Inspection Reports for
El Dorado Operator LLC
900 COUNTRY CLUB LANE, EL DORADO, KS, 67042
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
26 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
333% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
90% occupied
Based on a September 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 27, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of 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
Re-Inspection
Census: 45
Deficiencies: 6
Date: Sep 27, 2018
Visit Reason
Health resurvey to investigate allegations of abuse, neglect, and compliance with care planning and safety regulations.
Findings
The facility failed to timely report and investigate alleged theft of resident property, develop and implement baseline and comprehensive care plans within required timeframes, revise care plans after incidents, and ensure resident safety including fall prevention and elopement risk management.
Deficiencies (6)
F609: The facility failed to notify local police and state agency of alleged theft of $280 from resident #24's room within required timeframes.
F610: The facility failed to conduct a thorough investigation into the alleged theft of $280 from resident #24's room.
F655: The facility failed to develop and implement baseline care plans within 72 hours of admission for residents #4 and #7.
F656: The facility failed to develop and implement a comprehensive care plan for resident #8 and failed to review and update the plan by the target date.
F657: The facility failed to revise resident #39's care plan with interventions after a fall and failed to ensure interdisciplinary team review for residents #4, #7, and #8.
F689: The facility failed to ensure resident #8's safety when he left the facility unattended and failed to timely evaluate and revise fall interventions after resident #8's fall.
Report Facts
Resident census: 45
Amount of missing money: 280
BIMS score: 15
BIMS score: 9
BIMS score: 13
Bruise size: 2
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 27, 2018
Visit Reason
The visit was conducted to determine if the facility was 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, 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 2018-10-27.
Deficiencies (1)
The facility had an 'E' level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Signed the report and communicated findings and decisions. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Sep 24, 2018
Visit Reason
This plan of correction addresses deficiencies identified during a survey related to a report of missing money from resident #24 and issues with care plan reviews and updates for several residents.
Findings
The facility reported a missing money incident involving resident #24, re-educated staff on reporting abuse and care plan procedures, and updated care plans for multiple residents. The facility implemented corrective actions including resident education, staff re-education, and ongoing monitoring through QAPI committees.
Deficiencies (6)
F609: Report of resident #24 missing money was investigated and money was replaced. Resident was re-educated on securing money and given options for safekeeping. Staff were re-educated on abuse reporting requirements.
F610: Facility re-educated staff on abuse reporting and investigation procedures following the missing money report. Residents were interviewed about valuables and encouraged to use trust accounts or lock boxes.
F655: Care plans for residents #4 and #7 were reviewed and updated. Licensed nurses will be re-educated on baseline care plan implementation and completion within 72 hours of admission.
F656: Resident #8 care plan was reviewed and updated. IDT team received re-education on care plan development and review. Care plans will be reviewed weekly for three months.
F657: Care plans for residents #4, #7, #8, and #39 were reviewed and updated. Staff were re-educated on inviting residents and responsible parties to care plan meetings and on care plan procedures.
F689: Care plans for residents #8 and #39 were reviewed and revised. Staff were re-educated on care plan reviews, fall precautions, and implementation of interventions. Resident #8 received education on sign-out procedures and anger management treatment was arranged.
Report Facts
Complete Date: Oct 4, 2018
Complete Date: Oct 27, 2018
Resident Interviews: 3
Care Plan Reviews: 3
Resident Care Plan Updates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Administrator | Submitted the plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 25, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a revised complaint revisit inspection conducted on 08/25/2017 at El Dorado Care.
Findings
The Plan of Correction addresses fall care plans for residents at risk, re-education of nursing staff on mechanical lift use, implementation of bowel and bladder diaries, installation and monitoring of motion sensor alarms, and auditing of resident transfers and toileting plans to improve care quality.
Deficiencies (1)
F323 - Resident #1, #2, and #4 fall care plans have been reviewed and updated. Nursing staff were re-educated on mechanical lift use and transfer competencies were completed to ensure proper resident handling.
Report Facts
Audit frequency: 5
Audit frequency: 3
Audit frequency: 2
Audit frequency: 5
Audit frequency: 3
Audit frequency: 2
Audit frequency: 5
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Aug 25, 2017
Visit Reason
This inspection was a non-compliance revisit and investigation of complaint #119179 regarding resident safety and supervision.
Complaint Details
The investigation was triggered by complaint #119179. The complaint was substantiated as the facility failed to monitor high fall risk residents adequately, leading to falls and unsafe conditions.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent falls for two high fall risk residents. Staff did not consistently monitor residents as required by care plans, resulting in multiple falls and unsafe toileting attempts.
Deficiencies (1)
483.25(d)(1)(2)(n)(1)-(3) The facility failed to ensure adequate supervision and assistive devices to prevent falls for residents #2 and #4, resulting in multiple falls and unsafe toileting without staff awareness.
Report Facts
Resident census: 40
Fall risk scores: 18
Fall risk scores: 14
Fall risk scores: 11
Fall risk scores: 14
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jul 12, 2017
Visit Reason
This document is a Plan of Correction submitted by El Dorado Care and Rehab in response to a complaint investigation conducted on 2017-07-11.
Complaint Details
This Plan of Correction responds to a complaint investigation dated 2017-07-11 regarding alleged verbal abuse and other regulatory deficiencies.
Findings
The facility addressed multiple deficiencies related to abuse allegations, staff hiring practices, equipment safety, and resident care plans. Corrective actions include staff re-education, audits, equipment inspections, and ongoing monitoring by the QAPI Committee.
Deficiencies (6)
F225: The facility investigated an alleged verbal abuse incident involving Resident #1 and found no substantiation. The accused staff member was reassigned and mentored, and staff were re-educated on abuse, neglect, and exploitation (ANE).
F226: The facility educated employees on ANE and improved hiring practices including mandatory reference, background, registry, OIG, and license checks before new hires can work.
F323: The facility implemented safety measures for residents with mobility aids, including removal of side rails and audits of wheelchair equipment to prevent hazards.
F328: The facility established cleaning protocols for resident BIPAP equipment, including staff education and documentation requirements.
F456: The facility ensured adequate mechanical lift equipment by leasing and scheduled maintenance, with staff re-education on reporting lift issues.
F496: The facility reinforced employment compliance with Federal and State guidelines through re-education of department heads and audits of personnel records.
Report Facts
Estimate for lift repair: 13783
Audit frequency: 3
Audit frequency: 4
Maintenance check frequency: 2
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 6
Date: Jul 11, 2017
Visit Reason
Complaint investigations #117615, 117222, and 117745 were conducted to assess allegations of abuse, neglect, and exploitation at the facility.
Complaint Details
The investigation was triggered by allegations of staff abuse made by resident #1, including verbal abuse and failure to protect residents from the alleged perpetrator. The facility was found deficient in timely reporting, investigation, and protection of residents.
Findings
The facility failed to protect residents from abuse by allowing an alleged perpetrator to continue working after an allegation was made. The facility also failed to provide abuse, neglect, and exploitation training to new employees, failed to conduct reference checks prior to hire, failed to ensure safe environment and supervision to prevent falls, failed to maintain respiratory equipment cleaning schedules, failed to maintain mechanical lifts in safe operating condition, and failed to complete nurse aide registry verification for an employee.
Deficiencies (6)
F225: The facility failed to immediately protect residents from an alleged staff abuse incident and failed to properly investigate and report the allegation.
F226: The facility failed to provide abuse, neglect, and exploitation training to 5 employees prior to hire and failed to conduct reference checks on 4 employees as required.
F323: The facility failed to ensure safe environment and supervision to prevent falls, including improper use of bed rails and wheelchair foot pedals for multiple residents.
F328: The facility failed to maintain a cleaning schedule for a resident's Bi-PAP machine and failed to provide instructions for cleaning the equipment.
F456: The facility failed to maintain mechanical lifts in safe operating condition, including battery maintenance, placing residents at risk during transfers.
F496: The facility failed to complete nurse aide registry verification for 1 of 3 employees reviewed as required.
Report Facts
Resident census: 39
Employees lacking abuse training: 5
Employees lacking reference checks: 4
Residents reviewed for accidents: 5
Residents requiring mechanical lift: 6
Employees reviewed for nurse aide registry verification: 3
Employees lacking nurse aide registry verification: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Care Staff | Named in abuse allegation and failure to protect residents; denied verbal abuse but was monitored for 2.5 hours after allegation. |
| Staff B | Administrative Nursing Staff | Failed to protect residents by allowing alleged perpetrator to remain on duty; failed to send staff H home after abuse allegation. |
| Staff T | Licensed Nurse | Interviewed resident about abuse allegation; lacked training on abuse, neglect, and exploitation. |
| Staff U | Licensed Nurse | Visited resident after abuse allegation but failed to document. |
| Administrative Staff Z | Administrator | Verified failure to conduct reference checks and nurse aide registry verification. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 11, 2017
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 facility was found not in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety. Enforcement remedies including denial of payment for new admissions were imposed.
Deficiencies (1)
F225, "L", CFR 483.12(a)(3)(4)(c)(1)-(4): The facility was not in substantial compliance, constituting immediate jeopardy to resident health or safety.
Report Facts
Denial of payment effective date: Aug 1, 2017
Recommended provider agreement termination date: Dec 11, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter as Complaint Coordinator for the Survey, Certification, and Credentialing Commission |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 5, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported 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: Apr 5, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the facility's plan of correction.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report lists multiple regulatory citations with completed correction dates.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 13
Date: Mar 8, 2017
Visit Reason
The inspection was a health resurvey to evaluate compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to act on resident grievances, inadequate housekeeping and maintenance services, incomplete care plans especially related to urinary catheter care, failure to provide restorative services, improper medication monitoring and administration, unsanitary food storage and preparation areas, expired medications stored improperly, ineffective infection control practices, and inadequate environmental conditions including ventilation.
Deficiencies (13)
F 244: The facility failed to act upon grievances of the resident council regarding housekeeping and needed supply issues in resident rooms/areas.
F 253: The facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in 20 of 38 resident rooms and the beauty shop.
F 279: The facility failed to develop a comprehensive care plan for resident #64 related to urinary indwelling catheter treatment and services.
F 315: The facility failed to ensure necessary treatment and services for resident #64 with urinary catheter including tubing off the floor and adequate anchoring to prevent urethral trauma.
F 318: The facility failed to ensure resident #2 received timely restorative services following therapy to prevent further decrease in range of motion.
F 329: The facility failed to monitor for unnecessary medications for 3 residents including failure to monitor black box warnings, bowel movements, and pulse prior to antihypertensive medication administration.
F 371: The facility failed to store, prepare, distribute and serve food under sanitary conditions in the kitchen.
F 425: The facility failed to ensure correct administration of medications to 2 residents including improper inhaler use and incorrect eye drop administration.
F 428: The facility failed to conduct monthly drug regimen reviews that identified irregularities including failure to monitor medications with black box warnings and failure to monitor resident bowel movements and pulse.
F 431: The facility failed to ensure appropriate storage of medications off the floor and failed to remove expired medications from use.
F 441: The facility failed to maintain an effective infection control program including improper storage of urine specimen equipment, inadequate glove changes during dressing changes, inadequate room cleaning, and linens placed on the floor.
F 465: The facility failed to provide a clean and sanitary environment in multiple storage rooms, janitor closets, laundry, kitchen, and resident water container room.
F 467: The facility failed to maintain a functioning outside exhaust system in the beauty shop.
Report Facts
Residents present: 39
Resident rooms inspected: 38
Residents sampled: 13
Days without bowel movement: 7
Expired medications found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Activities Staff | Named in grievance handling and resident council communication |
| Staff J | Direct Care Staff | Named in medication administration errors for inhalers and eye drops |
| Staff H | Licensed Nursing Staff | Named in improper glove use during dressing change |
| Staff K | Licensed Nursing Staff | Named in medication storage and expired medication verification |
| Staff M | Dietary Staff | Named in kitchen sanitation observations |
| Staff N | Maintenance Staff | Named in environmental sanitation and ventilation system verification |
| Staff B | Administrative Licensed Nursing Staff | Named in medication monitoring and infection control oversight |
| Staff C | Administrative Licensed Nursing Staff | Named in medication monitoring and infection control oversight |
| Consultant Staff T | Consultant Pharmacist | Named in medication review and administration consultation |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 8, 2017
Visit Reason
A Health 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 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 based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the plan of correction acceptance letter. |
Inspection Report
Plan of Correction
Deficiencies: 13
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 to address and correct identified issues.
Findings
The plan outlines corrective actions taken to address deficiencies related to housekeeping, environmental cleanliness, catheter care, restorative programming, medication management including black box warnings, dietary sanitation, medication storage, room cleaning, laundry and storage room cleanliness, and facility ventilation. The facility implemented staff education, environmental cleaning, equipment repair, audits, and ongoing monitoring to ensure compliance and resident safety.
Deficiencies (13)
F244: The facility recognized a deficiency affecting quality of living related to housekeeping and resident grievances, and implemented corrective actions including terminating contracted services and instituting in-house environmental services.
F253: Housekeeping and maintenance deficiencies were corrected by deep cleaning, disinfecting, and repairing multiple areas including beauty shop, resident halls, bathrooms, and equipment to meet set standards.
F279: Deficiency related to catheter care was addressed by re-educating nursing staff on assessments, care plans, and catheter care with audits to maintain compliance.
F315: Direct care staff were re-educated on catheter care and infection control, and protective liners were purchased to ensure proper anchoring devices for residents with indwelling catheters.
F318: Restorative programming deficiencies were addressed by daily interdisciplinary meetings and audits to ensure continuity of care and prevent decline.
F329: Care plans were updated to reflect black box warnings and nursing staff re-educated on bowel management protocols with audits to ensure proper interventions.
F371: Dietary sanitation deficiencies were corrected by cleaning, disposing of improperly stored products, staff re-education, and ongoing sanitation audits.
F425: Medication administration deficiencies were addressed by re-educating nursing staff on inhaler and eye drop procedures with audits and resident assessments.
F428: Medication management deficiencies related to black box warnings were addressed by pharmacist consultant reviews, staff re-education, and audits to ensure proper care plans and medication orders.
F431: Medication storage deficiencies were corrected by removing expired medications, prohibiting floor storage, and auditing medication carts and rooms regularly.
F441: Room cleaning deficiencies were addressed by staff re-education on cleaning procedures and daily monitoring to prevent bacterial spread.
F465: Facility environmental cleanliness deficiencies were corrected by deep cleaning, disinfecting, repairing floors and walls, and proper storage of supplies with ongoing inspections.
F467: Facility ventilation system in the beauty shop was repaired and will be monitored monthly to maintain compliance.
Report Facts
Dates of corrective actions and verifications: Multiple dates from 2017-02-09 to 2017-04-05 for corrective actions and verifications
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | CEO | Signed submission of Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 20, 2017
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 revisit confirmed that all previously cited deficiencies, including those under regulations 483.24 and 483.25(k)(l), were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 2
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 from a complaint investigation (El Dorado complaint 01242017).
Findings
The facility recognized deficiencies related to resident care including assessment and documentation of change of conditions, oral hygiene and denture care, bathing preferences and schedules, and personal hygiene monitoring. The Plan of Correction outlines re-education of staff, monitoring procedures, and ongoing quality assurance interventions to improve resident care.
Deficiencies (2)
F309-D: The facility failed to properly assess and document resident change of conditions, notify the primary care provider, and follow up on clinical documentation for residents with infections and antibiotic use.
F312-D: The facility did not adequately assess and respect resident bathing preferences, ensure completion of baths, or monitor personal hygiene and appearance for all residents.
Report Facts
Re-education completion date: Feb 10, 2017
Plan of Correction submission date: Feb 1, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | CEO | Submitted the Plan of Correction. |
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 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)
A 'D' level deficiency was cited 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 contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: Jan 24, 2017
Visit Reason
Complaint investigation #109884 was conducted to evaluate the facility's compliance with care and services provided to residents, focusing on quality of life, pain management, dialysis, and activities of daily living.
Complaint Details
Complaint investigation #109884 focused on quality of life, pain management, dialysis, and ADL care. The investigation substantiated failures in assessment, monitoring, and hygiene care for three residents.
Findings
The facility failed to ensure adequate assessment, monitoring, and documentation of three residents during acute illness episodes, resulting in hospitalization for respiratory infection and dehydration. Additionally, the facility failed to provide bathing and personal hygiene services to maintain good hygiene for two residents, despite their extensive care needs and behavioral challenges.
Deficiencies (2)
F309: The facility failed to monitor, assess, and document acute illness for three residents, resulting in inadequate care and hospitalization for respiratory infection and dehydration.
F312: The facility failed to provide bathing and personal hygiene services as expected for two dependent residents, resulting in poor hygiene and neglect of care needs.
Report Facts
Resident census: 37
Residents reviewed: 3
Baths provided: 1
Baths provided: 6
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 20, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that all previously cited deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected and completed by 11/20/2016.
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.
Deficiencies (1)
F323 deficiency was cited as a 'D' level indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
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 investigation involved three complaint investigations (#107564, #106315, and #107512) concerning resident elopement risk and supervision. The complaint was substantiated by the finding that a resident left the facility without staff knowledge.
Findings
The facility failed to ensure adequate supervision to prevent a resident at risk of elopement from leaving the facility without staff knowledge. One resident with severe cognitive impairment self-propelled their wheelchair approximately 1/4 mile from the facility without staff awareness.
Deficiencies (1)
483.25(h) The facility did not ensure the resident environment was free of accident hazards and failed to provide adequate supervision to prevent a resident at risk of elopement from leaving the facility unnoticed.
Report Facts
Resident census: 36
Samples reviewed: 3
Residents identified as elopement risk: 2
Resident BIMS score: 6
Resident BIMS score: 12
Distance resident traveled: 0.25
Temperature: 74
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 30, 2016
Visit Reason
The plan of correction addresses deficiencies cited following a complaint investigation related to a resident leaving the premises without notifying staff.
Findings
The facility identified a deficiency regarding resident supervision and outdoor privileges, specifically concerning Resident #01 leaving without notification. The facility implemented new protocols for resident outdoor privileges based on cognitive status and established monitoring programs to ensure compliance and resident safety.
Deficiencies (1)
F323: The facility failed to ensure Resident #01 did not leave the premises without notifying staff. The facility implemented new outdoor privilege protocols based on residents' BIMS scores and monitoring procedures to maintain safety.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Chief Executive Officer | Named in relation to counseling Resident #01 and submitting 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 complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
The facility was cited with deficiencies at an 'F' level for Life Safety Code compliance, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Dec 8, 2016
Provider agreement termination date: Mar 8, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the survey results letter. |
| 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 visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.20(k)(3)(i) and 483.60(b), (d), (e) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 483.20(k)(3)(i) deficiency was corrected by the revisit date.
Regulation 483.60(b), (d), (e) deficiencies were corrected by the revisit date.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 13, 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 the most serious deficiencies to be 'E' level, indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.
Deficiencies (1)
The facility had 'E' level deficiencies indicating no actual harm but 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
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Jul 13, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#102403) regarding medication administration practices at the facility.
Complaint Details
The complaint investigation (#102403) substantiated failures in medication administration practices and medication storage security.
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)
F 281: Two licensed nursing staff failed to follow professional standards related to medication preparation and administration for one resident. Medications were left unattended in the resident's room and administered by a nurse who did not prepare them.
F 431: The facility failed to ensure medications, including narcotics, were stored in locked compartments in one of two medication carts. The medication cart was left unlocked during administration, and narcotics were not under double lock as required.
Report Facts
Resident census: 35
Medication pills left unattended: 5
Sampled residents: 3
Medication carts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse C | Prepared and set up medications but left them unattended in resident's room. | |
| Licensed Nurse D | Administered medications without preparing them and lacked knowledge of the medications given. | |
| Administrative Nurse A | Provided medication administration policy and conducted in-service training after the incident. | |
| Certified Medication Aide E | Left medication cart unlocked while administering medications. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 12, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior complaint investigation at the facility.
Findings
The facility acknowledged deficiencies related to medication administration and medication storage. Corrective actions include staff in-service training, medication pass observations, and random medication cart audits to ensure compliance with policies and regulations.
Deficiencies (2)
F281: The facility identified a deficiency in medication administration practices affecting all residents. Staff were in-serviced on the 5 rights of medication administration and medication pass guidelines, with ongoing observations planned to ensure compliance.
F431: The facility identified a deficiency in medication storage and securement affecting all residents. Staff were in-serviced on facility policy and regulations, and random medication cart audits were scheduled to maintain compliance.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 31, 2016
Visit Reason
This post-certification revisit 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 previously cited deficiency under regulation 483.25(h) was corrected as of 03/10/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 03/10/2016.
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 during a regulatory inspection.
Findings
The facility acknowledged deficiencies related to resident care and outlined corrective actions including reassessment of resident behaviors, care plan updates, staff in-services on the 'Stop and Watch' program, and ongoing monitoring by the QAPI Committee.
Deficiencies (1)
F323: The facility recognized a deficiency with potential to affect other residents. Resident #1 was provided a modified dining chair and moved to a less stimulating area with increased assistance. Staff will perform 15-minute visual checks and be trained on the 'Stop and Watch' program to monitor resident condition changes.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 0
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 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 granted.
Report Facts
Denial of payment effective date: Mar 27, 2016
Previous complaint survey date: Aug 27, 2015
Termination recommendation date: Sep 2, 2016
Civil Money Penalty minimum amount: 5000
IDR submission deadline: 10
Hearing request deadline: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions regarding the matter and IDR instructions. |
| Lisa Hauptman | CMS Contact | Contact person for questions regarding the matter by phone. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 8, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report confirms that the deficiencies previously cited have been corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 8, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies at the facility.
Findings
The report documents that previously reported deficiencies have been corrected as of the revisit date. Only one deficiency is explicitly identified with correction completed.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected as of 12/08/2015.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 13, 2015
Visit Reason
This document is a Plan of Correction submitted by Golden Living El Dorado in response to deficiencies cited during a prior annual survey completed on 2015-08-27.
Findings
The facility acknowledged 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 department oversight by a Licensed Registered Dietician.
Deficiencies (2)
F314: The facility failed to ensure proper wound care for resident #77, including appropriate use of positioning devices and dressings. Corrective actions included provision of specialized equipment and staff training on skin care guidelines.
K600: The facility lacked a Certified Dietary Manager policy and had difficulty maintaining qualified dietary management after staff resignation. The facility promoted an employee enrolled in a dietary program and implemented weekly monitoring by the Licensed Registered Dietician.
Report Facts
Deficiency completion dates: Nov 13, 2015
Annual survey date: Aug 27, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 4, 2015
Visit Reason
This document reports the results of a first revisit conducted on November 4, 2015, following an 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 to be a 'G' level deficiency related to pressure ulcers (F314). Due to noncompliance, a denial of payment for new Medicare and Medicaid admissions was imposed effective November 27, 2015, with a recommendation for termination of the provider agreement on February 27, 2016.
Deficiencies (1)
F314 Pressure Ulcers: The facility failed to ensure that avoidable pressure ulcers would not occur and that residents received appropriate care to prevent worsening of existing 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 | Signed letter and contact for questions regarding enforcement action |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 4, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously reported deficiencies listed by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory requirements.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 4, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies were corrected as of the revisit date. The report lists multiple regulation numbers with correction completion dates confirming compliance.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 4, 2015
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency with regulation number 28-39-160 was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-160 deficiency was corrected on 2015-11-04.
Report Facts
Deficiency correction date: Nov 4, 2015
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 4, 2015
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the deficiency identified by regulation 28-39-160 with ID prefix S0770 was corrected as of 11/04/2015.
Deficiencies (1)
Regulation 28-39-160 deficiency identified by code S0770 was corrected on 11/04/2015.
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 related to pressure sore prevention and treatment.
Complaint Details
This visit was a complaint investigation #93426 and a non-compliance revisit related to pressure sore prevention and treatment.
Findings
The facility failed to develop and implement timely interventions to prevent development and promote healing of pressure ulcers for one resident. The resident developed an unstageable pressure ulcer on the spine and two stage II pressure ulcers on the buttocks despite documented risk assessments and care plans.
Deficiencies (1)
F314: The facility failed to implement interventions to prevent and promote healing of pressure ulcers for a resident who developed an unstageable pressure ulcer on the spine and two stage II pressure ulcers on the buttocks.
Report Facts
Resident census: 43
Sample size: 7
Pressure ulcer measurements: 5.3
Pressure ulcer measurements: 3.4
Pressure ulcer area: 11.5
Pressure ulcer area: 5.2
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Sep 25, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection. It outlines corrective actions to address identified issues and ensure compliance with regulatory requirements.
Findings
The facility acknowledged multiple deficiencies affecting residents, including medication administration errors, skin care issues, weight monitoring delays, environmental maintenance concerns, and dietary service problems. Corrective actions include staff in-service training, enhanced monitoring, repairs, cleaning, and policy development to prevent recurrence and maintain compliance.
Deficiencies (11)
F157-D: The facility failed to follow physician orders regarding medication administration for resident #18, including administering Lasix when systolic blood pressure was below 110. Licensed nursing staff will be in-serviced and compliance monitored.
F253-E: The facility had environmental maintenance issues including stained carpets, scuffed walls, peeling paint, and unclean areas. Repairs and cleaning were scheduled and completed by maintenance and housekeeping.
F279-D: The facility failed to properly assess and treat a scabbed area on resident #33's nose and ensure skin care documentation. Licensed nursing staff will be in-serviced and care plans monitored.
F309-D: Licensed nursing staff initiated skin assessments and notified the PCP for resident #33's scabbed nose area. The facility will monitor healing and maintain documentation.
F318-D: The facility failed to ensure proper use of splints for resident #4. Staff will be educated and audits conducted to ensure proper adaptive device use.
F325-G: The facility's weight monitoring system was slow to notify staff of changes. The system was changed to a weekly exception report and monitoring procedures enhanced.
F333-D: Medication errors for resident #18 were addressed by notifying the PCP and responsible party. Audits of medication administration records will be conducted to prevent recurrence.
F371-F: Dietary staff were in-serviced on cleaning schedules and food handling. Multiple cleaning and replacement actions were completed to maintain sanitation and compliance.
F428-D: The facility recognized deficiencies affecting all residents and implemented corrective actions.
K600-F: Due to the resignation of the dietary manager, an in-house employee was promoted and enrolled in a dietary manager program. The Licensed Registered Dietitian will oversee operations until certification is complete.
K770-C: The facility will develop and implement a written policy and procedure for adult day care services, including admission, discharge, and clinical record maintenance.
Report Facts
Plan of Correction completion date: Sep 25, 2015
Staff in-service completion date: Sep 10, 2015
Weight monitoring system change date: Sep 1, 2015
Resident discharge date: Sep 1, 2015
Cleaning and repair completion dates: Sep 15, 2015
Inspection Report
Enforcement
Deficiencies: 0
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 to be a "G" level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective November 27, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Report Facts
Denial of Payment Effective Date: Nov 27, 2015
Termination Recommendation Date: Feb 27, 2016
Civil Money Penalty Minimum: 5000
Civil Money Penalty Minimum: 50000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator |
Inspection Report
Enforcement
Deficiencies: 0
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 a 'G' level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective November 27, 2015, until substantial compliance is achieved or the provider agreement is terminated.
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 as Enforcement Coordinator |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 9
Date: Aug 27, 2015
Visit Reason
Health Resurvey and Complaint Investigation triggered by complaints #89429 and #89612.
Complaint Details
Complaint investigations #89429 and #89612 were conducted, revealing multiple deficiencies including failure to notify physicians of significant changes, medication errors, and sanitation issues.
Findings
The facility failed to notify physicians of significant changes in residents' conditions, maintain sanitary housekeeping and maintenance, develop comprehensive care plans for skin conditions, ensure use of splints for limited range of motion, prevent significant weight loss, avoid medication errors related to Lasix administration, and maintain sanitary food preparation and storage.
Deficiencies (9)
F157: Facility failed to notify physicians of significant changes for 2 residents, including failure to hold Lasix when systolic blood pressure was below 110 and failure to notify physician of significant weight loss.
F253: Facility failed to maintain sanitary, orderly, and comfortable interior with multiple maintenance and housekeeping deficiencies across resident hallways.
F279: Facility failed to develop individualized comprehensive care plans addressing skin conditions for 2 residents with altered skin integrity and bruising.
F309: Facility failed to assess and monitor bruising and skin conditions for 2 residents, including failure to monitor a scabbed area on the nose and bruising.
F318: Facility failed to ensure use of right hand/arm splint as ordered for resident with limited range of motion to prevent further decrease.
F325: Facility failed to prevent significant weight loss for a resident by not timely identifying weight loss or notifying physician for intervention.
F333: Facility failed to ensure resident remained free of significant medication errors by administering Lasix when systolic blood pressure was below ordered parameters 11 times.
F371: Facility failed to store, prepare, and serve food under sanitary conditions with multiple sanitation and maintenance issues in dietary department.
F428: Pharmacy consultant failed to identify medication irregularities related to Lasix administration when resident's systolic blood pressure was below parameters on 10 occasions.
Report Facts
Resident census: 47
Residents sampled: 17
Lasix doses not held: 11
Weight loss percentage: 16.51
Weight loss percentage: 7.7
Weight loss percentage: 4
Weight values: 91
Weight values: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Mentioned in relation to failure to notify physician of medication and weight loss issues | |
| Licensed nursing staff D | Mentioned in relation to medication administration and skin condition monitoring | |
| Consultation staff G | Pharmacy consultant who failed to identify medication irregularities | |
| Direct care staff K | Mentioned in relation to resident care and splint use | |
| Licensed nurse S | Mentioned in relation to physician notification about weight loss | |
| Consultant R | Mentioned in relation to resident weight monitoring | |
| Licensed nursing staff E | Mentioned in relation to resident eating difficulties |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 20, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-07-22.
Findings
The report documents that the previously identified deficiency under regulation 483.15(h)(3) was corrected as of 2015-08-20. No other deficiencies or issues were noted.
Deficiencies (1)
Regulation 483.15(h)(3) deficiency was corrected as of 08/20/2015.
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 that constitutes 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 August 20, 2015.
Deficiencies (1)
The most serious deficiency was an "E" level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory for the survey report. |
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 in a complaint-related inspection at Golden Living El Dorado.
Complaint Details
This Plan of Correction is related to a complaint investigation at Golden Living El Dorado. The deficiency was addressed by facility department heads and the contracted housekeeping and laundry service company.
Findings
The facility recognized a deficiency related to laundry services that could potentially affect all residents. The plan outlines corrective actions to ensure adequate staffing, linen availability, and ongoing monitoring to maintain compliance.
Deficiencies (1)
F254: The facility identified a deficiency in laundry services affecting all residents. The plan includes hiring staff, tracking linen availability twice daily, monthly linen inventories, and communication with the contracted laundry service to maintain compliance.
Report Facts
Plan of Correction completion date: The facility aims to be in substantial compliance by 2015-08-20.
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 related to laundry and linen services at the facility.
Complaint Details
The findings represent the results of complaint investigations #89421 and #88905.
Findings
The facility failed to provide adequate clean bed and bath linens and personal clothing laundry for 40 residents whose laundry was handled by the facility. Observations included soiled laundry barrels, lack of laundry staff, insufficient linens in closets, and difficulties with contracted laundry services.
Deficiencies (1)
483.15(h)(3) The facility failed to provide clean bed and bath linens in good condition for residents. Laundry services were inadequate, resulting in insufficient linens and personal clothing availability.
Report Facts
Resident 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 conditions. | |
| Contracted laundry/housekeeping supervisor staff C | Reported leaving laundry early 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 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 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, and not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
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 complied 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, and 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)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 26, 2014
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 deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 06/26/2014.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 26, 2014
Visit Reason
This visit was 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
All deficiencies previously reported were corrected by the revisit date of 06/26/2014, as documented by the correction completion dates for each cited regulation.
Report Facts
Deficiencies corrected: 13
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 26, 2014
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 06/26/2014.
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Jun 26, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a regulatory survey. It outlines corrective actions to address identified issues and achieve substantial compliance.
Findings
The facility acknowledges multiple deficiencies affecting residents, including bathing preferences, equipment malfunctions, environmental repairs, staffing shortages, dietary service issues, and catheter care. The plan details specific corrective actions, staff in-service training, equipment replacement, and ongoing monitoring to ensure compliance.
Deficiencies (13)
F 242: The facility will provide residents with bathing options of their choice and install a new whirlpool tub with maintenance oversight.
F 246: The facility will in-service direct care staff on equipment issues and resident preferences with reporting to the DNS or ED for interventions.
F 248: The facility will ensure resident participation in activities with documentation and staff training on participation expectations.
F 253: The facility will repair and repaint damaged walls, replace broken tiles and shower hoses, and ensure proper chemical storage.
F 314: The facility will in-service staff on equipment malfunctions causing pain or injury and ensure corrective measures are taken.
F 315: The facility will re-educate staff on catheter care protocols and ensure proper handling to reduce contamination risks.
F 318: The facility will reinstate restorative programs for residents and train staff on restorative and hospice care.
F 323: The facility will replace the electrical outlet for the hydroculator with a GFCI outlet and notify the QAPI Committee upon completion.
F 353: The facility has hired additional CNAs and nurses to address staffing shortages and will monitor staffing adequacy.
F 371: The facility will dispose of improperly labeled or stored food products and in-service dietary staff on food safety and cleaning protocols.
F 456: The facility recognizes deficiencies affecting all residents and will maintain compliance through ongoing interventions.
F 465: The facility will repair environmental issues including floor coverings, insulation debris, and guttering, with ongoing monitoring by maintenance and environmental services.
S 600: The facility hired a dietary manager in training and will have the Licensed Registered Dietician oversee dietary operations and staff training until certification is complete.
Report Facts
Dates of staff in-service: Jun 5, 2014
Plan of correction completion date: Jun 26, 2014
Staff hires: 4
Gutter length replaced: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Loos | Executive Director | Signed submission of Plan of Correction |
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 operation concerns.
Complaint Details
The inspection was triggered by complaints regarding resident care issues including bathing preferences, pressure ulcers, catheter care, staffing shortages, and environmental concerns. Multiple residents reported call lights not being answered timely and inadequate staffing, especially on nights and weekends.
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, insufficient nursing staff to meet resident needs, unsafe food storage and preparation practices, malfunctioning essential equipment, and unsafe and unsanitary environment conditions.
Deficiencies (12)
F242: The facility failed to provide the preferred bathing style for a resident due to a non-functioning whirlpool tub.
F246: The facility failed to accommodate a resident's preference for a different shower sling, causing discomfort and a pressure ulcer.
F248: The facility failed to provide individualized activities according to a resident's preferences, resulting in lack of meaningful engagement.
F253: The facility failed to maintain a sanitary and comfortable interior, with multiple maintenance and housekeeping deficiencies observed.
F314: The facility failed to prevent development of a pressure ulcer caused by use of an inappropriate shower sling for a resident.
F315: The facility failed to ensure urinary catheter tubing remained off the floor, increasing risk of urinary tract infections for two residents.
F318: The facility failed to provide restorative services to maintain range of motion and prevent further decline for a resident.
F323: The facility failed to maintain a therapy room free of accident hazards by not using a ground fault circuit interrupter for a hydroculator.
F353: The facility failed to provide sufficient nursing staff to meet resident care needs and timely response to call lights.
F371: The facility failed to store, prepare, and distribute food under sanitary conditions, including uncovered foods, improper storage, and unclean equipment.
F456: The facility failed to maintain the whirlpool tub in working order for resident use for over a year.
F465: The facility failed to maintain a safe, sanitary, and comfortable environment, with multiple maintenance and cleanliness issues observed.
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
Days with completed AM cook duties: 15
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 complaints about call lights |
| Licensed Nursing Staff S | Licensed Nursing Staff | Reported knowledge of resident discomfort with shower sling and catheter care issues |
| Administrative Staff A | Administrative Staff | Confirmed whirlpool tub non-functioning for over a year and environmental issues |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Aug 9, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-07-11.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Deficiencies (7)
Regulation 483.10(c)(2)-(5): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.15(h)(2): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.25(l): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.25(m)(1): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.35(i): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.65: Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.70(h): Previously cited deficiency corrected as of 08/09/2013.
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 in the Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected by the revisit date of 2013-08-09.
Deficiencies (7)
Regulation 483.10(c)(2)-(5): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.15(h)(2): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.25(l): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.25(m)(1): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.35(i): Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.65: Previously cited deficiency corrected as of 08/09/2013.
Regulation 483.70(h): Previously cited deficiency corrected as of 08/09/2013.
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 a prior survey identifying deficiencies. It outlines corrective actions to address cited deficiencies and achieve substantial compliance.
Findings
The plan of correction addresses multiple deficiencies affecting residents, including handling of resident funds, facility maintenance issues, medication administration, food storage, and sanitation. The facility commits to corrective actions and ongoing monitoring to maintain compliance.
Deficiencies (7)
F159: The facility failed to properly handle resident #22's funds without written permission and appropriate safeguards. The plan includes obtaining consent, securing funds, and auditing all resident monies.
F253: Multiple maintenance issues were found including damaged paint, stained ceilings, and damaged wallpaper in resident rooms. Repairs and renovations are planned and ongoing.
F329: The facility lacked adequate behavior monitoring for resident #11 and monitoring for unnecessary medications. Clinical audits and reviews will be implemented.
F332: Medication administration records for residents #34 and #18 were unclear, leading to medication errors. Audits and physician notifications were conducted.
F371: Food storage issues included an open and unlabeled box of bacon. Staff were in-serviced and audits established to ensure proper labeling and storage.
F441: Resident #42's bathroom required disinfection. Staff were trained on proper disinfection protocols and responsible for procurement and storage of disinfectants.
F465: Plumbing issues in the dietary department were repaired including cleaning grease traps and fixing drain pipes. Monthly maintenance inspections were instituted.
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 was triggered by complaint investigation #63362.
Findings
The facility was found deficient in multiple areas including management of resident personal funds, housekeeping and maintenance services, drug regimen monitoring, medication error rates, food procurement and sanitation, infection control, and maintaining a safe and sanitary environment.
Deficiencies (7)
F 159: The facility failed to manage a resident's personal funds according to accounting principles by not obtaining written consent and not placing funds in an interest-bearing account.
F 253: The facility failed to provide housekeeping and maintenance services to maintain a sanitary and orderly environment on 3 of 4 hallways and in the dining room.
F 329: The facility failed to adequately monitor a resident on antipsychotic medications by not initiating a behavior monitoring sheet upon admission.
F 332: The facility failed to ensure medication error rates were 5% or less, with 2 medication errors out of 28 opportunities, resulting in a 7.1% error rate.
F 371: The facility failed to maintain a clean and sanitary dietary department, including uncovered raw bacon in the walk-in cooler and unclean kitchen equipment.
F 441: The facility failed to provide care in a sanitary manner to prevent the spread of infection after a resident had an incontinent episode on the bathroom floor.
F 465: The facility failed to maintain a safe, functional, and sanitary environment in the kitchen, including a grease trap covered with dust and debris 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
Inspection Report
Follow-Up
Deficiencies: 5
Date: Apr 30, 2012
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 or LSC provision numbers were corrected as of the revisit date.
Deficiencies (5)
Regulation 483.10(c)(6) deficiency was corrected by 04/30/2012.
Regulation 483.10(c)(7) deficiency was corrected by 04/30/2012.
Regulation 483.12(b)(1)&(2) deficiency was corrected by 04/30/2012.
Regulation 483.35(i) deficiency was corrected by 04/30/2012.
Regulation 483.65 deficiency was corrected by 04/30/2012.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Apr 30, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All deficiencies previously reported were corrected by the revisit date of 2012-04-30, as documented by the correction completion dates for each cited regulation.
Deficiencies (5)
Regulation 483.10(c)(6): Previously cited deficiency corrected as of 04/30/2012.
Regulation 483.10(c)(7): Previously cited deficiency corrected as of 04/30/2012.
Regulation 483.12(b)(1)&(2): Previously cited deficiency corrected as of 04/30/2012.
Regulation 483.35(i): Previously cited deficiency corrected as of 04/30/2012.
Regulation 483.65: Previously cited deficiency corrected as of 04/30/2012.
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.
Findings
The Plan of Correction outlines multiple corrective actions including closure and audit of resident accounts, increase of surety bond for resident funds, re-education of staff on bed hold policies, food delivery procedures, infection control, and facility maintenance to ensure substantial compliance.
Deficiencies (5)
F160-D: Affected resident accounts were closed and monies returned to state recovery. Business Office Manager was re-educated on regulations regarding personal funds upon death.
F161-E: Facility increased the Surety Bond for resident funds to $100,000 and re-educated the Business Office Manager on the Surety Bond policy.
F205-E: Staff were re-educated on the bed hold policy and a tracking device was created to monitor hospital or therapeutic leave dates and notifications.
F371-F: DSM conducted in-services on food delivery procedures and implemented a cleaning schedule for kitchen equipment and utensils.
F441-D: Nurses were re-educated on infection control policies and monitoring during wound care was established twice weekly.
Report Facts
Surety Bond amount: 100000
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 regulations regarding resident personal funds, surety bond security, bed-hold policy, food sanitation, and infection control.
Complaint Details
The inspection included a complaint investigation identified as #55029.
Findings
The facility failed to convey deceased residents' personal funds within 30 days, did not maintain a surety bond covering resident personal funds, failed to provide bed-hold policy notices upon resident transfers, did not maintain sanitary food storage and preparation conditions, and failed to follow proper infection control procedures during a dressing change.
Deficiencies (5)
483.10(c)(6) The facility failed to convey 2 of 4 deceased residents' personal funds to state recovery within the 30 day requirement.
483.10(c)(7) The facility failed to provide a surety bond in an amount to cover resident personal accounts from November 2011 through March 31, 2012.
483.12(b)(1)&(2) The facility failed to provide the bed-hold policy notice to 9 Medicaid residents at the time of transfer to acute care from 10-01-11 through 4-2-2012.
483.35(i) The facility failed to store, prepare, and serve food under sanitary conditions, including bare fingers touching glass rims and kitchen equipment with debris and grease buildup.
483.65 The facility failed to use aseptic technique during a dressing change for a resident with MRSA, risking cross-contamination and infection transmission.
Report Facts
Resident census: 33
Deceased residents' personal funds not conveyed: 2
Resident accounts: 37
Resident accounts: 38
Resident accounts: 35
Surety bond amount: 45000
Resident personal funds balance: 72392.12
Resident personal funds balance: 69296.46
Resident personal funds balance: 70510.19
Residents transferred without bed-hold notice: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008003 POC NVTL11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified as ASPEN with State ID N008003.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or record for a Plan of Correction entry with no records found.
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