Inspection Reports for
Eskridge Operator LLC
505 N MAIN STREET, ESKRIDGE, KS, 66423
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
11.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
93% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
100% occupied
Based on a December 2017 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Jan 12, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan outlines corrective actions taken to address multiple deficiencies including wound care, environmental cleanliness and maintenance, fall prevention, medication management, infection control, and immunization education. It details measures to prevent recurrence and monitoring plans for each issue.
Deficiencies (10)
F580-D: Resident #49 skin/wound care plan was reviewed and updated with physician involvement. Re-education on wound prevention and physician notification was conducted for licensed nurses.
F584-E: Environmental issues including stains, peeling caulk, broken fixtures, and maintenance repairs were addressed in multiple resident rooms and common areas to meet set standards.
F644-D: Facility sent required information for Resident #25's PASARR review and re-educated staff on PASARR process to ensure compliance.
F686-G: Resident #49's wound assessment and care plan were updated; licensed nurses re-educated on wound care with competency checks.
F689-D: Fall care plans for Residents #8 and #22 were reviewed and updated; nursing staff re-educated on fall procedures and root cause identification.
F741-F: Behavioral Evaluation Response Training was provided to nursing, dietary, housekeeping, and IDT staff; mental health first aid training scheduled.
F758-D: Pharmacy recommendations reviewed and validated; PRN medication stop dates added and monitored monthly by DON/designee.
F880-F: Laundry staff inserviced on infection control to prevent cross contamination; environmental monitoring of laundry practices implemented.
F883-E: Residents and representatives re-educated on pneumovac immunization; audit and offering of vaccines to residents ongoing.
F921-E: Environmental Supervisor called for bids to repair exterior facility issues including broken concrete, peeling paint, and rotten wood; monitoring and maintenance plans established.
Report Facts
Resident rooms with brown/black stains removed: 11
Resident rooms with peeling caulk removed and re-caulked: 6
Resident rooms with bathroom floors cleaned and disinfected: 2
Towel rods replaced: 3
Resident rooms with toilet bowls cleaned and disinfected: 2
Resident rooms with brown-stained sinks repaired and disinfected: 2
Resident rooms with closet doors sanded and painted: 4
Resident rooms with insulation installed on air conditioning pipes: 4
Resident bed frames with rust removed and protective coating installed: 3
Resident beds with missing footboards replaced: 2
Broken floor tiles replaced in lobby area: 3
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 10
Date: Dec 14, 2017
Visit Reason
Annual health resurvey and complaint investigations were conducted to assess compliance with regulatory requirements.
Findings
The facility had multiple deficiencies including failure to notify physicians of resident condition changes, inadequate housekeeping and maintenance, failure to coordinate PASARR assessments, insufficient pressure ulcer care, inadequate fall prevention interventions, lack of competent staff training for mental health needs, improper psychotropic medication management, infection control lapses, incomplete pneumococcal immunization documentation, and unsafe exterior environment conditions.
Deficiencies (10)
The facility failed to notify and consult with the resident's physician regarding deterioration of pressure ulcers for one resident.
The facility failed to provide housekeeping and maintenance services to maintain a safe, sanitary, orderly, and comfortable environment in multiple resident areas.
The facility failed to coordinate PASARR assessments and obtain required level II resident review after temporary approval expired for one resident.
The facility failed to provide timely and appropriate pressure ulcer care and monitoring for one resident with multiple pressure ulcers.
The facility failed to provide appropriate fall prevention interventions and investigate root causes for two residents with repeated falls.
The facility failed to ensure agency staff had appropriate training and competencies to care for residents with mental health needs.
The facility failed to ensure two residents were free from unnecessary psychotropic medications and failed to monitor unused PRN psychotropic medications.
The facility failed to handle, store, process, and transport linens and personal care items properly to prevent infection spread and failed to follow sanitary wound treatment procedures.
The facility failed to provide pneumococcal vaccine education, obtain consent or refusal, and document administration for four residents.
The facility failed to provide a safe, functional, sanitary, and comfortable exterior environment, including broken concrete, peeling paint, exposed wood, debris, and missing safety features.
Report Facts
Resident census: 60
Residents sampled: 16
Agency CNAs: 18
Fall risk score: 12
Fall risk score: 4
Fall risk score: 6
Fall risk score: 7
Fall risk score: 7
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 5
Pressure ulcer measurements: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Nursing Staff | Named in wound care hygiene and treatment deficiencies |
| Staff B | Administrative Nursing Staff | Named in pressure ulcer and fall prevention deficiencies |
| Staff D | Housekeeping Staff | Named in infection control and environmental deficiencies |
| Staff E | Laundry Staff | Named in infection control deficiencies |
| Staff F | Direct Care Staff | Named in pressure ulcer and fall prevention deficiencies |
| Staff H | Administrative Nursing Staff | Named in pressure ulcer and fall prevention deficiencies |
| Staff I | Licensed Nursing Staff | Named in fall prevention deficiencies |
| Staff L | Nursing Staff | Named in wound care deficiencies |
| Staff M | Administrative Staff | Named in PASARR deficiencies |
| Staff O | Direct Care Staff | Named in pressure ulcer deficiencies |
| Staff P | Consultant Staff | Named in psychotropic medication and PASARR deficiencies |
| Staff Q | Direct Care Staff | Named in staff competency deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Mar 21, 2016
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiencies identified by regulation numbers 28-39-234(c) and 28-39-235(a) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 28-39-234(c) deficiency was corrected as of 03/21/2016.
Regulation 28-39-235(a) deficiency was corrected as of 03/21/2016.
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 have 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.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Mar 21, 2016
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the 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)
Regulation 28-39-234(c) deficiency was corrected as of 03/21/2016.
Regulation 28-39-235(a) deficiency was corrected as of 03/21/2016.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 21, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies identified on the CMS-2567 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Mar 21, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior survey report. It outlines corrective actions, systemic changes, and monitoring plans to ensure compliance with regulatory requirements.
Findings
The Plan of Correction addresses multiple deficiencies related to fall prevention, resident hygiene, medication management including Black Box Warning (BBW) documentation, infection control related to ice machine cleaning, crisis management policies, and mental health plan evaluations. The facility describes specific corrective actions, staff education, and ongoing monitoring to prevent recurrence.
Deficiencies (8)
F280-D Fall prevention care plans were reviewed and revised with new interventions, and staff were educated to prevent falls. Ongoing monitoring includes daily clinical meetings to review fall care plans.
F311-D Resident hygiene deficiencies were addressed by assisting residents with showers and clean clothing, educating staff on hygiene and documentation, and monitoring care tracker reports daily.
F323-E Resident care plans were reviewed and revised to include appropriate fall prevention interventions. Therapy room door locking procedures were implemented and monitored.
F329-D Medication lacking Black Box Warning (BBW) information was corrected by placing documentation in binders and care plans. Staff were educated on BBW and non-pharmacological pain interventions with ongoing monitoring.
F428-D BBW information and non-pharmacological interventions were added to care plans. Nurses and CMAs were re-educated on documentation and offering alternatives prior to pain medication.
F441-F Ice machine cleaning procedures were reviewed and staff were in-serviced. Monthly cleaning and monitoring documentation were established to ensure infection control.
M0240-C Crisis management policies and alternative de-escalation methods were updated and staff were in-serviced. Policies and posters were made accessible and compliance monitored through rounds.
M0250-F Monthly written evaluations of residents' responses to mental health plans will be completed by a psychiatric nurse and monitored for compliance.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Date: Feb 23, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations #KS00096689 and #KS00096149.
Complaint Details
The inspection included 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. Additionally, the facility did not ensure that a contracted psychiatric nurse performed monthly written evaluations of each resident's response to their mental health plan of care.
Deficiencies (2)
28-39-234(c) QUALITY OF CARE: The facility failed to ensure the written policy and procedure for crisis intervention was available to residents and their families. The policy did not address alternative methods for dealing with residents with violent behaviors or identify a hierarchy of positive approaches.
28-39-235(a) NURSING SERVICES: 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 for all residents.
Report Facts
Resident census: 59
Sampled residents for review: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Interviewed regarding crisis intervention policy availability. | |
| Administrative nurse D | Interviewed regarding psychiatric nurse evaluations. | |
| Psychiatric Nurse Practitioner I | Assessed residents but did not complete monthly evaluations for all residents. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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 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 the credible allegation of compliance.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Life Safety
Deficiencies: 1
Date: Dec 21, 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 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.
Deficiencies (1)
The facility was cited for deficiencies resulting in an 'F' level severity, indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: 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 for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Feb 12, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all cited deficiencies related to regulations 483.15(e)(2), 483.15(h)(2), and 483.25(h) were corrected as of 01/09/2015.
Deficiencies (3)
Regulation 483.15(e)(2) deficiency was corrected by 01/09/2015.
Regulation 483.15(h)(2) deficiency was corrected by 01/09/2015.
Regulation 483.25(h) deficiency was corrected by 01/09/2015.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Feb 12, 2015
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 report confirms that the deficiencies identified in the prior survey were corrected by the dates indicated, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (3)
Regulation 483.15(e)(2) deficiency was corrected by 01/09/2015.
Regulation 483.15(h)(2) deficiency was corrected by 01/09/2015.
Regulation 483.25(h) deficiency was corrected by 01/09/2015.
Report Facts
Correction completion date: Jan 9, 2015
Follow-up survey date: Dec 10, 2014
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 12, 2015
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
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.15(e)(2), 483.15(h)(2), and 483.25(h) were corrected by 01/09/2015.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Feb 12, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report confirms that the previously cited deficiencies identified by regulation numbers 483.15(e)(2), 483.15(h)(2), and 483.25(h) were corrected as of January 9, 2015.
Deficiencies (3)
Regulation 483.15(e)(2): Previously cited deficiency was corrected by 01/09/2015.
Regulation 483.15(h)(2): Previously cited deficiency was corrected by 01/09/2015.
Regulation 483.25(h): Previously cited deficiency was corrected by 01/09/2015.
Report Facts
Correction completion dates: Jan 9, 2015
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Dec 14, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior survey of Golden Living Center Eskridge. It outlines corrective actions to address issues found during the inspection.
Findings
The plan addresses deficiencies related to resident notification prior to room moves, facility cleanliness and maintenance, and fall prevention interventions. The facility has implemented systems and monitoring processes to ensure compliance and prevent recurrence.
Deficiencies (3)
F247-D: The facility failed to ensure residents were notified prior to room moves. A system was developed to notify residents and document conversations before transfers.
F253-E: The facility had areas with black substance, damaged paint, stained curtains, and faulty toilet bolts. These were cleaned, repaired, or replaced and daily rounds were instituted to monitor cleanliness and maintenance.
F323-G: Immediate care plan interventions were implemented to prevent falls with injury. Fall assessments and care plan reviews are conducted regularly, with ongoing monitoring and staff education.
Inspection Report
Enforcement
Deficiencies: 0
Date: 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 to be at a 'G' level. Enforcement remedies including denial of payment for new Medicare admissions were imposed due to failure to achieve substantial compliance.
Report Facts
Denial of payment effective date: Mar 10, 2015
Substantial compliance deadline: Jun 10, 2015
Civil Money Penalty threshold: 5000
IDR submission deadline: 10
Inspection Report
Enforcement
Deficiencies: 0
Date: Dec 10, 2014
Visit Reason
The survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be at a "G" level. As a result, enforcement remedies including denial of payment for new Medicare admissions effective March 10, 2015, were imposed due to failure to achieve substantial compliance.
Report Facts
Denial of payment effective date: Mar 10, 2015
Substantial compliance deadline: Jun 10, 2015
Civil Money Penalty threshold: 5000
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Date: 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 requirements.
Complaint Details
The visit was triggered by complaint investigation #80657 regarding resident rights violations, housekeeping deficiencies, and failure to prevent falls.
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 cognition.
Deficiencies (3)
483.15(e)(2) The facility failed to give 2 residents notice prior to receiving new roommates as required by policy and resident rights.
483.15(h)(2) The facility failed to maintain a sanitary environment, with black substances on walls and floors, missing toilet bolts, rust, and grime in multiple areas.
483.25(h) The facility failed to prevent multiple injury falls for a resident with impaired cognition, judgment, and a history of falls despite interventions.
Report Facts
Resident census: 55
Residents reviewed for accidental hazards: 4
Residents with multiple injury falls: 1
Fall risk assessment scores: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff M | Acknowledged lack of documentation for roommate notice and described fall prevention interventions | |
| Licensed nursing staff K | Reported expectations for resident notice and fall prevention assistance | |
| Maintenance staff C | Reported awareness of black substance and maintenance plans | |
| Direct care staff F | Assisted resident transfers and described fall risk | |
| Direct care staff I | Reported resident education on walker use | |
| Direct care staff J | Described fall prevention measures | |
| Administrative nursing staff B | Described fall risk identification and supervision strategies |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 20, 2014
Visit Reason
A Life Safety Code survey was conducted 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 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.
Deficiencies (1)
The facility was cited with an 'F' level deficiency that was widespread, indicating noncompliance with Life Safety Code requirements with potential for more than minimal harm but no immediate jeopardy.
Report Facts
Effective date for denial of payments: Aug 20, 2014
Effective date for provider agreement termination: Nov 20, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 20, 2014
Visit Reason
A Life Safety Code survey was conducted 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 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.
Deficiencies (1)
The facility was cited with an 'F' level deficiency that was widespread, indicating noncompliance with Life Safety Code requirements with potential for more than minimal harm but no immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Aug 20, 2014
Provider agreement termination date: Nov 20, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Sep 18, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.20(d)(3), 483.10(k)(2), 483.25(a)(2), 483.25(d), 483.25(l), and 483.60(c) were corrected as of the revisit date.
Deficiencies (6)
Regulation 483.20(d), 483.20(k)(1): Previously cited deficiencies were corrected by 09/18/2013.
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiencies were corrected by 09/18/2013.
Regulation 483.25(a)(2): Previously cited deficiencies were corrected by 09/18/2013.
Regulation 483.25(d): Previously cited deficiencies were corrected by 09/18/2013.
Regulation 483.25(l): Previously cited deficiencies were corrected by 09/18/2013.
Regulation 483.60(c): Previously cited deficiencies were corrected by 09/18/2013.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 18, 2013
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
The report documents that the deficiency identified as Reg. # 26-40-305 (3) with ID Prefix S1364 was corrected as of 09/18/2013.
Deficiencies (1)
Regulation 26-40-305 (3) deficiency previously cited was corrected by the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 18, 2013
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously cited deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-305 (3) deficiency identified by prefix S1364 was corrected by 09/18/2013.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: 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. It outlines corrective actions to address identified deficient practices.
Findings
The Plan of Correction details multiple deficiencies related to resident care, including assistance with activities of daily living (ADLs), care plan revisions, incontinence management, bowel movement monitoring, and electrical safety. The facility describes systemic changes and monitoring plans to prevent recurrence.
Deficiencies (7)
F279: The facility failed to ensure residents received assistance with ADLs and personal hygiene. Action rounds and care plans were implemented to address this.
F280: Care plans for residents were not consistently reviewed and revised to reflect status changes. The facility instituted daily clinical reviews and weekly behavior meetings.
F311: A resident did not receive adequate assistance with shaving. Daily observation and action rounds were established to ensure completion of shaving and other ADLs.
F315: Incontinence care plans were not adequately maintained. A 3-day voiding pattern and quarterly reviews were implemented to improve care.
F329: The facility failed to monitor bowel movements and maintain Black Box warning care plans. Daily bowel movement reports and quarterly reviews were instituted.
F428: No negative outcomes were found from bowel movement documentation issues, but monitoring and quarterly reviews by pharmacy consultant were established.
S1364: The facility replaced an electrical outlet near water supply with a ground-fault circuit interrupter and implemented monthly maintenance checks.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: 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.
Complaint Details
The visit was a Health Resurvey and Complaint Investigation #KS67234.
Findings
The facility failed to provide a ground-fault circuit interrupter for one hydrocollator unit in the therapy room during the inspection. This deficiency was observed on one of four days on site and confirmed by interview with administrative staff.
Deficiencies (1)
26-40-305 (f)(3) P E - Electrical requirements: The facility failed to provide a ground-fault circuit interrupter for the hydrocollator unit in the therapy room as required.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 1, 2012
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report confirms that all previously identified deficiencies have been corrected by the revisit date of June 1, 2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 1, 2012
Visit Reason
This is a post-certification revisit to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by 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 the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jun 1, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior survey report and to ensure compliance with state and federal regulatory requirements.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including bed hold policy communication during hospital transfers, comprehensive care planning for hospice residents, proper positioning of residents during meals, behavior management with targeted medications, and dental care coordination.
Deficiencies (6)
F205: The facility failed to provide residents and family members a copy of the bed hold policy at the time of hospital transfer. Licensed nursing staff will be re-educated to send the bed hold policy with the resident and notify the responsible party.
F279: The facility failed to develop comprehensive care plans that include hospice services. The interdisciplinary team will review and update care plans to include hospice services and conduct random audits for compliance.
F309: The facility failed to properly position residents during meals. Staff will monitor and ensure proper positioning during meals, with evaluations by occupational therapy as needed.
F329: The facility failed to ensure behavior sheets had medications targeted to specific behaviors. Pharmacy consultant and interdisciplinary team will review behavior sheets regularly and conduct audits to ensure documentation and medication accuracy.
F412: The facility failed to ensure timely dental care and coordination. Dental orders will be reviewed daily and appointments scheduled promptly with monitoring by the executive director or designee.
F428: The facility failed to ensure behavior sheets had medications targeted to specific behaviors. The pharmacy consultant will review behavior sheets during scheduled visits and random audits will be conducted to ensure compliance.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 6
Date: May 2, 2012
Visit Reason
Health resurvey and investigation of complaint #56259 regarding regulatory compliance and resident care.
Complaint Details
Complaint #56259 triggered the health resurvey and investigation.
Findings
The facility failed to provide a bed hold policy 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 monitor and identify targeted behaviors related to psychotropic medications for multiple residents, and failed to timely provide dental services to a resident with dental pain.
Deficiencies (6)
483.12(b)(1)&(2) The facility failed to provide a bed hold policy to resident #32 and family after hospital admission.
483.20(d), 483.20(k)(1) The facility failed to develop a coordinated care plan identifying hospice services for resident #4.
483.25 The facility failed to ensure resident #10 was properly positioned during meals to reduce aspiration risk.
483.25(l) The facility failed to identify and monitor targeted behaviors related to psychotropic medications for seven of ten residents reviewed (#19, #31, #43, #46, #25, #20, #27).
483.55(b) The facility failed to timely provide dental services to resident #18 with dental pain and need for extractions.
483.60(c) The facility failed to ensure pharmacist identified and reported irregularities in psychotropic medication monitoring for seven residents.
Report Facts
Census: 59
Sample size: 15
Deficiencies cited: 7
Tylenol doses: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N099002 POC 670U11
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility identified as ASPEN with State ID N099002.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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