Inspection Reports for
Family Health & Rehabilitation Center
639 S MAIZE COURT, WICHITA, KS, 67209
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
25.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
325% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
82% occupied
Based on a March 2016 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 31, 2016
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 all previously cited deficiencies identified by regulation numbers 483.15(a), 483.25, and 483.35(i) have been corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 31, 2016
Visit Reason
This visit was conducted as a follow-up 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. The specific deficiency identified by regulation 28-39-158(a) was corrected by 03/31/2016.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected as of 03/31/2016.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 16, 2016
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.
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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 1
Date: Mar 16, 2016
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to employ a full-time dietary supervisor who had completed a certified dietary manager's training/education course. The dietary manager supervised all dietetic services but was not yet certified.
Deficiencies (1)
KAR 28-39-158(a)(1) The facility failed to employ a full-time dietary supervisor who successfully completed a certified dietary manager's training/education course. The dietary manager was currently enrolled but had not completed the certification.
Report Facts
Resident census: 59
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Mar 16, 2016
Visit Reason
This document is a Plan of Correction submitted by Family Health and Rehabilitation Center to address deficiencies cited during a prior survey conducted on March 16, 2016.
Findings
The facility developed corrective actions to ensure staff treat residents with dignity, update care plans reflecting resident preferences, and prepare and serve food under safe and sanitary conditions. The plan includes staff training, monitoring by leadership and dieticians, and ongoing quality assurance reviews.
Deficiencies (4)
F241-E: Staff must treat residents with dignity by addressing them by their preferred name and not by room number or derogatory terms. Resident #53 will be served meals simultaneously with others at the table.
F309-D: Care plans must include goals and interventions reflecting resident choices and preferences to maintain their highest practicable physical well-being. Resident #53's care plan was updated to include preferences related to death, religion, social work, spiritual needs, and hospice care.
F371-E: Foods must be prepared and served under safe and sanitary conditions, including restraining hair, cleaning thermometers between food items, and washing hands between glove use and kitchen re-entry.
S0600-F: The facility must employ a full-time dietary supervisor who has completed a dietary manager's training or education course.
Report Facts
Plan of Correction completion date: Mar 31, 2016
Dietary Manager Training Completion: 98
Dietician weekly hours: 16
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 24, 2014
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 of 12/24/2014.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 24, 2014
Visit Reason
This is a post-certification revisit to verify that previously identified deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All deficiencies previously reported have been corrected as of the revisit date. The report lists multiple regulation citations with correction completion dates.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Dec 24, 2014
Visit Reason
This document is a Plan of Correction submitted by Family Health and Rehabilitation Center to address deficiencies cited during a prior survey.
Findings
The facility developed and implemented corrective actions for multiple deficiencies including notification of room changes, catheter care, medication management, food preparation, and medication security. The plan outlines education, monitoring, and quality assurance measures to ensure compliance.
Deficiencies (9)
F247-D: The facility failed to ensure residents and their representatives were notified of room or roommate changes with proper documentation.
F279-D: The facility lacked comprehensive individualized care plans for residents with urinary catheters.
F315-D: The facility failed to provide appropriate catheter care and monitoring for residents with urinary catheters.
F329-D: The medication regimen included unnecessary medications without proper monitoring and documentation of behaviors and bowel movements.
F364-D: The facility did not ensure staff prepared pureed foods to conserve nutritive value for residents.
F371-E: Ready to eat foods were not handled in a sanitary manner, including failure to remove expired items and date opened foods.
F425-E: Narcotic medications were not secured under double lock and medication administration procedures were not properly followed.
F431-E: Medications were not maintained safely, including failure to lock medication carts and date insulin pens after opening.
F520-F: The facility failed to ensure a designated physician attended the Quality Assurance Performance Improvement team meetings at least quarterly.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 25, 2014
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 9
Date: Nov 25, 2014
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements.
Complaint Details
The inspection included a complaint investigation #80575 related to failure to notify residents/families of room changes and other care deficiencies.
Findings
The facility was found deficient in multiple areas including failure to notify residents or families of room changes, failure to develop comprehensive care plans for residents with urinary catheters, inadequate catheter care, failure to prevent urinary tract infections, improper medication management including psychotropic drug monitoring, improper food preparation and sanitation, and medication storage and security issues.
Deficiencies (9)
F247: The facility failed to notify resident #95 prior to a roommate change and failed to notify resident #58's family of a room change.
F279: The facility failed to develop comprehensive care plans for residents #76 and #89 related to urinary catheter care and failed to provide individualized catheter and perineal care.
F315: The facility failed to provide proper indwelling catheter care for resident #76 and failed to implement a bladder incontinence program for resident #66.
F329: The facility failed to ensure medication regimens were free from unnecessary drugs for residents #84, #95, and #52 by not monitoring behaviors, not attempting non-pharmacological interventions prior to PRN medication use, and lacking black box warnings in care plans.
F364: The facility failed to prepare pureed foods according to approved recipes to conserve nutritive value and failed to measure ingredients properly.
F371: The facility failed to serve ready-to-eat foods in a sanitary manner and failed to remove expired food items from use in 3 of 4 kitchens.
F425: The facility failed to ensure narcotic medications were secured under double lock, failed to ensure accuracy of narcotic counts, and failed to prepare medications for one resident at a time in 2 of 4 houses.
F431: The facility failed to label multi-use medication vials and insulin pens with dates opened, failed to discard expired medications, and failed to keep medication carts locked when unattended.
F520: The facility failed to ensure a designated physician attended the Quality Assessment and Assurance committee at least quarterly.
Report Facts
Deficiencies cited: 9
Residents in sample: 30
Residents census: 71
Days without bowel movement: 3
Temperature of pureed eggs: 158
Temperature of pureed eggs recipe serving: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Social Services Staff | Interviewed regarding notification of room changes. |
| Staff B | Administrative Nursing Staff | Interviewed regarding room change notification processes. |
| Staff I | Administrative Nursing Staff | Interviewed regarding room change documentation. |
| Staff M | Direct Care Staff | Interviewed regarding catheter care and bowel movement monitoring. |
| Staff K | Direct Care Staff | Interviewed regarding catheter care and resident toileting. |
| Staff F | Licensed Staff | Interviewed regarding catheter care standards. |
| Staff E | Licensed Nursing Staff | Interviewed regarding psychotropic medication monitoring and black box warnings. |
| Staff V | Direct Care Staff | Interviewed regarding resident behaviors and medication monitoring. |
| Staff R | Licensed Nursing Staff | Observed preparing medications and interviewed regarding medication administration. |
| Staff CC | Licensed Nursing Staff | Interviewed regarding medication cart and narcotic administration. |
| Staff S | Licensed Nursing Staff | Observed medication preparation and narcotic counts. |
| Staff T | Licensed Nursing Staff | Interviewed regarding medication cart security. |
| Staff L | Direct Care Staff | Observed medication cart left unlocked. |
| Staff BB | Dietary Staff | Observed preparing pureed foods without measuring ingredients. |
| Staff DD | Dietary Staff | Observed preparing pureed eggs without recipe and measuring. |
| Staff EE | Dietary Staff | Interviewed regarding pureed food preparation and recipe availability. |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding medication policies, catheter care, and QAA committee attendance. |
| Administrative Staff A | Administrative Staff | Interviewed regarding QAA committee attendance. |
| Administrative Nurse H | Administrative Nurse | Interviewed regarding medication policies and QAA committee attendance. |
| Administrative Nurse I | Administrative Nurse | Interviewed regarding medication policies and QAA committee attendance. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 25, 2014
Visit Reason
The visit was a Health survey 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 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 and alleged compliance, which was accepted by KDADS, resulting in a finding of substantial compliance effective December 24, 2014.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 14, 2014
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
The report confirms that the previously identified deficiency with regulation 483.13(c) was corrected as of 09/29/2014. No other deficiencies or issues are noted in this revisit report.
Deficiencies (1)
Regulation 483.13(c) deficiency was corrected as of 09/29/2014.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Complaint Details
This plan of correction addresses deficiencies cited during a complaint survey identified as Family Health 091114 Complaint.
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 at-risk residents.
Deficiencies (1)
F224-G: The facility failed to supervise staff to ensure all residents receive care and services necessary to avoid physical harm. A protocol was established to frequently check residents at risk from bedpan use and remove bedpans promptly.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Sep 11, 2014
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of mistreatment, neglect, and misappropriation at the facility.
Complaint Details
The complaint investigation involved two complaint numbers (#77571 and #73842). The complaint was substantiated by findings that a resident was neglected by being left on a bed pan for an extended period during the night shift, causing physical harm.
Findings
The facility failed to supervise staff adequately, resulting in one dependent resident being left on a bed pan for more than 8 hours, causing avoidable physical harm including pressure ulcers and skin breakdown.
Deficiencies (1)
483.13(c) The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse. Staff left a dependent resident on a bed pan for over 8 hours, resulting in pressure ulcers and skin damage.
Report Facts
Facility census: 63
Pressure ulcer measurements: 20
Pressure ulcer measurements: 2
Pressure ulcer measurements: 2.5
Bed pan time: 8
Bed pan time: 15
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 16, 2014
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 isolated 'D' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for 'D' level deficiencies indicating isolated issues with no harm but potential for more than minimal harm that is not immediate jeopardy.
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 as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 16, 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 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.
Deficiencies (1)
The facility was found to have 'D' level deficiencies in Life Safety Code compliance, indicating isolated issues with no immediate jeopardy but potential for more than minimal harm.
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 |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 24, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report documents that previously identified deficiencies have been corrected as of the indicated correction dates.
Deficiencies (1)
Regulation 26-40-305 (c)(1)(2) deficiency identified by prefix S1354 was corrected on 08/28/2013.
Report Facts
Correction completion date: Aug 28, 2013
Follow-up survey date: Sep 24, 2013
Previous survey follow-up completion date: Aug 9, 2013
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 24, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were corrected by the dates indicated, with corrections completed mostly on 08/28/2013 and one on 08/09/2013. The facility was sent a summary of uncorrected deficiencies on 08/09/2013.
Report Facts
Deficiency correction dates: 11
Inspection Report
Follow-Up
Deficiencies: 12
Date: Sep 24, 2013
Visit Reason
This is a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously cited deficiencies were corrected by the dates indicated, with corrections completed mostly on 08/28/2013 and one on 08/09/2013.
Deficiencies (12)
Regulation 483.15(c)(6): Deficiency previously cited was corrected by 08/28/2013.
Regulations 483.20(d), 483.20(k)(1): Deficiency previously cited was corrected by 08/28/2013.
Regulations 483.20(d)(3), 483.10(k)(2): Deficiency previously cited was corrected by 08/28/2013.
Regulation 483.25(c): Deficiency previously cited was corrected by 08/28/2013.
Regulation 483.25(d): Deficiency previously cited was corrected by 08/28/2013.
Regulation 483.25(i): Deficiency previously cited was corrected by 08/28/2013.
Regulation 483.25(l): Deficiency previously cited was corrected by 08/28/2013.
Regulation 483.35(i): Deficiency previously cited was corrected by 08/28/2013.
Regulation 483.55(a): Deficiency previously cited was corrected by 08/28/2013.
Regulations 483.60(a),(b): Deficiency previously cited was corrected by 08/28/2013.
Regulation 483.60(c): Deficiency previously cited was corrected by 08/28/2013.
Regulation 483.65: Deficiency previously cited was corrected by 08/09/2013.
Inspection Report
Plan of Correction
Deficiencies: 13
Date: 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. It outlines corrective actions to ensure compliance with state and federal regulations.
Findings
The facility developed and implemented a facility-wide system to assure correction and continued compliance with cited deficiencies. The plan addresses issues such as resident grievances, comprehensive care plans including dental care, pressure ulcer prevention, catheter use, nutritional status, medication administration, food safety, dental services, pharmaceutical services, and ventilation system maintenance.
Deficiencies (13)
F0000 Preparation and execution of this plan of correction does not constitute admission of the facts alleged but serves to comply with state and federal law. The facility has developed a system to assure correction and continued compliance with regulations.
F244-E The facility will listen to and act upon resident grievances and communicate resolutions at monthly resident council meetings. Administration will be available to address complaints immediately and grievances will be reviewed by the QAPI team.
F279-D The facility will develop and revise comprehensive care plans including dental care for affected residents. Assessments will be done upon admission and quarterly, with audits to ensure oral needs are met.
F280-D The facility will revise care plans to reflect interventions for pressure ulcer healing. Licensed nursing staff will receive ongoing training to prevent recurrence, with compliance measured through audits.
F314-G The facility will implement interventions to prevent new pressure ulcers and provide intensive staff training with follow-up competency assessments to maintain compliance.
F315-D The facility will ensure residents are catheterized only when medically necessary, with assessments and monitoring of UTI frequency reported to the QAPI committee monthly.
F325-D The facility will maintain nutritional status with documented interventions to prevent weight loss, with regular assessments and monitoring by dining services and clinical staff.
F329-D The facility will monitor effectiveness of PRN medications including narcotics, provide staff training, and audit medication administration records with monthly reporting to the QAPI team.
F371-E The facility will maintain safe and sanitary food preparation and serving through staff training and periodic audits, with trends reported monthly to the QAPI team.
F411-D The facility will provide routine and emergency dental services through outside resources, assist residents with appointments, and update care plans to include oral health assessments.
F425-D The facility will ensure accurate medication administration through transcription audits and communication with consulting pharmacy to resolve errors promptly.
F428-D The drug regimen of each resident will be reviewed monthly by a licensed pharmacist who will report irregularities. Staff will receive training on PRN medication administration and documentation with ongoing audits.
S1354-E The facility will maintain adequate ventilation for the beauty shop, with repairs completed and weekly monitoring by staff, reporting to the QAPI team monthly.
Report Facts
Date of Plan of Correction completion: Aug 28, 2013
Training date: Aug 16, 2013
Food service training date: Aug 14, 2013
Ventilation system repair date: Aug 8, 2013
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 11
Date: Aug 9, 2013
Visit Reason
The inspection was conducted as a health resurvey and complaint investigations related to multiple complaint numbers.
Complaint Details
The inspection included complaint investigations related to multiple complaint numbers (#62368, #63167, #63201, #66843, #67570).
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 appropriate treatment and services for pressure ulcers, failure to assess medical need for catheter use, failure to maintain nutritional status, failure to monitor effectiveness of PRN pain medication, failure to ensure sanitary food preparation, failure to provide routine dental services, and failure to ensure accurate pharmaceutical services including medication transcription and administration.
Deficiencies (11)
F244: The facility failed to communicate responses to resident council grievances regarding staffing and care issues.
F279: The facility failed to develop a comprehensive care plan addressing dental care needs for a resident with multiple broken or missing teeth.
F279: The facility failed to review and revise the care plan for a resident with pressure ulcers to reflect changes in condition and treatment.
F314: The facility failed to provide necessary treatment and services to prevent new pressure ulcers and to promote healing for residents with pressure ulcers.
F315: The facility failed to assess the medical need for an indwelling catheter and failed to attempt trial removal for a resident with a catheter.
F325: The facility failed to provide nutritional interventions and follow-up for a resident with significant weight loss.
F329: The facility failed to monitor the effectiveness of PRN narcotic pain medication and failed to document follow-up for one resident.
F371: The facility failed to ensure proper hand hygiene and sanitary food handling practices in 3 of 4 kitchens during food preparation.
F411: The facility failed to provide or obtain routine dental services to meet the needs of a resident with multiple broken or missing teeth.
F425: The facility failed to accurately transcribe physician orders onto MARs and failed to administer medications according to physician orders for 2 residents.
F428: The facility's pharmacist failed to identify irregularities in medication administration and follow-up for PRN medications for one resident.
Report Facts
Resident census: 72
Residents sampled: 23
PRN Norco administrations: 22
PRN Norco administrations without follow-up: 5
Weight loss: 4.8
Weight loss: 14
Inspection Report
Follow-Up
Deficiencies: 8
Date: May 30, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously identified deficiencies listed on the CMS-2567 have been corrected as of May 17, 2012.
Deficiencies (8)
Regulation 483.13(c) deficiency was corrected on 05/17/2012.
Regulations 483.20(d) and 483.20(k)(1) deficiencies were corrected on 05/17/2012.
Regulations 483.20(d)(3) and 483.10(k)(2) deficiencies were corrected on 05/17/2012.
Regulation 483.20(k)(3)(i) deficiency was corrected on 05/17/2012.
Regulation 483.25(c) deficiency was corrected on 05/17/2012.
Regulation 483.25(i) deficiency was corrected on 05/17/2012.
Regulations 483.35(d)(1)-(2) deficiencies were corrected on 05/17/2012.
Regulation 483.35(i) deficiency was corrected on 05/17/2012.
Inspection Report
Follow-Up
Deficiencies: 8
Date: May 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 were corrected as of May 17, 2012, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (8)
Regulation 483.13(c): Deficiency identified under this regulation was corrected by 05/17/2012.
Regulations 483.20(d) and 483.20(k)(1): Deficiencies identified under these regulations were corrected by 05/17/2012.
Regulations 483.20(d)(3) and 483.10(k)(2): Deficiencies identified under these regulations were corrected by 05/17/2012.
Regulation 483.20(k)(3)(i): Deficiency identified under this regulation was corrected by 05/17/2012.
Regulation 483.25(c): Deficiency identified under this regulation was corrected by 05/17/2012.
Regulation 483.25(i): Deficiency identified under this regulation was corrected by 05/17/2012.
Regulations 483.35(d)(1)-(2): Deficiencies identified under these regulations were corrected by 05/17/2012.
Regulation 483.35(i): Deficiency identified under this regulation was corrected by 05/17/2012.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: 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.
Findings
The plan addresses multiple areas including abuse/neglect policies, comprehensive care plans, participation in care planning, skin integrity monitoring, nutrition status maintenance, and food service sanitation. The facility outlines corrective actions and staff training to ensure compliance and improve resident care.
Deficiencies (9)
F226: Abuse/Neglect policies were reviewed and staff instructed on reporting and investigation procedures including complaint solicitation and variance reporting.
F279: Comprehensive care plans are developed and updated on admission, quarterly, annually, and with significant changes to meet residents' physical, mental, and psychosocial needs.
F280: Residents participate in care planning with plans updated to reflect changes including discharge planning and individualized support needs.
F281: Services meet professional standards with temporary care plans used until comprehensive plans are finalized and regularly updated.
F314: Skin integrity monitoring and documentation are part of new employee orientation and ongoing competency verification.
F314: CNAs inspect residents' skin for bruises and altered integrity; care plans updated to address wounds with communication to physicians.
F325: Nutrition status is maintained with staff trained on monitoring weight changes and dietary recommendations communicated to physicians.
F364: Dietary staff counseled on following approved menus and proper serving utensils to ensure nutritive value and presentation.
F371: Dietary team retrained on sanitary food handling and use of utensils; staff instructed to avoid contamination and wear hairnets.
Report Facts
Corrective action completion date: May 17, 2012
Staff inservice meeting dates: May 1, 2012
Dietary team inservice meeting date: Apr 20, 2012
Certified Wound Nurse training dates: May 10, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 8
Date: Apr 18, 2012
Visit Reason
Annual health resurvey of Family Health & Rehabilitation Center to assess compliance with regulatory requirements including resident care, abuse prevention, and facility operations.
Findings
The facility had multiple deficiencies including failure to develop and implement abuse/neglect policies, incomplete comprehensive care plans for residents with pressure ulcers and weight loss, failure to revise care plans after falls, inadequate nutritional interventions, and unsanitary food handling practices.
Deficiencies (8)
F 226: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse, and failed to immediately report two allegations of abuse/neglect to the State Agency.
F 279: The facility failed to develop a comprehensive care plan for resident #78 regarding pressure ulcer management and prevention of new pressure ulcers, lacking nutritional recommendations and treatment changes.
F 280: The facility failed to revise care plans for residents #25 and #39 to reflect changes in fall prevention and oral care needs, including missing fall care plans and oral hygiene interventions.
F 281: The facility failed to develop initial care plans sufficient to meet the needs of newly admitted residents with pressure ulcers and weight loss, and failed to provide adequate pressure ulcer treatment and nutritional interventions for resident #78.
F 314: The facility failed to ensure resident #78 received pressure relieving measures and nutritional interventions to prevent development of new avoidable pressure ulcers, and failed to monitor and implement dietary recommendations.
F 325: The facility failed to maintain acceptable nutritional status for resident #102, who sustained an unplanned severe weight loss of 6.9% body weight in one month, and failed to implement timely interventions.
F 364: The facility failed to measure ground meat servings accurately for residents on mechanical soft diets, resulting in inconsistent portions and potential loss of nutritive value.
F 371: The facility failed to ensure sanitary food serving practices in the Esther and Daisy Houses, including cross contamination of utensils and improper handling of plates and bowls.
Report Facts
Resident census: 70
Resident census sample: 17
Weight loss: 6.9
Braden score: 20
Ground pork portion planned: 3
Ground pork portion served: 2.5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087061 POC EYTC11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as State ID N087061.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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