Inspection Reports for Family Health & Rehabilitation Center
639 S MAIZE COURT, WICHITA, KS, 67209
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 24, 2014, found deficiencies related to notification of room changes, catheter care, medication management, food preparation, narcotic security, and physician participation in quality assurance meetings. Earlier inspections showed a pattern of similar issues, including inadequate care planning, medication errors, unsanitary food handling, and insufficient staff supervision, with one substantiated complaint involving neglect that led to pressure ulcers. Inspectors cited recurring themes in resident care, medication safety, infection control, and food service practices. Complaint investigations were mostly substantiated, notably one involving prolonged neglect of a resident resulting in physical harm. The facility demonstrated some improvement by correcting prior deficiencies, but issues persisted through the most recent survey.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
26.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
345% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
71 residents
Based on a November 2014 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 9
Dec 24, 2014
Visit Reason
This document is a Plan of Correction submitted by Family Health and Rehabilitation Center in response to deficiencies cited during a prior survey inspection.
Findings
The plan outlines corrective actions for multiple deficiencies including notification of room changes, catheter care, medication management, food preparation, narcotic security, and staff education to ensure compliance with regulatory standards.
Severity Breakdown
D: 5
E: 3
F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to notify residents or representatives of room or roommate changes with proper documentation. | D |
| Lack of comprehensive care plans for residents with urinary catheters. | D |
| Inadequate catheter care and lack of individualized bladder incontinence programs. | D |
| Medication regimen included unnecessary medications without proper monitoring and documentation. | D |
| Failure to prepare pureed foods to conserve nutritive value. | D |
| Improper handling of ready-to-eat foods, including failure to remove expired items and date opened items. | E |
| Narcotic medications not secured under double lock and inaccuracies in narcotic counts. | E |
| Medications not maintained safely; medication carts left unlocked and insulin pens not dated. | E |
| Failure to ensure a designated physician attends the Quality Assurance Performance Improvement (QAPI) team meetings quarterly. | F |
Inspection Report
Follow-Up
Deficiencies: 9
Dec 24, 2014
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
All deficiencies previously cited in the original survey were corrected as of the revisit date, with corrections documented for multiple regulatory requirements.
Deficiencies (9)
| Description |
|---|
| Deficiency related to regulation 483.15(e)(2) |
| Deficiency related to regulations 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulations 483.35(d)(1)-(2) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulations 483.60(a),(b) |
| Deficiency related to regulations 483.60(b), (d), (e) |
| Deficiency related to regulation 483.75(o)(1) |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 10
Nov 25, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #80575 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to notify residents or families of room changes, inadequate development of comprehensive care plans especially related to urinary catheter care, failure to prevent urinary tract infections, improper medication management including psychotropic drug monitoring, unsanitary food preparation and storage practices, unsecured narcotic medications, and lack of physician attendance at Quality Assessment and Assurance committee meetings.
Complaint Details
The visit was triggered by a complaint investigation #80575.
Severity Breakdown
SS=D: 6
SS=E: 3
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to notify resident #95 prior to roommate change and failure to notify resident #58's family of room change. | SS=D |
| Failure to develop comprehensive care plans for residents #76 and #89 related to urinary catheter care. | SS=D |
| Failure to provide appropriate catheter care for resident #76, including perineal care and catheter maintenance. | SS=D |
| Failure to ensure resident #66 received appropriate bladder incontinence program and toileting assistance. | SS=D |
| Failure to ensure medication regimen was free from unnecessary drugs for residents #84, #95, and #52, including lack of monitoring and non-pharmacological interventions prior to PRN antianxiety medication use. | SS=D |
| Failure to prepare pureed foods according to approved recipes to conserve nutritive value. | SS=D |
| Failure to serve ready-to-eat foods in a sanitary manner and failure to remove expired food items from use in multiple kitchens. | SS=E |
| Failure to ensure narcotic medications were secured under double lock, accurate narcotic counts, and preparation of medications for one resident at a time in 2 of 4 houses. | SS=E |
| Failure to label multi-use medication vials and insulin pens with date opened and failure to keep medication cart locked when unattended. | SS=E |
| Failure to ensure a designated physician attended the facility's Quality Assessment and Assurance committee at least quarterly. | SS=F |
Report Facts
Residents in sample: 30
Residents census: 71
Deficiencies cited: 10
Days without bowel movement: 3
Temperature of pureed eggs: 158
Temperature of pureed foods: 140
Insulin pen expiration: 28
Tuberculin vial expiration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Social Services Staff | Interviewed regarding notification of room changes for residents #58 and #95. |
| Staff I | Administrative Nursing Staff | Interviewed regarding documentation of room change notifications. |
| Staff B | Administrative Nursing Staff | Interviewed regarding processes for room and roommate changes. |
| Staff L | Direct Care Staff | Observed and interviewed regarding catheter care for resident #76. |
| Staff K | Direct Care Staff | Observed and interviewed regarding catheter care for resident #76. |
| Staff M | Direct Care Staff | Observed and interviewed regarding catheter care for resident #76. |
| Staff O | Direct Care Staff | Interviewed regarding catheter care procedures. |
| Staff P | Licensed Staff | Interviewed regarding catheter care standards. |
| Staff F | Licensed Staff | Interviewed regarding catheter care standards. |
| Staff E | Licensed Nursing Staff | Interviewed regarding psychotropic medication monitoring and behavior sheets. |
| Staff V | Direct Care Staff | Interviewed regarding behavior charting and resident care. |
| Staff R | Licensed Nursing Staff | Observed and interviewed regarding medication preparation and narcotic counts. |
| Staff S | Licensed Nursing Staff | Observed and interviewed regarding medication preparation and narcotic counts. |
| Staff CC | Licensed Nursing Staff | Interviewed regarding medication preparation and narcotic counts. |
| Staff T | Licensed Nursing Staff | Interviewed regarding medication cart security. |
| Staff L | Direct Care Staff | Interviewed regarding medication cart security. |
| Staff BB | Dietary Staff | Observed preparing pureed foods without measuring ingredients. |
| Staff DD | Dietary Staff | Observed preparing pureed foods without measuring ingredients. |
| Staff EE | Dietary Staff | Interviewed regarding pureed food preparation and recipe availability. |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding medication administration, catheter care, and QAA committee attendance. |
| Administrative Staff A | Administrative Staff | Interviewed regarding QAA committee attendance. |
| Administrative Nurse H | Administrative Nurse | Interviewed regarding medication access and QAA committee attendance. |
| Administrative Nurse I | Administrative Nurse | Interviewed regarding medication access and QAA committee attendance. |
| Licensed Nursing Staff J | Licensed Nursing Staff | Interviewed regarding bowel movement monitoring and medication administration. |
| Direct Care Staff G | Direct Care Staff | Interviewed regarding resident behaviors and reporting. |
Inspection Report
Enforcement
Deficiencies: 1
Nov 25, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 24, 2014.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be an 'F' level deficiency, 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 | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey and enforcement action. |
Inspection Report
Follow-Up
Deficiencies: 1
Oct 14, 2014
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiency identified under regulation 483.13(c) with ID prefix F0224 was corrected on 09/29/2014. No other deficiencies are listed.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.13(c) identified by ID prefix F0224 |
Report Facts
Deficiency correction date: Sep 29, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 23, 2014
Visit Reason
This document is a Plan of Correction submitted by Family Health and Rehabilitation Center in response to deficiencies cited during a complaint survey.
Findings
The facility was found deficient in supervising staff to ensure residents receive necessary care to avoid physical harm, specifically related to the use of bedpans and monitoring of at-risk residents. The facility has developed and implemented a system to assure correction and continued compliance, including staff training and ongoing monitoring.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint survey identified as Family Health 091114 Complaint.
Deficiencies (1)
| Description |
|---|
| Failure to supervise staff to ensure all residents receive care and services necessary to avoid physical harm. |
Report Facts
Complete Date for F0000: Plan of Correction preparation and execution date 09/23/2014
Complete Date for F224-G: Facility to be in substantial compliance by 09/30/2014
Training Date: Intensive in-service training scheduled for 09/27/2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vicky Gooch | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Sep 11, 2014
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of mistreatment, neglect, and misappropriation at the facility, specifically concerning a resident left on a bed pan for more than 8 hours resulting in physical harm.
Findings
The facility failed to supervise staff adequately to ensure that one dependent resident received necessary care to avoid physical harm, resulting in the development of pressure ulcers due to being left on a bed pan for over 8 hours during the night shift. Surveillance footage and staff interviews confirmed prolonged neglect, and skin assessments documented multiple pressure injuries.
Complaint Details
The complaint visit involved allegations that a resident was left on a bed pan for an extended period during the night shift, resulting in pressure ulcers and skin breakdown. The complaint was substantiated based on interviews, surveillance camera review, and clinical assessments.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to supervise staff to ensure one dependent resident received care necessary to avoid physical harm from being left on a bed pan for more than 8 hours. | G |
Report Facts
Resident census: 63
Residents in sample: 4
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 2
Pressure ulcer measurements: 20
Pressure ulcer measurements: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Direct Care Staff | Interviewed regarding resident care and bed pan use on the night of the incident |
| Staff K | Direct Care Staff | Interviewed regarding resident care and bed pan use on the night of the incident |
| Licensed Nurse C | Licensed Nurse | Reported resident's unblanchable ring and open area after being left on bed pan |
| Licensed Nurse G | Licensed Nurse | Assessed resident's skin and notified house monitor of wounds |
| Administrative Nurse B | Administrative Nurse | Reported review of surveillance and resident condition |
| Administrative Staff A | Administrative Staff | Notified of incident and reviewed surveillance cameras |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 11, 2014
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 prior noncompliance on a resurvey in 2013, the facility will not be given an opportunity to correct deficiencies before remedies are imposed.
Severity Breakdown
Level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at a level of actual harm that is not immediate jeopardy | Level of actual harm |
Report Facts
Enforcement effective date: Sep 30, 2014
Compliance deadline: Mar 11, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions concerning the instructions contained in the letter |
Inspection Report
Life Safety
Deficiencies: 1
Jul 16, 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 deficiencies to be isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy | D |
Report Facts
Effective date for denial of payments: Oct 16, 2014
Provider agreement termination date: Jan 16, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator for Kansas Department for Aging and Disability Services |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Re-Inspection
Deficiencies: 1
Sep 24, 2013
Visit Reason
This report is a revisit 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 deficiency identified as S1354 under regulation 26-40-305 (c)(1)(2) was corrected on 08/28/2013. No other deficiencies or findings are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency S1354 under regulation 26-40-305 (c)(1)(2) |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 24, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected by the dates indicated, mostly on 08/28/2013, with one correction completed on 08/09/2013.
Report Facts
Deficiencies corrected: 12
Inspection Report
Plan of Correction
Deficiencies: 12
Aug 28, 2013
Visit Reason
This document is a Plan of Correction submitted by Family Health and Rehabilitation Center in response to deficiencies cited during a prior survey to comply with state and federal law.
Findings
The plan outlines corrective actions addressing multiple deficiencies including grievance handling, comprehensive care planning, pressure ulcer prevention, catheter use, nutritional status, medication administration, dental services, pharmaceutical services, and facility ventilation.
Deficiencies (12)
| Description |
|---|
| Failure to listen and act upon grievances and recommendations of residents concerning policy and operational decisions. |
| Failure to develop and revise comprehensive care plans including dental care for residents. |
| Failure to revise care plans to reflect interventions for pressure ulcer healing. |
| Failure to implement interventions to prevent new pressure ulcers. |
| Failure to ensure catheterization only when medically necessary. |
| Failure to maintain acceptable nutritional status with documented interventions. |
| Failure to monitor effectiveness of PRN medications including narcotics. |
| Failure to maintain safe and sanitary food preparation and serving conditions. |
| Failure to provide routine and emergency dental services to meet resident needs. |
| Failure to ensure accurate transcription and administration of medications. |
| Failure to review drug regimens monthly and identify irregularities in PRN medication administration. |
| Failure to maintain adequate ventilation for the beauty shop. |
Report Facts
Date: Aug 28, 2013
Training date: Aug 16, 2013
Training date: Aug 14, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vicky Gooch | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Census: 72
Deficiencies: 10
Aug 9, 2013
Visit Reason
The inspection was a health resurvey and complaint investigations covering multiple complaint numbers.
Findings
The facility had multiple deficiencies including failure to communicate resident grievances, failure to develop and revise comprehensive care plans especially related to dental care and pressure ulcers, failure to provide necessary treatment and services for pressure ulcers, failure to assess medical need for catheter use, failure to provide nutritional interventions for weight loss, failure to monitor effectiveness of PRN narcotic pain medication, failure to maintain sanitary food preparation conditions, failure to provide routine dental services, and failure to ensure accurate pharmaceutical services including medication transcription and administration.
Complaint Details
The inspection included complaint investigations #62368, #63167, #63201, #66843 and #67570.
Severity Breakdown
Level D: 6
Level E: 2
Level G: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to communicate decisions regarding resident council grievances about staffing issues. | Level E |
| Failed to develop a comprehensive care plan including dental care for a resident with broken/missing teeth. | Level D |
| Failed to revise care plan to reflect changes in interventions for pressure ulcers for a resident. | Level G |
| Failed to provide necessary treatment and services to prevent new pressure ulcers and failed to provide preventative care for residents at risk. | Level D |
| Failed to assess medical need for catheter and trial removal for a resident with indwelling catheter. | Level D |
| Failed to provide nutritional interventions and supplements for a resident with weight loss. | Level D |
| Failed to monitor effectiveness of PRN narcotic pain medication for a resident. | Level E |
| Failed to ensure sanitary food preparation and hand hygiene practices in 3 of 4 kitchens. | Level D |
| Failed to provide or obtain routine dental services to meet the needs of a resident. | Level D |
| Failed to ensure accurate pharmaceutical services including transcription errors, inaccurate medication administration times and doses for two residents. | Level D |
Report Facts
Deficiencies cited: 10
Resident census: 72
Resident sample size: 23
Weight loss: 4.8
Weight loss: 14
Medication administration: 22
Medication administration: 15
Medication administration: 7
Medication administration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Activity Director | Attended resident council meetings and documented grievances. |
| Staff H | Social Service Director | Managed grievance forms and complaint resolution process. |
| Staff F | Administrative Staff | Reviewed resident council minutes and confirmed lack of response to grievances. |
| Staff O | Direct Care Staff | Interviewed about resident oral care and complaints. |
| Staff Q | Licensed Staff | Interviewed about resident oral care and dental services. |
| Staff S | Licensed Staff | Interviewed about dental services availability. |
| Staff L | Licensed Nursing Staff | Reported care plan use and lack of updates for pressure ulcer care. |
| Staff M | Licensed Nursing Staff | Verified care plan interventions were not updated for pressure ulcers. |
| Staff J | Physical Therapy Staff | Reported resident's wounds caused by socks and therapy boots. |
| Staff W | Direct Care Staff | Recalled resident's pressure ulcers and nutritional intake. |
| Staff X | Direct Care Staff | Recalled resident's pressure ulcers and nutritional intake. |
| Staff A | Direct Care Staff | Reported resident's independence and nutritional intake. |
| Staff B | Licensed Nurse | Responsible for transcription of physician orders and medication administration checks. |
| Staff D | Dietary Staff | Observed with poor hand hygiene during food preparation. |
| Staff E | Administrative Dietary Staff | Reported expectations for hand hygiene and glove use in kitchen. |
| Staff N | Administrative Nurse | Reported medication administration and MAR checking procedures. |
| Staff R | Administrative Staff | Reported on catheter removal attempts and hospital discharge. |
| Consultant Y | Pharmacist Consultant | Reviewed medication regimen and failed to identify irregularities. |
| Administrative Nurse A | Administrative Nurse | Described PRN medication administration and follow up procedures. |
| Administrative Nurse C | Administrative Nurse | Reported on pressure ulcer prevention measures. |
| Administrative Nurse B | Administrative Nurse | Reported on resident edema and nutritional interventions. |
| Administrative Staff F | Administrative Staff | Reported on dental service arrangements. |
Inspection Report
Follow-Up
Deficiencies: 8
May 30, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected by 05/17/2012, as documented in this follow-up report.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.13(c) |
| Deficiency related to regulations 483.20(d), 483.20(k)(1) |
| Deficiency related to regulations 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.20(k)(3)(i) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulations 483.35(d)(1)-(2) |
| Deficiency related to regulation 483.35(i) |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 7
May 17, 2012
Visit Reason
This document is a Plan of Correction submitted by Family Health & Rehabilitation Center in response to deficiencies cited in a prior inspection report dated April 18, 2012. It outlines corrective actions to address alleged deficiencies related to abuse/neglect policies, comprehensive care plans, skin integrity monitoring, nutrition status, and food service practices.
Findings
The Plan of Correction details the facility's steps to review and update policies, conduct staff training, improve care planning and documentation, monitor skin integrity and nutrition, and ensure sanitary food handling. The facility asserts that the alleged deficiencies do not jeopardize resident health or safety and commits to completing corrective actions by May 17, 2012.
Severity Breakdown
D: 4
G: 2
E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to develop and implement abuse/neglect policies and reporting procedures | D |
| Failure to develop comprehensive care plans for residents on admission, annually, quarterly, and with significant changes | D |
| Failure to ensure residents' right to participate in planning care and revise care plans accordingly | D |
| Failure to provide services that meet professional standards including care planning prior to completion of first comprehensive assessment | D |
| Failure to monitor skin integrity and provide treatment/services to prevent or heal pressure sores | G |
| Failure to maintain nutrition status unless unavoidable | G |
| Failure to ensure food procurement, storage, preparation, and service are sanitary | E |
Report Facts
Corrective action completion date: May 17, 2012
Inspection report date: Apr 18, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Director of Nursing | Director of Nursing | Responsible for monitoring continued compliance and conducting staff meetings |
| Dietary Manager | Dietary Manager | Responsible for monitoring compliance related to nutrition and food service |
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 8
Apr 18, 2012
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with previously cited deficiencies and to assess the facility's overall regulatory compliance.
Findings
The facility was found deficient in multiple areas including failure to develop and implement abuse/neglect policies, failure to develop comprehensive care plans addressing pressure ulcer management and weight loss, failure to revise care plans after falls and for oral care, failure to meet professional standards in care planning for newly admitted residents, failure to provide adequate treatment and nutritional interventions for pressure ulcers, failure to maintain nutritional status, and failure to ensure sanitary food handling practices.
Severity Breakdown
SS=D: 4
SS=G: 2
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to develop and implement written policies and procedures prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property, and failure to immediately report allegations of abuse/neglect to the State Agency. | SS=D |
| Failure to develop a comprehensive care plan for pressure ulcer management and prevention of new pressure ulcers for resident #78. | SS=D |
| Failure to revise care plans for falls and toothbrushing/oral care for residents #25 and #39. | SS=D |
| Failure to develop an initial care plan sufficient to meet the needs of newly admitted residents with pressure ulcers and weight loss for residents #146, #78, and #102. | SS=D |
| Failure to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for resident #78. | SS=G |
| Failure to maintain acceptable parameters of nutritional status for resident #102 who sustained an unplanned severe weight loss of 6.9% body weight in one month. | SS=G |
| Failure to provide food prepared by methods that conserve nutritive value, flavor, and appearance; and food that is palatable, attractive, and at the proper temperature, including failure to measure ground meat portions for mechanical soft diets for three residents. | SS=D |
| Failure to ensure sanitary food handling practices including cross contamination of serving utensils and food contact surfaces in the Esther and Daisy Houses. | SS=E |
Report Facts
Deficiencies cited: 8
Census: 70
Weight loss percentage: 6.9
Braden score: 20
Ground pork portion: 3
Ground pork portion served: 2.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Consultant GG | Dietitian | Made nutritional recommendations for resident #78 including increased protein and vitamin C |
| Staff T | Dietary Staff | Observed serving food with cross contamination in Esther and Daisy Houses |
| Staff W | Dietary Staff | Observed serving food with cross contamination in Esther House |
| Administrative Staff B | Administrative Nursing Staff | Reported on nutritional interventions and care planning |
| Administrative Staff N | Administrative Nursing Staff | Reported on care planning and pressure ulcer prevention |
| Administrative Staff O | Administrative Nursing Staff | Reported on care planning and dietitian recommendations |
| Consultant Q | Consultant | Reported on nutritional interventions and care planning |
Report
Apr 24, 2024
File
complaint-inspection_2024-04-24.pdf
Report
Apr 24, 2024
File
health-inspection_2024-04-24.pdf
Report
Aug 14, 2023
File
infection-control-inspection_2023-08-14.pdf
Report
Aug 31, 2022
File
health-inspection_2022-08-31.pdf
Report
Jan 7, 2021
File
health-inspection_2021-01-07.pdf
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