Inspection Reports for Homestead Health Center
2133 S. ELIZABETH STREET, KS, 67213-3403
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 31, 2014, found deficiencies related to documentation of meal intake, drug regimen monitoring, and blood sugar management. Earlier inspections identified issues with care planning, pain management, infection control, nutrition, medication administration, and food safety. Complaint investigations substantiated failures in nutritional status maintenance and insulin administration, while most other complaints were unsubstantiated. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. The facility showed some improvement over time by correcting prior deficiencies, but recurring issues with documentation and medication management persisted in the latest inspection.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
217% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
49 residents
Based on a October 2014 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 3
Oct 31, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the previously reported deficiencies identified by regulation numbers 483.25(i), 483.25(l), and 483.60(c) were corrected as of 10/31/2014.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Oct 31, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection related to meal intake documentation, drug regimen monitoring, and blood sugar management.
Findings
The facility identified issues with documenting meal and supplement intake to prevent weight loss, ensuring drug regimens are free from unnecessary drugs, and monthly review of drug regimens with monitoring of blood sugar parameters. Corrective actions include monitoring by nursing and dietary staff, notification of physicians and dieticians, and staff in-service training.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to document intake of meals and supplements to determine if interventions are necessary to prevent weight loss. | D |
| Failure to ensure each resident's drug regimen is free from unnecessary drugs. | D |
| Failure to ensure each resident's drug regimen is reviewed monthly and irregularities reported. | D |
Report Facts
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Vestring | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Oct 2, 2014
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 participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective October 31, 2014.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Report Facts
Effective date of substantial compliance: Oct 31, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 3
Oct 2, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #68631 to assess compliance with regulatory requirements related to resident care and medication administration.
Findings
The facility failed to maintain acceptable nutritional status for two residents by not documenting meal and supplement intake during weight loss periods. Additionally, the facility failed to administer insulin per sliding scale orders for one resident and the consultant pharmacist did not address this medication regimen irregularity.
Complaint Details
The visit was triggered by a complaint investigation (#68631) focusing on nutritional status maintenance and medication administration practices.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to document intake of meals and supplements for residents #55 and #27 who experienced significant weight loss. | SS=D |
| Facility failed to administer insulin per sliding scale orders for resident #15 with diabetes mellitus. | SS=D |
| Consultant pharmacist failed to report and act on irregularity of sliding scale insulin administration for resident #15. | SS=D |
Report Facts
Resident census: 49
Weight loss: 23.8
Weight loss: 22
Blood sugar readings over 250: 17
Insulin doses: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Verified failure to administer sliding scale insulin to Resident #15 | |
| Administrative Nurse A | Verified failure to administer sliding scale insulin and described weight monitoring procedures | |
| Registered Dietician E | Registered Dietician | Confirmed facility did not document meal and supplement intake regularly for residents at risk of weight loss |
| Consultant Pharmacist D | Consultant Pharmacist | Verified failure to address lack of sliding scale insulin administration for Resident #15 |
Inspection Report
Life Safety
Deficiencies: 1
Jan 14, 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. 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 |
|---|---|
| Deficiencies cited during the Life Safety Code survey | F |
Report Facts
Effective date for denial of payments: Apr 14, 2014
Provider agreement termination date: Jul 14, 2014
IDR request timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Vestring | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Author of the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 7
Jul 23, 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 identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25, 483.25(d), 483.25(h), 483.25(j), 483.35(i), and 483.65 were corrected as of the revisit date.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(j) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Jul 23, 2013
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 plan outlines corrective actions for multiple deficiencies including care plan revisions, pain management, catheter care, fall prevention, hydration, food safety, and infection control. The facility describes monitoring and education efforts to ensure substantial compliance.
Severity Breakdown
D: 5
E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Care plans revised to address pain and accidents. | D |
| Medication administration prior to range of motion exercises and pain management. | D |
| Appropriate catheter care to prevent urinary tract infections. | D |
| Use of alarms and care plans for fall prevention. | D |
| Provision of sufficient fluids to maintain hydration. | D |
| Sanitary storage, preparation, distribution, and serving of food. | E |
| Establishment and maintenance of an Infection Control Program for housekeeping and laundry. | E |
Report Facts
Residents assessed: 10
Date of in-service: Jun 26, 2013
Date of catheter care in-service: Jul 1, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Vestring | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 7
Jun 24, 2013
Visit Reason
Annual health resurvey of Homestead Health Center to assess compliance with regulatory requirements including care planning, pain management, fall prevention, catheter care, hydration, food handling, and infection control.
Findings
The facility was found deficient in multiple areas including failure to revise care plans for pain and fall prevention, inadequate pain management, improper catheter care, inconsistent use of fall prevention alarms, insufficient hydration support, unsafe food handling practices, and inadequate housekeeping leading to infection control risks.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to revise care plans to include non-pharmacological pain interventions and ensure provision of as needed pain medications prior to range of motion and splint application. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable well-being, specifically pain management for one resident. | SS=D |
| Failure to provide appropriate catheter care to prevent infections for one resident with a suprapubic catheter. | SS=D |
| Failure to ensure residents remained free of accidents due to inconsistent use of planned fall prevention interventions including floor alarm mats and chair alarms. | SS=D |
| Failure to provide sufficient fluid intake to maintain proper hydration for two residents, including failure to keep fluids within reach and failure to encourage fluid intake. | SS=D |
| Failure to store, prepare, and serve food under sanitary conditions, including improper handling of hamburger buns with gloved hands that touched menus and serving utensils. | SS=E |
| Failure to provide appropriate housekeeping services to prevent spread of infection in an isolation room for a resident with MRSA, including improper cleaning and disinfection procedures and inadequate wet times for disinfectants. | SS=E |
Report Facts
Facility census: 47
Residents sampled: 23
Residents receiving sloppy joes: 10
BUN level: 34
Fluid intake: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Dietary Staff | Handled hamburger buns with gloved hands that touched menus and serving utensils |
| Staff O | Housekeeping Staff | Cleaned isolation room for MRSA resident with improper disinfectant application and procedures |
| Licensed nurse B | Licensed Nurse | Interviewed regarding pain management and fall prevention care plan updates |
| Administrative nurse A | Administrative Nurse | Interviewed regarding care plan updates and fall prevention interventions |
Inspection Report
Follow-Up
Deficiencies: 2
Mar 2, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report confirms that the deficiencies identified under regulations 483.25(c) and 483.35(d)(1)-(2) were corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.35(d)(1)-(2) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Mar 2, 2013
Visit Reason
This document is a Plan of Correction submitted by Homestead Health Center in response to deficiencies identified in a prior inspection related to pressure ulcer care and pureed diet provision.
Findings
The facility identified deficiencies in care planning for residents with pressure ulcers and in providing nutritious, palatable pureed diets. Corrective actions include updating care plans, staff in-service training, and monitoring by the Director of Nursing and Dietary Manager.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents with pressure ulcers have and follow care plans to promote healing and prevent further ulcers. | D |
| Failure to ensure residents requiring pureed diets receive food that is nutritious, palatable, attractive, and at the proper temperature. | E |
Report Facts
Residents requiring pureed diet: 7
Plan of correction completion date: Mar 2, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Vestring | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Feb 1, 2013
Visit Reason
The inspection was conducted as a result of complaint investigations #61279 and #62054 to assess compliance with treatment and services to prevent and heal pressure sores and nutritive value and preparation of food.
Findings
The facility failed to identify and treat pressure ulcers properly for residents at risk, did not consistently follow care plans to promote healing and prevent further pressure ulcers, and failed to prepare and serve food according to recipes and serving sizes, affecting nutritive value for residents on pureed diets.
Complaint Details
The inspection findings represent the results of complaint investigations #61279 and #62054.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to identify and treat pressure ulcers and follow care plans for residents with pressure ulcers. | SS=D |
| Failed to prepare and serve food that conserved nutritive value, flavor, and appearance, affecting residents on pureed diets. | SS=E |
Report Facts
Facility census: 53
Residents reviewed for pressure ulcers: 3
Residents on pureed diets: 7
Pressure ulcer measurements: 0.6
Pressure ulcer measurements: 1.2
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.4
Pressure ulcer measurements: 4
Pressure ulcer measurements: 4.75
Braden scale score: 15
Braden scale score: 11
Weight loss: 5
Weight loss: 10
Chicken broth used: 2.5
Chicken pieces: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse K | Licensed Nurse | Reported meaning of + or - on Treatment Administration Record and documentation expectations |
| Administrative nurse D | Administrative Nurse | Performed weekly pressure wound rounds and provided wound progress notes |
| Direct care staff E | Direct Care Staff | Assisted resident with peri-care and reported on restorative massage and pressure relief |
| Direct care staff F | Direct Care Staff | Reported on shower skin sheet book and documentation |
| Licensed nurse G | Licensed Nurse | Reviewed shower skin sheet book and assisted with wound dressing changes |
| Direct care staff H | Direct Care Staff | Reported on repositioning and elevation of pressure areas |
| Licensed nurse I | Licensed Nurse | Reported on use of boots and repositioning for pressure ulcer prevention |
| Direct care staff J | Direct Care Staff | Reported on repositioning frequency and care plan adherence |
| Dietary staff A | Dietary Staff | Prepared pureed diets and reported on recipe adherence and serving sizes |
| Dietary staff B | Dietary Staff | Reported on pureed food consistency and serving sizes |
| Consultant staff C | Consultant Staff | Reported on pureed food consistency and serving size standards |
Inspection Report
Plan of Correction
Deficiencies: 9
Mar 30, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection related to compliance with Federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions for multiple deficiencies including resident fund accessibility, thorough investigations of abuse allegations, comprehensive resident assessments including dental care, individualized care plans, pain assessment, nutrition maintenance, food preparation standards, dental services, and infection control measures.
Deficiencies (9)
| Description |
|---|
| Residents with a personal fund account will have funds available seven days per week. |
| Investigations of abuse, neglect, or exploitation allegations will be thorough and include multiple interviews and reviews. |
| Comprehensive assessments including dental concerns will be conducted upon admission and periodically. |
| Comprehensive care plans will be developed to maintain residents' highest practicable physical, mental, and psychosocial well-being. |
| Necessary care and services will be provided for residents' highest practicable well-being, including pain assessment and follow-up. |
| All residents will maintain their nutrition status unless unavoidable, with monitoring and interventions for those at risk. |
| Food served will have nutritive value, be palatable, and served at preferred temperature. |
| Routine dental services will be provided or obtained to meet residents' needs. |
| An Infection Control Program will be maintained to provide a safe environment and prevent disease transmission. |
Report Facts
Residents on pureed foods: 9
Plan of Correction completion dates: Mar 30, 2012
In-service date: Mar 6, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Vestring | Administrator | Submitted the Plan of Correction. |
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 10
Mar 1, 2012
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements including management of personal funds, investigation of abuse allegations, comprehensive assessments, care planning, provision of care, nutrition, food preparation, dental services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to develop a system for residents to access personal funds during off hours, incomplete investigations of injury of unknown source, incomplete comprehensive assessments and care plans, failure to promptly assess and treat pain, failure to maintain nutritional status and provide supplements, failure to prepare pureed foods according to approved recipes, failure to serve food at proper temperatures, failure to provide routine dental services, and failure to maintain an effective infection control program including proper isolation and laundering procedures for residents with C-diff.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to develop a system to allow residents to withdraw personal funds during off hours and weekends. | SS=D |
| Failed to thoroughly investigate an injury of unknown source (wrist fracture) to rule out abuse. | SS=D |
| Failed to conduct a complete and accurate comprehensive assessment for a resident with dental concerns. | SS=D |
| Failed to develop comprehensive care plans reflecting residents' activity preferences and needs. | SS=D |
| Failed to provide necessary care and services to promptly assess and treat new onset of severe pain. | SS=D |
| Failed to ensure resident maintained acceptable nutritional status by not consistently providing planned supplements and lacking knowledge of weight loss risk and interventions. | SS=D |
| Failed to prepare pureed meatloaf and beets according to dietician approved recipes, affecting nutritive value. | SS=E |
| Failed to serve food at proper temperature and failed to ensure food was served at resident's preferred temperature. | SS=E |
| Failed to provide or obtain routine dental services to meet the needs of a resident with broken teeth. | SS=D |
| Failed to maintain an infection control program including failure to isolate resident with C-diff, failure to double bag and properly launder contaminated clothing, and use of disinfectants that do not kill C-diff spores. | SS=F |
Report Facts
Facility census: 53
Residents with managed funds: 3
Residents reviewed for comprehensive assessments: 18
Residents reviewed for nutritional status: 3
Residents receiving pureed diets: 9
Weight loss: 5.5
Weight loss percentage: 5.2
Weight loss percentage: 6
Weight loss percentage: 7.6
Food temperature: 129.7
Food temperature: 126.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Administrative Nurse | Named in failure to investigate injury and infection control findings |
| Staff H | Named in personal funds access deficiency | |
| Staff G | Licensed Nursing Staff | Named in dental services deficiency |
| Staff F | Dietary Staff | Named in food preparation and nutrition deficiencies |
| Staff AA | Laundry Staff | Named in infection control and laundry procedures deficiency |
| Staff Y | Housekeeper | Named in infection control and cleaning procedures deficiency |
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