Inspection Reports for
Greenwood Skilled Nursing & Rehabilitation Center LLC
14200 W 134TH PLACE, OLATHE, KS, 66062-6140
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
72% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
93% occupied
Based on a April 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 3
Date: May 1, 2026
Visit Reason
This document is a Plan of Correction submitted by Nottingham Health and Rehabilitation Center in response to deficiencies cited during a prior survey.
Findings
The facility developed and implemented corrective actions and systemic changes to address deficiencies related to self-administration of medications, call light accessibility, and medication storage. Weekly audits and staff training are planned to ensure ongoing compliance.
Deficiencies (3)
Tag F554: Resident 80 was found to have self-administered medications without proper assessment, physician orders, and care plan. The facility conducted a facility-wide audit and initiated staff training and weekly audits to ensure compliance with the self-administration policy.
Tag F689: Resident 15’s call light location was checked to ensure accessibility regardless of bed positioning. A facility-wide audit was conducted to ensure call lights are within reach, with staff training and weekly audits planned to maintain compliance with the Fall Prevention policy.
Tag F761: Medication storage areas were audited for appropriate and functional locks. No issues were identified. Staff training and weekly audits will continue to ensure compliance with the Medication Storage policy.
Report Facts
Weekly medication pass audits: 4
Weekly call light placement audits: 80
Weekly medication storage audits: 4
Plan of Correction submission date: 2026
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 3
Date: Apr 8, 2026
Visit Reason
A recertification survey with complaint investigation was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Complaint reference number 002735844 was investigated.
Complaint Details
Complaint reference number 002735844 was investigated during the recertification survey.
Findings
Deficiencies were identified related to failure to assess a resident's ability to self-administer medications, failure to ensure call lights were within reach of a resident, and failure to properly secure medication and treatment carts.
Deficiencies (3)
42 CFR 483.10(c)(7) The facility failed to assess Resident 80 for safe self-administration of medications before leaving medications at her bedside unsupervised.
42 CFR 483.25(d)(1)(2) The facility failed to ensure Resident 15’s call lights were within her reach, posing a risk for accidents.
42 CFR 483.45(g)(h)(1)(2) The facility failed to ensure medication and treatment carts were locked when unattended, risking unauthorized access.
Report Facts
Facility census: 74
Sample size: 18
BIMS score: 15
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided information on medication self-administration and call light placement policies |
| Licensed Nurse H | Licensed Nurse | Observed medication left at Resident 80's bedside and took pills to ask Certified Medication Aide |
| Certified Nurse’s Aide M | Certified Nurse’s Aide | Commented on proper placement of Resident 15's call light |
| Licensed Nurse J | Licensed Nurse | Stated medication carts should be locked when unattended |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-06-20.
Findings
All deficiencies have been corrected as of the compliance date of 2024-07-15, 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 to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including resident dignity, care plan revisions, accident hazards, dialysis communication, bedrail safety, food storage sanitation, infection control practices, and immunization documentation.
Deficiencies (8)
F550 Resident Rights: The facility failed to ensure Resident 40 was treated with respect and dignity when personal care was provided with window blinds open, risking negative psychosocial outcomes.
F657 Care Plan Timing and Revision: The facility failed to revise Resident 44's care plan to reflect toileting needs after meals, placing the resident at risk for preventable accidents and falls.
F689 Free of Accident Hazards: The facility failed to secure electrical panels and cleaning chemicals and did not implement fall interventions for Residents 43 and 2, placing residents at risk for accidents and falls.
F698 Dialysis: The facility failed to consistently communicate Resident 7's medical condition with a pre-dialysis assessment prior to hemodialysis, risking adverse outcomes.
F700 Bedrails: The facility failed to ensure Resident 60 had a documented risk assessment, consent, and advisement of risks and benefits for side rail use, risking uninformed decisions and impaired safety.
F812 Food Procurement, Storage, Preparation, and Service: The facility failed to ensure food items were properly labeled and dated after opening, risking food-borne illness.
F880 Infection Prevention and Control: The facility failed to follow infection control standards related to enhanced barrier precautions, hand hygiene, and disinfection of shared mechanical lifts, risking infectious disease transmission.
F883 Influenza and Pneumococcal Immunizations: The facility failed to offer or obtain consents or declinations for pneumococcal and influenza vaccinations for Resident 17, increasing risk for related complications.
Report Facts
Census: 74
Residents in sample: 19
Residents on enhanced barrier precautions: 14
Fall incidents: 2
Hemodialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including dignity, care plan revisions, accident hazards, dialysis communication, infection control |
| Licensed Nurse I | Licensed Nurse | Named in dignity and bedrail assessment findings |
| Certified Nurse Aide T | Certified Nurse Aide | Named in infection control finding for improper sanitization of mechanical lift |
| Certified Medication Aide S | Certified Medication Aide | Named in dignity and accident hazard findings |
| Certified Nurse Aide M | Certified Nurse Aide | Named in infection control finding for hand hygiene and care plan knowledge |
| Administrative Nurse E | Infection Preventionist | Named in immunization finding |
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 regulatory survey conducted on June 20, 2024.
Findings
The facility identified multiple deficiencies related to resident privacy, care plan revisions, environmental hazards, dialysis communication, bed cane use, food storage, infection control, and immunization policies. The Plan of Correction outlines corrective actions, staff training, and ongoing monitoring to achieve substantial compliance by July 15, 2024.
Deficiencies (8)
Tag F550 483.10(a)(1)(2)(b)(1)(2): Resident privacy was deficient, potentially causing negative psychosocial effects due to lack of privacy during cares.
Tag F657 483.21(b)(2)(i)-(iii): Care plan revisions were not timely or adequate to address resident needs, including fall interventions.
Tag F689 483.25(d)(1)(2): Environmental hazards and chemical storage were not properly secured or monitored.
Tag F698 483.25(I): Dialysis communication policy was deficient, affecting resident care coordination.
Tag F700 483.25(n)(1)-(4): Bed cane use lacked proper assessment and consent documentation for affected residents.
Tag F812 483.60(i)(1)(2): Food storage practices were deficient, with open food not properly dated or monitored.
Tag F880 483.80(a)(1)(2)(4)(e)(f): Infection control policies, including hand hygiene and equipment disinfecting, were not fully followed.
Tag F883 483.80(d)(1)(2): Pneumonia vaccination consent and administration were deficient, requiring audits and staff training.
Report Facts
Weeks of monitoring: 4
Substantial compliance date: Jul 15, 2024
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 23, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-10-04.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2022-11-04, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 3
Date: Oct 4, 2022
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements following a prior survey.
Findings
The facility failed to adequately assess and manage bladder and bowel continence for residents R24 and R13, failed to provide appropriate pain management for resident R17, and failed to properly label and discard expired insulin pens in medication carts.
Deficiencies (3)
F 690: The facility failed to assess and identify services necessary to promote bladder and bowel continence for residents R24 and R13, placing them at risk of decreased psycho-social wellbeing and increased incontinence.
F 697: The facility failed to address and treat resident R17's pain during care, placing her at risk of ongoing pain and diminished quality of life.
F 761: The facility failed to date one insulin pen and failed to discard one expired insulin pen in medication carts, risking adverse consequences or ineffective medication treatment.
Report Facts
Resident census: 40
Residents in sample: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Interviewed regarding continence care and pain management for residents R24, R13, and R17 |
| Certified Nurses Aide M | Certified Nurses Aide | Interviewed regarding continence care and pain management for residents R13 and R17 |
| Certified Nurses Aide N | Certified Nurses Aide | Interviewed regarding continence care for resident R24 |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding continence care and medication cart management |
| Administrative Staff A | Administrative Staff | Interviewed regarding continence care, pain management, and medication cart audits |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding medication cart management |
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 to address deficiencies identified in a prior inspection conducted on October 4, 2022.
Findings
The plan addresses deficiencies related to bowel and bladder assessments, pain management, and medication labeling and storage. The facility implemented Quality Assurance Performance Improvement (QAPI) plans, staff education, and ongoing monitoring to achieve substantial compliance by November 4, 2022.
Deficiencies (3)
F690: Bowel and Bladder assessment was completed on 10/5/22 and care plans were updated. Residents who were incontinent were identified and assessed.
F697: Resident R17 was assessed for pain related to ADLs on 10/5/22 and care plan updated. No other residents were identified with unidentified pain.
F761: Outdated insulin pens were destroyed and reordered. Medication labeling and storage policies were reviewed and staff were in-serviced.
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 to verify correction of all previous deficiencies cited on 2022-02-10.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2022-02-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 18, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-02-10.
Findings
All previously cited deficiencies were corrected as of 2022-02-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
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 residents requiring two staff members for transfers and implemented a Quality Assurance Performance Improvement plan to ensure sufficient staffing and compliance with care standards.
Deficiencies (1)
F0725: Resident 1 will have two staff members available for hoyer transfers and has been notified of this policy. Fifteen out of 34 residents require two staff members for transfers and/or cares.
Report Facts
Residents requiring two 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 based on multiple complaint investigations (KS00169403, KS00168363, KS00168302, and KS00165689).
Complaint Details
The findings represent the results of complaint investigations KS00169403, KS00168363, KS00168302, and KS00165689.
Findings
The facility failed to ensure sufficient nursing staff were on duty to provide resident R1 with necessary care, supervision, and services 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.
Deficiencies (1)
F725: The facility failed to provide sufficient nursing staff to meet resident R1's needs, including the absence of a second staff member for Hoyer lift transfers and daily ADLs, resulting in R1 needing to hire a personal caregiver.
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 to verify correction of all previous deficiencies cited on 2021-05-20.
Findings
All deficiencies have been corrected as of the compliance date of 2021-06-09, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
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 and to ensure compliance with applicable regulations.
Findings
The facility developed and implemented a facility-wide system to assure correction and continued compliance with multiple regulatory deficiencies related to resident rights, care plans, medication administration, infection control, and other areas. The plan includes audits, staff education, policy updates, and ongoing monitoring.
Deficiencies (10)
F550 Resident Rights: An audit identified residents without dining preferences in their care plans, which were updated. A new Dining Preferences Policy was initiated with staff education and weekly monitoring.
F565 Resident Council: No residents were identified as affected. A QAPI plan was initiated for resident council grievance follow-up with education and audits.
F689 Care Plan Policy: Care plans for residents with falls were reviewed and updated. A QAPI plan was initiated with staff education and weekly monitoring for timely care plan updates.
F756 Drug Regimen Review: Medication and treatment records were audited by a licensed pharmacist. A QAPI plan was initiated with policy review, education, and monthly audits.
F757 Unnecessary Drugs: Medication regimens were reviewed and adjusted. A facility-wide audit identified 21 residents on cardiac medications with hold parameters. A QAPI plan with education and weekly audits was initiated.
F760 Medication Errors: One resident was identified with intravenous antibiotic medication issues. A QAPI plan was initiated with policy revision, staff education, and weekly monitoring.
F761 Medication Storage: No residents were identified as affected. A QAPI plan was initiated with policy revision, staff education, and weekly audits for medication storage compliance.
F880 Infection Prevention & Control: Resident R182 is no longer in the facility. A QAPI plan for hand hygiene was initiated with policy revision, staff education, and weekly monitoring including hand hygiene demonstrations.
S500 Name Badges: No residents were identified. A QAPI plan was initiated with audits ensuring all direct care staff have name badges.
S966 Call Light Within Reach: Rooms of several residents were inspected and additional call lights were provided to ensure accessibility. A QAPI plan was initiated with policy review and staff education.
Report Facts
Residents identified with cardiac medication hold parameters: 21
Hand Hygiene demonstrations per week: 10
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 8
Date: May 20, 2021
Visit Reason
Health Resurvey and Complaint Investigation KS00161870 conducted to assess compliance with resident rights, grievance resolution, accident hazards, medication administration, drug regimen review, medication storage, and infection control.
Complaint Details
The inspection was triggered by a complaint investigation KS00161870 focusing on resident rights, grievance resolution, accident hazards, medication administration, drug regimen review, medication storage, and infection control.
Findings
The facility failed to promote dignity and quality of life for a nonverbal resident by leaving her at the dining table without interaction for extended periods. Resident council grievances about staff not wearing name badges were not resolved. The facility failed to ensure a safe environment by not providing call lights and proper assistance to residents at risk of falls. Medication administration errors were found, including failure to hold medications per physician orders and missed IV antibiotic doses. Medication storage and labeling deficiencies were noted, including expired and improperly labeled medications. Infection control practices were inadequate, with staff failing to perform proper hand hygiene.
Deficiencies (8)
F550: The facility failed to maintain dignity and quality of life for a nonverbal resident by placing her at the dining table for over 30 minutes without interaction or preferred activities.
F565: The facility failed to resolve resident council grievances about staff not wearing name badges, risking unresolved issues and negative psychosocial outcomes.
F689: The facility failed to ensure a safe environment by not providing a bathroom call light for a resident with prior falls, not implementing fall interventions, and not using two staff for transfers as required.
F756: The facility failed to ensure the consultant pharmacist identified and reported failure to hold antihypertensive medication per physician order, risking medical complications.
F757: The facility failed to administer medications according to physician orders, including giving antihypertensive medication despite low blood pressure, risking adverse effects.
F760: The facility failed to administer IV antibiotic medication as ordered, missing seven doses without documentation or physician notification, risking prolonged infection and complications.
F761: The facility failed to properly label, store, and dispose of medications, including expired drugs, unlabeled insulin pens, and outdated vaccines, risking ineffective treatment and complications.
F880: The facility failed to ensure staff practiced proper hand hygiene between glove changes and after resident contact, increasing risk of infection transmission.
Report Facts
Resident census: 35
Residents sampled: 16
Medication doses missed: 7
Expired medication patches: 12
Expired medication bottles: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Interviewed regarding medication administration and fall interventions |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding medication errors, fall interventions, infection control, and medication storage |
| CNA P | Certified Nurse Aide | Interviewed regarding fall interventions and hand hygiene |
| Consultant GG | Consultant Pharmacist | Interviewed regarding medication regimen review |
| LN H | Licensed Nurse | Observed providing wound care with improper hand hygiene |
| Consultant HH | Consultant | Observed examining residents without removing gloves or hand hygiene |
| LN I | Licensed Nurse | Interviewed regarding medication administration documentation |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were cited in this survey.
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
Abbreviated Survey
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).
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Report Facts
Sample Size: 5
Supplemental: 0
Inspection Report
Plan of Correction
Deficiencies: 1
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 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.
Deficiencies (1)
A COVID-19 Focused Infection Control survey was conducted on 06/25/20. 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 verify 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 related to the applicable regulations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 25, 2019
Visit Reason
The visit was a health resurvey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The resurvey resulted in no deficiency citations related to the applicable regulations for long term care facilities.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 25, 2019
Visit Reason
The health resurvey was conducted to verify 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 related to the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 19, 2018
Visit Reason
The document is a Plan of Correction submitted in response to a Health Survey and multiple Complaint Investigations for a long term care 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 inspection was conducted as a health survey combined with multiple complaint investigations identified by case numbers KS00095567, KS00094366, KS00094375, KS00093970, KS00093870, KS00093768, KS00093210, and KS00092378.
Complaint Details
Multiple complaint investigations were conducted as part of the survey. No deficiencies were found, indicating complaints were not substantiated.
Findings
The survey and complaint investigations resulted in no deficiency citations related 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 for complaint numbers KS00126827, KS00126908, and KS00126682.
Complaint Details
The complaints were investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found and 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 2018-03-09 for complaint numbers KS00126827, KS00126908, and KS00126682.
Complaint Details
The complaints were investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 9, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies listed on the CMS-2567 were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 9, 2017
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 2017-05-09.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 10
Date: Apr 17, 2017
Visit Reason
Health Resurvey and Complaint Investigation including multiple complaint numbers.
Complaint Details
The visit was a complaint investigation including multiple complaint numbers (#96240, #112870, #104530, #111870, #96720, #103470, #97389).
Findings
The facility was found deficient in multiple areas including failure to provide accurate Medicare Part A discharge notices, failure to report and investigate a resident fall resulting in hip fracture, inadequate wheelchair positioning and restorative services, failure to provide scheduled bathing, failure to prevent pressure ulcers, inadequate supervision to prevent falls, medication administration errors, improper medication storage and labeling, and infection control deficiencies related to cleaning and glucometer disinfection.
Deficiencies (10)
F156: The facility failed to provide accurate documentation and notices (CMS form #10055) to residents discharged from Medicare Part A services for 3 residents (#2, #3, #4).
F225: The facility failed to report and investigate an unwitnessed fall for Resident #83 who fell and fractured his/her right hip.
F309: The facility failed to provide necessary care and services to maintain appropriate wheelchair positioning and posture for Resident #50.
F312: The facility failed to provide bathing as scheduled for 3 residents (#48, #61, #71), placing them at risk for poor personal hygiene.
F314: The facility failed to implement effective interventions to prevent pressure ulcers for Resident #37 who developed a blister on his/her great toe.
F318: The facility failed to provide restorative services to maintain and/or prevent further decrease in function and range of motion for Resident #50.
F323: The facility failed to provide adequate supervision to prevent accidents for Resident #83 who fell and refractured his/her hip.
F332: The facility failed to ensure Resident #40 was free of medication errors by administering medications outside the liberalized time frame.
F431: The facility failed to ensure 1 Lantus insulin vial was counted, labeled, and discarded in accordance with accepted professional practice.
F441: The facility failed to provide a sanitary environment by improper cleaning of a resident bathroom and glucometers, risking infection spread.
Report Facts
Resident census: 37
Medication count: 11
Fall incidents: 1
Bathing refusals: 3
Days without bathing: 31
Days without bathing: 13
Days without bathing: 11
Days without bathing: 16
Days without bathing: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Staff C | Verified failure to send Medicare Part A CMS form #10055 notices. | |
| Nurse I | Medication Aide | Administered medications outside liberalized time frame and improperly cleaned glucometer. |
| Housekeeping Staff Q | Improperly cleaned resident's toilet and contaminated glasses. | |
| Administrative Nurse A | Verified medication administration times, glucometer cleaning, and insulin pen labeling deficiencies. | |
| Nurse Aide E | Reported resident #50's wheelchair positioning and care needs. | |
| Nurse D | Reported resident #50's care needs and lack of restorative services. | |
| Therapy Staff F | Reported lack of restorative services for resident #50. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 17, 2017
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found widespread 'F' level deficiencies 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)
The facility had widespread 'F' level deficiencies that constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 17, 2017
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found widespread 'F' level deficiencies that constitute no actual harm but have potential for more than minimal harm without 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)
The facility had widespread 'F' level deficiencies constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
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 compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was found to have deficiencies at the 'F' level under the Life Safety Code survey, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Oct 20, 2016
Provider agreement termination date: Jan 20, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement actions. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
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 compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with deficiencies at an 'F' level indicating no harm but potential for more than minimal harm without 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 referenced in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
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 have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.10(b)(11), 483.13(c)(1)(ii)-(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.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 14, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies identified on the CMS-2567 were corrected as of 03/26/2016, with no uncorrected deficiencies noted at the time of revisit.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 5
Date: Mar 18, 2016
Visit Reason
Complaint investigation # KS 97974 regarding failure to notify family of room changes and failure to timely notify physician of resident condition changes.
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 failed to timely notify the physician of a resident's change in condition. The facility also failed to thoroughly investigate and report allegations of abuse, provide adequate social services for a resident with behavioral issues, manage resident behaviors appropriately, and obtain physician-ordered laboratory tests.
Deficiencies (5)
483.10(b)(11) The facility failed to notify responsible family members of room changes and failed to timely notify the physician of a resident's change in condition.
483.13(c)(1)(ii)-(iii), (c)(2)-(4) The facility failed to thoroughly investigate and report potential allegations of abuse for two residents and failed to take appropriate corrective action.
483.15(g)(1) The facility failed to provide medically-related social services to maintain the highest practicable well-being for a resident with behavioral issues.
483.25(f)(2) The facility failed to monitor and treat behaviors of declined social interaction, anger, and depression for a resident, and failed to provide timely and appropriate behavior management interventions.
483.75(j)(2)(i) The facility failed to obtain physician-ordered laboratory tests for a resident and drew an un-ordered lab test.
Report Facts
Resident census: 64
Residents sampled: 3
Days resident rejected cares: 4
Attempts to provide care: 9
Days antidepressant medication received: 7
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, 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 April 15, 2016.
Deficiencies (1)
The most serious deficiencies found were D level, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Mar 18, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at Nottingham Health and Rehab.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation at Nottingham Health and Rehab on 03/18/2016.
Findings
The facility reviewed and revised policies and procedures related to physician notification of significant resident changes, abuse prevention and investigation, social services for residents with depression and agitation, behavior assessment and treatment, and laboratory services. Staff received mandatory training on these topics, and responsible administrators were assigned to monitor compliance.
Deficiencies (5)
F157-D: The facility failed to properly notify physicians of significant changes in residents' conditions and document room changes or hospitalizations. Staff received training and monitoring was assigned.
F225-D: The facility failed to fully prevent and investigate abuse, neglect, or exploitation of residents. Investigations found no abuse but management was counseled and staff retrained.
F250-D: The facility failed to adequately address social services for residents experiencing depression, anxiety, and agitation. Plans of care were reviewed and staff retrained.
F320-D: The facility failed to properly assess and treat resident behaviors to prevent decline. Plans of care were updated and staff received training.
F504-D: The facility failed to ensure all ordered laboratory tests were obtained and reviewed by physicians. Records were reviewed and staff retrained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paul A. Varner | VP OPS | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 5
Date: Mar 7, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #96386, 97473, and 97508.
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-physician ordered insulin causing hospitalization, and provide sufficient nursing staff to meet resident needs and respond timely to call lights.
Deficiencies (5)
F155: The facility failed to ensure CPR certified staff accompanied full code residents during facility transports.
F281: The facility failed to implement a temporary care plan on admission for a resident reviewed for care planning.
F309: The facility failed to monitor, treat, and assess skin conditions for 2 of 3 residents sampled for skin conditions.
F333: The facility failed to ensure the resident remained free from medication errors when staff administered non-physician ordered insulin causing hospitalization for hypoglycemia.
F353: The facility failed to provide sufficient nursing staff to meet resident needs and respond to requests in a timely manner.
Report Facts
Resident census: 78
Residents sampled: 5
Units of Novolog insulin administered in error: 46
Call light wait times: 30
Residents requiring 2 staff assistance: 7
Residents assigned to charge nurse: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff W | Transport driver who was not CPR certified and transported full code residents | |
| Administrative nursing staff D | Interviewed about CPR certification and wound care expectations | |
| Administrative staff A | Aware staff W was not CPR certified and transported residents | |
| Direct care staff Q | Interviewed about care plan awareness and wound care | |
| Licensed nursing staff K | Acknowledged resident wounds and care plan responsibilities | |
| Licensed nursing staff L | Performed wound care and skin assessments | |
| Direct care staff S | Reported resident wound care | |
| Licensed nursing staff I | Administered insulin in error during orientation | |
| Licensed nursing staff J | Supervised staff I and notified physician after insulin error | |
| Direct care staff O | Interviewed about resident alertness and orientation | |
| Direct care staff L | Reported difficulty answering call lights timely | |
| Direct care staff R | Reported inability to answer call lights timely | |
| Licensed nursing staff J | Charge nurse for 19 residents, reported staffing shortages | |
| Practitioner consultant Z | Reported insufficient staffing based on resident acuity |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 7, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy. Based on this and the facility's history of noncompliance from a prior resurvey, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Report Facts
Enforcement 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 |
| Lisa Hauptman | CMS Contact | Contact for questions regarding the matter |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Mar 7, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Nottingham Health and Rehabilitation Center.
Complaint Details
This Plan of Correction responds to deficiencies cited during a complaint investigation at Nottingham Health and Rehabilitation Center.
Findings
The facility addressed multiple deficiencies including staff certification for transporting full code residents, implementation of temporary care plans, skin assessment and monitoring, medication administration including insulin, and sufficient staffing. Corrective actions include policy reviews, staff training, and monitoring by the Director of Nursing.
Deficiencies (5)
F155-E: The facility lacked proper certification of staff accompanying full code residents during transportation. The transport driver now receives CPR training and management staff have been in-serviced on this requirement.
F281-D: Temporary care plans were not consistently completed or implemented. The facility reviewed recent admissions and ensured all have temporary care plans, with nursing management attending mandatory in-servicing.
F309-D: Skin assessment and monitoring were inadequate for some residents. The facility reviewed records and ensured weekly skin assessments and treatments are provided as necessary.
F333-G: Medication administration, including insulin, was deficient. Two nurses were terminated and reported for not following the Kansas Nurses Practice Act and residents' rights. Mandatory in-service training was conducted.
F353-F: Staffing was insufficient to provide timely services. The facility is monitoring call light response times and has conducted mandatory training on timely response and accountability.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 30, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously cited deficiency under regulation 483.60(a),(b) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.60(a),(b) deficiency was corrected by the revisit date of 09/30/2015.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 23, 2015
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at Nottingham Health and Rehabilitation.
Findings
The report documents that the previously cited deficiency identified by regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) deficiency was corrected by the revisit date of 09/23/2015.
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 deficiency identified under regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) was corrected as of 09/23/2015.
Deficiencies (1)
Regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) deficiency was corrected on 09/23/2015.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 23, 2015
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at Nottingham Health and Rehabilitation.
Findings
The revisit report shows that the previously cited deficiency under regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) was corrected as of 09/23/2015.
Deficiencies (1)
Regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) deficiency was corrected on 09/23/2015.
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 confirms that the deficiency identified under regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) was corrected as of 09/23/2015.
Deficiencies (1)
Regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) deficiency was corrected by the revisit date.
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 a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The most serious deficiency was a 'D' level deficiency indicating 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
Plan of Correction
Deficiencies: 1
Date: Sep 23, 2015
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation related to medication administration errors at the facility.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation related to medication administration errors.
Findings
The facility identified errors in following policy and procedures for ordering and administering medications. Corrective actions include staff education, in-service training, and routine medication audits to ensure compliance.
Deficiencies (1)
F425 Pharmaceutical SVC-Accurate Procedures: An error was found in following facility policy and procedure for ordering and administering medication for Resident #1. Nurses were educated and will be in-serviced on proper medication procedures, with ongoing audits planned.
Report Facts
Complete Date for corrective actions: Sep 30, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Greta Wakefield | Administrator/Executive Director | Submitted the Plan of Correction |
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 for resident #1.
Complaint Details
Complaint #91445 was substantiated as the facility failed to provide medications as ordered for resident #1.
Findings
The facility failed to administer medications as ordered by the physician for one resident, resulting in the resident missing all medications for over 24 hours after admission.
Deficiencies (1)
F425 Pharmaceutical services: The facility failed to administer medications as ordered for resident #1, who missed all medications for over 24 hours after admission.
Report Facts
Facility census: 57
Residents sampled: 5
Residents reviewed for medications: 3
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 9, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-07-23.
Findings
The report confirms that the previously identified deficiencies under regulations 483.20(b)(1) and 483.25(a)(3) were corrected as of 2015-09-09.
Deficiencies (2)
Regulation 483.20(b)(1): Previously cited deficiency was corrected by the revisit date.
Regulation 483.25(a)(3): Previously cited deficiency was corrected by the revisit date.
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: Aug 21, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on 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.
Findings
The facility failed to conduct comprehensive and accurate assessments of residents' skin conditions and failed to provide necessary personal hygiene services, including bathing, to dependent residents. Specific failures included incomplete skin assessments and lack of bathing for residents despite documented care plans.
Deficiencies (2)
F 272: The facility failed to ensure accurate and complete skin assessments for residents, missing documentation of existing skin conditions and failing to monitor skin integrity as reported by the hospital.
F 312: The facility failed to provide necessary bathing services to dependent residents, resulting in residents not receiving baths for 10 and 13 days despite care plans specifying bathing needs.
Report Facts
Resident census: 69
Sampled residents: 4
Days without bath: 10
Days without bath: 13
Open excoriated area size: 1
Redness size surrounding excoriation: 0.3
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 21, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Nottingham Health.
Complaint Details
This Plan of Correction addresses deficiencies cited in a complaint investigation at Nottingham Health.
Findings
The facility failed to complete comprehensive assessments including full body and skin condition assessments upon admission and did not ensure complete documentation of residents' ADL care related to bathing. The plan outlines corrective actions including audits, re-education of staff, and quality assurance reviews.
Deficiencies (2)
F272 Comprehensive Assessment: The facility failed to complete full body assessments upon admission and did not fully document skin condition assessments for residents.
F312 ADL Care provided for Dependent Residents: The facility failed to ensure complete documentation of residents' bathing care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Greta Wakefield | Administrator/Executive Director | Submitted the Plan of Correction |
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)
The facility had "D" level deficiencies indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Enforcement
Deficiencies: 0
Date: Jul 31, 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 deficiency to be at a 'G' level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective October 31, 2015, until substantial compliance is achieved or the provider agreement is terminated.
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 the enforcement letter |
Inspection Report
Enforcement
Deficiencies: 0
Date: Jul 31, 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 deficiency to be a 'G' level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective October 31, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Report Facts
Denial of Payment Effective Date: Oct 31, 2015
Termination Recommendation Date: Jan 31, 2016
Civil Money Penalty Minimum: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
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 involving multiple complaint numbers.
Complaint Details
The visit was complaint-related involving complaint investigation numbers #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. Uncovered barrels and folding net hampers containing soiled laundry were observed in the soiled laundry receiving areas.
Deficiencies (1)
KAR 26-40-303 8 (a) Laundry services. The facility failed to maintain laundry in tight fitting containers prior to washing, with uncovered barrels containing soiled laundry observed in multiple care units on several days.
Report Facts
Resident census: 68
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 potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payment for new admissions and termination of provider agreement were outlined if substantial compliance was not achieved.
Deficiencies (1)
The facility was cited with an "F" level deficiency indicating widespread noncompliance with Life Safety Code requirements posing potential for more than minimal harm without immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payment: Jul 13, 2015
Effective date for termination: Oct 13, 2015
Days to request Informal Dispute Resolution: 10
Days to request fair hearing: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution and enforcement actions. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
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 potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payment for new admissions and possible termination of provider agreement were outlined.
Deficiencies (1)
The facility was cited with an "F" level deficiency indicating widespread noncompliance with Life Safety Code requirements, posing potential for more than minimal harm without immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payment: Jul 13, 2015
Effective date for termination: Oct 13, 2015
Days to request Informal Dispute Resolution: 10
Days to request fair hearing: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution and appeals related to deficiencies. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: N046084 POC 135Q11
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 facility reviewed and updated policies and procedures related to multiple areas including Medicare billing, abuse prevention, resident care and positioning, hygiene, skin assessment, restorative services, supervision, medication administration, drug labeling, sanitation, and dietary management. Staff received in-service training and monitoring plans were established to ensure compliance.
Deficiencies (11)
F156-F: The facility failed to provide accurate documentation for residents receiving Part A services including CMS Form #10055 upon discharge.
F225-D: The facility failed to properly prevent and investigate abuse, neglect, or exploitation of residents and report incidents accordingly.
F309-D: The facility failed to maintain appropriate wheelchair positioning for a resident.
F312-D: The facility failed to provide timely hygiene, personal care, and assistance with ADLs as documented in residents' plans of care.
F314-D: The facility failed to properly assess skin, document skin assessments, and implement preventative skin measures.
F318-D: The facility failed to provide adequate restorative services to maintain or prevent decline in function and range of motion.
F323-D: The facility failed to properly supervise residents visiting other inpatient residents, creating potential safety issues.
F332-D: The facility failed to administer medications timely and according to residents' needs and wants.
F431-D: The facility failed to properly identify and label drugs and biologicals, including the Lantus vial in question.
F441-F: The facility failed to maintain a sanitary environment to prevent disease and infection transmission, including proper cleaning of glucometers and bathrooms.
S0600-C: The facility failed to employ a full-time Certified Dietary Manager as required.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046084 POC 90JS11
Visit Reason
This document is a Plan of Correction related to a previous inspection event identified as 90JS11 Nottingham dated 9.25.19.
Findings
No deficiencies were found in the referenced inspection report, as indicated by the 'Deficiency Free' status.
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