Inspection Reports for Fountainview Living LLC
601 N. ROSE HILL ROAD, ROSE HILL, KS, 67133
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 30, 2017, found no outstanding deficiencies, confirming that previously cited issues had been corrected. Earlier inspections showed a pattern of deficiencies primarily related to resident care planning, supervision to prevent elopement and falls, medication management, dietary services, and maintaining sanitary conditions in food preparation and the environment. Several complaint investigations substantiated failures in supervision and care, including incidents of residents leaving the facility unsupervised and inadequate fall prevention measures, but enforcement actions such as fines or license suspensions were not listed in the available reports. The facility also faced repeated citations for infection control and medication administration issues over time. The trend indicates improvement, with the most recent inspections showing correction of prior deficiencies and acceptance of plans of correction.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
40 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
567% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
35 residents
Based on a June 2017 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 9
Date: Jun 30, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each deficiency fully identified by regulation number and marked as completed.
Deficiencies (9)
Deficiency identified under regulation 483.20(d);483.21(b)(1)
Deficiency identified under regulation 483.10(c)(2)(ii,iii,v);483.21(b)(2)
Deficiency identified under regulation 483.25(b)(1)
Deficiency identified under regulation 483.25(e)(1)-(3)
Deficiency identified under regulation 483.25(c)(1)
Deficiency identified under regulation 483.45(d)(e)(1)-(2)
Deficiency identified under regulation 483.60(i)(1)-(3)
Deficiency identified under regulation 483.45(a)(b)(1)
Deficiency identified under regulation 483.45(b)(2)(3)(g)(h)
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 30, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Fountainview Nursing & Rehab Center have been corrected.
Findings
The report confirms that the previously cited deficiency related to regulation 28-39-158(a) was corrected as of 06/30/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency related to regulation 28-39-158(a)
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 1, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, 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 credible allegation of compliance and evidence of correction effective June 30, 2017.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Named as contact and signatory related to findings and compliance decision |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Jun 1, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations #98427 and #102897.
Complaint Details
The visit was triggered by complaint investigations #98427 and #102897.
Findings
The facility failed to retain the services of a full-time certified dietary manager to oversee the dietary staff and maintain a clean and sanitary dietary department for food storage, preparation, and service to residents.
Deficiencies (1)
Failure to retain the services of a full-time certified dietary manager to perform managerial duties and oversee dietary staff in maintaining a clean and sanitary dietary department.
Report Facts
Census: 35
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Jun 1, 2017
Visit Reason
This document is a Plan of Correction submitted by Fountainview Nursing and Rehabilitation Center in response to deficiencies identified during a survey conducted on 06/01/2017.
Findings
The plan outlines corrective actions taken to address multiple deficiencies including comprehensive care planning, prevention of pressure ulcers, urinary tract infection prevention, medication management, dietary services, and bowel monitoring. The facility asserts substantial compliance and ongoing interventions to maintain regulatory standards.
Deficiencies (10)
Failure to develop comprehensive person-centered care plans including restorative programs.
Failure to timely review and revise care plans with appropriate goals and interventions.
Failure to prevent pressure ulcers and ensure use of pressure relieving devices.
Failure to prevent urinary tract infections and insertion site trauma for residents with Foley catheters.
Failure to prevent reduction in range of motion unless clinically unavoidable.
Failure to implement an effective bowel monitoring program.
Failure to ensure foods are prepared and stored under sanitary conditions.
Failure to follow physician orders and ensure timely availability of medications.
Failure to store drugs and biologicals appropriately and prevent expired medications.
Failure to have a qualified Certified Dietary Manager (CDM) in place.
Report Facts
Deficiencies cited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Billinger | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 21, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at an 'F' level, indicating no harm but with 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)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm not constituting immediate jeopardy.
Report Facts
Effective date for denial of payments: Jan 21, 2017
Effective date for provider agreement termination: Apr 21, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned as contact for enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 29, 2016
Visit Reason
This document serves as the provider's plan of correction following deficiencies identified in a complaint survey at Fountainview Nursing and Rehabilitation Center.
Complaint Details
This plan of correction is related to a complaint investigation identified by complaint number 01272016.
Findings
The plan outlines corrective actions taken to address an elopement risk, including relocating trash removal routes, installing new door alarm annunciators, and staff education to ensure compliance with safety regulations.
Deficiencies (1)
Elopement risk due to door security issues and trash removal through an exit door.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Billinger | Administrator | Submitted the plan of correction. |
| Shirley Boltz | Contact person for plan of correction assistance. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Jan 27, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#95873) regarding the facility's failure to prevent a resident from leaving the facility unsupervised.
Complaint Details
The complaint investigation #95873 found that the facility failed to prevent a cognitively impaired resident with a history of wandering and exit seeking from leaving the facility unsupervised and without staff knowledge. The resident was found outside the facility with a walker and blanket, was not cold or shivering, and was returned safely. Staff did not hear the alarm and were uncertain when the resident left. The facility policy on elopements was reviewed but not effectively followed.
Findings
The facility failed to implement effective interventions and provide adequate supervision to prevent one resident with cognitive impairment and wandering behaviors from leaving the facility without staff knowledge. The resident was found outside the facility unsupervised, despite use of wanderguards and increased observation.
Deficiencies (1)
Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision to prevent a resident from leaving the facility unsupervised.
Report Facts
Census: 40
Resident sample size: 3
BIMS score: 99
Date of incident: Jan 22, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff C | Reported being in the dining room during the incident and not hearing the alarm. | |
| Licensed nursing staff D | Found the resident knocking on the door outside and brought the resident back inside. | |
| Direct care staff E | Reported the resident can walk independently with a walker and has exit-seeking behaviors. | |
| Direct care staff F | Observed the resident in the dining room before and after the incident and was unaware of the elopement until asked. | |
| Administrative staff A | Reported no one admitted to turning off the alarm during the investigation. |
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Nov 3, 2015
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.
Findings
All deficiencies previously cited with specific regulation numbers were corrected as of the revisit date, November 3, 2015.
Deficiencies (5)
Deficiency related to regulation 26-41-203 (e)
Deficiency related to regulation 26-41-204 (i)
Deficiency related to regulation 26-41-205 (b)
Deficiency related to regulation 26-41-205 (l)
Deficiency related to regulation 26-41-206 (e) (1)
Inspection Report
Follow-Up
Deficiencies: 6
Date: Nov 3, 2015
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
The report confirms that all previously identified deficiencies were corrected by the revisit date of 11/03/2015, with no uncorrected deficiencies remaining.
Deficiencies (6)
Deficiency with regulation 483.15(h)(2)
Deficiency with regulation 483.25(d)
Deficiency with regulation 483.25(l)
Deficiency with regulation 483.35(i)
Deficiency with regulation 483.60(c)
Deficiency with regulation 483.65
Report Facts
Deficiencies corrected: 6
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 5
Date: Oct 6, 2015
Visit Reason
The inspection was conducted as a Health Licensure Resurvey and complaint investigation #92386 to assess compliance with regulatory requirements.
Complaint Details
The inspection included a complaint investigation #92386 as stated in the initial comments.
Findings
The facility failed to maintain sanitary and comfortable conditions in resident areas including halls and shower rooms, did not follow physician orders for blood sugar notifications, failed to document self-administration of medications in service agreements, lacked quarterly pharmacist medication regimen reviews for a resident, and failed to maintain sanitary food storage and preparation conditions.
Deficiencies (5)
Facility failed to provide sanitary and comfortable areas in 2 of 2 halls and the shower room, including cracked floor coverings, stained and worn carpets, and ceiling cracks.
Facility failed to follow physician orders related to notification of blood sugar values out of specified parameters for one resident.
Facility failed to reflect self-administration of medication on the negotiated service agreement for one resident.
Facility failed to ensure licensed pharmacist conducted medication regimen review at least quarterly for one resident.
Facility failed to store, prepare, and serve food under sanitary conditions, including unclean pans, peeling skillet surface, and dirty cabinets.
Report Facts
Blood sugar readings above parameters: 5
Resident census: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Verified carpet condition and cleaning schedule. | |
| Direct care staff G | Reported resident self-administered accu-checks and staff documented results. | |
| Direct care staff E | Reported medication aides notify charge nurse if blood sugar out of parameters. | |
| Administrative nursing staff B | Licensed administrative nursing staff | Reported lack of physician notification for blood sugar levels and pharmacist medication review issues. |
| Dietary staff C | Verified unclean kitchen equipment and cleaning schedule deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Oct 5, 2015
Visit Reason
This document is a Plan of Correction submitted by Fountainview Nursing and Rehabilitation Center in response to a survey conducted on 10/5/2015, outlining corrective actions to address identified deficiencies.
Findings
The plan details corrective actions including maintenance improvements, staff re-education on blood sugar monitoring, updating negotiated service agreements for self-administered medications, ensuring quarterly pharmacist medication reviews, and improving kitchen sanitation.
Deficiencies (5)
Maintenance services to maintain sanitary and comfortable areas including carpet cleaning and shower room remodel.
Health care services provided by qualified staff including blood sugar monitoring and physician notification.
Negotiated service agreements updated to reflect self-administration of medications.
Licensed pharmacist to conduct quarterly medication regimen reviews.
Food stored, prepared, and distributed under sanitary conditions with kitchen sanitation in-service and equipment replacement.
Report Facts
Dates for corrective actions: Oct 30, 2015
Dates for corrective actions: Nov 3, 2015
Dates for corrective actions: Oct 13, 2015
Dates for corrective actions: Oct 21, 2015
Dates for corrective actions: Oct 12, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Billinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 5, 2015
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious 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, resulting in a finding of substantial compliance effective November 3, 2015.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date of substantial compliance: Nov 3, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as contact and signatory related to enforcement and survey findings |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Oct 5, 2015
Visit Reason
This Plan of Correction document responds to deficiencies identified during the survey exit on 10/5/2015 at Fountainview Nursing and Rehabilitation Center, outlining corrective actions to achieve substantial compliance by 11/3/2015.
Findings
The facility addressed multiple deficiencies including housekeeping and maintenance issues, toileting plans and assessments, medication monitoring, food sanitation, pharmacy consultant communication, and infection control practices. Corrective actions and staff re-education were implemented with ongoing quality assurance monitoring.
Deficiencies (6)
Housekeeping and maintenance services to maintain a sanitary comfortable environment including repairs and cleaning.
Provision of effective toileting plan and assessment for residents.
Appropriate monitoring of medications, specifically blood pressure monitoring for residents on anti-hypertensive medications.
Food storage, preparation, and distribution under sanitary conditions.
Pharmacy consultant notification to Director of Nursing of irregularities in blood pressure monitoring.
Maintenance of an Infection Control Program including proper sanitization and hand washing.
Report Facts
Deficiency completion date: Nov 3, 2015
Survey exit date: Oct 5, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Billinger | Administrator | Administrator submitting the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 6
Date: Oct 1, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #90283 to assess housekeeping, maintenance, toileting care, medication monitoring, food sanitation, infection control, and other compliance issues.
Complaint Details
The visit was triggered by a complaint investigation #90283 focusing on housekeeping, maintenance, toileting care, medication monitoring, food sanitation, infection control, and related issues.
Findings
The facility failed to maintain sanitary housekeeping and maintenance in multiple resident areas, failed to provide an effective toileting plan for a dependent resident, failed to monitor blood pressure weekly for a resident on antihypertensive medication, failed to maintain sanitary food preparation conditions, failed to identify medication monitoring deficiencies by the pharmacist, and failed to maintain infection control practices including proper cleaning and hand hygiene.
Deficiencies (6)
Failed to provide housekeeping and maintenance services on 2 of 3 hallways; multiple resident rooms had damaged walls, loose cove base, broken blinds, rusted heating units, and debris.
Failed to maintain an effective toileting plan for one resident, including inadequate assessment and failure to provide toileting opportunities.
Failed to monitor blood pressure and pulse weekly for one resident on antihypertensive medication as ordered by physician.
Failed to store, prepare, and serve food under sanitary conditions; kitchen pans and cabinets were dirty and not properly cleaned.
Pharmacist failed to identify facility's failure to monitor blood pressure and pulse for a resident on antihypertensive medication.
Failed to maintain infection control program for cleaning and use of multi-resident glucometer and failed to ensure proper handwashing after cleaning an isolation room.
Report Facts
Census: 39
Residents sampled: 10
Residents reviewed for unnecessary medications: 5
Blood pressure parameters: 80/50 to 200/100
Medication dose: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Advised about water fountain repair and removal | |
| Maintenance staff E | Advised about replacement of broken mini blinds | |
| Direct care staff G | Failed to provide toileting opportunities to resident #42 | |
| Licensed nursing staff C | Reported on toileting and medication monitoring issues | |
| Direct care staff J | Assisted resident #42 with cares and transfers | |
| Direct care staff H | Properly cleaned glucometer after use | |
| Housekeeping staff M | Failed to wash hands after cleaning isolation room | |
| Consultant staff D | Reported on glucometer cleaning requirements | |
| Consultant staff N | Reported on pharmacist's failure to identify medication monitoring deficiency |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 17, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.
Deficiencies (1)
Most serious deficiencies found were 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Sep 17, 2015
Provider agreement termination date: Dec 17, 2015
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
Re-Inspection
Deficiencies: 1
Date: Mar 3, 2015
Visit Reason
This revisit inspection was conducted to verify that previously cited deficiencies had been corrected as of the revisit date.
Findings
The report indicates that the previously reported deficiency identified by regulation 26-41-204 (i) with ID prefix S3171 was corrected as of 03/03/2015.
Deficiencies (1)
Deficiency previously reported under regulation 26-41-204 (i) with ID prefix S3171
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 1
Date: Feb 13, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#83201) related to the care provided to residents, specifically focusing on falls and the facility's response to a resident's physical decline and fall incidents.
Complaint Details
The complaint investigation focused on the care of a resident who experienced multiple falls, including one resulting in serious injuries such as fractured hip, fractured ribs, and pneumothorax. The facility failed to implement fall prevention interventions and adequately document the resident's falls and care needs. The resident was admitted to inpatient hospice after the second fall and expired two days later.
Findings
The facility failed to provide care according to acceptable standards of practice by not implementing timely and appropriate interventions following a resident's physical decline and falls. One resident experienced multiple falls resulting in a fractured hip, fractured ribs, and pneumothorax, with inadequate fall prevention interventions and documentation.
Deficiencies (1)
Failure to provide care according to acceptable standards of practice with failure to implement timely and appropriate interventions following a physical decline and fall to meet the needs of a resident.
Report Facts
Resident census: 16
Fall risk assessment score: 3
Fall risk assessment score: 11
Pain rating: 9
Date of resident's death: Jan 18, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Direct Care Staff | Reported resident's decline and frustration with care, noted lack of fall prevention interventions |
| Staff D | Licensed Nursing Staff | Reported concerns about resident's decline, lack of interventions, and staffing limitations |
| Staff B | Administrative Nursing Staff | Confirmed facility responsibility for resident safety and lack of fall prevention plan |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 13, 2015
Visit Reason
This document serves as the plan of correction submitted by Fountainview Nursing and Rehabilitation Center in response to deficiencies identified during the survey exiting on 02/13/2015.
Findings
The plan outlines corrective actions taken and ongoing interventions to address identified deficiencies, including fall reporting and investigation procedures, staff inservices, and quality assurance monitoring to ensure compliance.
Deficiencies (1)
Resident #1 has expired. All residents have the potential to be affected. A 24 hr. report sheet and summary has been created for the AL unit to track falls and investigations.
Report Facts
Date of survey exit: Feb 13, 2015
Plan of correction completion date: Mar 8, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Billinger | Administrator | Administrator who submitted the plan of correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 7, 2014
Visit Reason
This revisit inspection was conducted to verify that previously identified deficiencies at Fountainview Nursing & Rehab Center were corrected.
Findings
The report confirms that the previously cited deficiency under regulation 26-41-205 (d) (1-2) with ID prefix S3200 was corrected as of 11/07/2014.
Deficiencies (1)
Deficiency under regulation 26-41-205 (d) (1-2) previously cited
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 1
Date: Oct 28, 2014
Visit Reason
The inspection was conducted as a complaint investigation for complaint numbers 79215 and 78362 regarding medication administration at the facility.
Complaint Details
The investigation was based on complaints #79215 and #78362. The deficiency was substantiated as the facility failed to administer medications as ordered for resident #3.
Findings
The facility failed to administer medications in accordance with physician's orders for one resident (#3), who did not receive prescribed medications for at least three days due to unavailability and pharmacy issues.
Deficiencies (1)
Failure to administer medications in accordance with physician's orders for one resident (#3), resulting in at least three missed doses for each medication.
Report Facts
Census: 17
Residents reviewed for medication administration: 6
Missed doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff A and B were involved in observations and interviews regarding medication administration but full names were not provided. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 28, 2014
Visit Reason
This document is a Plan of Correction submitted by Fountainview Health Care and Rehabilitation Center in response to findings from a complaint survey conducted on 10/28/2014.
Complaint Details
The plan of correction was submitted as a result of findings from a complaint survey exiting 10/28/14.
Findings
The facility addressed deficiencies related to medication administration, specifically ensuring timely receipt and proper transcription of medications for residents, including Resident #3. Staff were inserviced on new admission medication procedures and ongoing compliance measures were implemented.
Deficiencies (1)
Failure to ensure all residents receive their medications as ordered by the physician.
Report Facts
Date of complaint survey exit: Oct 28, 2014
Date medication brought for Resident #3: Oct 27, 2014
Date of MAR audit: Oct 27, 2014
Date of staff inservice: Oct 30, 2014
Plan of correction completion date: Nov 7, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Administrator who submitted the plan of correction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 27, 2014
Visit Reason
This post-certification revisit was conducted 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 or LSC provision numbers were corrected as of the revisit date, October 27, 2014.
Report Facts
Deficiencies corrected: 22
Previous survey date: Jun 23, 2014
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 27, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that the previously cited deficiency with ID prefix F0323 related to regulation 483.25(h) was corrected on 2014-10-10.
Deficiencies (1)
Deficiency with ID prefix F0323 related to regulation 483.25(h)
Report Facts
Deficiency correction date: Oct 10, 2014
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 2, 2014
Visit Reason
This document is a Plan of Correction submitted by Fountainview Health Care and Rehabilitation Center in response to deficiencies identified during a survey exiting on October 2, 2014.
Findings
The facility addressed deficiencies related to accident hazards, supervision, and door monitoring systems, including discharge of a resident to a more appropriate unit, re-education of staff on alarm and elopement policies, and plans for improved security measures such as keypad systems and daily monitoring of wander guard bracelets.
Deficiencies (2)
Free of accident hazards, supervision, and devices (F323)
Door monitoring system (S0976)
Report Facts
Date of survey exit: Oct 2, 2014
Plan of correction completion date: Oct 10, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added the Plan of Correction | |
| Mary Jane Kennedy | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Oct 2, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#78625) regarding the facility's failure to provide adequate supervision to prevent elopement of a resident identified at risk.
Complaint Details
Complaint investigation #78625 focused on the facility's failure to prevent elopement of resident #1, who was found outside the facility without staff knowledge for approximately two hours due to alarm system failures and inadequate supervision.
Findings
The facility failed to provide adequate supervision and secure exit door alarms, resulting in a resident at risk for elopement leaving the facility unnoticed for approximately two hours. The door alarms were found deactivated, and staff failed to properly monitor the resident despite care plans and risk assessments identifying the resident as an elopement risk.
Deficiencies (1)
Failure to provide adequate supervision to prevent elopement of a resident at risk.
Report Facts
Resident census: 37
Residents sampled for accidents: 3
Elopement duration: 2
Fall risk assessment score: 8
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 2, 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 to be at a 'D' level, indicating non-compliance. Enforcement remedies including denial of payment for new Medicare admissions were imposed and will continue until substantial compliance is achieved.
Deficiencies (1)
Most serious deficiency found at a 'D' level
Report Facts
Denial of payment effective date: Sep 19, 2014
Termination recommendation date: Dec 23, 2014
Civil Money Penalty minimum amount: 5000
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person for questions concerning the instructions contained in the letter |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 28, 2014
Visit Reason
The revisit was conducted on August 28, 2014, as a first revisit following the June 23, 2014 Health survey to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Complaint Details
The denial of payment action was based on deficiencies found during this revisit and a Complaint investigation conducted on October 28, 2013.
Findings
The revisit found the most serious deficiency to be a 'G' level deficiency related to pressure ulcers (F314). Due to noncompliance, a denial of payment for all new Medicare admissions was imposed effective September 16, 2014, and further enforcement remedies may be considered if substantial compliance is not achieved.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers
Report Facts
Months until termination recommendation: 6
Denial of payment effective date: Sep 16, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as contact for questions concerning the instructions contained in the letter. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 28, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that all previously cited deficiencies under regulations 483.25(m)(1), 483.25(n), 483.35(i), and 483.60(b),(d),(e) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 4
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 13
Date: Aug 28, 2014
Visit Reason
The inspection was conducted as a Non-Compliance Revisit and complaint investigations related to allegations of sexual abuse, falls with injury, and bruising of unknown origin.
Complaint Details
The visit was complaint-related involving investigations of allegations of sexual abuse, falls with injury, and bruising of unknown origin. The facility failed to thoroughly investigate and report these allegations as required.
Findings
The facility failed to thoroughly investigate and report allegations of sexual abuse, falls with injury, and bruising. Additionally, the facility failed to promote dignified care, maintain a sanitary environment, conduct comprehensive assessments, develop and revise care plans, provide necessary treatments and services including pressure ulcer prevention, urinary continence management, range of motion maintenance, and ensure adequate staffing and supervision. Infection control practices were also deficient, and pharmaceutical services failed to ensure timely medication administration.
Deficiencies (13)
Failed to thoroughly investigate and report allegations of sexual abuse, falls with injury, and bruising of unknown origin.
Failed to promote care in a dignified manner for residents, including failure to ensure proper clothing coverage and assistance with personal hygiene.
Failed to maintain a homelike and sanitary environment due to strong urine odors in resident hallways and front entrance.
Failed to conduct comprehensive and accurate assessments, including Care Area Assessments and Minimum Data Set assessments, leading to inadequate care planning.
Failed to develop and revise comprehensive care plans to address residents' medical, nursing, and psychosocial needs, including falls prevention, range of motion, toileting, and pain management.
Failed to provide necessary care and services to maintain physical well-being, including skin care, pain management, and edema management.
Failed to provide treatment and services to prevent pressure ulcers, including timely repositioning and skin assessments.
Failed to provide appropriate treatment and services to prevent urinary tract infections and maintain bladder function, including individualized toileting plans and timely toileting assistance.
Failed to provide appropriate treatment and services to increase or maintain range of motion, including adequate restorative therapy and range of motion exercises.
Failed to ensure a safe environment free of accident hazards and adequate supervision, resulting in falls including a fall with fracture due to carpet cleaning hoses blocking a hallway.
Failed to provide pharmaceutical services to assure medication administration as ordered, including missed doses of multiple medications due to pharmacy delivery issues.
Failed to maintain infection control practices, including failure to change gloves between soiled and clean tasks during perineal care, risking spread of infection.
Failed to maintain an effective quality assurance committee that develops and implements plans of action to correct quality of life and care deficiencies.
Report Facts
Resident census: 42
Residents reviewed: 17
Fall risk score: 14
Braden scale score: 13
Number of falls: 4
Number of days without BM: 7
Number of days without BM: 4
Number of days without BM: 4
Medication doses missed: 4
Medication doses administered: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Direct Care Staff | Named in failure to investigate sexual abuse allegation and failure to provide toileting and perineal care properly |
| Staff K | Direct Care Staff | Named in failure to provide toileting assistance and failure to monitor edema |
| Staff E | Licensed Nursing Staff | Named in failure to investigate sexual abuse allegation, failure to monitor toileting plans, and medication administration issues |
| Staff O | Direct Care Staff | Named in failure to provide dignified care and toileting assistance |
| Staff L | Direct Care Staff | Named in failure to provide dignified care and toileting assistance |
| Staff V | Direct Care Staff | Named in failure to provide toileting assistance and perineal care |
| Staff C | Administrative Nursing Staff | Named in failure to investigate abuse allegations and infection control training |
| Staff D | Licensed Nursing Staff | Named in failure to complete comprehensive assessments |
| Staff Y | Activity Staff | Named in staffing shortages affecting activity schedule |
| Staff Z | Activity Staff | Named in staffing shortages affecting activity schedule |
Inspection Report
Plan of Correction
Deficiencies: 18
Date: Aug 28, 2014
Visit Reason
This document is a Plan of Correction submitted by Fountainview Health Care and Rehabilitation Center in response to deficiencies identified during a survey exiting on August 28, 2014.
Findings
The plan outlines corrective actions taken and ongoing interventions to address multiple deficiencies related to abuse investigation, dignity and respect, housekeeping, assessments, care planning, professional standards, skin care, infection control, medication management, staffing, and quality assurance. The facility asserts substantial compliance with regulations by September 26, 2014.
Deficiencies (18)
Investigate and report allegations of abuse, falls with injury, and bruises of unknown origin.
Promote care for residents in a manner that maintains or enhances dignity and respect.
Provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior.
Conduct comprehensive, accurate, standardized assessments of each resident's functional capacity.
Conduct accurate comprehensive Minimum Data Set assessments to plan care accordingly.
Develop comprehensive care plans with measurable objectives and timetables.
Develop comprehensive care plans with resident participation and periodic review.
Ensure services meet professional standards of quality.
Provide care and services to attain or maintain highest practicable well-being.
Provide treatment and services to prevent and heal pressure sores.
Ensure residents without indwelling catheters are not catheterized unless necessary and prevent urinary tract infections.
Provide treatment and services to increase or prevent decrease in range of motion.
Ensure resident environment is free of accident hazards and provide adequate supervision and assistive devices.
Ensure drug regime is free from unnecessary drugs and monitor bowel elimination.
Maintain sufficient 24-hour nursing staff per care plans.
Ensure pharmaceutical services provide accurate medication administration.
Establish and maintain infection control program to prevent spread and ensure proper glove use.
Maintain a quality assessment and assurance committee that meets quarterly and develops plans of action.
Report Facts
Date of survey exit: Aug 28, 2014
Plan of correction completion date: Sep 26, 2014
Number of toileting slings ordered: 5
Training dates: Aug 23, 2014
Training dates: Sep 10, 2014
New Director of Nursing employment start date: Sep 2, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 7
Date: Aug 8, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (7)
Deficiency identified under regulation 26-41-201 (a) (b)
Deficiency identified under regulation 26-41-202 (c)
Deficiency identified under regulation 26-41-203 (e)
Deficiency identified under regulation 26-41-204 (i)
Deficiency identified under regulation 26-41-205 (a) (1)
Deficiency identified under regulation 26-41-102 (d)
Deficiency identified under regulation 26-41-206 (e) (1)
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Jul 21, 2014
Visit Reason
This document is a Plan of Correction submitted by Fountainview (Carriage House) Assisted Living in response to deficiencies identified during a survey conducted on 7/21/2014.
Findings
The facility identified multiple deficiencies including late functional capacity screenings, admission negotiated service agreements, routine maintenance issues, health care services standards, self-administration of medications assessments, staff qualifications and employee records, and food storage practices. Corrective actions and ongoing interventions have been implemented to ensure compliance with regulations.
Deficiencies (7)
Functional Capacity Screen on Admission was completed late for resident #2.
Admission Negotiated Service Agreement was completed late for resident #2.
Routine Maintenance issues including window hardware, hallway walls, carpet seams, and patio door metal siding cap.
Health Care Services and Standards of Practice deficiencies related to diabetes management and medication administration.
Self Administration of Medications assessments were incomplete for residents #1 and #3.
Staff Qualifications Employee Records lacked complete documentation including licensure, criminal background checks, and nurse aide registry verifications.
Facility Food Storage was not maintained under safe and sanitary conditions; items were cleaned and staff re-educated.
Report Facts
Date of survey: Jul 21, 2014
Completion dates for corrective actions: Aug 1, 2014
Completion dates for corrective actions: Aug 8, 2014
Completion date for food storage corrective action: Aug 1, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Administrator who submitted the Plan of Correction |
| Director of Nursing | Re-educated nursing staff on diabetes management and medication administration | |
| Director of Maintenance | Responsible for addressing maintenance concerns and work order log | |
| Dietary Manager | Responsible for auditing food storage and compliance | |
| Business Office Manager/HR | Developed plan for timely criminal background checks | |
| ADON | Assistant Director of Nursing | Implemented tracking system for lab orders and medication assessments |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 7
Date: Jul 21, 2014
Visit Reason
The inspection was conducted as a licensure survey and complaint investigation for complaint numbers 75348 and 74323.
Complaint Details
The inspection included complaint investigations for complaint numbers 75348 and 74323.
Findings
The facility failed to complete required functional capacity screenings and negotiated service agreements upon admission for a resident, did not provide adequate housekeeping and maintenance, failed to provide care according to acceptable standards including medication administration and laboratory testing, failed to complete self-administration medication assessments, did not timely request criminal background checks for employees, and failed to maintain a clean and sanitary dietary environment.
Deficiencies (7)
Failure to complete a functional capacity screening on or before admission for 1 of 3 residents reviewed.
Failure to develop a negotiated service agreement upon admission for 1 of 3 residents reviewed.
Failure to provide adequate housekeeping and maintenance services to provide sanitary and comfortable areas in resident halls, conference room, and dining room siding.
Failure to provide health care services according to acceptable standards of practice, including failure to follow physician orders related to laboratory testing, medication administration, and failure to establish blood sugar parameters.
Failure to complete self-administration of medication assessments for 2 of 3 residents reviewed.
Failure to request criminal background checks in a timely manner for 2 of 4 certified employees reviewed.
Failure to maintain a clean and sanitary dietary environment, including undated food items, unclean ice machine, frost buildup, and improper storage of non-food items in food storage areas.
Report Facts
Census: 20
Residents reviewed: 3
Certified employee files reviewed: 4
Days delay for criminal background check: 35
Days delay for criminal background check: 15
Inspection Report
Enforcement
Deficiencies: 1
Date: Jun 23, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services 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 deficiencies in the facility to be at an "F" level, resulting in enforcement remedies including denial of payment for new Medicare admissions effective September 23, 2014, until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Deficiencies found at "F" level severity
Report Facts
Denial of payment effective date: Sep 23, 2014
Termination recommendation date: Dec 23, 2014
Timeframe for substantial compliance: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 17
Date: Jun 23, 2014
Visit Reason
Annual health resurvey and complaint investigations including elopement, falls, and infection control.
Findings
The facility had multiple deficiencies including failure to thoroughly investigate elopement, failure to promote dignity and respect for residents, inadequate housekeeping and maintenance, incomplete comprehensive assessments and care plans, failure to provide timely repositioning and toileting, medication errors, expired medications, lack of immunization consent documentation, insufficient nursing staff, unsanitary food storage and preparation, and inadequate infection control practices.
Deficiencies (17)
Failure to thoroughly investigate an elopement incident and failure to timely report it to the state agency.
Failure to promote care in a dignified manner including improper clothing coverage and use of pet names without consent.
Failure to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior.
Failure to conduct comprehensive assessments and complete care area assessments (CAAs) to identify care concerns and develop care plans.
Failure to accurately complete comprehensive assessments reflecting resident's functional limitations.
Failure to develop comprehensive care plans with measurable objectives and timetables to meet residents' needs.
Failure to provide necessary care and services to promote physical well-being including pain management and skin care.
Failure to provide timely position changes to prevent pressure ulcers.
Failure to provide appropriate treatment and services to restore bladder function and prevent urinary tract infections.
Failure to provide restorative nursing services to increase or prevent decline in range of motion.
Failure to ensure resident environment is free of accident hazards and provide adequate supervision to prevent falls and injuries.
Failure to maintain medication error rate below 5%, including incorrect dose and failure to administer ordered medications.
Failure to provide required documentation of resident or legal representative consent or refusal for influenza and pneumococcal immunizations.
Failure to provide sufficient nursing staff to meet resident care needs and supervision.
Failure to procure, store, prepare, distribute and serve food under sanitary conditions.
Failure to maintain drug records, label and store drugs and biologicals properly, including expired medications and unlabeled insulin pens.
Failure to maintain an effective infection control program including failure to track infections, improper glove use, and inadequate cleaning of soiled wheelchair.
Report Facts
Medication error rate: 6.89
Resident census: 41
Fall risk score: 13
Braden score: 9
Braden score: 16
Braden score: 13
Medication doses: 15
Medication doses: 45
Medication doses: 40
Medication doses: 20
Medication doses: 15
Medication doses: 5
Medication doses: 30
Medication doses: 100
Medication doses: 12
Medication doses: 81
Medication doses: 400
Medication doses: 1000
Medication doses: 5
Medication doses: 20
Medication doses: 325
Medication doses: 15
Medication doses: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Reported lack of infection control monitoring and medication cart oversight |
| Staff C | Administrative Nursing Staff | Reported immunization documentation missing and care plan deficiencies |
| Staff U | Direct Care Staff | Observed failing to change gloves after perineal care |
| Staff V | Direct Care Staff | Observed failing to change gloves after perineal care and inadequate perineal hygiene |
| Staff J | Direct Care Staff | Observed failing to provide timely toileting and perineal care |
| Staff K | Direct Care Staff | Reported resident toileting needs and observed failure to reposition resident timely |
| Staff L | Direct Care Staff | Observed providing limited range of motion and no documentation |
| Staff Z | Therapy Staff | Reported resident discharged from therapy with leg brace orders not implemented |
| Staff EE | Consultant Staff | Reported lack of toileting programs and incomplete restorative care |
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Jun 23, 2014
Visit Reason
This document is a Plan of Correction submitted by Fountainview Health Care and Rehabilitation Center in response to deficiencies identified during a survey conducted on June 23, 2014.
Findings
The facility identified multiple deficiencies related to investigation and reporting of allegations, dignity and respect of residents, housekeeping and maintenance, comprehensive assessments, care planning, medication management, infection control, and other regulatory requirements. The Plan of Correction outlines corrective actions including staff re-education, policy reinforcement, audits, and ongoing monitoring to achieve substantial compliance by July 22, 2014.
Deficiencies (19)
Failure to investigate and report allegations of mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property.
Failure to promote care that maintains or enhances each resident's dignity and respect in full recognition of individuality.
Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Failure to conduct comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity.
Failure to ensure resident assessments accurately reflect the resident's status.
Failure to develop comprehensive care plans based on assessments.
Failure to develop and revise care plans with participation of interdisciplinary team and resident/family.
Failure to provide services that meet professional standards of quality.
Failure to provide care and services to attain or maintain the highest practicable well-being.
Failure to provide treatments and services to prevent and heal pressure sores.
Failure to prevent unnecessary catheterization and provide bladder restoration services.
Failure to provide treatment and services to increase or prevent decrease in range of motion.
Failure to maintain a resident environment free of accident hazards and provide adequate supervision and assistive devices.
Failure to ensure drug regime is free from unnecessary drugs.
Failure to maintain medication error rates below 5%.
Failure to ensure influenza and pneumococcal immunizations are administered per policy.
Failure to have sufficient 24-hour nursing staff per care plans.
Failure to ensure drugs are recorded, labeled, and stored appropriately.
Failure to establish and maintain an infection control program to prevent spread of infection.
Report Facts
Deficiencies cited: 17
Plan of Correction completion date: Jul 22, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Signed submission of Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Person who added and modified Plan of Correction document |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 13, 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 483.25(h) with ID prefix F0323 was corrected on 2014-04-18. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency under regulation 483.25(h) previously cited
Report Facts
Deficiency correction date: Apr 18, 2014
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Apr 3, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#72958) regarding the facility's failure to provide adequate supervision and assistive devices to prevent accidents for residents requiring mechanical lifts.
Complaint Details
The complaint investigation (#72958) found that the facility did not follow proper mechanical lift sling size recommendations, leading to a resident falling during transfer and sustaining injuries.
Findings
The facility failed to follow mechanical lift sling size recommendations, resulting in a resident falling from the sling during transfer and sustaining abrasions and skin tears. The resident weighed 122 pounds but was transferred using an x-large sling instead of the appropriate small sling.
Deficiencies (1)
Failure to provide adequate supervision and/or assistive devices to prevent an accident for a resident requiring a Hoyer mechanical lift for transfers.
Report Facts
Census: 60
Resident weight: 122
Skin tear size: 3
Skin tear size: 0.5
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 18, 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.
Deficiencies (1)
Isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy
Report Facts
Effective date for denial of payments: Jun 18, 2014
Provider agreement termination date: Sep 18, 2014
IDR request timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Named as facility administrator in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 1, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected on 03/01/2014. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency under regulation 483.25(h) previously cited
Report Facts
Deficiency correction date: Mar 1, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 1, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Complaint Details
This Plan of Correction is linked to the Fountainview 022414 Complaint, indicating the visit was complaint-related.
Findings
The facility was found deficient in ensuring the resident environment was free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. Specifically, a Wanderguard device was not properly placed, posing a risk to the resident.
Deficiencies (1)
Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents.
Report Facts
Plan of Correction completion date: Mar 1, 2014
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Added the Plan of Correction | |
| Mary Jane Kennedy | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Feb 24, 2014
Visit Reason
The inspection was conducted as an investigation of complaint #71958 regarding the facility's failure to provide adequate supervision and assistive devices to prevent resident elopement.
Complaint Details
Investigation of complaint #71958 found the facility failed to prevent elopement of resident #01, who left the facility without staff knowledge and sustained a skin tear. The front door alarm failed to sound and the resident's wanderguard bracelet was missing at the time of elopement.
Findings
The facility failed to adequately supervise and ensure adequate assistive devices for a resident identified as an elopement risk, who left the facility without staff knowledge and sustained a skin tear. The front door alarm did not sound during the incident, and the resident was out of the facility for approximately 15 minutes without supervision.
Deficiencies (1)
Failure to provide adequate supervision and assistive devices to prevent elopement of a resident.
Report Facts
Resident census: 43
Elopement risk residents: 6
Sampled residents considered elopement risks: 3
Skin tear size (cm): 1.4
Skin tear size (cm): 0.5
Elopement duration (minutes): 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff B | Found resident in parking lot after elopement and reported resident stopped by office before leaving | |
| licensed staff C | Assessed and attended to resident's skin tear after elopement | |
| certified nursing staff F | Reported routine wanderguard checks and history of wanderguard removal by resident | |
| certified staff members D and E | Reported observing resident leaving dining room before elopement | |
| certified nursing staff G | Acknowledged resident occasionally went toward front door thinking he/she was going home |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 20, 2014
Visit Reason
This document is a Plan of Correction submitted in response to a complaint-related deficiency regarding resident safety and proper use of lifting slings.
Complaint Details
This Plan of Correction addresses a complaint investigation related to resident safety and proper sling use during transfers.
Findings
The facility was found deficient in ensuring the resident environment was free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents, specifically related to the proper sizing and use of slings during transfers.
Deficiencies (1)
Failure to ensure the resident environment remains free of accident hazards and proper use of lifting slings for safe resident transfer.
Report Facts
Complete Date: Apr 18, 2014
Inservice Dates: Feb 20, 2014
Inservice Dates: Apr 9, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 18, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that deficiencies previously cited under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) have been corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 2
Inspection Report
Follow-Up
Deficiencies: 5
Date: Dec 5, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies have been corrected as of the revisit date, with corrections completed for multiple regulatory items.
Deficiencies (5)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 5
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Dec 5, 2013
Visit Reason
The inspection was a non-compliant revisit of complaints #69819, #70227, and #70305, focusing on investigations of falls and care plan revisions related to resident safety and supervision.
Complaint Details
The visit was triggered by complaints #69819, #70227, and #70305. The investigation found substantiated issues related to falls, inadequate care plan revisions, and insufficient supervision leading to repeated accidents and injuries.
Findings
The facility failed to review and revise care plans adequately for residents with cognitive impairments who continued to self-transfer and fall. The facility also failed to ensure adequate supervision and assistive devices to prevent repeated falls and accidents for two residents, resulting in injuries including lacerations and skin tears.
Deficiencies (2)
Failed to review and revise the plan of care for appropriate assistive devices to prevent repeated accidents for residents with cognitive impairment who continued to self-transfer following falls.
Failed to ensure the resident environment remained free of accident hazards and failed to provide adequate supervision and assistive devices to prevent repeated falls for residents with impaired cognition.
Report Facts
Census: 43
Residents selected for review: 8
Falls documented for Resident #2: 7
Skin tear length: 18
Skin tear size: 5
Skin tear size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| direct care staff A | Reported attempts to supervise Resident #1 and assisted with transfers | |
| licensed nursing staff B | Explained fall incident of Resident #1 and interventions implemented | |
| direct care staff C | Observed Resident #2's behavior and assisted after self-transfer |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Nov 22, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the Fountainview facility.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as Fountainview 102813 Complaint.
Findings
The facility identified multiple deficiencies related to resident care, including failure to notify responsible parties of significant changes, inadequate skin and wound care, improper catheter care, and infection control issues. Corrective actions included staff training, skin assessments, wound care protocols, and ongoing monitoring by the Director of Nursing.
Deficiencies (5)
Failure to inform resident and responsible parties of accidents resulting in injury and potential physician intervention.
Failure to provide necessary care and services to maintain highest practicable physical, mental, and psychosocial well-being.
Failure to prevent development of pressure sores and provide necessary treatment.
Failure to ensure appropriate catheter care and prevent urinary tract infections.
Failure to maintain an effective Infection Control Program to prevent disease and infection transmission.
Report Facts
Date for substantial compliance: Nov 22, 2013
Number of residents referenced: 4
Duration of monitoring: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Submitted the Plan of Correction. |
| Staff G | Named in infection control and wound care education and corrective actions. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 5
Date: Oct 28, 2013
Visit Reason
The inspection was an abbreviated survey for complaint investigations #69715, 69717, 69818, and #69795.
Complaint Details
The survey was conducted in response to complaint investigations #69715, 69717, 69818, and #69795.
Findings
The facility failed to timely notify family and physician of resident injuries, failed to provide adequate care and treatment for skin tears and pressure ulcers, failed to conduct consistent skin assessments, and failed to prevent urinary tract infections by improper catheter care. Additionally, infection control practices were inadequate during wound dressing changes.
Deficiencies (5)
Failed to notify family and physician timely about resident injury (skin tears).
Failed to provide care and services to maintain highest well-being for residents with skin tears and hematomas.
Failed to provide treatment and services to prevent and heal pressure sores, including failure to identify and treat a facility acquired Stage 3 pressure ulcer.
Failed to provide treatment and services to prevent urinary tract infections for resident with indwelling catheter.
Failed to maintain infection control during wound dressing changes, including improper handling of wound supplies shared between residents.
Report Facts
Resident census: 43
Skin tear measurements: 4
Skin tear measurements: 3.5
Pressure ulcer measurements: 1.1
Pressure ulcer measurements: 0.7
Urine output: 580
Urine output: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff G | Named in findings related to delayed treatment of skin tears and wound care. | |
| licensed staff C | Named in findings related to catheter care and wound dressing changes. | |
| direct care staff N | Reported finding skin tears on resident #2. | |
| administrative licensed staff E | Provided statements regarding skin assessments and wound care. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Aug 9, 2013
Visit Reason
This revisit report documents the correction of deficiencies previously reported during a prior survey, verifying that corrective actions were accomplished.
Findings
The report confirms that previously identified deficiencies with regulation numbers 28-39-158(g) and 26-41-205(l)(1) were corrected as of 08/09/2013.
Deficiencies (2)
Deficiency related to regulation 28-39-158(g)
Deficiency related to regulation 26-41-205(l)(1)
Report Facts
Deficiencies corrected: 2
Inspection Report
Follow-Up
Deficiencies: 10
Date: Aug 9, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date, 08/09/2013.
Deficiencies (10)
Deficiency identified by ID Prefix F0246 related to regulation 483.15(e)(1)
Deficiency identified by ID Prefix F0280 related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency identified by ID Prefix F0309 related to regulation 483.25
Deficiency identified by ID Prefix F0314 related to regulation 483.25(c)
Deficiency identified by ID Prefix F0329 related to regulation 483.25(l)
Deficiency identified by ID Prefix F0332 related to regulation 483.25(m)(1)
Deficiency identified by ID Prefix F0363 related to regulation 483.35(c)
Deficiency identified by ID Prefix F0371 related to regulation 483.35(i)
Deficiency identified by ID Prefix F0428 related to regulation 483.60(c)
Deficiency identified by ID Prefix F0431 related to regulations 483.60(b), (d), (e)
Report Facts
Deficiencies corrected: 10
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Aug 9, 2013
Visit Reason
This document is a Plan of Correction submitted by Fountainview Nursing and Rehabilitation in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction details corrective actions for multiple deficiencies related to call light availability, care planning, pain and skin assessments, pressure sore prevention, medication administration, nutritional needs, food service sanitation, pharmacy recommendations, and medication storage and labeling. Staff training and monitoring plans are described to ensure substantial compliance.
Deficiencies (10)
Call lights of residents were not within reach or properly managed.
Care plans for residents were not current or accurate.
Inadequate nursing assessments for pain and skin issues.
Deficiencies in prevention and healing of pressure sores.
Use of unnecessary medications and lack of evaluation of psychotropic medication efficacy.
Medication administration practices not meeting standards.
Nutritional needs and staff training on portion sizes were deficient.
Sanitary conditions in food storage, preparation, and service were inadequate.
Pharmacy consultant recommendations were not fully implemented.
Medication storage and labeling were not compliant with standards.
Report Facts
Date of Plan of Correction completion: Aug 9, 2013
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 25, 2013
Visit Reason
This Plan of Correction is submitted as a written allegation of compliance for deficiencies cited during a prior inspection, with deficiencies to be reviewed by the facility's Quality Assurance Committee on July 25, 2013.
Findings
The deficiencies cited involved sanitary conditions related to food storage, preparation, and service, and issues with obtaining and reporting laboratory results to physicians. Corrective actions included policy reviews, staff training, and monitoring by designated managers.
Deficiencies (2)
Sanitary conditions related to storage, preparation, and service of food were deficient.
Failure to obtain and report laboratory results to the physician appropriately.
Report Facts
Deficiencies cited: 2
Date of Quality Assurance Committee review: Jul 25, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol George | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 8
Date: Jul 18, 2013
Visit Reason
The inspection was a health resurvey to evaluate compliance with regulatory requirements and to follow up on previously cited deficiencies.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had access to call lights, inadequate care plan revisions for pressure ulcers and skin conditions, failure to provide timely pain management, medication errors, improper food portioning, unsanitary food handling, and improper medication storage and labeling.
Deficiencies (8)
Failure to ensure 3 residents had access to call lights at all times in their rooms.
Failure to review and revise care plans for pressure ulcers and skin issues for 2 residents.
Failure to provide necessary care and services to promote highest practicable well-being for 3 residents related to pain management and skin conditions.
Failure to ensure drug regimen free from unnecessary drugs for 1 resident due to inadequate behavior monitoring and follow-up on PRN medications.
Medication error rate of 16% due to incorrect dosing and administration of medications to 3 residents.
Failure to serve adequate planned sized meal portions to 37 residents.
Failure to store, prepare, and serve food under sanitary conditions including dirty fryer oil, unclean utensils, expired food, and improper food handling.
Failure to maintain pharmaceutical drugs with proper labeling and expiration dates in medication room and cart.
Report Facts
Census: 45
Medication administration opportunities: 25
Medication errors: 4
Medication error rate: 16
Residents with pureed diet: 3
Residents with regular diet: 34
Expired insulin pen days: 12
Expired insulin pen days: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff W | Licensed Nursing Staff | Reported expired insulin pens and medication storage issues |
| Staff Z | Direct Care Staff | Administered incorrect medication doses and reported medication labeling issues |
| Staff D | Dietary Staff | Reported inadequate food portion sizes and unsanitary kitchen conditions |
| Staff O | Direct Care Staff | Administered medications and reported medication administration timing issues |
| Administrative Staff B | Licensed Nursing Staff | Reported medication administration and wound care issues |
| Consultant Staff BB | Consultant Pharmacist | Reported lack of follow-up on PRN medication effectiveness and medication labeling issues |
Inspection Report
Renewal
Census: 19
Deficiencies: 2
Date: Jul 8, 2013
Visit Reason
The inspection was a licensure resurvey to assess compliance with regulatory requirements for the facility's continued licensure.
Findings
The facility failed to maintain sanitary conditions in food storage, preparation, and serving areas, including improper handling of food and utensils. Additionally, the facility failed to monitor laboratory tests and medication regimens for residents, resulting in potential medication-related problems.
Deficiencies (2)
Failure to store, prepare, and serve food under sanitary conditions, including use of dirty deep fryer oil, expired food items, improper food handling by staff, and unclean kitchen utensils.
Failure to monitor laboratory blood work for residents to identify potential or current medication-related problems, including lack of lab tests and inconsistent blood sugar monitoring.
Report Facts
Census: 19
Frozen cinnamon sweet rolls handled: 24
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff D | Reported on fryer oil and food handling issues; observed with yellow dried food on mixer | |
| Dietary staff F | Observed handling frozen rolls with bare hands initially, then with gloves; scooped cereal improperly | |
| Dietary staff G | Observed scooping cereal with bare hands | |
| Direct care staff R | Observed blowing on residents' food to cool it | |
| Licensed nursing staff C | Confirmed lack of laboratory blood work and inconsistent blood sugar monitoring |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 25, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all previously cited deficiencies were corrected as of the revisit date, with multiple regulatory items addressed and corrected.
Report Facts
Deficiencies corrected: 11
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Apr 25, 2012
Visit Reason
This document is a Plan of Correction submitted by LakePoint Nursing and Rehabilitation Center addressing deficiencies cited during a prior survey inspection.
Findings
The facility identified multiple deficiencies related to comprehensive assessments, care plan development and review, toileting and urinary care, environmental safety, assistance for cognitively impaired residents, medication monitoring and administration, dietary services, and infection control. The Plan of Correction outlines corrective actions including policy reviews, staff in-services, orientation for new employees, and monitoring responsibilities.
Deficiencies (10)
Deficiency in conducting comprehensive assessments through resident assessment protocols.
Deficiency in development of care plans.
Deficiency in review process of care plans.
Deficiency in following care plans regarding toileting/urinary status.
Deficiency in maintaining an environment free from potential accidents or hazards.
Deficiency in assisting cognitively impaired residents and residents at risk for weight loss.
Deficiency in monitoring medications or use of unnecessary medication.
Deficiency in administering medication as prescribed by physician or pharmacist.
Deficiency in dietary services including storage, preparation, and serving food under sanitary conditions.
Deficiency in infection control and sanitary conditions.
Report Facts
Complete Date: Apr 25, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol George | Director of Nursing | Submitted the Plan of Correction and is responsible for monitoring multiple deficiencies. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 9
Date: Mar 26, 2012
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 #55213.
Findings
The facility was found deficient in multiple areas including comprehensive assessments, care planning, infection control, medication administration, accident prevention, nutritional supervision, and sanitary food handling. Specific failures included inadequate assessment and care planning for urinary incontinence, failure to prevent repeated falls, failure to monitor bowel movements and medication side effects, medication errors, improper infection control practices, and unsanitary food storage and preparation.
Deficiencies (9)
Failed to adequately assess and develop a comprehensive care plan for a resident's urinary incontinence.
Failed to review and revise care plans following numerous falls for two residents.
Failed to ensure appropriate treatment and services to prevent urinary tract infections and promote continence.
Failed to provide adequate supervision and assistive devices to prevent accidents for three residents, including failure to use gait belts and implement fall prevention interventions.
Failed to ensure one resident received supervision for meals as directed by the care plan and failed to provide a policy to direct staff in restorative dining.
Failed to ensure residents were free from unnecessary drugs, including failure to monitor bowel elimination and behavior changes related to medication adjustments.
Failed to administer medications as ordered, including incorrect dosing and timing of medications.
Failed to store, prepare, and serve food under sanitary conditions, including unclean kitchen areas, improper food temperature control, and inadequate assistance with dining services.
Failed to maintain an effective infection control program, including improper glove use, inadequate cleaning of equipment between residents, failure to track infections, and failure to report an influenza outbreak.
Report Facts
Census: 38
Medication opportunities: 51
Medication errors: 3
Resident weight: 134
Resident weight: 121.2
Fall risk score: 11
Bowel movement gap: 12
Bowel movement gap: 11
Fall count: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff R | Named in infection control deficiency for improper glove use during resident care | |
| Direct care staff J | Named in infection control deficiency for improper glove use during resident care | |
| Direct care staff G | Named in medication administration errors and infection control deficiencies | |
| Licensed nursing staff D | Named in medication administration errors and infection control deficiencies | |
| Dietary staff F | Named in food service sanitation and temperature control deficiencies | |
| Administrative nursing staff B | Named in infection control program deficiencies and outbreak reporting |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N008004 POC SHOK12
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation related to fall interventions and care plan updates for residents.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Fountainview 120513 RV Complaint.
Findings
The facility identified deficiencies related to fall risk assessments, care plan updates, and environmental safety to prevent accidents. Corrective actions include new fall assessments, care plan revisions, staff inservices, and ongoing audits to ensure compliance.
Deficiencies (2)
Failure to develop a comprehensive care plan within 7 days after assessment including fall interventions and cognitive status updates.
Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision and assistive devices to prevent accidents.
Report Facts
Complete Date: Dec 18, 2013
Audit Frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008004 Y2XR11
Visit Reason
This document is a Plan of Correction related to a facility inspection event identified by ASPEN Event ID Y2XR11 and State ID N008004.
Findings
No specific deficiencies or findings are detailed in this document; it appears to be a placeholder or summary page indicating no records found for the Plan of Correction.
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