Inspection Reports for Heritage Gardens Health and Rehabilitation Center LLC
700 CHEROKEE, KS, 66066
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 23, 2025, found the facility in compliance with all surveyed regulations and no new deficiencies. Prior inspections showed multiple deficiencies related mainly to resident transfer notices, activity scheduling, weight monitoring, wheelchair cushions, call light accessibility, oxygen tubing storage, dementia care interventions, diet preparation, and immunization documentation. Complaint investigations in recent years substantiated issues with supervision and elopement risk management, as well as timely reporting and investigation of abuse allegations. Enforcement actions included denial of payment for new admissions in 2016 and 2017 due to immediate jeopardy findings related to abuse and safety concerns, but no fines or license suspensions were listed in the available reports. The facility appears to have addressed many prior deficiencies over time, with recent inspections showing correction of previously cited issues and no new noncompliance noted.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
23.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
297% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
54 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 23, 2025
Visit Reason
An offsite revisit survey was conducted on 07/23/25 for all previous deficiencies cited on 05/22/25 to verify correction of prior deficiencies.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 06/19/25, 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
Deficiencies: 10
Jun 19, 2025
Visit Reason
This document is a Plan of Correction submitted by Heritage Gardens Health and Rehabilitation Center addressing deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions, system changes, and monitoring processes for multiple deficiencies related to resident transfer notices, activity scheduling, weight monitoring, wheelchair cushions, call light accessibility, oxygen tubing storage, dementia care interventions, puree diet preparation, and immunization offers.
Severity Breakdown
D: 6
E: 4
Deficiencies (10)
| Description | Severity |
|---|---|
| Resident R38 was not provided timely written notice of transfer/discharge and bed hold notice. | D |
| Activities were not planned for weekends in June 2025. | E |
| Daily weights ordered by doctor were not consistently monitored or refusals documented. | D |
| Resident R35 declined wheelchair cushion offer; care plan updated accordingly. | D |
| Call lights or call bells were not ensured to be within reach in resident rooms. | D |
| Oxygen and BIPAP tubing were not properly stored in resident rooms. | D |
| Nonpharmacological interventions were not consistently used for residents with dementia before pharmacological interventions. | D |
| Dietary cooks were not consistently following puree diet recipes to maintain nutritional value. | E |
| Resident R9’s oxygen and BIPAP tubing storage corrected; no correction for R35 due to resident expiring. | E |
| Audit to determine if residents need to be offered PCV20 vaccine; education on immunization process provided. | E |
Report Facts
Plan of Correction completion date: Jun 19, 2025
Audit frequency: 1
Audit duration: 4
Audit start date: Jun 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Hartman | Administrator | Submitted the Plan of Correction |
| Deb Harper | Added and modified the Plan of Correction | |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 10
May 22, 2025
Visit Reason
Health Recertification Survey conducted to assess compliance with federal regulations for nursing facilities.
Findings
The facility had multiple deficiencies including failure to provide proper transfer/discharge notices, inconsistent weekend activities, failure to follow physician orders for daily weights, lack of pressure redistribution cushion for a resident's wheelchair, inadequate fall prevention interventions, improper storage of respiratory equipment, inconsistent dementia care, failure to follow pureed diet recipes, infection control lapses, and failure to document pneumococcal immunization consent or declination.
Severity Breakdown
SS=D: 6
SS=E: 4
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide written notice of transfer/discharge and bed hold notice for Resident 38. | SS=D |
| Failed to consistently provide activities on weekends for residents with cognitive impairment. | SS=E |
| Failed to consistently follow physician's order for daily weights for Resident 9. | SS=D |
| Failed to provide pressure redistribution cushion for Resident 35's wheelchair. | SS=D |
| Failed to provide fall interventions as directed by care plan for Resident 21 and failed to implement new interventions for Resident 28. | SS=D |
| Failed to ensure proper sanitary storage of Resident 9's BIPAP mask and nasal cannula. | SS=D |
| Failed to provide consistent dementia-related care services for Resident 35. | SS=D |
| Failed to follow nutritionally approved recipes during preparation of pureed meals. | SS=E |
| Failed to maintain infection prevention and control program to ensure sanitary storage of respiratory equipment for Residents 9 and 36. | SS=E |
| Failed to obtain consent or declinations for pneumococcal vaccination for Residents 36, 2, 35, and 21. | SS=E |
Report Facts
Census: 54
Sample size: 14
Residents on pureed diet: 8
Residents on Enhanced Barrier Precautions: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Provided statements regarding nursing responsibilities, infection control, and immunization processes. | |
| Licensed Nurse G | Provided statements regarding nursing responsibilities, fall interventions, and respiratory equipment storage. | |
| Certified Nurse Aide M | Provided statements regarding resident safety, fall precautions, and respiratory equipment storage. | |
| Dietary Staff CC | Observed preparing pureed pork chops and did not follow recipe. | |
| Dietary Staff/Social Service BB | Commented on pureed food preparation and recipe adherence. | |
| Administrative Staff A | Stated social service and business office responsibilities for transfer/discharge notices. | |
| Administrative Staff B | Admitted bed-hold notices were not sent for Resident 38. |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 1, 2023
Visit Reason
An offsite revisit survey was conducted on 12/01/23 to verify correction of all previous deficiencies cited on 11/06/23.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 11/15/23, and no new noncompliance was found. The facility is in compliance with all surveyed regulations.
Report Facts
Previous deficiencies: 0
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 17, 2023
Visit Reason
An offsite revisit survey was conducted on 11/17/23 for all previous deficiencies cited on 09/20/23 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 10/27/23, 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
Deficiencies: 1
Nov 6, 2023
Visit Reason
This plan of correction is submitted to address deficiencies related to wandering/elopement risk residents identified during an audit on 11/6/2023.
Findings
The facility identified 12 residents at risk for wandering/elopement who were care planned accordingly. The facility updated the elopement book and implemented staff education and ongoing audits to ensure compliance and accuracy of care plans and documentation.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly care plan and document wandering/elopement risk residents. | D |
Report Facts
At risk residents identified: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Hartman | Administrator | Submitted the plan of correction |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Nov 6, 2023
Visit Reason
The inspection was conducted as a result of complaint investigations #KS00183801, KS00183765, and KS00183769.
Findings
The facility failed to provide adequate supervision and failed to identify and implement interventions to address elopement risk and attempts for Resident 1 (R1), who exhibited exit seeking behavior and actual attempts to elope from the facility, placing the resident at risk for elopement and other preventable accident hazards.
Complaint Details
The findings represent the results of complaint investigations #KS00183801, KS00183765, and KS00183769.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide adequate supervision and failed to identify and implement interventions to address elopement risk and attempts for Resident 1 with exit seeking behavior and actual attempts to elope. | SS=D |
Report Facts
Census: 50
Wandering/Elopement Risk Scale score: 10
BIMS score: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | Certified Nurse Aide | Stated that Resident 1 liked to stay in her room and was not ambulatory. |
| Licensed Nurse H | Licensed Nurse | Stated Resident 1 was moved to the secure unit due to behaviors including exit seeking. |
| Administrative Nurse D | Administrative Nurse | Stated Resident 1's Care Plan should have included elopement risk and been updated after elopement attempts. |
Inspection Report
Plan of Correction
Deficiencies: 15
Sep 20, 2023
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on 09/20/2023.
Findings
The plan outlines corrective actions, identification of residents at risk, system changes, and monitoring procedures to address multiple deficiencies related to psychosocial follow-up, resident rights, environment safety, care planning, infection control, and staff training. The facility aims to achieve substantial compliance by October 27, 2023.
Severity Breakdown
D: 7
F: 3
E: 2
C: 1
: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Psychosocial follow-up care planning and resident rights education for residents on the memory care unit. | D |
| Accessibility of required state agency and advocacy posters to residents. | F |
| Provision of Advanced Beneficiary Notice (ABN) forms to Medicare A residents. | D |
| Maintenance and environmental conditions including tile replacement and air freshening devices. | E |
| Care planning for activities of daily living (ADL) assistance. | D |
| Bathing care plan review and staff education on ADL care for dependent residents. | D |
| Pressure injury prevention and management including ordering heel protecting boots and staff education. | D |
| Provision of additional hand splints to reduce skin irritation. | D |
| Education and monitoring for prevention of decline in range of motion. | — |
| Removal of hazardous chemicals and environmental safety audits. | E |
| Implementation of a 72-hour voiding diary and toileting program for residents at risk. | D |
| Employee evaluations and mandatory training compliance monitoring. | F |
| Posting of nurse staffing information to be readily available. | C |
| Referral for talk therapy for resident with dementia-related behavioral disturbances. | D |
| Education of licensed nurses and staff on infection control and hand washing policies. | F |
Report Facts
Residents affected: 12
Audit frequency: 4
Audit frequency: 2
Audit frequency: 5
Audit frequency: 12
Date: Oct 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Hartman | Administrator | Named as submitting administrator and responsible for education and monitoring |
| Felicia Majewski | Added and modified Plan of Correction document | |
| Brenda Groves | Partnered with facility to provide dementia training |
Inspection Report
Health Resurvey And Complaint Investigation
Census: 52
Deficiencies: 14
Sep 20, 2023
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation for Heritage Gardens Health and Rehabilitation Center.
Findings
The facility was cited for multiple deficiencies including failure to ensure dignified care environment, required postings, Medicaid/Medicare coverage notices, safe and homelike environment, comprehensive care planning, ADL care, pressure ulcer prevention and treatment, range of motion maintenance, accident hazards, bowel/bladder incontinence management, nurse aide performance reviews, nurse staffing postings, dementia care, and infection prevention and control.
Complaint Details
The inspection included a complaint investigation related to dignified care environment and other resident care concerns.
Severity Breakdown
SS=D: 7
SS=F: 3
SS=E: 2
SS=C: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure a dignified care environment for Resident R1, allowing verbal aggression from another resident. | SS=D |
| Failed to post pertinent state agencies and advocacy groups in an accessible and visible manner. | SS=F |
| Failed to issue required Medicare notification forms timely for residents R11 and R16. | SS=D |
| Failed to maintain a safe, clean, comfortable, and homelike environment including odor control, maintenance, and noise issues. | SS=E |
| Failed to identify level of care assistance needed for activities of daily living on Resident R44's care plan. | SS=D |
| Failed to provide consistent bathing opportunities for Residents R44 and R33, placing them at risk for infections and skin breakdown. | SS=D |
| Failed to implement preventive measures including use of heel protectors for Resident R33 at risk for pressure ulcers and failed to complete weekly wound assessments for Resident R4. | SS=D |
| Failed to provide left-hand splint to Resident R19 as ordered to prevent contractures and maintain range of motion. | SS=D |
| Failed to secure rooms containing hazardous materials to keep out of reach of cognitively impaired independently mobile residents. | SS=E |
| Failed to implement individualized timed toileting interventions for Resident R44 with bowel and bladder incontinence. | SS=D |
| Failed to ensure three of five Certified Nurse Aides reviewed had yearly performance evaluations and required 12 hours of in-service education. | SS=F |
| Failed to post daily nurse staffing data for all three days of the onsite survey in a clear, readable format accessible to residents and visitors. | SS=C |
| Failed to provide appropriate dementia care and services for Resident R27's dementia-related behaviors. | SS=D |
| Failed to ensure staff practiced proper hand hygiene during wound care and disinfected bedside tables after soiled items; failed to track and trend infections. | SS=F |
Report Facts
Residents in sample: 15
Residents census: 52
Residents discharged from Medicare Part A: 26
Bathing occasions for R44: 4
Days between wound assessments for R4: 14
CNA staff lacking yearly in-service: 3
CNA staff lacking yearly performance evaluations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse/Infection Preventionist | Provided multiple statements on facility policies, deficiencies, and infection control |
| Certified Nurse Aide M | CNA | Observed and intervened in resident behavior incident; assisted with wound care |
| Licensed Nurse G | Licensed Nurse | Provided statements on dementia care and bathing |
| Certified Nurse Aide N | CNA | Provided statements on resident monitoring and bathing schedules |
| Licensed Nurse H | Licensed Nurse | Provided statements on splint use and infection control |
| Administrative Nurse E | Administrative Nurse | Performed wound care and provided statements on infection control |
| Certified Nurse Aide O | CNA | Provided statements on bathing and splint use |
| Social Services X | Social Services | Responsible for Medicare notification forms |
| Administrative Staff A | Administrative Staff | Provided statements on postings and education tracking |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 28, 2023
Visit Reason
An offsite revisit survey was conducted on 04/28/23 to verify correction of all previous deficiencies cited on 03/20/23.
Findings
All deficiencies cited in the previous inspection have been corrected as of 04/14/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies correction compliance date: Apr 14, 2023
Inspection Report
Plan of Correction
Deficiencies: 5
Mar 20, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a survey conducted on March 20, 2023, at the facility.
Findings
The plan addresses deficiencies related to resident injury assessment, transfer procedures using two person/Hoyer lifts, staff training on transfer protocols, and abuse, neglect, and exploitation prevention and reporting. The facility outlines corrective actions including re-education of staff, random transfer observations, and ongoing review by the Quality Assurance and Performance Improvement Committee.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident #3 was assessed for injury, head to toe skin assessment conducted, trauma care plan created and implemented, and medication review conducted. | D |
| Other residents who transfer via two person/Hoyer lift will be reviewed by the Interdisciplinary team to ensure transfer status accuracy and appropriateness. | D |
| Current staff responsible for transferring residents will receive mandatory re-education on transfer training and plan of care review. | D |
| Staff will be re-educated regarding Abuse, Neglect, Exploitation, preventing, identifying and reporting. | D |
| Acting Administrator and Interim Director of Nursing re-educated on timeliness of reporting to regulatory agency. | D |
Report Facts
Dates for corrective actions: Apr 14, 2023
Dates for staff re-education: Apr 12, 2023
Dates for staff re-education: Apr 13, 2023
Date of injury assessment and trauma care plan: Mar 12, 2023
Date of follow-up and reporting start: Apr 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gerald Harman | Regional Vice President (RVP) | Submitted the Plan of Correction to KDADS |
| Felicia Majewski | Added and modified the Plan of Correction document | |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Mar 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of abuse and neglect involving Resident 3 (R3).
Findings
The facility failed to prevent neglect when staff did not use the appropriate transfer method for R3 as care planned, resulting in bruising on R3's upper chest. Additionally, the facility failed to report allegations of abuse made by R3 to the State Agency within the mandated timeframe.
Complaint Details
The complaint investigations #KS00178670 and KS00178243 involved allegations of abuse and neglect concerning Resident 3. The facility failed to prevent neglect by not using the care planned mechanical lift for transfers, causing bruising. The facility also failed to report the abuse allegations to the State Agency within the required two-hour timeframe, placing the resident at risk for unresolved and ongoing abuse.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to prevent neglect when staff failed to provide the appropriate transfer method to Resident 3 as care planned, resulting in bruising on R3's upper chest. | SS=D |
| Failure to report allegations of abuse involving Resident 3 to the State Agency within the mandated timeframe. | SS=D |
Report Facts
Census: 44
Residents sampled for abuse: 3
Time to report allegations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA O | Certified Nurse Aide | Named in the neglect finding for providing care to R3 without following the care plan transfer method |
| LN G | Licensed Nurse | Noted bruising on R3 and participated in interviews and investigation |
| Administrative Nurse D | Administrative Nurse | Provided statements about transfer procedures and reporting abuse allegations |
| Consultant GG | Consultant | Involved in notification and investigation of abuse allegations |
| Administrative Staff A | Abuse Coordinator | Responsible for abuse allegation reporting and investigation oversight |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 6, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-11-07.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2022-11-25, 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
Deficiencies: 2
Nov 7, 2022
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a survey conducted on November 7, 2022, related to investigation processes for bruising injuries to resident R1.
Findings
The facility failed to properly investigate bruising injuries to resident R1 and did not follow required processes to prevent potential abuse, exploitation, or mistreatment. Corrective actions include staff in-service training, ongoing monitoring, and review by the Quality Assurance and Performance Improvement Committee.
Deficiencies (2)
| Description |
|---|
| Failure to follow the process for investigating injury of bruising to resident R1. |
| Failure to follow the process for investigation of bruising to R1 to prevent further potential abuse, exploitation, or mistreatment. |
Report Facts
Deficiencies cited: 2
Plan of Correction completion date: 2022
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Nov 7, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse and neglect involving bruises of unknown origin on Resident 1 (R1).
Findings
The facility failed to ensure that bruises of unknown origin on R1 were reported as potential abuse or neglect to the State Agency and failed to investigate these bruises properly. This placed the resident at risk for unresolved and ongoing abuse, decreased psychosocial well-being, and further injuries.
Complaint Details
The complaint investigations #KS00175735 and KS00175738 involved allegations of abuse and neglect related to bruises on Resident 1. The facility failed to report and investigate these bruises as required.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility staff failed to report bruises of unknown origin on Resident 1 as potential abuse or neglect to the State Agency. | SS=D |
| Facility staff failed to investigate bruises of unknown origin on Resident 1 as potential abuse or neglect. | SS=D |
Report Facts
Resident census: 40
Medication dosage: 650
Dates: 2017
Dates: 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Observed bruising on Resident 1's knees and reported it to the next shift; involved in bruise assessment | |
| Licensed Nurse G | Contacted consultant regarding Resident 1's leg pain and ordered x-rays; reported bruising on shin area | |
| Certified Nurse Aide M | Reported Resident 1's complaints of hip pain and observed internal rotation of leg | |
| Licensed Nurse H | Assessed Resident 1 and reported bruising to Director of Nursing if found | |
| Administrative Nurse D | Could not locate investigation on bruising; stated staff expected to fill out Risk Management reports |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 3, 2022
Visit Reason
An offsite revisit survey was conducted on 10/03/22 to verify correction of all previous deficiencies cited on 08/29/22.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 08/29/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Aug 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #KS00174013 and KS00173960.
Findings
The facility failed to ensure Resident 1 was able to use a telephone without interference from staff, specifically when staff took the phone from him during a call, placing the resident at risk for isolation and impairing dignity and well-being.
Complaint Details
The complaint investigations #KS00174013 and KS00173960 were substantiated by findings that staff interfered with Resident 1's use of the telephone, including taking the phone away during a call and denying access, which was documented through observations, interviews, and record reviews.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure Resident 1 had reasonable access to use a telephone without staff interference, violating resident rights to communication privacy and access. | SS=D |
Report Facts
Census: 45
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in the finding for taking the phone from Resident 1 and denying phone use. |
| M | Certified Nurse Aide | Interviewed regarding phone use and staff behavior related to Resident 1. |
| Administrative Staff A | Interviewed about resident rights to phone use and staff training. |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 29, 2022
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey, addressing compliance with Federal Medicare and Medicaid requirements.
Findings
The Plan of Correction outlines corrective actions related to residents' rights to use telephones privately without staff interference, including education provided to staff and residents, identification of affected residents, and implementation of private phone use areas. Monitoring and reporting to the QAPI committee are planned.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents' right to use a telephone without interference from staff was not ensured. | D |
Report Facts
Residents interviewed monthly: 5
Monitoring frequency: 3
Monitoring frequency: 1
Inspection Report
Follow-Up
Deficiencies: 0
Mar 11, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-01-27.
Findings
All deficiencies cited in the previous inspection were corrected as of the compliance date 2022-02-22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 17
Feb 22, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions and education plans to ensure compliance with federal Medicare and Medicaid requirements.
Findings
The facility addressed multiple deficiencies related to resident dignity during meals, notification of roommate changes, surety bond for resident funds, privacy for phone calls, termination notice of skilled services, safe and homelike environment, accurate MDS coding, comprehensive care plans, medication safety, infection control, and COVID screening. The facility implemented education, audits, and monitoring plans to ensure ongoing compliance and quality assurance.
Severity Breakdown
D: 11
E: 5
F: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Facility does treat each resident with dignity during meals | D |
| Facility notifies residents when getting a new roommate | D |
| Facility has a surety bond to guarantee security of residents' personal funds | E |
| Facility provides personal privacy for phone calls in Special Care Unit | E |
| Facility ensures notice of termination of skilled services no later than two days prior | D |
| Facility provides a safe, clean, homelike atmosphere | E |
| Facility accurately codes MDS assessments | D |
| Facility develops comprehensive care plans | D |
| Facility reviews and revises resident care plans | D |
| Facility monitors bowel movements for residents | D |
| Facility provides range of motion to residents at risk for decline | D |
| Facility provides environment free of accident hazards and secures medications | E |
| Facility provides appropriate treatment and services to maintain well-being | D |
| Facility provides drug regimens free from unnecessary drugs | D |
| Facility ensures medication administration is free from significant errors | D |
| Facility ensures medication carts do not contain expired medication and are properly secured | E |
| Facility conducts complete COVID screening and infection control practices | F |
Report Facts
Date of Plan of Correction completion: Feb 22, 2022
Frequency of audits: 4
Frequency of audits: 3
Frequency of audits: 1
Medication cart visualizations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| JEANIE BURK | RN, BSN, LNHA | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction | |
| Felicia Majewski | Modified Plan of Correction |
Inspection Report
Census: 44
Deficiencies: 15
Jan 27, 2022
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #168245 and #168437.
Findings
The facility was found deficient in multiple areas including resident dignity during meals, notification of roommate changes, security of personal funds, privacy during phone calls, safe and homelike environment, accuracy of assessments, comprehensive care planning, medication administration errors, medication storage, infection prevention and control, and behavioral health services.
Complaint Details
The inspection included complaint investigations #168245 and #168437.
Severity Breakdown
SS=D: 8
SS=E: 4
SS=F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure staff treated residents with dignity during meals, including assisting residents while seated and serving meals simultaneously. | SS=D |
| Failed to notify a resident of a new roommate prior to the roommate's arrival. | SS=D |
| Failed to have a surety bond or assurance to secure residents' personal funds equal to or greater than total resident funds. | SS=E |
| Failed to provide personal privacy for phone calls for residents in the Special Care Unit without personal phones. | SS=E |
| Failed to provide timely and complete Medicaid/Medicare coverage and liability notices to residents. | SS=D |
| Failed to maintain a safe, clean, comfortable, and homelike environment including damaged furniture, stained tiles, broken blinds, and water stains. | SS=E |
| Failed to accurately assess a resident's status on the Minimum Data Set (MDS), specifically regarding oral health. | SS=D |
| Failed to develop and implement a comprehensive care plan addressing a resident's history of constipation and related interventions. | SS=D |
| Failed to review and revise a resident's care plan to include required transfer assistance. | SS=D |
| Failed to provide range of motion exercises for a resident with contracted fingers after discharge from occupational therapy. | SS=D |
| Failed to provide an environment free of accident hazards including unsecured grab bar and unlocked treatment carts with medications. | SS=E |
| Failed to provide necessary behavioral health care and services to maintain highest practicable well-being for a resident with severe cognitive impairment and behavioral symptoms. | SS=D |
| Failed to ensure medication administration was free from significant errors by crushing extended release medications. | SS=D |
| Failed to label insulin vials with date opened, failed to remove expired medications from medication carts, and failed to secure medication carts. | SS=E |
| Failed to provide infection prevention and control including incomplete COVID screening, failure to disinfect shared thermometers, and failure to perform proper hand hygiene and glove changes during tracheotomy and incontinent care. | SS=F |
Report Facts
Residents present: 44
Residents in sample: 17
Personal fund accounts total: 36071.14
Surety bond coverage: 20000
Consecutive days without bowel movement: 19
Consecutive days without bowel movement: 10
Consecutive days without bowel movement: 6
Consecutive days without bowel movement: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA O | Certified Nurse Aide | Named in dignity during meals deficiency assisting residents while standing |
| CNA P | Certified Nurse Aide | Named in dignity during meals deficiency and incontinent care glove use |
| Administrative Staff A | Verified dignity and roommate notification deficiencies | |
| Administrative Nurse D | Administrative Nurse | Verified dignity, roommate notification, bowel care, restorative care, medication errors, and infection control deficiencies |
| Licensed Nurse G | Licensed Nurse | Named in medication administration and transfer care deficiencies |
| Certified Medication Aide R | Certified Medication Aide | Named in medication administration errors and medication storage deficiencies |
| Physical Therapy GG | Physical Therapist | Named in transfer and restorative care deficiencies |
| Licensed Nurse I | Licensed Nurse | Named in bowel care and medication cart security deficiencies |
| Certified Nurse Aide Q | Certified Nurse Aide | Named in incontinent care and bowel care deficiencies |
| Certified Nurse Aide OO | Certified Nurse Aide | Named in incontinent care glove use deficiency |
| Transportation Aid MM | Transportation Aide | Named in COVID screening and infection control deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 14, 2022
Visit Reason
An offsite revisit survey was conducted on 01/14/22 for all previous deficiencies cited on 12/22/21 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 12/27/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Dec 22, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of staff to resident abuse involving Resident 1 and Licensed Nurse G.
Findings
The facility failed to submit a completed investigation of the staff to resident abuse allegation to the state survey agency within five working days as required by federal regulations. The investigation paperwork could not be found despite the facility's assertion that the incident was thoroughly investigated.
Complaint Details
The complaint investigation involved allegations of staff to resident abuse concerning Resident 1 and Licensed Nurse G. The facility did not report the results of the completed investigation to the state agency within the required timeline.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a completed investigation of a staff to resident abuse allegation to the state survey agency within five working days. | SS=D |
Report Facts
Census: 45
Days for reporting investigation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in the staff to resident abuse allegation |
| Administrative Staff A | Interviewed regarding missing investigation paperwork and facility reporting procedures |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 22, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey, outlining corrective actions to achieve substantial compliance with federal Medicare and Medicaid requirements.
Findings
The facility reported results of completed investigations to the state agency within the required timeline and implemented a home-wide system to assure correction and continued compliance with regulations. The facility was found to be in substantial compliance as of 12/27/2021.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report results of investigations to the state agency within the appropriate timeline as directed by federal regulations. | D |
Report Facts
Working days for reporting final investigation results: 5
Monitoring timeframe: 4
Monitoring timeframe: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanie Burk | RN, BSN, LNHA | Submitted the Plan of Correction to KDADS. |
| Felicia Majewski | Added and modified the Plan of Correction. | |
| Regional Vice President | Counseled the Administrator regarding reporting final investigation results. |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 18, 2021
Visit Reason
An offsite revisit survey was conducted on 11/18/21 for all previous deficiencies cited on 09/30/21 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 11/01/21 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
Deficiencies: 2
Sep 30, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on 9/30/2021 at Heritage Gardens.
Findings
The facility addressed deficiencies related to prevention of staff to resident abuse and immediate reporting of abuse incidents. Staff training and education were provided, and corrective actions including performance improvement plans and ongoing monitoring were implemented.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| This facility does prevent incidents of staff to resident abuse. | D |
| This facility does ensure staff immediately report to the facility administrator an incident of abuse. | D |
Report Facts
Dates of corrective actions: Sep 29, 2021
Dates of corrective actions: Oct 19, 2021
Dates of corrective actions: Nov 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanie Burk | RN, BSN, LNHA | Submitted the Plan of Correction to KDADS |
| Felicia Majewski | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 2
Sep 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#KS00165996) regarding an alleged incident of abuse involving a resident on the secure dementia unit.
Findings
The facility failed to prevent an incident of staff-to-resident abuse when a Licensed Nurse forcefully escorted an agitated and confused resident to her room, causing a red mark on the resident's neck. Additionally, staff failed to immediately report the incident to the facility administrator, delaying notification by two days. This placed the resident and 16 other residents at risk for injury and impaired psychosocial wellbeing.
Complaint Details
The complaint investigation involved allegations that Licensed Nurse G forcefully escorted Resident 1 to her room on 09/26/21, causing a red mark on the resident's neck. Witnesses included Licensed Nurse H and Certified Medication Aide M, who delayed reporting the incident until 09/28/21. The facility investigation confirmed the incident and the failure to report immediately.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to prevent an incident of staff-to-resident abuse when a Licensed Nurse forcefully escorted a resident to her room by holding her shoulder. | SS=D |
| Failed to ensure staff immediately reported an incident of abuse to the facility administrator. | SS=D |
Report Facts
Census: 46
Residents at risk: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in the abuse incident for forcefully escorting Resident 1. |
| Licensed Nurse H | Licensed Nurse | Witnessed the incident and delayed reporting due to fear of retaliation. |
| Certified Medication Aide M | Certified Medication Aide | Witnessed the incident and delayed reporting due to being busy. |
| Administrative Staff A | Received the abuse report and suspended Licensed Nurse G pending investigation. | |
| Administrative Nurse D | Administrative Nurse | Interviewed staff during the investigation. |
| Licensed Nurse I | Licensed Nurse | Day shift nurse who denied witnessing the incident. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 16, 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
Dec 16, 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 12/16/2020.
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
Re-Inspection
Deficiencies: 0
Jul 7, 2020
Visit Reason
An offsite revisit survey was conducted on 07/07/20 to verify correction of all previous deficiencies cited on 03/17/20.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 03/18/20, 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
Deficiencies: 0
Jul 1, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on July 01, 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: 37
Deficiencies: 0
Jul 1, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with 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.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 6
Mar 17, 2020
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation #149905 to assess compliance with regulatory requirements.
Findings
The facility failed to provide a safe, clean, and comfortable environment in multiple hallways, failed to prevent accidents for certain residents, failed to properly review and manage drug regimens including psychotropic medications, and failed to maintain sanitary conditions in the kitchen and food preparation areas.
Complaint Details
The inspection was triggered by complaint investigation #149905. The facility was found to have multiple deficiencies related to environment safety, accident prevention, medication management, and food safety.
Severity Breakdown
SS=E: 1
SS=D: 3
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to provide a safe, clean, comfortable environment on four of five facility hallways with dull floor tiles, stains, flaking ceilings, and lack of preventative maintenance policy. | SS=E |
| Facility failed to assess and provide supervision to prevent accidents for two residents, including lack of smoking assessment and failure to report and investigate a resident fall. | SS=D |
| Pharmacy consultant failed to identify inappropriate diagnosis for antipsychotic medication (Zyprexa) for a resident. | SS=D |
| Facility failed to ensure PRN psychotropic medication (Xanax) had a 14 day stop date and failed to ensure appropriate diagnoses for use of Risperdal and Zyprexa for residents. | SS=D |
| Facility failed to prepare, store, distribute, and serve food under sanitary conditions including lint on light fixtures, water stains and flaking paint on ceilings, and lack of cleaning and preventative maintenance policy. | SS=F |
| Facility failed to provide a safe, functional, sanitary, and comfortable environment in the kitchen including discolored, dingy, and missing floor tiles with brown grease and grime buildup and lack of maintenance schedule. | SS=F |
Report Facts
Census: 41
Length of brown dried substance: 7
Size of brown stain on ceiling: 6
Abrasion size: 1
Medication dosage: 5
Medication dosage: 0.5
Medication dosage: 0.25
Floor tile size: 8
Missing floor tile area: 4
Light fixture size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Verified environmental findings and fall incident | |
| Maintenance Staff U | Verified environmental findings during tour | |
| Administrative Nurse E | Verified smoking policy, medication administration, and diagnoses | |
| Administrative Nurse D | Verified medication administration for resident | |
| Dietary Staff BB | Verified kitchen conditions and sanitation issues |
Inspection Report
Plan of Correction
Deficiencies: 6
Mar 17, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on 3/17/2020 at Hickory Pointe.
Findings
The facility addressed multiple deficiencies related to environmental conditions, fall assessments, medication management, psychotropic medication documentation, food safety, and sanitation. Corrective actions include staff reeducation, policy reviews, audits, and scheduled maintenance to ensure compliance and resident safety.
Severity Breakdown
E: 1
D: 3
F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility environment issues including dull floors, ceiling markings, and grout appearance. | E |
| Inaccurate fall assessments and prevention measures. | D |
| Inappropriate diagnosis documentation for medications. | D |
| Lack of documentation and stop dates for PRN psychotropic medications. | D |
| Food preparation and sanitation not fully compliant with FDA Food Code 2017. | F |
| Unsafe, unsanitary, or uncomfortable kitchen environment including ceiling and flooring damage. | F |
Report Facts
Days for floor buffing or burnishing: 45
Stop date for PRN psychotropic medications: 14
Frequency of Dietary Manager cleaning log reviews: 5
Frequency of kitchen sanitation observations: 2
Duration of Administrator environmental rounds: 60
Duration of environmental rounds with supervisors: 90
Number of records audited monthly for antipsychotic medication: 10
Number of residents reviewed for psychotropic medication orders: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanie Burk | RN, BSN, LNHA | Submitted the Plan of Correction to KDADS |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 25, 2019
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies were corrected as of 03/25/2019, with corrections documented for multiple regulatory requirements.
Report Facts
Deficiencies corrected: 13
Inspection Report
Plan of Correction
Deficiencies: 13
Mar 25, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions and compliance measures.
Findings
The facility addressed multiple deficiencies related to resident rights, documentation of advance directives, grievance procedures, discharge notices, assessment accuracy, care planning, respiratory care, nurse staffing information, and medication regimen reviews. Staff were reeducated, and monitoring plans were established to ensure ongoing compliance.
Severity Breakdown
D: 10
E: 2
F: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to properly document resident's resuscitation desires and advance directives. | D |
| Failure to ensure residents' right to file grievances anonymously and without reprisal. | F |
| Failure to provide notices before transfers or discharges and submit discharge notices to the ombudsman. | D |
| Failure to conduct comprehensive, accurate, standardized assessments of resident functional capacity. | D |
| Failure to encode and transmit all resident MDS data as required. | E |
| Failure to ensure accuracy of assessments in resident medical records, specifically insulin injection recording. | D |
| Failure to develop and implement comprehensive, person-centered care plans addressing dental, fall, and mental health needs. | D |
| Failure to develop and implement comprehensive care plans within 7 days of assessment completion. | D |
| Failure to provide respiratory care consistent with professional standards, including proper transcription and administration of CPAP orders. | D |
| Failure to post required nurse staffing information accurately and timely. | E |
| Failure to ensure monthly pharmacist review of each resident's drug regimen including pain, antidepressant side effect, and behavior monitoring. | D |
| Failure to ensure each resident drug regimen is free from unnecessary drugs. | D |
| Failure to ensure residents are free from unnecessary psychotropic medications and proper monitoring of behavioral needs. | D |
Report Facts
Monitoring period: 60
Monitoring period: 90
Medical records reviewed per month: 5
Medical records monitored per week: 5
Medical records monitored per week: 3
Audit frequency: 5
Audit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Lacey Hunter | Submitted and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 10
Mar 7, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for multiple complaint numbers.
Findings
The facility was found deficient in multiple areas including failure to clearly identify residents' resuscitation choices, failure to maintain a grievance log and ensure anonymous grievance filing, failure to notify the State Long-Term Care Ombudsman of resident transfers to hospital, failure to complete Care Area Assessments timely, failure to electronically transmit MDS data timely, failure to develop comprehensive care plans addressing dental, fall, and mental health needs, failure to provide necessary respiratory care including CPAP use, failure to post and retain nurse staffing data, failure to ensure pharmacist review of missed pain and behavior monitoring documentation, and failure to adequately monitor residents on psychotropic medications.
Complaint Details
The visit was triggered by complaints identified by complaint investigation numbers KS00138623, KS00137956, KS00134836.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to clearly identify expressed choices to initiate or withhold resuscitative measures for 3 of 4 sampled residents. | SS=D |
| Failure to maintain a grievance log and ensure residents' right to file grievances anonymously. | SS=F |
| Failure to provide written notification to the State Long-Term Care Ombudsman for 2 residents transferred to hospital. | SS=D |
| Failure to complete Care Area Assessments within 14 days after MDS transmission for 2 residents. | SS=D |
| Failure to electronically transmit encoded, accurate, and complete MDS data within 14 days after completion for 3 residents. | SS=E |
| Failure to develop and implement comprehensive person-centered care plans addressing dental and fall needs for resident #14 and mental health needs for resident #29. | SS=D |
| Failure to provide necessary respiratory care and services including CPAP use for resident #31. | SS=D |
| Failure to post and retain Full Time Equivalent (FTE) nursing hours and facility census for 176 days. | SS=E |
| Failure to ensure pharmacist noted missed documentation for pain and behavior monitoring for 2 residents. | SS=D |
| Failure to ensure residents #29 and #18 did not receive unnecessary psychotropic medications and adequately monitor for behavioral disturbances. | SS=D |
Report Facts
Residents sampled: 31
Residents with advanced directive issues: 3
Days missing nurse staffing data: 176
Missed pain assessments: 38
Missed behavior monitoring: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff D | Administrative Nursing Staff | Confirmed missing grievance logs, lack of grievance posting, and issues with CPAP orders and monitoring. |
| Licensed staff G | Licensed Nursing Staff | Confirmed missing DNR consent forms and monitoring of psychotropic medication behaviors. |
| Social services staff X | Social Services Staff | Confirmed failure to notify Ombudsman of hospital transfers and grievance process issues. |
| Administrative staff A | Administrative Staff | Unaware of missed documentation issues and grievance process problems. |
Inspection Report
Routine
Deficiencies: 1
Jun 28, 2018
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'E' level deficiency, pattern, indicating 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 effective 06/20/2018.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'E' level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Contact person for questions concerning the information in the letter. |
| Shellie Sonnentag | Administrator | Administrator of Hickory Pointe Care & Rehab Center, recipient of the survey report. |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 28, 2018
Visit Reason
An offsite revisit survey was conducted on 06/28/2018 to verify correction of all previous deficiencies cited on 06/07/2018.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 06/20/2018, 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
Deficiencies: 8
Jun 20, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to achieve substantial compliance with federal Medicare and Medicaid requirements.
Findings
The Plan of Correction details multiple deficiencies related to G-Tube care, medication administration, infection control, medication labeling, and monitoring of medication effectiveness. The facility describes training and in-service plans for nursing staff, monitoring systems, and timelines to ensure compliance and prevent recurrence of cited deficiencies.
Severity Breakdown
D: 7
E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure proper G-Tube placement, functionality, and administration of medication, water, and feeding for residents fed by enteral means. | D |
| Licensed nursing staff lacked appropriate training, skills, and competencies to care for residents with gastrostomy and tracheostomy tubes. | D |
| Consultant pharmacist did not review each resident’s medications monthly and report irregularities appropriately. | D |
| Failure to monitor effectiveness of medications and side effects adequately. | D |
| Limit on as needed (PRN) antipsychotic and antianxiety medications not properly enforced to 14 days. | D |
| Medication administration via enteric route not performed individually and medication error rates exceeded 5%. | D |
| Medications were not appropriately labeled and expired medications were not removed/discarded. | E |
| Improper infection control practices including hand hygiene, glove use, glucometer handling, and blood covered medical waste handling. | D |
Report Facts
Medication carts with expired medications discarded: 3
Medication error rate: 5
Minimum monitoring period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garold Fowler | Administrator | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 8
Jun 7, 2018
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation triggered by complaints identified as #KS00117854, KS00117138, KS00101467.
Findings
The facility was found deficient in multiple areas including failure to provide proper gastrostomy tube care and medication administration, insufficient nursing staff competencies, failure to report and act on pharmacist medication irregularities, failure to monitor medication side effects and effectiveness, failure to limit psychotropic medication use, medication errors exceeding 5%, improper labeling and storage of medications, and inadequate infection prevention and control practices.
Complaint Details
The inspection included a complaint investigation based on complaints #KS00117854, KS00117138, KS00101467.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide proper G-Tube care and maintenance for 1 sampled resident (#30). | SS=D |
| Failure to ensure licensed nursing staff had appropriate skills and competencies to care for residents with gastrostomy and tracheostomy tubes. | SS=D |
| Consultant pharmacist failed to report medication irregularities and attending physician failed to document review for 2 residents (#6, #26). | SS=D |
| Failure to monitor medication side effects and effectiveness for resident #186. | SS=D |
| Failure to limit PRN antipsychotic and antianxiety medications to 14 days for 2 residents (#1 and #186). | SS=D |
| Medication error rate of 6.9% due to improper mixing and administration of medications via G-tube. | — |
| Failure to ensure medications were appropriately labeled and not expired in 3 of 4 medication carts. | SS=E |
| Failure to follow proper infection control practices including glove use and sanitary handling of glucometer and blood-covered waste. | SS=D |
Report Facts
Medication error rate: 6.9
Census: 35
Sample size: 12
Medication observations: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Licensed Nursing Staff | Named in medication administration error and infection control deficiencies. |
| Staff D | Administrative Nursing Staff | Named in multiple findings including nursing competencies, medication review process, and infection control. |
| Staff H | Licensed Nursing Staff | Named in infection control and medication cart labeling deficiencies. |
| Staff M | Direct Care Staff | Named in medication side effect monitoring deficiency. |
| Staff I | Licensed Nursing Staff | Named in medication side effect monitoring deficiency. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 21, 2018
Visit Reason
A revisit survey was conducted on 05/21/18 to verify correction of all previous deficiencies cited on 04/05/18.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 04/06/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
May 21, 2018
Visit Reason
A revisit survey was conducted on 05/21/18 to verify correction of all previous deficiencies cited on 04/05/18.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 04/06/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 2
Apr 5, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited related to alleged abuse, neglect, exploitation, or mistreatment involving residents on the secured unit.
Findings
The facility identified alleged abuse by resident #2 towards residents #3 and #4 on the secured unit and took corrective actions including moving resident #2 off the secured unit and providing staff in-servicing on abuse prevention and safety measures. The home implemented a system to monitor and prevent further occurrences and aimed for substantial compliance by 04-06-2018.
Deficiencies (2)
| Description |
|---|
| Failure to provide an environment free from abuse, neglect, exploitation, and misappropriation of resident property involving resident #2 and residents #3 and #4 on the secured unit. |
| Failure to respond to and investigate alleged violations of abuse, neglect, exploitation, or mistreatment involving resident #2. |
Report Facts
Date resident moved off secured unit: Apr 5, 2018
Staff in-servicing start time: 1600
Staff in-servicing completion time: 2215
QAPI meeting date: Apr 16, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garold Fowler | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Apr 5, 2018
Visit Reason
The inspection was conducted as a partially extended complaint survey related to allegations of abuse by resident #2 against other residents in a secured unit.
Findings
The facility failed to protect residents #3 and #4 from repetitive abuse by resident #2, placing them and the other 9 residents in the secured unit in immediate jeopardy. Despite interventions after each incident, the facility did not adequately prevent further abuse until resident #2 was moved out of the secured unit on 4/5/2018.
Complaint Details
The complaint investigation #KS00128245 found that resident #2 repeatedly abused residents #3 and #4 in one of the two secured units. The facility failed to protect all 9 residents in the secured unit from harm. Immediate jeopardy was abated when resident #2 was moved out of the secured unit on 4/5/2018.
Severity Breakdown
E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents were free from repetitive abuse by another resident in a secured unit. | E |
| Failure to thoroughly investigate and prevent further abuse during the investigation period. | E |
Report Facts
Census: 36
Residents in secured unit: 9
Abrasion size: 1.5
Abrasion size: 1.25
Facilities contacted for placement: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff O | Reported resident #2's behavior and monitoring practices. | |
| Licensed staff I | Reported administrative review of incidents and care plan updates. | |
| Administrative staff D | Reported Quality Assurance team's observations and staff reassignments. | |
| Licensed staff H | Charge nurse for secured units, described staff communication and monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 5, 2018
Visit Reason
A revisit survey was conducted on 3/5/18 to verify correction of all previous citations cited on 1/11/18.
Findings
All deficiencies cited on 1/11/18 have been corrected as of the compliance date of 3/5/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Deficiencies (1)
| Description |
|---|
| All previous citations cited on 1/11/18 have been corrected. |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 5, 2018
Visit Reason
A revisit survey was conducted on 3/5/18 for all previous citations cited on 1/11/18 to verify correction of deficiencies.
Findings
All deficiencies cited on 1/11/18 have been corrected as of the compliance date of 3/5/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 5, 2018
Visit Reason
A revisit survey was conducted on 3/5/18 for all previous citations cited on 1/11/18 to verify correction of deficiencies.
Findings
All deficiencies cited on 1/11/18 have been corrected as of the compliance date of 3/5/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 2
Jan 11, 2018
Visit Reason
A revisit survey was conducted on 1/11/18 to verify correction of previous deficiencies cited on 11/17/17, specifically related to abuse and reporting incidents.
Findings
The facility failed to provide an environment free from physical abuse when resident #4 punched resident #5 on 11/20/17 and failed to report this incident of physical abuse to the State Agency as required.
Complaint Details
The visit was complaint-related, involving an incident of physical abuse between residents. The facility failed to report the incident to the State Agency as required. The incident was substantiated based on record review and interviews.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide an environment free from physical abuse when resident #4 punched resident #5 on 11/20/17. | SS=D |
| Failed to report an incident of physical abuse to the State Agency when resident #4 punched resident #5 on 11/20/17. | SS=D |
Report Facts
Census: 37
Residents reviewed for abuse: 3
Incident date: Nov 20, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| direct care staff O | Called for immediate assistance during resident altercation. | |
| direct care staff M | Reported behaviors and incidents to charge nurse and administrative staff. | |
| licensed nursing staff G | Reported incidents immediately to administrative nursing staff. | |
| administrative nursing staff D | Started incident investigation and found no injuries to resident #5. | |
| administrative staff A | Did not feel the incident should have been reported to the state agency. |
Inspection Report
Plan of Correction
Deficiencies: 2
Jan 11, 2018
Visit Reason
This document is a Plan of Correction submitted in response to a complaint revisit inspection conducted at Hickory Pointe on January 11, 2018.
Findings
The facility was found to have deficiencies related to ensuring an environment free from abuse, neglect, exploitation, and misappropriation of resident property, and for thoroughly investigating and reporting all alleged violations involving mistreatment or abuse. The facility implemented corrective actions including re-education of staff, resident room reassignment, close monitoring, and daily incident reviews by the interdisciplinary team.
Complaint Details
This Plan of Correction is in response to a complaint revisit inspection at Hickory Pointe. The facility addressed incidents involving residents #4 and #5, including monitoring and separation to prevent further aggression. The facility maintains that the alleged deficiencies do not jeopardize resident health or safety.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide an environment free from abuse, neglect, exploitation, and misappropriation of resident property. | D |
| Failure to ensure all alleged violations involving mistreatment, neglect, or abuse are thoroughly investigated and reported immediately. | D |
Report Facts
Date of substantial compliance: Jan 11, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Mercier | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Caryl Gill | Modified the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 2
Jan 11, 2018
Visit Reason
The revisit was conducted on January 11, 2018, as a result of an abbreviated survey to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The revisit found the most serious deficiencies to be F223 and F225, both at 'D' level severity. Due to these deficiencies, a denial of payment for new Medicare and Medicaid admissions was imposed effective December 7, 2017, and termination of the provider agreement was recommended if substantial compliance is not achieved by May 17, 2018.
Complaint Details
This action is based on deficiencies found on the current revisit and a complaint survey conducted on November 17, 2017. The denial of payment was imposed due to deficiencies constituting a level of actual harm or above.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficiency F223 | D |
| Deficiency F225 | D |
Report Facts
Denial of payment effective date: Denial of payment for new Medicare and Medicaid admissions effective December 7, 2017
Termination recommendation date: Provider agreement termination recommended on May 17, 2018 if substantial compliance is not achieved
Civil Money Penalty threshold: 10483
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to the complaint and enforcement action |
Inspection Report
Plan of Correction
Deficiencies: 4
Nov 18, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a revised complaint inspection dated 11/17/2017, addressing alleged deficiencies related to resident abuse, neglect, mistreatment, and related care issues.
Findings
The facility outlines corrective actions including staff in-service training on abuse and neglect policies, updating care plans to address resident behaviors, monitoring and reporting procedures, and ensuring compliance with regulatory requirements. The facility asserts that the alleged deficiencies do not jeopardize resident health or safety and aims for substantial compliance by 11/05/2017.
Severity Breakdown
J: 2
F: 1
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide an environment free from abuse, neglect, exploitation, and misappropriation of resident property. | J |
| Failure to ensure all alleged violations involving mistreatment, neglect, or abuse are thoroughly investigated and reported. | F |
| Failure to ensure each resident receives necessary care and services to attain or maintain the highest practicable well-being. | J |
| Failure to provide sufficient nursing staff with appropriate competencies and skill sets to assure resident safety and well-being. | E |
Report Facts
Plan of Correction completion date: Nov 5, 2017
Staff in-service training dates: Oct 31, 2017
Staff in-service training completion date: Nov 2, 2017
Plan of Correction submission date: Nov 18, 2017
Monitoring period: 3
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Nov 17, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse, neglect, and failure to provide adequate care and services at Hickory Pointe Care & Rehab Center.
Findings
The facility failed to provide an environment free from verbal and physical abuse by resident #2 towards residents #3, #4, and #5, failed to timely report and investigate abuse allegations, failed to perform timely assessments and emergency response for resident #1 who experienced respiratory failure and subsequent death, and failed to provide adequate staffing to meet residents' needs.
Complaint Details
The complaint investigation KS00122760 was substantiated with findings of verbal and physical abuse by resident #2 towards other residents, failure to timely report and investigate abuse, failure to provide adequate care and emergency response to resident #1, and inadequate staffing.
Severity Breakdown
Level G: 1
Level F: 1
Level J: 1
Level E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to provide an environment free from verbal and physical abuse when resident #2 repeatedly verbally and physically abused residents #3, #4, and #5. | Level G |
| Facility failed to report instances of potential abuse timely, failed to investigate allegations, and failed to protect residents during an investigation related to resident #2's abuse of others. | Level F |
| Facility failed to perform comprehensive assessments, continued monitoring, and initiate emergency medical response in a timely manner for resident #1 who was found unresponsive with difficulty breathing and low oxygen saturation, resulting in hospitalization and death. | Level J |
| Facility failed to have adequate nursing and direct care staffing to meet residents' needs, especially on secured units. | Level E |
Report Facts
Census: 40
Residents reviewed for abuse: 5
Oxygen saturation level: 44
Time lapse: 75
Staffing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse H | Licensed Nurse | Named in findings related to failure to respond timely to resident #1's respiratory distress and subsequent suspension and termination |
| Administrative licensed nurse C | Administrative Licensed Nurse | Acknowledged staffing inadequacies and lack of documentation related to abuse and resident assessments |
| Direct care staff CC | Direct Care Staff | Reported resident #2's aggressive behaviors and frequent altercations |
| Direct care staff O | Direct Care Staff | Reported resident #1's low oxygen saturation and difficulty breathing |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Nov 17, 2017
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 facility was found not in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety. Deficiencies cited included F223, F309, and F225, resulting in enforcement remedies including denial of payment for new admissions and recommendation for termination of the provider agreement if substantial compliance is not achieved.
Severity Breakdown
immediate jeopardy: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Noncompliance with F223, "J", CFR 483.12(a)(1) | immediate jeopardy |
| Noncompliance with F309, "J", CFR 483.24, 483.25(k)(l) | immediate jeopardy |
| Noncompliance with F225, "F", CFR 483.12(a)(3)(4)(c)(1)-(4) | — |
Report Facts
Denial of payment effective date: Dec 7, 2017
Provider agreement termination date: May 17, 2018
Civil Money Penalty minimum amount: 10483
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Mercier | Administrator | Facility administrator named in the report |
| Caryl Gill | Complaint Coordinator | Signed the letter and provided contact information related to the survey |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 8, 2017
Visit Reason
The off-site visit was conducted to verify that the deficiencies cited on September 22, 2017 were corrected.
Findings
The deficiencies cited on September 22, 2017 were found to be corrected effective September 26, 2017.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 9, 2017
Visit Reason
The off-site visit was conducted to verify that the deficiency cited on August 25, 2017 was corrected.
Findings
The deficiency cited on August 25, 2017 was found to be corrected effective August 29, 2017.
Inspection Report
Plan of Correction
Deficiencies: 5
Sep 26, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Hickory Pointe.
Findings
The facility submitted corrective actions addressing grievances, employee background checks, skin assessments and wound prevention, physician order compliance, and nurse staffing documentation to achieve substantial compliance by 09/26/2017.
Complaint Details
This Plan of Correction is related to Hickory Pointe complaint dated 09/22/2017.
Severity Breakdown
F166-F: 1
F226-D: 1
F314-D: 1
F329-D: 1
F356-F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Grievance policy documentation and resident access to grievance information | F166-F |
| Registry verification and criminal background checks for employees before working with residents | F226-D |
| Skin assessment and wound prevention policy implementation and weekly skin assessments | F314-D |
| Following and documenting all physician's orders and treatments for resident #14 | F329-D |
| Retention and posting of daily nurse staffing with required data | F356-F |
Report Facts
Days for monitoring and reporting: 30
Days for weekly review: 60
Date for substantial compliance: Sep 26, 2017
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 5
Sep 22, 2017
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint investigation numbers related to grievances, abuse/neglect policies, pressure ulcer care, unnecessary drug use, and nurse staffing postings.
Findings
The facility failed to make grievance filing information available to residents, lacked documentation of resident grievances, failed to verify licensure and criminal background checks for staff, failed to provide timely and effective pressure ulcer care for one resident, failed to administer prescribed topical medication for another resident, and failed to retain and post nurse staffing data as required.
Complaint Details
The inspection was triggered by multiple complaint investigations identified by numbers #KS00120243, #KS00120095, #KS00119972, #KS00119928, #KS00117845, #KS00117924, #KS00110083, #KS00105406, and #KS00101572.
Severity Breakdown
SS=F: 2
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to make information on how to file a grievance or complaint available to residents and lacked documentation of resident grievances. | SS=F |
| Failed to provide evidence of licensure verification for 1 of 2 licensed staff and criminal background checks for 3 of 3 direct care staff prior to allowing them to work. | SS=D |
| Failed to develop and implement timely and effective interventions and complete weekly skin assessments to prevent facility-acquired pressure ulcers for one resident. | SS=D |
| Failed to provide prescribed topical skin ointment treatment for one resident with itching from Oak Mite bites. | SS=D |
| Failed to retain daily nurse staffing information for 44 out of 91 days and failed to document required data on daily postings. | SS=F |
Report Facts
Resident census: 45
Days of missing nurse staffing records: 44
Number of licensed staff missing license verification: 1
Number of direct care staff missing criminal background checks: 3
Residents reviewed for unnecessary medications: 2
Resident with pressure ulcers: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 22, 2017
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 an 'F' level deficiency indicating 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 reviewed and accepted, resulting in a finding of substantial compliance effective September 26, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was an 'F' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Inspection Report
Plan of Correction
Deficiencies: 2
Aug 25, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in the Hickory Pointe complaint inspection conducted on 08/25/2017.
Findings
The facility submitted a Plan of Correction addressing deficiencies related to physician documentation for resident discharge and the content of involuntary discharge notices. The facility asserts that the alleged deficiencies do not jeopardize resident health or safety and outlines corrective actions including staff re-education and monitoring for 60 days.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Hickory Pointe complaint 08252017.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident physician documentation does not appropriately state the reason the resident no longer meets or needs the services provided by the facility. | D |
| Involuntary discharge notice does not contain the appropriate information for discharges. | D |
Report Facts
Plan of Correction completion date: Aug 29, 2017
Monitoring period: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Mercier | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Caryl Gill | Modified the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 2
Aug 25, 2017
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's involuntary discharge procedures for a resident.
Findings
The facility failed to ensure the resident's physician documented the reason for involuntary discharge in the medical record and failed to include the location of transfer or discharge in the 30-day notice to the resident.
Complaint Details
The complaint investigation KS00119775 found deficiencies related to involuntary discharge documentation and notice requirements.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the resident's physician documented in the medical record the reason the resident no longer needed the services provided by the facility. | SS=D |
| Failed to ensure the 30 day involuntary discharge notice contained the location to which the resident would be transferred or discharged. | SS=D |
Report Facts
Census: 47
Resident sampled: 1
Discharge notice days: 30
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 25, 2017
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 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, and the facility was found to be in substantial compliance effective August 29, 2017.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 1
May 3, 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
The report confirms that the deficiencies previously cited have been corrected as of 04/14/2016, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected. |
Report Facts
Date correction completed: Apr 14, 2016
Inspection Report
Follow-Up
Deficiencies: 0
May 3, 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 by the facility.
Findings
All previously cited deficiencies were corrected as of April 2016, with completion dates ranging from April 1 to April 14, 2016. The revisit confirmed that corrective actions were accomplished for all identified deficiencies.
Report Facts
Deficiencies corrected: 16
Inspection Report
Follow-Up
Deficiencies: 1
May 3, 2016
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates when corrective actions were completed.
Findings
The revisit confirmed that the previously cited deficiency with regulation 28-39-149(d) was corrected as of 04/01/2016. No other deficiencies or severity levels were noted in this report.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 28-39-149(d) previously cited and corrected |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Apr 13, 2016
Visit Reason
The inspection was conducted as a partial extended complaint investigation related to resident safety and supervision concerns, specifically regarding an elopement incident involving a cognitively impaired resident.
Findings
The facility failed to provide adequate supervision to a cognitively impaired, independently mobile resident at high risk for elopement, resulting in the resident leaving the facility unnoticed for over 6 hours, suffering hypothermia and requiring hospitalization. The facility lacked clear policies and procedures for assessing and managing elopement risk and failed to maintain adequate environmental safeguards.
Complaint Details
The complaint investigation involved two complaint numbers (#96755 and #98665) concerning the facility's failure to supervise a resident who eloped on 3/23/16 and was missing for over 6 hours, resulting in hypothermia and hospitalization. The facility was found to have inadequate elopement risk assessment and management policies.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision and prevent elopement of a cognitively impaired resident, resulting in immediate jeopardy. | G |
Report Facts
Census: 40
Elopement risk residents: 6
Time missing: 6
Temperature: 64
Temperature: 37
Rectal temperature: 96.1
Elopement risk residents list: 6
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 13, 2016
Visit Reason
An Abbreviated Survey was conducted by the Kansas Department for Aging & 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 that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety from March 23, 2016 through April 11, 2016 related to F323, CFR 483.25(h). Enforcement remedies including denial of payment for new admissions were imposed.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F323, CFR 483.25(h) resulting in immediate jeopardy to resident health or safety. | Immediate Jeopardy |
Report Facts
Denial of payment effective date: Apr 3, 2016
Recommended termination date: Sep 9, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Mercier | Administrator | Facility administrator named in the report |
| Caryl Gill | Complaint Coordinator | Named as contact for questions regarding the matter |
| Lisa Hauptman | CMS contact for questions | |
| Codi Thurness | Commissioner | Commissioner of KDADS mentioned in the report |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 11, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in an amended complaint inspection report dated 04/13/2016 for Hickory Pointe facility.
Findings
The facility addressed deficiencies related to ensuring a safe resident environment free of accident hazards and adequate supervision to prevent accidents, specifically focusing on residents at risk for exit seeking or elopement. Staff were in-serviced on revised policies and care plans were updated accordingly.
Deficiencies (1)
| Description |
|---|
| Failure to ensure the resident environment remains free of accident hazards and adequate supervision to prevent accidents, particularly related to elopement risk. |
Report Facts
Plan of Correction completion date: Apr 14, 2016
Elopement Risk Policy in-service dates: 4
Monitoring period: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Mercier | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 17
Apr 1, 2016
Visit Reason
This document is a Plan of Correction prepared by the facility in response to deficiencies cited in a prior inspection report, addressing corrective actions for various regulatory violations.
Findings
The plan outlines corrective actions for multiple deficiencies including notification of significant resident status changes, final accounting of deceased resident funds, investigation of alleged mistreatment and abuse, promotion of resident dignity, housekeeping and maintenance, individualized care plans, medication management, infection control, and security of resident possessions. The facility commits to staff in-service training, monitoring, and reporting to ensure substantial compliance by April 1, 2016.
Deficiencies (17)
| Description |
|---|
| Failure to immediately inform residents' physician or legal representative of significant changes in resident status. |
| Failure to convey final accounting of deceased resident funds within 30 days. |
| Failure to thoroughly investigate and report alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property. |
| Failure to promote care that enhances residents' dignity and respect. |
| Failure to maintain a sanitary, orderly, and comfortable environment. |
| Failure to review and revise care plans to provide individualized interventions. |
| Failure to complete incontinence assessment and voiding diary for individualized toileting plan. |
| Failure to ensure resident environment is free of accident hazards and provide adequate supervision to prevent falls. |
| Failure to maintain acceptable nutritional parameters and timely implement therapeutic diets. |
| Failure to maintain a resident drug regimen free from unnecessary drugs and monitor side effects. |
| Failure to store, prepare, distribute, and serve food under sanitary conditions. |
| Failure to provide resident physical therapy, speech language pathology, occupational therapy, and mental health rehabilitative services. |
| Failure to provide pharmaceutical services assuring accurate acquiring, receiving, dispensing, and administering of drugs. |
| Failure to review resident drug regimen monthly by a licensed pharmacist. |
| Failure to maintain records of receipt and disposition of controlled drugs for accurate reconciliation. |
| Failure to maintain an infection control program to prevent disease transmission. |
| Failure to ensure security of each resident's personal possessions. |
Report Facts
Plan of Correction completion date: Apr 1, 2016
Staff in-service completion dates: Mar 25, 2016
Monitoring period: 60
Monitoring period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Mercier | Administrator | Administrator responsible for monitoring findings and reporting to QA committee |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Mar 9, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving multiple complaint numbers related to facility compliance.
Findings
The facility failed to maintain written inventories of residents' personal possessions for 2 of 3 sampled residents (#72 and #64), including missing documentation of items brought at admission and items sent to hospital. Administrative staff confirmed that inventory sheets were not typically completed, and the facility policy requiring such inventories was not followed.
Complaint Details
The visit was complaint-related, involving multiple complaint investigations (#85231, #86059, #86865, #87396, #88496, #91730, #92229, #93750, #95177, #95158, #95294, #95060, and #96312).
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain personal inventories for 2 of 3 residents sampled (#72 and #64). | SS=D |
Report Facts
Census: 43
Residents sampled: 26
Residents with inventory deficiencies: 2
BIMS score: 6
BIMS score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff B | Interviewed regarding lack of inventory sheets and facility procedures related to residents #72 and #64. |
Inspection Report
Enforcement
Deficiencies: 0
Mar 9, 2016
Visit Reason
A Health recertification 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, with deficiencies cited on this survey and a prior abbreviated survey on May 5, 2015. Due to the history of noncompliance, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.
Complaint Details
The enforcement action was based on deficiencies found on the current survey and a complaint survey conducted on May 5, 2015 Abbreviated survey.
Report Facts
Denial of payment effective date: Apr 3, 2016
Non-compliance resolution timeframe: 6
Civil Money Penalty minimum amount: 5000
Hearing request deadline: 60
IDR request deadline: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Contact person for questions regarding the enforcement action. |
Inspection Report
Life Safety
Deficiencies: 1
Dec 23, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an "F" level, indicating 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at "F" level with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Mar 23, 2016
Provider agreement termination date: Jun 23, 2016
IDR request timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution requests. |
Inspection Report
Re-Inspection
Deficiencies: 2
Jun 30, 2015
Visit Reason
This report is a revisit conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that deficiencies identified in prior inspections, specifically those referenced by regulation number 28-39-160 with ID prefixes S0740 and S0760, were corrected by 05/06/2015.
Deficiencies (2)
| Description |
|---|
| Deficiency identified under regulation 28-39-160 with ID prefix S0740 |
| Deficiency identified under regulation 28-39-160 with ID prefix S0760 |
Report Facts
Correction completion date: May 6, 2015
Follow-up survey completion date: May 5, 2015
Inspection Report
Follow-Up
Deficiencies: 3
Jun 30, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that deficiencies previously cited under regulations 483.10(b)(11), 483.13(b), and 483.13(c)(1)(i-iii), (c)(2)-(4) were corrected by 05/06/2015.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulations 483.13(b), 483.13(c)(1)(i) |
| Deficiency related to regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 5
May 5, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Findings
The facility addressed deficiencies related to resident safety, abuse prevention, notification procedures, and admission/discharge criteria for the Special Care Unit. Staff were in-serviced on relevant policies and procedures, and ongoing monitoring and reporting to the Quality Assurance committee were planned.
Complaint Details
This Plan of Correction is in response to a complaint investigation as indicated by references to 'Complaint State' and 'Complaint Federal' reports.
Severity Breakdown
D: 1
L: 1
F: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to immediately consult with resident physician and notify family/legal representative of accidents involving injury and significant changes in resident status. | D |
| Failure to protect residents from resident-to-resident sexual or physical abuse and failure of staff to protect residents from unwelcome sexual advances and abuse. | L |
| Failure to ensure all alleged violations involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property are thoroughly investigated and reported. | F |
| Failure to develop admission and discharge criteria identifying diagnosis, behavior, and clinical needs for residents served in the Special Care Unit. | F |
| Failure to develop admission and discharge criteria or assessment specific to clinical needs of residents served on the Special Care Unit and failure to update SCU programming for specialized activities. | F |
Report Facts
Plan of Correction completion date: Apr 25, 2015
Staff in-service dates: Apr 23, 2015
Staff in-service completion date: Apr 25, 2015
Monitoring period: 6
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 5, 2015
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 that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from March 20, 2015 through April 25, 2015. Deficiencies cited included noncompliance with F223, CFR 483.13(b), 483.13(c)(1)(i) and related regulations, resulting in substandard quality of care.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F223, CFR 483.13(b), 483.13(c)(1)(i) and F225, CFR 483.13(c)(1)(ii)-(iii), (c)(2) - (4) constituting immediate jeopardy and substandard quality of care. | Immediate Jeopardy |
Report Facts
Denial of payment effective date: May 26, 2015
Provider agreement termination date: Nov 5, 2015
Civil Money Penalty threshold: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions concerning the instructions contained in the letter. |
Inspection Report
Census: 53
Deficiencies: 2
Apr 24, 2015
Visit Reason
The inspection was conducted to evaluate compliance with admission and discharge criteria, comprehensive resident assessments, and care planning for residents in the special care unit.
Findings
The facility failed to obtain physician orders for admission to the special care unit and did not develop admission criteria identifying diagnosis, behavior, or clinical needs. Additionally, the comprehensive assessments and care plans did not indicate that residents would benefit from the special care unit's program, and the unit lacked specialized activities for residents.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure staff obtained a physician's order for admission to the special care unit. | SS=F |
| Failed to develop criteria identifying diagnosis, behavior, or specific clinical needs of residents served in the special care unit. | SS=F |
Report Facts
Resident census: 53
Residents in special care unit: 15
Sampled residents: 3
Activity records reviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff L | Reported all residents in the special care unit had cognitive impairment and described resident activities | |
| Administrative nursing staff D | Reported the interdisciplinary team made the decision to place a resident in the special care unit | |
| Direct care staff O | Reported residents wandered and that some residents were taken out of the unit for activities | |
| Direct care staff T | Reported residents did not have evening activities and described resident behaviors | |
| Direct care staff N | Reported no ongoing activities on the special care unit and that activity staff took residents out for group activities |
Inspection Report
Plan of Correction
Deficiencies: 5
Jan 14, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The facility outlines corrective actions for multiple deficiencies including provision of clean linens, comprehensive resident assessments, resident participation in care planning, maintenance of urinary function, and ensuring hot water temperatures meet state regulations. The facility states it will be in substantial compliance by January 14, 2015.
Deficiencies (5)
| Description |
|---|
| Failure to provide and make available clean/bath linens in good condition. |
| Failure to conduct comprehensive assessments for all residents' functional capacity. |
| Failure to provide residents the right to participate in planning care and treatment. |
| Failure to provide appropriate treatment and services to maintain urinary function. |
| Failure to ensure residents have access to hot water temperatures within state regulations. |
Report Facts
Completion date: Jan 14, 2015
In-service date: Dec 30, 2014
Monitoring period: 60
Hot water temperature monitoring frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Mercier | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 5
Jan 14, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that all previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.15(h)(3) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Dec 22, 2014
Visit Reason
The inspection was conducted as a health survey and complaint investigations (complaints 75375 and 75376) to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to consistently provide clean linens in resident rooms, incomplete comprehensive assessments for residents with significant changes in condition, failure to revise care plans appropriately, inadequate treatment to maintain urinary function for a resident with incontinence, and unsafe water temperatures exceeding 120 degrees in resident rooms.
Complaint Details
The visit was triggered by complaints numbered 75375 and 75376. The findings represent the results of the health survey and complaint investigations.
Severity Breakdown
SS=E: 2
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to have clean bed and bath linens available in resident rooms consistently. | SS=E |
| Failure to conduct comprehensive assessments when significant changes in resident functional capacity occurred. | SS=D |
| Failure to revise care plan for a cognitively impaired resident regarding falls. | SS=D |
| Failure to provide appropriate treatment and services to maintain urinary function for a resident with urinary incontinence. | SS=D |
| Failure to ensure residents did not have access to water temperatures above 120 degrees. | SS=E |
Report Facts
Census: 49
Deficiencies cited: 5
Water temperatures: 135
Water temperatures: 130.5
Water temperatures: 123
Water temperatures: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff E | Confirmed responsibility for linen distribution and care plan revisions; confirmed resident functional improvement and care plan issues. | |
| Direct Care Staff Q | Provided information about resident ambulation and toileting assistance. | |
| Licensed Nursing Staff H | Provided information about resident care and call light use. | |
| Maintenance Supervisor X | Reported water temperature testing procedures and lack of checks in special care unit. |
Inspection Report
Enforcement
Deficiencies: 1
Dec 22, 2014
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an "E" level deficiency pattern, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be an "E" level deficiency pattern | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey and certification |
Inspection Report
Life Safety
Deficiencies: 1
Jun 5, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Sep 5, 2014
Effective date for provider agreement termination: Dec 5, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Mercier | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Plan of Correction
Deficiencies: 13
Sep 26, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior statement of deficiencies, as required by state and federal law, to address areas of non-compliance identified during a regulatory inspection.
Findings
The facility identified multiple deficiencies related to notification of Medicare non-coverage, resident fund account statements, facility cleanliness and maintenance, individualized care plans, assistive devices, activities of daily living, restorative nursing care, dietary services, medication administration, and staffing. Corrective actions include staff re-training, audits, and ongoing monitoring with reporting to the Quality Assurance Performance Improvement Committee (QAPI).
Severity Breakdown
D: 8
E: 2
F: 3
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to provide CMS Notice of Expedited Appeal Notice and timely Notice of Medicare Non Coverage to appropriate residents. | D |
| Failure to provide quarterly statements to residents showing amounts in resident fund accounts and notices if amounts are near Medicaid limits. | D |
| Areas cited for cleaning and repair were addressed; housekeeping and maintenance policies reviewed. | E |
| Resident care plans reviewed and modified to ensure comprehensive and individualized care plans. | D |
| New admit records reviewed to ensure comprehensive care plans were in order. | D |
| Care plans reviewed to ensure assistive devices were present as assessed and properly documented. | D |
| Activities of Daily Living (ADL) provided as needed and staff in-serviced on ADL policies. | D |
| Care plans updated to ensure range of motion (ROM) needs and restorative nursing care plans were in place. | D |
| Care plans reviewed and updated for residents in memory care unit to include assistive devices and ensure environment safety. | E |
| Care plans updated to include necessary interventions; staff in-serviced on communication and documentation of new orders. | D |
| Facility will adjust staffing based on census and resident needs; staff in-serviced on call light response and care plans. | F |
| Dietary staff in-serviced on sanitary food production and storage; audits to be conducted. | F |
| Nurses reinstructed on medication administration policies and care plan implementation related to self-administration of drugs. | D |
Report Facts
Plan of Correction submission timeframe: 10
Monitoring period: 60
Monitoring period: 90
Residents observed weekly: 6
Meals monitored per week: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Mercier | NHA | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 26, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 15
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 13
Aug 27, 2013
Visit Reason
Health Resurvey and Complaint Investigation #KS68204, 67248 conducted to assess compliance with federal regulations related to resident rights, facility management, care planning, staffing, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare non-coverage notices, inadequate management of resident personal funds, unsanitary and unsafe environmental conditions, incomplete and inaccurate care plans, insufficient nursing staffing, failure to provide therapeutic diets and restorative therapy, and unsafe medication administration practices.
Complaint Details
The inspection was triggered by complaints regarding resident rights violations, inadequate care, unsafe environment, and staffing concerns.
Severity Breakdown
Level D: 9
Level E: 2
Level F: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide the Notice of Medicare Provider Non-coverage form (CMS 10123) to 3 residents prior to terminating skilled services. | Level D |
| Failed to inform a Medicaid resident's responsible party when personal funds exceeded allowable limits for 4 months. | Level E |
| Failed to maintain a sanitary, comfortable, and homelike environment including water leaks, soiled bedding, urine odor, and damaged walls. | Level D |
| Failed to develop a comprehensive and individualized care plan for a resident's neck contracture and range of motion goals. | Level D |
| Failed to revise a care plan to reflect a resident's therapeutic diet and supplement orders after hospital readmission. | Level D |
| Failed to develop an initial care plan addressing assistive positioning devices for a resident with impaired mobility. | Level D |
| Failed to ensure a resident with severely impaired cognition received necessary services to maintain grooming and oral hygiene. | Level D |
| Failed to provide restorative therapy to a resident with a neck contracture and cognitive impairment. | Level E |
| Failed to identify and address potential accident hazards including unsafe bed rails and unsecured thumb tacks on the secured dementia unit. | Level D |
| Failed to provide a therapeutic diet and interventions for weight loss for two residents, including failure to offer alternatives when food was refused and failure to notify physician of weight loss. | Level F |
| Failed to maintain sufficient nursing staff on two units to meet residents' needs and respond timely to call lights. | Level F |
| Failed to prepare and serve food in a sanitary manner including employees wiping nasal drainage on sleeves, improper hairnet use, and uncovered clean pots and pans. | Level D |
| Failed to ensure a cognitively impaired resident received medications as ordered and failed to ensure medications were not left unattended accessible to residents. | Level D |
Report Facts
Residents missing Medicare non-coverage notice: 3
Resident census: 41
Months personal funds exceeded limit: 4
Weight loss: 7
Duration call light unanswered: 10
Duration call light unanswered: 7
Number of residents on secured unit: 12
Number of cognitively impaired residents on front halls: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Confirmed failure to issue CMS form 10123 to residents prior to therapy termination | |
| Business office staff LL | Acknowledged resident #31 received Medicaid and personal funds exceeded limits | |
| Business office staff M | Aware resident's personal funds should not exceed $2000 | |
| Environmental services staff Y | Acknowledged water damage, urine odor, and unsafe conditions on secured unit | |
| Maintenance services staff X | Acknowledged facility maintenance concerns including water leaks and wall damage | |
| Licensed nurse H | Discussed resident #43's contracture and lack of restorative therapy | |
| Administrative licensed nurse D | Acknowledged care plan errors, staffing levels, and medication administration issues | |
| Dietary staff EE | Dietary Manager | Observed unsanitary food preparation and acknowledged diet card errors |
| Direct care staff S | Observed resident #20 with poor grooming and delayed meal service | |
| Direct care staff T | Observed resident #20 with poor grooming and delayed meal service | |
| Direct care staff U | Reported dentures not soaked night before for resident #20 | |
| Direct care staff V | Discussed resident #20's meal service and grooming | |
| Licensed nurse J | Confirmed medications left unattended on resident #24 bedside table |
Inspection Report
Follow-Up
Deficiencies: 3
Jul 16, 2012
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.10(b)(11), 483.25(h), and 483.75(o)(1) have been corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 3
Previous survey date: May 3, 2012
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 16, 2012
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies at Hickory Pointe Care & Rehab Center have been corrected.
Findings
The revisit report confirms that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 07/16/2012.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited |
Report Facts
Deficiency correction date: Jul 16, 2012
Inspection Report
Plan of Correction
Deficiencies: 4
Jun 27, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The facility outlines corrective actions for deficiencies related to resident notification of significant changes, prevention of accidents and falls, quality assessment and assurance processes, and dietary services. The plan includes staff in-service training, monitoring of residents, and ongoing quality assurance committee oversight.
Severity Breakdown
D: 1
G: 1
F: 1
C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to inform resident physician, legal representative, or family of significant changes in the resident. | D |
| Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision and assistance devices to prevent accidents. | G |
| Failure to maintain a quality assessment and assurance committee with appropriate review and follow-up of incident reports and care plans. | F |
| Failure to employ a Registered Dietician Consultant and ensure dietary processes are supervised and certified. | C |
Report Facts
Residents monitored: 3
Plan of correction completion date: Facility aims for substantial compliance by 2012-06-27
CDM course completion date: Scheduled for October 2012
Inspection Report
Follow-Up
Deficiencies: 13
Jun 14, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date, as documented by the correction completion dates.
Deficiencies (13)
| Description |
|---|
| Deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency identified under regulation 483.15(h)(2) |
| Deficiency identified under regulation 483.20(d), 483.20(k)(1) |
| Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency identified under regulation 483.25 |
| Deficiency identified under regulation 483.25(d) |
| Deficiency identified under regulation 483.25(e)(2) |
| Deficiency identified under regulation 483.25(l) |
| Deficiency identified under regulation 483.35(i) |
| Deficiency identified under regulation 483.60(c) |
| Deficiency identified under regulation 483.65 |
| Deficiency identified under regulation 483.70(c)(2) |
| Deficiency identified under regulation 483.70(h) |
Report Facts
Correction completion date: Jun 14, 2012
Correction completion date: Jun 12, 2012
Follow-up survey completion date: May 3, 2012
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Jun 14, 2012
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint investigation for citations #KS57645 and 57673.
Findings
The facility failed to provide a certified dietary manager for 2 of 2 days on resurvey. Observations and staff interviews confirmed the dietary staff was not certified and the dietician only visited monthly.
Complaint Details
The visit was complaint-related as part of a Health Resurvey and Complaint investigations #KS57645 and 57673.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a certified dietary manager for the facility. | SS=C |
Report Facts
Census: 39
Inspection Report
Plan of Correction
Deficiencies: 15
Jun 1, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report, outlining corrective actions to address alleged violations and ensure compliance.
Findings
The facility outlines corrective actions for multiple deficiencies including notification of significant resident status changes, investigation of abuse allegations, housekeeping and maintenance issues, individualized care planning, infection control, medication monitoring, and environmental safety. The facility commits to staff in-service training, monitoring, and reporting to the Quality Assurance committee to achieve substantial compliance by June 1, 2012.
Severity Breakdown
D: 8
E: 5
F: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to immediately inform residents' physician or legal representative of significant changes in resident status. | D |
| Failure to ensure thorough investigation and reporting of alleged violations involving mistreatment, neglect, or abuse. | D |
| Inadequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior. | E |
| Failure to develop comprehensive care plans with measurable objectives for residents' medical, nursing, and psychosocial needs. | E |
| Failure to revise care plans to provide individualized interventions for residents diagnosed with Clostridium difficile. | D |
| Failure to provide care services to ensure residents' highest well-being, including assessments and documentation. | D |
| Failure to provide appropriate treatment and services to restore bladder function. | D |
| Failure to ensure residents with limited range of motion receive appropriate treatment and services. | D |
| Failure to effectively monitor drug regimens for behaviors, unnecessary medications, blood pressure, and bowel elimination in cognitively impaired residents. | D |
| Failure to handle residents' drinking glasses in a sanitary manner and maintain a clean environment during food preparation and serving. | F |
| Failure to have a drug regimen reviewed and reported by a licensed pharmacist for irregularities. | D |
| Failure to maintain an infection control program to prevent disease transmission. | E |
| Failure to maintain essential mechanical, electrical, and patient care equipment in safe operating condition. | E |
| Failure to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. | E |
| Failure to employ a Registered Dietician Consultant on a regularly scheduled basis to ensure dietary processes. | F |
Report Facts
Plan of correction completion date: Jun 1, 2012
Staff in-service date: May 11, 2012
Dietary staff in-service date: May 14, 2012
Maintenance repair dates: May 4, 2012
Maintenance repair dates: May 11, 2012
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 1
May 3, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to provide a certified dietary manager for 4 of 4 days during the survey period, indicating non-compliance with staffing requirements for dietetic services.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide a certified dietary manager for the facility for 4 of 4 days during the survey. | SS=F |
Report Facts
Census: 42
Days without certified dietary manager: 4
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