-04, with no uncorrected deficiencies remaining.
Deficiencies (9)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(e)(2)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(m)(2)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Report Facts
Deficiencies corrected: 9
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 4, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the deficiency identified by regulation number 28-39-160 with ID prefix S0770 was corrected as of 11/04/2015.
Deficiencies (1)
Deficiency identified under regulation 28-39-160 with ID prefix S0770
Report Facts
Deficiency correction date: Nov 4, 2015
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 4, 2015
Visit Reason
The revisit was conducted on November 4, 2015, as a result of the August 27, 2015 Health survey to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The revisit found the most serious deficiency in the facility to be a 'G' level deficiency related to noncompliance with F314, Pressure Ulcers. Due to this noncompliance, a denial of payment for new Medicare and Medicaid admissions was imposed effective November 27, 2015, and termination of the provider agreement was recommended.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers
Report Facts
Denial of payment effective date: Nov 27, 2015
Provider agreement termination date: Feb 27, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
| Jane Weiler | Survey & Certification Branch, CMS | Contact person for questions regarding the matter |
| David Loos | Administrator | Facility administrator named in the report |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 4, 2015
Visit Reason
This document is a Plan of Correction submitted by Golden Living El Dorado in response to deficiencies cited during a prior survey conducted on 8/27/2015.
Findings
The Plan of Correction addresses deficiencies related to resident care, including wound care and dietary management. Corrective actions include staff in-service training, implementation of care audits, monitoring by the Director of Nursing Services, and dietary oversight by a Licensed Registered Dietician and a promoted dietary manager in training.
Deficiencies (2)
Deficiency related to wound care and resident #77's positioning and treatment.
Deficiency related to the lack of a Certified Dietary Manager policy and dietary management staffing.
Report Facts
Date of annual survey: Aug 27, 2015
Date of QAPI Committee Meeting: Nov 6, 2015
Date of Plan of Correction completion: Nov 13, 2015
Anticipated completion date for dietary manager program: 201606
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Nov 4, 2015
Visit Reason
The inspection was conducted as a non-compliance revisit and complaint investigation #93426 regarding the facility's failure to prevent and properly treat pressure sores in a resident.
Complaint Details
The visit was a complaint investigation (#93426) and non-compliance revisit focused on pressure sore prevention and treatment. The complaint was substantiated by findings of inadequate care leading to pressure ulcers.
Findings
The facility failed to develop and implement timely interventions to prevent the development and promote healing of pressure ulcers for one resident (#77). The resident developed an unstageable pressure ulcer on the spine and two stage II pressure ulcers on the buttocks. Documentation and interviews revealed inadequate repositioning, delayed notification to the physician, and insufficient preventive measures.
Deficiencies (1)
Failure to develop and implement timely interventions to prevent and promote healing of pressure ulcers for resident #77.
Report Facts
Census: 43
Resident sample size: 7
Pressure ulcer measurements: 5.3
Pressure ulcer measurements: 3.4
Pressure ulcer inflammation size: 11.5
Pressure ulcer inflammation size: 5.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Staff | Notified physician late about pressure ulcer and considered the area an unstageable pressure ulcer. |
| Staff H | Direct Care Staff | Assisted resident with toileting and repositioning; failed to place positioning pillows as required. |
| Staff B | Administrative Nursing Staff | Asked about missing positioning pillows and explained air mattress usage policy. |
| Staff D | Licensed Staff | Changed dressing on resident's spine pressure ulcer. |
| Staff E | Physician | Provided orders for pressure ulcer treatment and commented on wound progression and healing difficulties. |
| Staff G | Hospice Licensed Staff | Assisted with dressing changes and commented on resident's fragile skin. |
| Staff I | Hospice Direct Care Staff | Noticed bandaged area on resident's spine about a week after admission. |
| Staff J | Off Duty Licensed Staff | Performed full body skin assessment at admission. |
| Staff K | Hospice Licensed Staff | Commented on rapid onset of pressure ulcer and resident's poor nutrition. |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Sep 25, 2015
Visit Reason
This document is a Plan of Correction submitted by Golden Living El Dorado facility in response to deficiencies cited in a prior inspection report, outlining corrective actions to address identified issues.
Findings
The facility acknowledges multiple deficiencies affecting residents and facility conditions, including medication administration errors, skin care issues, weight monitoring delays, environmental maintenance, and dietary service concerns. Corrective actions include staff in-service training, enhanced monitoring, repairs, cleaning, and policy development to ensure compliance and resident quality of care.
Deficiencies (10)
Medication administration errors related to resident #18, including Lasix given when systolic blood pressure was below 110.
Environmental maintenance issues including carpet stains, scuffed walls, peeling paint, and vent cleaning.
Skin care deficiency for resident #33's scabbed nose area and related care planning.
Use of splints for resident #4 and ensuring proper adaptive device use for all residents.
Weight monitoring system was slow to notify changes affecting resident #55 and others.
Medication administration errors audit and monitoring for residents with physician ordered parameters.
Dietary service deficiencies including improper food storage, cleaning, and sanitation.
General deficiency affecting all residents acknowledged without specific detail.
Dietary manager vacancy and interim management plan with in-service training.
Adult day care services policy and procedure development for admission, discharge, and clinical records.
Report Facts
Plan of correction completion date: Sep 25, 2015
In-service training completion date: Sep 10, 2015
Weight monitoring system change date: Sep 1, 2015
Expected delivery date for bedside table: Nov 15, 2015
Dietary manager certification anticipated completion: 201605
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Submitted the Plan of Correction and involved in oversight and compliance activities. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 27, 2015
Visit Reason
A health survey 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 deficiency in the facility to be at a 'G' level, resulting in a denial of payment for new Medicare and Medicaid admissions effective November 27, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Most serious deficiency found at 'G' level
Report Facts
Denial of Payment Effective Date: Nov 27, 2015
Termination Recommendation Date: Feb 27, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter and contact for questions concerning instructions |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 9
Date: Aug 27, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to allegations and compliance with regulatory requirements.
Complaint Details
The visit was triggered by complaints related to medication errors, failure to notify physicians of significant changes, inadequate housekeeping, and care planning deficiencies.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant changes in residents' conditions, inadequate housekeeping and maintenance services, failure to develop comprehensive and individualized care plans especially related to skin conditions and bruising, failure to ensure use of prescribed splints for range of motion, failure to prevent significant weight loss in a resident, medication errors related to administration of Lasix despite low blood pressure, and unsanitary food storage and preparation conditions.
Deficiencies (9)
Failure to notify physician of significant changes including medication administration and weight loss for residents #18 and #55.
Failure to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior.
Failure to develop individualized comprehensive care plans for residents #33 and #57 regarding skin conditions and bruising.
Failure to provide care and services to maintain highest practicable well-being including monitoring and assessment of skin conditions and bruising for residents #33 and #57.
Failure to ensure use of prescribed right hand/arm splint for resident #4 to prevent decrease in range of motion.
Failure to maintain nutrition status and prevent significant weight loss for resident #55.
Failure to ensure resident #18 remained free of significant medication errors related to administration of Lasix when systolic blood pressure was below ordered parameters.
Failure to store, prepare, and serve food under sanitary conditions in the dietary department.
Failure of pharmacy consultant to identify medication irregularities related to administration of Lasix outside physician ordered parameters for resident #18.
Report Facts
Resident census: 47
Residents sampled: 17
Lasix doses not held: 12
Weight loss percentage: 16.51
Weight loss percentage: 4
Weight loss percentage: 7.7
Weight loss percentage: 11.92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Named in findings related to failure to notify physician and medication administration errors |
| Staff D | Licensed Nursing Staff | Named in findings related to medication administration and skin care |
| Staff G | Consultation Staff / Pharmacy Consultant | Named in findings related to failure to identify medication irregularities |
| Staff K | Direct Care Staff | Named in findings related to resident care and splint application |
| Staff P | Direct Care Staff | Named in findings related to resident skin condition |
| Staff O | Direct Care Staff | Named in findings related to resident skin condition |
| Staff E | Licensed Nursing Staff | Named in findings related to resident nutrition and skin care |
| Staff H | Dietary Staff | Named in findings related to dietary sanitation |
| Staff I | Direct Care Staff | Named in findings related to splint application |
| Staff J | Direct Care Staff | Named in findings related to splint application |
| Staff L | Direct Care Staff | Named in findings related to restorative care and splint application |
| Staff R | Consultant | Named in findings related to nutrition and weight loss |
| Staff S | Licensed Nurse | Named in findings related to physician notification of weight loss |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 20, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiency identified under regulation 483.15(h)(3) with ID prefix F0254 was corrected as of 08/20/2015.
Deficiencies (1)
Deficiency under regulation 483.15(h)(3) previously cited with ID prefix F0254
Report Facts
Deficiency correction date: Aug 20, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 22, 2015
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 deficiency to be an 'E' level deficiency constituting 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, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Deficiencies (1)
Most serious deficiency was an 'E' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person regarding the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 22, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Golden Living El Dorado.
Complaint Details
The Plan of Correction addresses deficiencies cited during a complaint investigation at Golden Living El Dorado.
Findings
The facility acknowledged a deficiency related to laundry services that had the potential to affect all residents. The Plan of Correction outlines steps to ensure adequate staffing, linen availability, and ongoing monitoring to maintain compliance.
Deficiencies (1)
Laundry services deficiency affecting linen availability and staffing
Report Facts
Plan of Correction completion date: Aug 20, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Jul 20, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #89421 and #88905 regarding the facility's laundry and linen services.
Complaint Details
The visit was triggered by complaint investigations #89421 and #88905. The facility was found to have inadequate laundry services, including lack of linens and personal clothing for residents, and issues with contracted laundry/housekeeping services.
Findings
The facility failed to provide adequate clean bed and bath linens as well as personal clothing laundry services for 40 residents. Observations included soiled laundry barrels, lack of laundry staff, insufficient linens in closets, and difficulty in providing linens and personal clothing during residents' bath days.
Deficiencies (1)
Failure to provide clean bed and bath linens in good condition for residents.
Report Facts
Census: 46
Residents with laundry by family members: 6
Residents with laundry services by facility: 40
Soiled laundry barrels: 14
Fitted sheets per hallway linen closet: 3
Flat sheets per hallway linen closet: 3
Bath towels in linen carts: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Provided information about laundry contract and facility laundry conditions | |
| Contracted laundry/housekeeping supervisor staff C | Explained absence from laundry due to housekeeping staff illness | |
| Direct care staff D | Reported lack of linens for resident bed changes during bath days | |
| Resident #02 | Reported calling family member for clean sheets due to lack of linens | |
| Direct care staff E | Reported difficulty finding residents' personal clothing | |
| Licensed nursing staff B | Explained facility policy on baths/showers and linen changes |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 19, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in 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 enforcement remedies were recommended.
Deficiencies (1)
Most serious deficiencies found were 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Aug 19, 2015
Provider agreement termination date: Nov 19, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 12
Date: Jun 26, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that all previously cited deficiencies were corrected by the revisit date of 06/26/2014, with no uncorrected deficiencies remaining.
Deficiencies (12)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.15(e)(1)
Deficiency related to regulation 483.15(f)(1)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(e)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.30(a)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.70(c)(2)
Deficiency related to regulation 483.70(h)
Report Facts
Deficiencies corrected: 12
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 26, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected by the facility.
Findings
The report confirms that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 06/26/2014.
Deficiencies (1)
Deficiency under regulation 28-39-158(a)
Report Facts
Deficiency correction date: Jun 26, 2014
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Jun 26, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, as required by State and Federal Law within ten days of the survey.
Findings
The facility acknowledges multiple deficiencies that have the potential to affect residents, including issues related to bathing preferences, equipment malfunctions, environmental repairs, staffing shortages, dietary service concerns, and infection control. The Plan of Correction outlines specific corrective actions, staff in-service training, equipment replacement, and ongoing monitoring to achieve substantial compliance by 6/26/2014.
Deficiencies (12)
Deficiency related to bathing preferences and whirlpool tub availability.
Deficiency related to equipment issues and resident preferences.
Deficiency related to resident activity participation documentation.
Environmental deficiencies including damaged walls, flooring, and shower tiles requiring repair and repainting.
Deficiency related to equipment or assistive device malfunctions causing pain or injury.
Deficiency related to catheter care and infection control.
Deficiency related to restorative program participation and documentation.
Deficiency related to electrical outlet replacement for therapy equipment.
Staffing shortages and hiring deficiencies.
Food safety and dietary service deficiencies including improper labeling, storage, and cleaning.
Environmental maintenance deficiencies including floor covering replacement and debris removal.
Dietary manager certification and training deficiency.
Report Facts
Plan of Correction completion date: Jun 26, 2014
Staff in-service date: Jun 5, 2014
Whirlpool tub expected delivery date: Jun 16, 2014
Environmental repair timeframe: 90
Dates of hiring activity: May 25, 2014
Dates of hiring activity: Jun 2, 2014
Dietary staff in-service date: Jun 2, 2014
Kitchen tour date: May 13, 2014
Environmental tour date: May 20, 2014
Dietary manager certification anticipated completion: 201409
Dietary manager certification anticipated testing: 201411
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Submitted the Plan of Correction and responsible for staffing and facility compliance. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 12
Date: May 27, 2014
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation related to multiple resident care and facility concerns.
Complaint Details
The inspection included a complaint investigation #70865 regarding resident care issues including bathing preferences, pressure ulcers, catheter care, staffing, and environmental concerns.
Findings
The facility was found deficient in multiple areas including failure to provide resident choice in bathing due to a non-functioning whirlpool tub, failure to accommodate resident preferences for shower sling causing discomfort and pressure ulcers, inadequate activities for residents, poor housekeeping and maintenance, failure to prevent pressure ulcers, improper catheter care leading to infection risk, inadequate restorative services, insufficient nursing staff to meet resident needs, unsanitary food storage and preparation, malfunctioning whirlpool tub, and unsafe and unsanitary environment conditions.
Deficiencies (12)
Failure to provide preferred bathing style due to non-functioning whirlpool tub.
Failure to accommodate resident's preference for a different shower sling causing discomfort and pressure ulcers.
Failure to provide activities meeting interests and needs of residents.
Failure to maintain housekeeping and maintenance services to keep sanitary and comfortable interior.
Failure to prevent development of pressure ulcers related to use of shower sling.
Failure to maintain urinary catheter tubing off the floor to prevent urinary tract infections.
Failure to provide restorative services to maintain range of motion and prevent further decrease.
Failure to maintain resident environment free of accident hazards; hydroculator not on GFCI plug.
Failure to provide sufficient nursing staff to meet resident care needs and timely call light response.
Failure to store, prepare, and distribute food under sanitary conditions including uncovered food, improper storage, and inadequate cleaning.
Failure to maintain whirlpool tub in working order for resident use.
Failure to maintain a safe, sanitary, and comfortable environment including missing floor coverings, debris, and damaged walls.
Report Facts
Residents requiring 2 staff assist for transfers: 11
Residents requiring 1-2 staff assist for transfers: 10
Residents incontinent of bowel and/or bladder: 17
Call lights answered during observation: 17
Staff on night shift: 2
Residents in facility census: 42
Temperature of hot dogs prepared: 120
Temperature of hamburgers prepared: 125
Pressure ulcer size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff B | Administrative Nursing Staff | Reported resident council complaints about call lights and staffing shortages |
| Direct Care Staff G | Direct Care Staff | Reported understaffing and resident care issues |
| Licensed Nursing Staff S | Licensed Nursing Staff | Reported knowledge of resident discomfort with shower sling and catheter care |
| Administrative Staff A | Administrative Staff | Confirmed whirlpool tub non-functioning for over a year |
| Direct Care Staff M | Direct Care Staff | Reported resident complaints about shower sling and restorative services |
| Direct Care Staff Q | Direct Care Staff | Reported resident complaints about shower sling and pressure ulcers |
| Licensed Nursing Staff J | Licensed Nursing Staff | Reported resident wound caused by shower sling |
| Administrative Nursing Staff D | Administrative Nursing Staff | Confirmed resident voiced concerns about sling style and wound development |
| Direct Care Staff I | Direct Care Staff | Reported resident wound from shower sling and refusal to shower |
| Direct Care Staff V | Direct Care Staff | Observed catheter tubing dragging on floor |
| Direct Care Staff L | Direct Care Staff | Observed improper catheter bag placement on floor |
| Direct Care Staff W | Direct Care Staff | Reported catheter tubing contact with floor |
| Licensed Nursing Staff O | Licensed Nursing Staff | Reported staffing shortages on night shift |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Aug 9, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that all previously cited deficiencies were corrected by the revisit date of 08/09/2013, with no uncorrected deficiencies remaining.
Deficiencies (7)
Deficiency related to regulation 483.10(c)(2)-(5)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.25(m)(1)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.70(h)
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Aug 9, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, as mandated by State and Federal Law within ten days of the survey.
Findings
The facility acknowledges multiple deficiencies affecting residents and staff, including issues with resident funds handling, physical environment repairs, medication administration, food storage, disinfection protocols, and plumbing maintenance. Corrective actions and audits have been planned or implemented to achieve substantial compliance by 08/09/2013.
Deficiencies (7)
Improper handling and documentation of resident #22's funds.
Physical environment issues including damaged paint, stained ceilings, and flooring repairs in multiple resident rooms.
Lack of behavior monitoring sheet and monitoring for unnecessary medications for resident #11.
Medication administration records for residents #34 and #18 needed clarification and physician notification of errors.
Open and unlabeled food items and improper food storage in dietary department.
Inadequate disinfection of resident #42's bathroom floor and fixtures.
Grease trap and plumbing issues in dietary department requiring cleaning and repair.
Report Facts
Plan of Correction completion date: Aug 9, 2013
Date of in-service training: Jul 12, 2013
Date of dietary staff in-service: Jul 15, 2013
Date of dietary staff in-service: Jul 19, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Facility Office Manager | Responsible for handling resident funds and auditing. | |
| Facility Administrator | In-serviced staff and oversaw corrective actions. | |
| Director of Nursing (DON) | Responsible for clinical reviews, medication audits, and reporting. | |
| Director of Clinical Education | Conducts medication pass audits and staff in-service. | |
| Dietary Manager | Responsible for food storage audits and staff training. | |
| Facility Maintenance Director | Directed physical repairs and maintenance audits. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 7
Date: Jul 11, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation #63362 to assess compliance with regulatory requirements.
Complaint Details
The inspection included a complaint investigation identified as #63362.
Findings
The facility was found deficient in multiple areas including improper management of resident personal funds, inadequate housekeeping and maintenance services, failure to monitor unnecessary drug use, medication errors exceeding 5%, unsanitary food storage and preparation conditions, inadequate infection control practices, and unsafe and unsanitary kitchen environment.
Deficiencies (7)
Failed to manage one resident's personal funds in accordance with acceptable accounting principles, including failure to obtain written consent and failure to place funds in an interest bearing account.
Failed to provide housekeeping and maintenance services to maintain a sanitary and orderly resident environment on 3 of 4 hallways and in the dining room.
Failed to adequately monitor one resident to ensure freedom from unnecessary drugs, including failure to initiate a behavior monitoring sheet upon admission.
Failed to ensure medication error rates of 5% or less; two medication errors were identified resulting in a 7.1% error rate.
Failed to maintain a clean and sanitary dietary department, including uncovered raw bacon in walk-in cooler and dirty kitchen equipment.
Failed to provide care in a sanitary manner to prevent the spread of disease and infection after a resident had an incontinent episode on the bathroom floor.
Failed to maintain a safe, functional, sanitary, and comfortable environment in the kitchen area, including grease trap covered with dust and debris, missing tiles, and an open hole under the sink.
Report Facts
Census: 44
Residents with managed funds: 28
Residents reviewed for funds management: 5
Medication error opportunities: 28
Medication errors: 2
Medication error rate: 7.1
Resident #22 funds in envelope: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Office Manager G | Office Manager | Reported resident #22 did not have funds deposited in resident fund account and verified failure to deposit funds in interest bearing account. |
| Social Staff H | Social Service Staff | Stated belief that signed consent to hold resident's money was obtained. |
| Maintenance Personnel C | Maintenance Personnel | Participated in environmental tour identifying maintenance issues. |
| Housekeeping Manager D | Housekeeping Manager | Acknowledged need for cleaning in dining room and other areas. |
| Administrative Staff A | Administrative Staff | Reported new cleaning company scheduled and verified kitchen area deficiencies. |
| Licensed Nursing Staff E | Licensed Nurse | Administered double dose of Lasix medication to resident #34. |
| Licensed Nurse F | Licensed Nurse | Administered incorrect number of Senna S tablets to resident #18. |
| Dietary Staff L | Dietary Staff | Verified uncovered raw bacon in walk-in cooler. |
| Dietary Consultant Staff M | Dietary Consultant | Verified dirty kitchen equipment and lack of cleaning schedules. |
| Direct Care Staff O | Direct Care Staff | Observed cleaning feces with pre-moistened wipes and bagging soiled clothes. |
| Direct Care Staff N | Direct Care Staff | Assisted with cleaning feces and stated use of wipes for cleaning floor and toilet. |
| Licensed Staff J | Licensed Staff | Stated staff should disinfect toilet seat after contamination. |
| Licensed Staff I | Licensed Staff | Stated staff need to clean urine or feces spills and not call housekeeping. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 30, 2012
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
The revisit confirmed that all previously cited deficiencies identified by regulation numbers 483.10(c)(6), 483.10(c)(7), 483.12(b)(1)&(2), 483.35(i), and 483.65 were corrected as of 04/30/2012.
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Apr 11, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior survey report to demonstrate corrective actions and compliance with regulatory requirements.
Findings
The Plan of Correction outlines specific corrective actions taken or planned for various deficiencies including resident account management, surety bond increase, bed hold policy tracking, food delivery procedures, kitchen cleanliness, and infection control practices. The facility commits to ongoing monitoring and re-education to maintain substantial compliance.
Deficiencies (5)
Affected resident accounts have been closed and monies returned to state recovery; audits conducted and business office manager re-educated on regulation to convey personal funds upon death within 30 days.
Facility increased Surety Bond for resident funds to $100,000 and re-educated business office manager on Surety Bond policy.
Re-education of staff regarding bed hold policy and implementation of tracking device for hospital or therapeutic leave dates and notifications.
In-services conducted on proper procedures for delivery of food items; cleaning schedules developed and implemented for kitchen equipment and utensils; maintenance repairs planned.
Nurses re-educated on infection control policies; infection control monitoring during wound care twice weekly.
Report Facts
Surety Bond amount: 100000
Plan of Correction completion dates: Apr 30, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Inderhees | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 5
Date: Apr 3, 2012
Visit Reason
The inspection was conducted as a health facility resurvey and complaint investigation #55029 to assess compliance with regulatory requirements.
Complaint Details
The visit included a complaint investigation #55029. The complaint involved issues such as failure to convey deceased residents' funds, lack of surety bond coverage, failure to provide bed hold notices, unsanitary food handling, and infection control breaches.
Findings
The facility was found deficient in multiple areas including failure to convey deceased residents' personal funds within 30 days, failure to maintain a surety bond covering resident personal funds, failure to provide bed-hold policy notices upon resident transfer to acute care, unsanitary food storage and preparation conditions, and inadequate infection control practices during dressing changes.
Deficiencies (5)
Failed to convey 2 of 4 deceased residents' personal funds to state recovery within the 30 day requirement.
Failed to provide a surety bond in an amount to cover resident personal accounts from November 2011 through March 31, 2012.
Failed to provide the facility's bed hold policy to 9 residents with Medicaid at the time of transfer to acute care.
Failed to store, prepare, and serve food under sanitary conditions, including bare fingers touching glass rims and unclean kitchen equipment.
Failed to use aseptic technique during a dressing change for one resident, risking cross-contamination and infection transmission.
Report Facts
Census: 33
Residents selected for review: 17
Deceased residents' funds not conveyed timely: 2
Surety bond amount: 45000
Resident personal fund balances: 72392.12
Resident personal fund balances: 69296.46
Resident personal fund balances: 70510.19
Residents transferred without bed hold notice: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff G | Interviewed regarding personal funds and bed hold policy | |
| Dietary staff E | Observed placing bare fingers on residents' glasses | |
| Dietary staff C | Reported kitchen equipment conditions | |
| Licensed nurse D | Observed performing dressing change with infection control breaches | |
| Licensed nurse H | Observed assisting with dressing change | |
| Administrative nursing staff B | Acknowledged resident history of MRSA |
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