Inspection Report Summary
The most recent inspection on March 21, 2016, found deficiencies that the facility addressed through a plan of correction, including revisions to fall prevention and hygiene care plans, staff education, equipment security, medication documentation, infection control, crisis management policies, and mental health evaluations. Earlier inspections showed a pattern of deficiencies related to resident care planning, hygiene, fall prevention, medication management, and safety measures such as electrical protections. Complaint investigations identified issues with crisis intervention policies and mental health evaluations, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Prior enforcement actions included a denial of payment for new Medicare admissions in late 2014 due to significant noncompliance, but subsequent inspections documented corrective actions and improvements. The facility’s inspection history indicates ongoing efforts to address identified issues, with recent reports showing resolution of prior deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
59 residents
Based on a February 2016 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 7
Mar 21, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior survey report, outlining corrective actions to address identified deficiencies and prevent recurrence.
Findings
The Plan of Correction details multiple corrective actions including review and revision of care plans for residents with falls, staff education on hygiene and medication practices, securing therapy equipment, ensuring medication Black Box Warning (BBW) information is documented and non-pharmacological interventions are offered, cleaning and infection control procedures for ice machines, crisis management policy updates, and monthly mental health evaluations by a psychiatric nurse.
Deficiencies (7)
| Description |
|---|
| Fall prevention care plans reviewed and revised; staff educated on fall interventions. |
| Resident hygiene care plans reviewed; staff educated on hygiene and documentation. |
| Therapy door locking mechanism installed; staff educated on equipment security. |
| Medication lacking Black Box Warning (BBW) information corrected; staff educated on BBW and non-pharmacological pain interventions. |
| Ice machine cleaned regularly; staff trained on infection control and ice passing policy. |
| Updated crisis management policy and staff/resident education on de-escalation techniques. |
| Monthly written evaluations of residents' mental health responses completed by psychiatric nurse. |
Report Facts
Plan of Correction completion date: Mar 21, 2016
Quarterly review frequency: 4
Monthly review frequency: 1
Bi-annual training frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| GL Eskridge | Referenced in link to deficiency report | |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| RNAC | Registered Nurse Assessment Coordinator | Responsible for reviewing medication BBW information and care plans |
| DNS | Director of Nursing Services | Responsible for education, monitoring corrective actions, and oversight of care plans |
| DCE | Director of Clinical Education | Involved in monitoring and education related to corrective actions |
| MOD | Manager on Duty | Involved in monitoring corrective actions |
| ED | Executive Director | Responsible for monitoring compliance and documentation |
| DSD | Conducts quarterly med pass audits | |
| Pharmacy Consultant | Reviews BBW and non-pharmacological approaches monthly | |
| Psychiatric Nurse | Registered Nurse | Completes monthly written evaluations of residents' mental health responses |
Inspection Report
Follow-Up
Deficiencies: 6
Mar 21, 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
All previously cited deficiencies identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25(a)(2), 483.25(h), 483.25(l), 483.60(c), and 483.65 were corrected as of the revisit date.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
Inspection Report
Re-Inspection
Deficiencies: 2
Mar 21, 2016
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 28-39-234(c) and 28-39-235(a) have been corrected as of 03/21/2016.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 28-39-234(c) |
| Deficiency related to regulation 28-39-235(a) |
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 23, 2016
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 deficiencies, 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 the credible allegation of compliance and the plan of correction.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to the survey findings and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Feb 23, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations #KS00096689 and #KS00096149.
Findings
The facility failed to ensure the written policy and procedure for crisis intervention was available to residents and their families, and the policy did not address alternative methods for dealing with residents with violent behaviors. Additionally, the facility failed to ensure a contracted psychiatric nurse performed monthly written evaluations of each resident's response to their mental health plan of care.
Complaint Details
The visit included complaint investigations #KS00096689 and #KS00096149.
Severity Breakdown
SS=C: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to ensure the written policy and procedure for crisis intervention was available to residents and their families and did not address alternative methods for dealing with residents with violent behaviors. | SS=C |
| The facility failed to ensure the contracted psychiatric nurse performed monthly written evaluations of each resident's response to their mental health plan of care. | SS=F |
Report Facts
Residents present: 59
Residents sampled: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Confirmed the facility had a crisis intervention policy that was not accessible to residents or visitors | |
| Administrative nurse D | Confirmed Psychiatric Nurse Practitioner I assessed residents but did not complete monthly evaluations for all residents |
Inspection Report
Life Safety
Deficiencies: 1
Dec 21, 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 deficiency to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Denial of payments effective date: Mar 21, 2016
Provider agreement termination date: Jun 21, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 3
Feb 12, 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 all previously cited deficiencies, including those with ID prefixes F0247, F0253, and F0323, were corrected as of 01/09/2015.
Deficiencies (3)
| Description |
|---|
| Deficiency with ID Prefix F0247 related to regulation 483.15(e)(2) |
| Deficiency with ID Prefix F0253 related to regulation 483.15(h)(2) |
| Deficiency with ID Prefix F0323 related to regulation 483.25(h) |
Inspection Report
Follow-Up
Deficiencies: 3
Feb 12, 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 had been corrected.
Findings
The report documents that deficiencies identified in prior inspections were corrected by the dates listed, confirming compliance with the cited regulations.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.15(e)(2) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Dec 14, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior survey report for Golden Living Center Eskridge.
Findings
The Plan of Correction addresses deficiencies related to resident notification prior to room moves, facility cleanliness and maintenance, and fall prevention interventions. Corrective actions include improved documentation, daily monitoring of cleanliness and repairs, and implementation of care plans to prevent falls.
Severity Breakdown
D: 1
E: 1
G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify residents prior to room moves and new roommates. | D |
| Areas noted with black substance not cleaned; repairs and replacements needed for bathroom and bedroom walls, privacy curtains, and toilet bolts. | E |
| Inadequate fall prevention interventions for residents at risk of falls. | G |
Report Facts
Plan of Correction submission date: 2015
In-service training date: 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Francy Kearns | Senior Executive Director | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Dec 10, 2014
Visit Reason
The inspection 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 'G' level, resulting in enforcement remedies including a denial of payment for new Medicare admissions effective March 10, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found at 'G' level | G |
Report Facts
Denial of payment effective date: Mar 10, 2015
Termination recommendation date: Jun 10, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Frances Keearns | Administrator | Facility administrator named in the report header |
Inspection Report
Annual Inspection
Deficiencies: 1
Dec 10, 2014
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be at a 'G' level, indicating significant noncompliance. Enforcement remedies including denial of payment for new Medicare admissions were imposed effective March 10, 2015, with potential termination if substantial compliance is not achieved within six months.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found at 'G' level | G |
Report Facts
Denial of payment effective date: Mar 10, 2015
Compliance deadline: Jun 10, 2015
Civil Money Penalty threshold: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frances Keearns | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the letter |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Dec 10, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #80657 to assess compliance with resident rights, housekeeping, maintenance, and accident prevention.
Findings
The facility failed to provide residents with notice prior to roommate changes, maintain a sanitary environment, and prevent multiple injury falls for a resident with a history of mental illness and impaired judgment. Multiple deficiencies were documented including lack of documentation of notice, unsanitary conditions in utility and resident rooms, and inadequate fall prevention interventions.
Complaint Details
The complaint investigation revealed failure to provide notice before roommate changes for two residents, unsanitary conditions in multiple areas, and failure to prevent multiple injury falls for a resident with cognitive impairment and mental illness.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to give residents #54 and #58 notice prior to receiving new roommates. | SS=D |
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. | SS=E |
| Failed to ensure the resident environment remains free of accident hazards and provide adequate supervision to prevent multiple injury falls for resident #22. | SS=G |
Report Facts
Census: 55
Residents reviewed for accidental hazards: 4
Residents in sample: 18
Fall risk assessment scores: 11
Fall risk assessment scores: 17
Fall risk assessment scores: 22
Number of roommate changes for resident #54: 4
Number of roommate changes for resident #58: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| administrative nursing staff M | Acknowledged lack of documentation for roommate notice and described fall intervention responsibilities. | |
| licensed nursing staff K | Expected residents to be given notice prior to roommate changes and described fall prevention interventions. | |
| administrative nursing staff B | Reported social worker responsibility for roommate notice and described fall prevention program and supervision. | |
| maintenance staff C | Reported awareness of unsanitary conditions and maintenance plans. | |
| direct care staff F | Assisted resident transfers and described fall risk observations. | |
| direct care staff I | Reported education on walking techniques and walker use. | |
| direct care staff J | Reported fall risk interventions including 2 person assist and nonskid footwear. | |
| licensed nursing staff L | Reported encouragement of resident to use call light and supervision details. |
Inspection Report
Life Safety
Deficiencies: 1
May 20, 2014
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 a most serious deficiency classified as an 'F' level deficiency, widespread, with no harm but 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency classified as an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Aug 20, 2014
Date for recommended termination of provider agreement: Nov 20, 2014
IDR request timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Life Safety
Deficiencies: 1
May 20, 2014
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 deficiency to be an 'F' level deficiency, widespread, with no harm but 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Denial of payments effective date: Aug 20, 2014
Provider agreement termination date: Nov 20, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frances Kearns | Administrator | Named as facility administrator in the report. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator for Kansas Department for Aging and Disability Services. |
Inspection Report
Plan of Correction
Deficiencies: 4
Sep 18, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to address identified deficient practices.
Findings
The Plan of Correction details multiple corrective actions including development and revision of care plans, daily action rounds to monitor resident care and hygiene, quarterly reviews of care plans, monitoring of bowel and bladder care, and electrical safety improvements to prevent recurrence of deficiencies.
Deficiencies (4)
| Description |
|---|
| Failure to ensure residents received assistance with activities of daily living (ADLs) including personal hygiene and shaving. |
| Inadequate care planning and monitoring for incontinent residents and those requiring bowel management. |
| Missing Black Box warning care plans and inadequate monitoring of bowel movements. |
| Electrical outlets within 5 feet of water supply not equipped with ground-fault circuit interrupters (GFCI). |
Report Facts
Date for substantial compliance measurement: Sep 18, 2013
Number of resident records reviewed monthly by Pharmacy Consultant: 10
Distance for electrical outlet replacement: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Francyskeearns | Senior Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 6
Sep 18, 2013
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 had been corrected.
Findings
The revisit report confirms that all previously cited deficiencies related to various regulatory requirements were corrected as of the revisit date.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
Report Facts
Deficiencies corrected: 6
Inspection Report
Re-Inspection
Deficiencies: 1
Sep 18, 2013
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report indicates that deficiency with ID prefix S1364 related to regulation 26-40-305 (3) was corrected as of 09/18/2013. No other deficiencies or findings are listed.
Deficiencies (1)
| Description |
|---|
| Deficiency previously reported under regulation 26-40-305 (3) with ID prefix S1364 |
Report Facts
Deficiency correction date: Sep 18, 2013
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Aug 21, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS67234 to assess compliance with electrical safety requirements in the facility.
Findings
The facility failed to provide a ground-fault circuit interrupter for one hydrocollator unit in the therapy room, which is required for electrical safety in hydrotherapy equipment.
Complaint Details
The visit was complaint-related as part of a Health Resurvey and Complaint Investigation #KS67234.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a ground-fault circuit interrupter for one hydrocollator unit in the therapy room. | SS=D |
Report Facts
Census: 55
Days on site: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A interviewed regarding the lack of ground-fault circuit interrupter |
Inspection Report
Plan of Correction
Deficiencies: 6
Jun 1, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to address identified issues.
Findings
The Plan of Correction addresses multiple deficiencies including failure to provide bed hold policy during hospital transfers, incomplete hospice care plans, improper resident positioning during meals, inadequate behavior management documentation, and dental care follow-up. The facility outlines systemic changes, staff re-education, monitoring, and audit plans to ensure compliance and prevent recurrence.
Severity Breakdown
D: 4
E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide resident and family members a copy of the bed hold policy at time of transfer | D |
| Failure to develop comprehensive care plans identifying hospice services | D |
| Improper positioning of resident during meals | D |
| Behavior sheets and psychotropic medication documentation not consistently accurate or comprehensive | E |
| Failure to ensure timely dental care and follow-up | D |
| Behavior sheets with medications targeted to specific behaviors for control | E |
Report Facts
Substantial compliance measurement date: Jun 1, 2012
Staff in-service dates: May 10, 2012
Staff in-service date: Feb 3, 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Francy Kearns | Senior Administrator | Submitted the Plan of Correction to KDADS |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Follow-Up
Deficiencies: 6
Jun 1, 2012
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
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.12(b)(1)&(2), 483.20(d), 483.20(k)(1), 483.25, 483.25(l), 483.55(b), and 483.60(c) were corrected as of 06/01/2012.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.12(b)(1)&(2) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.55(b) |
| Deficiency related to regulation 483.60(c) |
Report Facts
Deficiencies corrected: 6
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 6
May 2, 2012
Visit Reason
The inspection was a health resurvey and investigation of complaint #56259, focusing on compliance with bed-hold policy, care planning, medication management, dental services, and other regulatory requirements.
Findings
The facility failed to provide a bed-hold policy notice to a resident and family after hospital transfer, failed to develop coordinated care plans for hospice services, failed to ensure proper positioning during meals for a resident, failed to identify and monitor targeted behaviors related to psychotropic medications for multiple residents, and failed to timely provide dental services to a resident with dental pain and needed extractions.
Complaint Details
The inspection was triggered by complaint #56259.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide a bed hold policy notice to a resident and family member after hospital transfer. | SS=D |
| Failed to develop a coordinated care plan that identified care and services for a resident receiving Hospice Services. | SS=D |
| Failed to ensure a resident was properly positioned during meals to prevent aspiration risk. | SS=D |
| Failed to identify and monitor targeted behaviors of psychotropic medications for multiple residents. | SS=E |
| Failed to timely provide dental services to a resident with dental pain and needed extractions. | SS=D |
| Failed to identify medication irregularities and report to the physician and facility regarding psychotropic medications and targeted behaviors. | SS=E |
Report Facts
Census: 59
Sample size: 15
Deficiencies cited: 6
Medication doses: 650
Medication doses: 220
Loading inspection reports...
