Inspection Reports for Greenwood Skilled Nursing & Rehabilitation Center LLC
14200 W 134TH PLACE, OLATHE, KS, 66062-6140
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 25, 2024, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed multiple deficiencies related to resident dignity during personal care, care plan revisions, environmental safety, dialysis communication, bedrail use documentation, food storage, infection control, and immunization consent. Complaint investigations included a substantiated case in 2022 where the facility failed to provide sufficient nursing staff as required by a resident’s care plan, leading to the resident hiring a private caregiver at personal expense. Enforcement actions were noted in 2015, including a denial of payment for new admissions due to a "G" level deficiency, but no enforcement actions or fines were listed in more recent reports. The facility appears to have addressed prior issues effectively, with recent inspections showing correction of cited deficiencies and compliance with regulations.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
113% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
74 residents
Based on a June 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
An offsite revisit survey was conducted on 07/25/24 for all previous deficiencies cited on 06/20/24 to verify correction of cited deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 07/15/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 74
Deficiencies: 8
Date: Jun 20, 2024
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with resident rights, care planning, accident prevention, dialysis care, bedrail use, food safety, infection control, and immunization requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity during personal care, inadequate care plan revisions, unsecured hazardous areas, failure to implement fall interventions, inconsistent dialysis communication, lack of documented bedrail risk assessments and consents, improper food storage practices, lapses in infection control practices, and failure to obtain required immunization consents.
Deficiencies (8)
Failed to ensure Resident 40's right to dignity when staff provided personal care with window blinds open.
Failed to revise Resident 44's care plan to reflect toileting needs after meals.
Failed to secure electrical panels and chemicals and implement fall interventions for Residents 43 and 2.
Failed to consistently communicate Resident 7's medical condition with a pre-dialysis assessment prior to hemodialysis.
Failed to ensure Resident 60 had documented risk assessment, consent, and advisement for side rail use.
Failed to ensure food items were properly stored, labeled, and dated after opening.
Failed to follow sanitary infection control standards related to enhanced barrier precautions, hand hygiene, and disinfection of shared mechanical lifts.
Failed to offer and/or obtain pneumococcal and influenza vaccine consents or declinations for Resident 17.
Report Facts
Census: 74
Residents reviewed: 19
Residents on enhanced barrier precautions: 14
Fall incidents: 2
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided statements on dignity, care plan revisions, fall interventions, dialysis communication, infection control, and side rail assessments |
| Licensed Nurse I | Licensed Nurse | Provided statements on dignity, fall interventions, side rail assessments, and infection control |
| Certified Nurse Aide N | Certified Nurse Aide | Observed providing personal care with window blinds open |
| Certified Medication Aide S | Certified Medication Aide | Provided statements on dignity and fall interventions |
| Certified Nurse Aide M | Certified Nurse Aide | Provided statements on fall interventions and infection control |
| Administrative Nurse E | Infection Preventionist | Provided statements on immunization consent and infection control |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jun 20, 2024
Visit Reason
This document is a Plan of Correction submitted by Nottingham Health and Rehabilitation Center in response to deficiencies cited during a survey conducted on June 20, 2024.
Findings
The facility developed and implemented corrective actions addressing multiple deficiencies related to resident privacy, care plan revisions, environmental hazards, dialysis communication, bed cane use, food storage, infection control, and vaccination policies. The plan includes staff training, audits, and ongoing monitoring to ensure compliance and prevent recurrence.
Deficiencies (8)
Lack of privacy during cares affecting resident R40
Inadequate care plan revisions for resident R44
Environmental hazards and hazardous room locks not properly secured
Dialysis communication policy not followed; resident R7 no longer at facility
Bed cane use assessments and consents not properly documented for resident 60
Food storage policy violations including undated open food
Infection control deficiencies related to hand hygiene and equipment disinfecting
Pneumonia vaccination consent and administration issues; resident 17 offered vaccine
Report Facts
Substantial compliance date: Jul 15, 2024
Audit duration: 4
Audit date: Jul 11, 2024
Survey date: Jun 20, 2024
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 23, 2022
Visit Reason
An offsite revisit survey was conducted on 11/23/22 for all previous deficiencies cited on 10/04/22 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of 11/04/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 10/04/22, all corrected by 11/04/22
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 3
Date: Oct 4, 2022
Visit Reason
The inspection was a health resurvey conducted to assess compliance with regulatory requirements related to bowel/bladder incontinence, catheter use, urinary tract infections, pain management, and medication labeling and storage.
Findings
The facility failed to assess and identify services necessary to promote bladder and bowel continence for two residents, failed to adequately address and treat pain for one resident, and failed to properly date and discard expired insulin pens in medication carts. These deficiencies placed residents at risk for decreased psychosocial wellbeing, increased incontinence, ongoing pain, and ineffective medication treatment.
Deficiencies (3)
Failed to assess and identify services and assistance necessary to promote bladder and bowel continence for residents R24 and R13.
Failed to address and treat Resident R17's pain when providing care.
Failed to date one insulin pen and discard one expired insulin pen in medication carts.
Report Facts
Census: 40
Residents reviewed: 12
Insulin pen expiration date: Sep 13, 2022
Insulin pen dosage: 650
Insulin pen dosage: 0.25
Insulin pen dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Interviewed regarding incontinence care and pain management for residents R24, R13, and R17 |
| Certified Nurses Aid N | Certified Nurses Aid | Interviewed regarding care and incontinence checks for resident R24 |
| Certified Nurses Aid M | Certified Nurses Aid | Interviewed regarding continence and pain care for residents R13 and R17 |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding bowel and bladder treatment policies and medication cart inspections |
| Administrative Staff A | Administrative Staff | Interviewed regarding individualized care plans and medication cart audits |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding medication cart inspections and insulin pen dating |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Oct 4, 2022
Visit Reason
This document is a Plan of Correction submitted by Nottingham Health and Rehabilitation Center in response to deficiencies cited in a prior inspection report dated 10/04/2022.
Findings
The plan addresses deficiencies related to bowel and bladder assessments, pain management, and medication labeling and storage. Corrective actions include assessments, care plan updates, staff education, policy revisions, and ongoing monitoring to achieve substantial compliance by November 4, 2022.
Deficiencies (3)
Failure to complete bowel and bladder assessments and update care plans accordingly.
Failure to properly assess and manage pain related to activities of daily living.
Use and storage of outdated insulin pens.
Report Facts
Weeks of monitoring: 4
Plan of Correction completion date: Facility aims for substantial compliance by November 4, 2022.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 18, 2022
Visit Reason
An offsite revisit survey was conducted on 03/18/22 for all previous deficiencies cited on 02/10/22 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 02/28/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 1
Date: Feb 28, 2022
Visit Reason
This document is a Plan of Correction submitted by Nottingham Health & Rehabilitation Center in response to deficiencies cited during a prior survey.
Findings
The facility identified deficiencies related to staffing for residents requiring two-person assistance for transfers. A Quality Assurance Performance Improvement plan was initiated to ensure compliance with sufficient staffing policies.
Deficiencies (1)
Resident 1 will have two staff members available for hoyer transfers and has been notified of this policy.
Report Facts
Residents requiring 2 staff members for transfers: 15
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Feb 10, 2022
Visit Reason
The inspection was conducted as a complaint investigation involving multiple complaint cases (KS00169403, KS00168363, KS00168302, and KS00165689) related to the facility's nursing staff sufficiency and care provision.
Complaint Details
The investigation was triggered by complaints KS00169403, KS00168363, KS00168302, and KS00165689. The facility was found to have insufficient nursing staff to meet the needs of resident R1, requiring her to hire a private caregiver at her own expense. The complaint was substantiated as the facility failed to provide adequate staffing per the resident's care plan.
Findings
The facility failed to ensure sufficient nursing staff were on duty to provide necessary care, supervision, and services to resident R1 as directed by her plan of care. Specifically, the facility did not provide a second staff member for mechanical lift transfers, daily ADLs, and psychosocial needs, requiring R1 to obtain and pay for a personal caregiver. The facility considered private caregivers as guests and did not count them as staff, leading to inadequate staffing for R1's high acuity needs.
Deficiencies (1)
Failed to ensure sufficient nursing staff to provide necessary care and supervision to resident R1, including failure to provide a second staff member for mechanical lift transfers, daily ADLs, and psychosocial needs.
Report Facts
Resident census: 36
Percentage of residents requiring assistance: 73.7
Percentage of residents dependent on staff for all ADLs: 14.7
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 20, 2021
Visit Reason
An offsite revisit survey was conducted on 06/20/21 for all previous deficiencies cited on 05/20/21 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 06/09/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: May 20, 2021
Compliance date: Jun 9, 2021
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Jun 9, 2021
Visit Reason
This document is a Plan of Correction submitted by Nottingham Health & Rehabilitation Center to address deficiencies cited during a prior survey. It outlines corrective actions, education, and monitoring systems implemented to ensure compliance with regulations.
Findings
The plan addresses multiple deficiencies related to resident rights, care planning, medication administration, medication storage, infection prevention, resident council grievances, name badges, and call light accessibility. The facility has initiated Quality Assurance Performance Improvement (QAPI) plans, staff education, audits, and ongoing monitoring to achieve and maintain compliance.
Deficiencies (10)
Dining preferences not identified in care plans
Resident council grievance follow-up issues
Falls care plans not updated timely
Drug regimen review deficiencies
Unnecessary drugs prescribed without proper oversight
Medication errors related to intravenous antibiotic administration
Medication storage policy non-compliance
Infection prevention and control deficiencies
Name badge policy non-compliance
Call lights not within reach in resident rooms
Report Facts
Residents identified with cardiac medication hold parameters: 21
Duration of weekly monitoring for dining preferences: 4
Duration of monitoring for resident council grievance follow-up: 2
Duration of weekly monitoring for care plan updates after falls: 4
Duration of monthly audits for drug regimen review: 2
Duration of weekly monitoring for unnecessary drugs: 4
Duration of weekly monitoring for medication errors: 4
Duration of weekly audits for medication storage: 4
Duration of weekly monitoring for infection prevention: 4
Duration of weekly audits for name badge compliance: 4
Duration of monthly monitoring for call light compliance: 4
Number of hand hygiene demonstrations per week: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Hudlin | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 8
Date: May 20, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation KS00161870.
Complaint Details
The inspection included a complaint investigation identified as KS00161870.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity and quality of life, failure to resolve resident council grievances, failure to ensure a safe environment free of accident hazards, failure to properly administer medications and report irregularities, failure to store and label medications properly, and failure to practice proper infection control and hand hygiene.
Deficiencies (8)
Failure to promote care in a manner to maintain and enhance dignity and quality of life when staff placed a nonverbal resident at the dining table for extended periods with no activity or interaction.
Failure to resolve grievances recorded during resident council meetings regarding staff not wearing name badges.
Failure to ensure the environment remained free of accident hazards for three residents, including failure to provide call lights and proper assistance.
Failure to ensure the Consultant Pharmacist identified and reported failure to administer medications following physician orders.
Failure to ensure resident's drug regimen was free from unnecessary drugs due to failure to follow physician medication orders.
Failure to ensure residents were free of significant medication errors, including failure to administer IV antibiotic as ordered.
Failure to ensure medication carts and medication rooms were free of expired medications; failure to properly label and store medications; failure to discard expired insulin pens and vaccine vials.
Failure to ensure staff practiced proper hand hygiene and infection control precautions, increasing risk of infection transmission.
Report Facts
Residents in sample: 16
Expired medication count: 12
Missed IV antibiotic doses: 7
Days medication given with BP below threshold: 11
Days medication given with BP below threshold: 14
Days medication given with BP below threshold: 2
Days medication given with BP below threshold: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Interviewed regarding resident feeding and medication administration |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding care plans, medication errors, infection control, and grievance follow-up |
| CNA P | Certified Nurse Aide | Interviewed regarding resident assistance and hand hygiene |
| Consultant GG | Consultant Pharmacist | Interviewed regarding medication review practices |
| LN H | Licensed Nurse | Observed performing wound care with improper hand hygiene |
| Consultant HH | Consultant | Observed wearing gloves and interacting with residents without hand hygiene |
| CNA M | Certified Nurse Aide | Interviewed regarding resident care and fall interventions |
| CNA N | Certified Nurse Aide | Interviewed regarding name badge use |
| CNA O | Certified Nurse Aide | Interviewed regarding name badge use |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS) on 12/09/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 35
Deficiencies: 0
Date: Jun 25, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS) on 06/25/20.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the COVID-19 focused infection control survey.
Report Facts
Sample Size: 5
Supplemental: 0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 25, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS) on 06/25/20.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 25, 2019
Visit Reason
The Health Resurvey was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The resurvey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 25, 2019
Visit Reason
The Health Resurvey was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The resurvey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 19, 2018
Visit Reason
The document is a Plan of Correction related to a Health Survey and multiple Complaint Investigations at the facility.
Findings
The Health Survey and Complaint Investigations resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 19, 2018
Visit Reason
The health survey was conducted along with multiple complaint investigations identified by KS00095567, KS00094366, KS00094375, KS00093970, KS00093870, KS00093768, KS00093210, and KS00092378.
Complaint Details
Multiple complaint investigations were conducted, all resulting in no deficiency citations.
Findings
The survey and complaint investigations resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 9, 2018
Visit Reason
A complaint survey was conducted on 3/9/18 for complaint #KS00126827, #KS00126908, and #KS00126682.
Complaint Details
The allegations made in the complaints were not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 9, 2018
Visit Reason
A complaint survey was conducted on 3/9/18 for complaint #KS00126827, #KS00126908, and #KS00126682.
Complaint Details
The allegations made in the complaints were not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 9, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each correction documented and completed on 2017-05-09.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: May 9, 2017
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were completed.
Findings
The revisit report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 05/09/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency under regulation 28-39-158(a) previously reported and now corrected
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Apr 26, 2017
Visit Reason
This document is a Plan of Correction submitted by Nottingham Health and Rehabilitation Center addressing deficiencies cited in a prior survey.
Findings
The Plan of Correction outlines corrective actions taken for multiple deficiencies related to documentation accuracy, abuse prevention, resident care including positioning, hygiene, skin assessment, restorative services, supervision, medication administration, drug labeling, infection control, and dietary management. Staff training and monitoring plans are detailed for each deficiency.
Deficiencies (11)
Failure to provide accurate documentation for residents receiving Part A services including CMS Form #10055 upon discharge.
Failure to prevent and investigate abuse, neglect, or exploitation of residents.
Failure to provide necessary cares and services to maintain appropriate wheelchair positioning.
Failure to provide hygiene, personal care, and assistance with ADLs as per plan of care.
Failure related to skin assessment, documentation, and preventative skin measures.
Failure to provide restorative services to maintain or prevent further decrease in function and range of motion.
Failure related to supervision and safety issues of resident visitation during inpatient treatment.
Failure to liberalize times to meet resident needs and medication timing issues.
Failure related to proper identification and labeling of all drugs and biologicals.
Failure to provide a sanitary environment to prevent disease and infection transmission.
Failure related to employment of a Full Time Certified Dietary Manager.
Report Facts
Date of in-service: Apr 11, 2017
Date of in-service: Apr 20, 2017
Date of in-service: May 9, 2017
Date of in-service: Apr 4, 2017
Date of in-service: Apr 12, 2017
Date of in-service: May 15, 2017
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 17, 2017
Visit Reason
A Health survey was conducted to determine if the facility was 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 which was accepted, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
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 | Signed letter regarding plan of correction acceptance and compliance status. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 10
Date: Apr 17, 2017
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation involving multiple complaint numbers, focusing on regulatory compliance related to residents' rights, abuse investigations, care quality, medication administration, and infection control.
Complaint Details
The visit was complaint-related as it included a complaint investigation with multiple complaint numbers (#96240, #112870, #104530, #111870, #96720, #103470, #97389).
Findings
The facility was found deficient in multiple areas including failure to provide residents with required Medicare Part A notices, failure to report and investigate an unwitnessed fall resulting in a fractured hip, inadequate wheelchair positioning and restorative services, failure to provide bathing as per care plans, medication errors related to timing, improper medication storage and labeling, and inadequate infection control practices including improper cleaning of resident bathrooms and glucometers.
Deficiencies (10)
Failed to provide accurate documentation for residents who received Medicare Part A services including the right to request or decline a demand bill upon discharge for 3 residents.
Failed to report and investigate an unwitnessed fall resulting in a fractured right hip for Resident #83.
Failed to provide necessary cares and services to maintain appropriate wheelchair positioning and posture for Resident #50.
Failed to provide bathing as per care plans for 3 residents (#48, #61, #71).
Failed to implement effective interventions to prevent development of pressure ulcers for Resident #37 who developed a blister on his/her great toe.
Failed to provide restorative services to maintain and/or prevent further decrease in function and range of motion for Resident #50.
Failed to ensure adequate supervision to prevent accidents for Resident #83 who fell and refractured his/her hip.
Failed to ensure medication administration within liberalized time frames for Resident #40, resulting in medication errors.
Failed to ensure proper labeling, dating, and discarding of insulin pens in medication storage.
Failed to provide a sanitary environment by improper cleaning of a resident bathroom and glucometers, risking infection spread.
Report Facts
Residents reviewed: 23
Residents with bathing deficiencies: 3
Residents with wheelchair positioning deficiency: 1
Residents with pressure ulcer deficiency: 1
Residents with medication errors: 1
Residents with fall and fracture: 1
Medications administered outside liberalized time frame: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Staff C | Verified failure to send Medicare Part A CMS Form #10055 notices | |
| Administrative Staff S | Unable to locate fall report to state agency for Resident #83 | |
| Nurse Aide E | Reported Resident #50 always leaned left in wheelchair | |
| Nurse D | Reported Resident #50 required extensive assistance and was unaware of restorative services | |
| Therapy Staff F | Reported no wheelchair evaluation since October 2016 and lack of restorative services since January 2017 | |
| Administrative Nurse A | Verified lack of restorative services and medication timing issues | |
| Housekeeping Staff Q | Observed improper cleaning of resident toilet and admitted wiping with soiled towels | |
| Nurse I | Observed improper glucometer cleaning | |
| Medication Aide N | Administered medications outside liberalized time frame |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 20, 2016
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 at the facility to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. A plan of correction was required, and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
Deficiencies cited at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy.
Report Facts
Effective date for denial of payments: Oct 20, 2016
Provider agreement termination date: Jan 20, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and is responsible for licensure certification and enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Apr 15, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.10(b)(11), 483.13(c)(1)(i)-(iii), (c)(2)-(4), 483.15(g)(1), 483.25(f)(2), and 483.75(j)(2)(i) were corrected as of the revisit date.
Deficiencies (5)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.13(c)(1)(i)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.15(g)(1)
Deficiency related to regulation 483.25(f)(2)
Deficiency related to regulation 483.75(j)(2)(i)
Report Facts
Deficiencies corrected: 5
Inspection Report
Follow-Up
Deficiencies: 5
Date: Apr 14, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.10(b)(4), 483.20(k)(3)(i), 483.25, 483.25(m)(2), and 483.30(a) were corrected as of 03/26/2016.
Deficiencies (5)
Deficiency related to regulation 483.10(b)(4)
Deficiency related to regulation 483.20(k)(3)(i)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(m)(2)
Deficiency related to regulation 483.30(a)
Report Facts
Date deficiencies corrected: Mar 26, 2016
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 18, 2016
Visit Reason
An abbreviated 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 D level, indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Deficiencies (1)
D level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person for the survey and plan of correction |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 5
Date: Mar 18, 2016
Visit Reason
Complaint investigation # KS 97974 was conducted due to allegations of failure to notify family of room changes and changes in condition, failure to investigate and report potential abuse, failure to provide medically-related social services, and failure to obtain physician ordered labs.
Complaint Details
Complaint investigation # KS 97974 focused on notification failures, abuse allegations, social service provision, behavior management, and lab order compliance.
Findings
The facility failed to notify family members of room changes and changes in condition, failed to thoroughly investigate and report allegations of abuse, failed to provide adequate social services and behavior management for a resident with depression and agitation, and failed to obtain physician ordered laboratory tests.
Deficiencies (5)
Failed to notify responsible family members of room changes and failed to timely notify physician of change in resident condition.
Failed to thoroughly investigate and report potential allegations of abuse involving staff behavior and mistreatment.
Failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of a resident with behavioral issues.
Failed to ensure a resident did not display a pattern of decreased social interaction, anger, and depressive behaviors without appropriate interventions.
Failed to provide or obtain laboratory services as ordered by the attending physician.
Report Facts
Census: 64
Residents sampled: 3
Deficiencies cited: 5
PHQ 9 score: 8
Medication doses: 7
Attempts to provide care: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff U | Social Service Staff | Responsible for notifying family of room changes; unaware of room change notification for resident #2 |
| Staff D | Administrative Nursing Staff | Expected family notification and investigation of abuse; aware of resident behaviors and care refusals |
| Staff E | Administrative Nursing Staff | Witnessed staff arguing with family member; addressed inappropriate staff behavior |
| Staff B | Clinical Liaison Staff | Reported resident complaints from hospital; notified administration of abuse allegations |
| Staff A | Administrative Staff | Responsible for abuse investigation; failed to thoroughly investigate and report |
| Staff P | Direct Care Staff | Observed resident's condition and refusal of care; reported resident's room condition |
| Staff O | Direct Care Staff | Observed resident's refusal of care; did not notify charge nurse |
| Staff H | Licensed Nursing Staff | Expected notification of refusals; contacted physician for antianxiety medication |
| Staff V | Physician Consultant | Ordered Xanax for resident; expected staff to follow care plan and notify family |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Mar 18, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Nottingham Health and Rehab on March 18, 2016.
Complaint Details
This Plan of Correction is in response to a complaint investigation conducted on 03/18/2016 at Nottingham Health and Rehab.
Findings
The Plan of Correction addresses multiple deficiencies related to notification of physician for significant resident condition changes, prevention and investigation of abuse, social services for residents with depression and agitation, behavior assessment and treatment, and laboratory services. The facility implemented policy reviews, staff training, and assigned monitoring responsibilities to nursing and administrative staff.
Deficiencies (5)
Failure to notify physician of significant change in resident's condition and improper documentation prior to room transfers or hospitalization.
Failure to prevent and properly investigate abuse, neglect, or exploitation of residents.
Inadequate social services related to care of residents experiencing depression, anxiety, and agitation.
Inadequate assessment and treatment of resident behaviors and prevention of decline.
Failure to obtain and review all ordered laboratory services and properly document results.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Paula Varner | VP OPS | Submitted the Plan of Correction to KDADS. |
| Irina Strakhova | Modified the Plan of Correction document. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 7, 2016
Visit Reason
An abbreviated survey was conducted on March 7, 2016, 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 deficiency to be at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to deficiencies cited and a history of noncompliance from a prior resurvey on July 31, 2015, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions.
Deficiencies (1)
Deficiencies constituting a level of actual harm that is not immediate jeopardy were found.
Report Facts
Denial of payment effective date: Mar 28, 2016
Prior resurvey date: Jul 31, 2015
Termination recommendation date: Sep 7, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions regarding the matter and informal dispute resolution |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 5
Date: Mar 7, 2016
Visit Reason
The inspection was conducted as a result of complaint investigations #96386, 97473, and 97508 to assess compliance with regulatory requirements.
Complaint Details
The inspection was triggered by complaint investigations #96386, 97473, and 97508.
Findings
The facility failed to ensure CPR certified staff accompanied full code residents during transports, implement temporary care plans on admission, monitor and treat skin conditions properly, prevent medication errors including administration of non-ordered insulin causing hospitalization, and provide sufficient nursing staff to meet resident needs and respond timely to call lights.
Deficiencies (5)
Failed to ensure CPR certified staff accompanied full code residents during facility transports.
Failed to implement a temporary care plan on admission for a resident reviewed for care planning.
Failed to monitor, treat, and assess skin conditions for 2 of 3 residents sampled for skin conditions.
Failed to ensure the resident remained free from medication errors when staff administered Novolog insulin not physician ordered, causing hospitalization for hypoglycemia.
Failed to have sufficient nursing staff to provide necessary care and respond to resident requests timely.
Report Facts
Census: 78
Residents sampled: 5
Units of Novolog insulin administered in error: 46
Blood sugar levels: 37
Call light wait times: 30
Residents assigned to charge nurse: 19
Residents requiring 2 staff assistance: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff W | Transport Driver | Transported full code residents without CPR certification. |
| Administrative nursing staff D | Acknowledged transport staff lacked CPR certification and planned certification; expected wound care completion and documentation; commented on staffing and medication error policies. | |
| Administrative staff A | Aware staff W lacked CPR certification and planned to ensure certification. | |
| Direct care staff Q | Unaware of resident wounds unless informed by nurse; commented on care plan access. | |
| Licensed nursing staff K | Acknowledged resident wounds and care plan responsibilities. | |
| Licensed nursing staff L | Performed wound care and assessments; commented on documentation. | |
| Direct care staff S | Reported resident wound care performed by nurse. | |
| Licensed nursing staff I | Administered insulin in error during orientation; described events leading to medication error. | |
| Licensed nursing staff J | Supervised staff I; notified physician after insulin error; reported staffing and call light response issues. | |
| Direct care staff O | Reported resident alertness and orientation. | |
| Direct care staff R | Reported inability to answer call lights timely and resident complaints. | |
| Practitioner consultant Z | Reported insufficient staffing based on resident acuity. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Mar 7, 2016
Visit Reason
This Plan of Correction document responds to deficiencies cited in the Nottingham Health and Rehabilitation Center complaint inspection conducted on March 7, 2016.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Nottingham Health and Rehabilitation Center.
Findings
The facility addressed multiple deficiencies related to staff certification for transporting full code residents, temporary care plans, skin assessment and monitoring, medication administration including insulin, and sufficient staffing. Corrective actions include policy reviews, staff in-service training, and monitoring by the Director of Nursing or Administrator.
Deficiencies (5)
Certification of staff accompanying full code residents during transportation lacking CPR training.
Incomplete or missing temporary care plans for recent admissions.
Inadequate skin assessment and monitoring for residents.
Improper administration of medications including insulin; two nurses terminated for cause.
Insufficient staffing and delayed response to resident needs.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 30, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies had been corrected as indicated in the prior CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the previously cited deficiency under regulation 483.60(a),(b) was corrected as of the revisit date.
Deficiencies (1)
Deficiency under regulation 483.60(a),(b)
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 24, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at the facility.
Complaint Details
This Plan of Correction is linked to a complaint investigation (Nottingham 092315 Complaint).
Findings
The facility identified an error related to following policy and procedure for ordering and administering medications to Resident #1, and outlined corrective actions including staff education and routine medication audits to ensure compliance.
Deficiencies (1)
Pharmaceutical service - accurate procedures not followed for ordering and administering medication to Resident #1
Report Facts
Complete Date for Plan of Correction: Sep 30, 2015
In-service Date: Sep 24, 2015
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Sep 23, 2015
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration errors at Nottingham Health and Rehabilitation.
Complaint Details
The citation represents findings of complaint #91445. The facility failed to ensure a dependent resident received medications as ordered for 24 hours after admission.
Findings
The facility failed to administer medications as ordered by the physician for one of three residents reviewed, resulting in a dependent resident missing all medications for over 24 hours after admission.
Deficiencies (1)
Failed to administer medications as ordered by the physician for one resident, resulting in missed medications for over 24 hours after admission.
Report Facts
Residents present: 57
Residents sampled: 5
Residents reviewed for medications: 3
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 23, 2015
Visit Reason
An abbreviated 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 deficiency to be a 'D' level deficiency that constitutes no actual harm 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 September 30, 2015.
Deficiencies (1)
Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 23, 2015
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at Nottingham Health and Rehabilitation.
Findings
The report documents that the previously reported deficiency identified by regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) was corrected as of 09/23/2015.
Deficiencies (1)
Deficiency identified under regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v)
Report Facts
Deficiency correction date: Sep 23, 2015
Followup to Survey Completed on: Jul 31, 2015
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 23, 2015
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at Nottingham Health and Rehabilitation.
Findings
The report documents that the previously reported deficiency identified by regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) with ID prefix S1146 was corrected as of 09/23/2015.
Deficiencies (1)
Deficiency identified under regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) with ID prefix S1146
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 20, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation for Nottingham Health.
Complaint Details
This Plan of Correction is related to a complaint investigation for Nottingham Health.
Findings
The facility was found deficient in completing comprehensive assessments including full body and skin assessments upon admission, and in documenting ADL care related to bathing for dependent residents. The plan outlines corrective actions including audits, re-education of staff, and quality assurance reviews.
Deficiencies (2)
Failure to complete full body assessments upon admission and incomplete skin condition documentation.
Incomplete documentation of residents' ADL care as it pertains to bathing.
Report Facts
Corrective action completion date: Sep 20, 2015
Staff re-education dates: Aug 25, 2015
Staff re-education dates: Aug 26, 2015
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Greta Wakefield | Administrator/Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 9, 2015
Visit Reason
This post-certification revisit was conducted to verify the correction of previously cited deficiencies from the prior survey completed on 2015-07-23.
Findings
The revisit report shows that the previously cited deficiencies identified under regulations 483.20(b)(1) and 483.25(a)(3) were corrected as of 2015-09-09.
Deficiencies (2)
Deficiency related to regulation 483.20(b)(1)
Deficiency related to regulation 483.25(a)(3)
Report Facts
Deficiencies corrected: 2
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 21, 2015
Visit Reason
An abbreviated 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 'D' level deficiencies that constitute no actual harm 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 September 9, 2015.
Deficiencies (1)
Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 3
Date: Aug 21, 2015
Visit Reason
The inspection was conducted as a complaint investigation for complaint investigation numbers #89272 and #89547.
Complaint Details
The inspection was triggered by complaints #89272 and #89547. The findings substantiated failures in skin assessment and personal hygiene care for sampled residents.
Findings
The facility failed to conduct comprehensive and accurate skin assessments for residents, specifically failing to fully assess and monitor skin issues for resident #1 and resident #2. Additionally, the facility failed to provide necessary personal hygiene services, including bathing, for dependent residents #1 and #4 over extended periods.
Deficiencies (3)
Failure to ensure staff accurately and completely assessed resident #1's skin issues after hospital discharge.
Failure to adequately assess and monitor resident #2's skin condition, including open excoriated areas.
Failure to provide necessary bathing services to dependent residents #1 and #4 for 10 and 13 days respectively.
Report Facts
Census: 69
Sampled residents: 4
Days without bath for resident #1: 10
Days without bath for resident #4: 13
Open excoriated area size: 1
Redness surrounding excoriated area: 0.3
Braden scale score: 15
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Jul 31, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation covering multiple complaint numbers.
Complaint Details
The visit was triggered by a complaint investigation with multiple complaint numbers referenced (#88613, #83700, #82504, #83565, #82200, #81098, #79311, #79172, #79133, and #78537).
Findings
The facility failed to properly store soiled resident and facility laundry in 2 of 4 care areas on 3 of 4 days during the survey. Specifically, uncovered barrels containing soiled laundry were observed in multiple care units.
Deficiencies (1)
Failure to properly store soiled resident and facility laundry in tight fitting containers prior to washing.
Report Facts
Census: 68
Dates of observations: 4
Folding net clothes hampers: 4
Inspection Report
Enforcement
Deficiencies: 1
Date: Jul 31, 2015
Visit Reason
A Health survey was conducted on July 31, 2015, 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 deficiency in the facility to be a "G" level. As a result, enforcement remedies including a denial of payment for new Medicare and Medicaid admissions effective October 31, 2015, will be imposed until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Most serious deficiency found was a "G" level
Report Facts
Denial of Payment Effective Date: Oct 31, 2015
Termination Recommendation Date: Jan 31, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 13, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an "F" level deficiency, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
Most serious deficiency found was an "F" level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: Jul 13, 2015
Termination effective date: Oct 13, 2015
Plan of correction submission timeframe: 10
Fair hearing appeal timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter and mentioned as Enforcement Coordinator. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution and appeals. |
Document
Deficiencies: 0
Date: N046084 POC IL8711
Visit Reason
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Findings
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