Inspection Reports for
Kearny County Hospital
607 COURT PLACE, LAKIN, KS, 67860
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
46% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-11-05.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2025-11-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-11-05.
Findings
All deficiencies have been corrected as of the compliance date of 2025-11-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-11-05.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2025-11-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-11-05.
Findings
All deficiencies have been corrected as of the compliance date of 2025-11-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 16
Deficiencies: 2
Date: Nov 5, 2025
Visit Reason
This is a resurvey of Kearny County Hospital Assisted Living conducted to verify correction of previously identified deficiencies.
Findings
The operator failed to ensure negotiated service agreements were fully developed based on residents' functional capacity screenings for two residents. Additionally, staff failed to secure chemicals properly to maintain resident and visitor safety.
Deficiencies (2)
KAR 26-41-202(a)(1) The operator failed to ensure negotiated service agreements were fully developed based on residents' functional capacity screenings, service needs, and preferences for residents R101 and R103.
KAR 28-39-254(a) The operator failed to ensure staff secured all chemicals, including nail polish remover and disinfectant sprays, to maintain the safety of residents and visitors.
Report Facts
Resident census: 16
Chemical items observed unsecured: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Provided statements regarding residents' behaviors and service agreement deficiencies | |
| Administrative Staff A | Provided statements regarding resident behavior and redirection |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 11, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-05-15.
Findings
All deficiencies have been corrected as of the compliance date of 2024-06-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 15, 2024
Visit Reason
This document represents the findings of a resurvey conducted for the assisted living facility on May 15 and May 16, 2024.
Findings
The document provides the provider's plan of correction in response to the resurvey findings. It does not detail specific deficiencies or findings within this text.
Inspection Report
Re-Inspection
Census: 16
Deficiencies: 11
Date: May 15, 2024
Visit Reason
The visit was a resurvey of Kearny County Hospital Assisted Living conducted on 05/15/2024 and 05/16/2024 to assess compliance with previously identified deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to post the most recent survey report, incomplete functional capacity screenings, inadequately developed negotiated service agreements, unlabeled medications, lack of quarterly medication regimen reviews, incomplete emergency preparedness reviews, improper food temperature documentation, and non-compliance with tuberculosis screening guidelines for residents and staff.
Deficiencies (11)
KAR 26-41-101(l) The operator failed to ensure a copy of the most recent survey report and plan of correction was available in a public area for residents and others to examine.
KAR 26-41-201(c)(1) The operator failed to ensure designated staff completed a Functional Capacity Screen for residents R101 and R103 at least once every 365 days.
KAR 26-41-202(a)(1) The operator failed to ensure the Negotiated Service Agreement was fully developed based on the Functional Capacity Screen, service needs, and preferences for residents R101, R102, and R103.
KAR 26-41-202(d)(1) The operator failed to ensure the Negotiated Service Agreement for residents R101 and R102 was revised at least once every 365 days.
KAR 26-41-204(d) The operator failed to ensure the Negotiated Service Agreement identified the licensed nurse responsible for implementation and supervision of the health care services plan for residents R101, R102, and R103.
KAR 26-41-205(g)(3) The operator failed to ensure a licensed pharmacist or nurse placed the full name of the resident on over-the-counter medications for four residents; nine containers were unlabeled.
KAR 26-41-205(g)(2) The operator failed to ensure prescription medication containers for four residents had labels provided by a dispensing pharmacist; seven containers were unlabeled.
KAR 26-41-205(l) The operator failed to ensure quarterly medication regimen reviews were completed by a licensed pharmacist for residents R101 and R103.
KAR 26-41-104(d)(3) The operator failed to ensure quarterly review of the facility's emergency management plan was conducted with all staff and residents.
KAR 26-41-206(d) The operator failed to ensure food items were served at the proper temperature; food temperature logs lacked documentation on multiple days for 300 and 400 Halls.
KAR 26-41-207(c) The operator failed to ensure compliance with tuberculosis guidelines; residents R101, R102, R103 and staff lacked required annual TB symptom screening questionnaires and two-step TB skin tests.
Report Facts
Census: 16
Unlabeled OTC medication containers: 9
Unlabeled prescription medication containers: 7
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Named in findings related to functional capacity screening, negotiated service agreements, medication labeling, medication regimen reviews, and tuberculosis screening |
| Certified Medication Aide B | Certified Medication Aide | Named in findings related to medication labeling |
| Administrative Nurse E | Administrative Nurse | Named as nurse responsible for health care services plan but no longer employed |
| Administrative Staff D | Administrative Staff | Acknowledged lack of documentation for emergency management plan reviews |
| Certified Medication Aide C | Certified Medication Aide | Named in tuberculosis screening deficiency for lack of initial two-step TST |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 16, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-10-20.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2022-11-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 24
Deficiencies: 11
Date: Oct 20, 2022
Visit Reason
The visit was a resurvey of the assisted living facility conducted to assess compliance with previously identified deficiencies related to functional capacity screening, negotiated service agreements, medication labeling, emergency preparedness, infection control, and tuberculosis guidelines.
Findings
The facility failed to complete functional capacity screens accurately and timely for residents, did not fully develop or update negotiated service agreements, failed to label over-the-counter medications with resident names, lacked complete emergency management plans including missing persons and natural gas leak protocols, did not conduct quarterly emergency plan reviews with all staff and residents, and failed to comply with tuberculosis testing guidelines for residents and new employees.
Deficiencies (11)
26-41-201(a)(b) Functional Capacity Screen on Admission was incomplete or not timely for residents R101 and R102, missing cognition and bladder incontinence documentation.
26-41-201(d) Functional Capacity Screen did not accurately reflect R102's vision impairment due to macular degeneration.
26-41-202(a) Negotiated Service Agreement was not fully developed to address all triggers from the Functional Capacity Screen for residents R101, R102, and R103.
26-41-202(c) Admission Negotiated Service Agreement was not completed at admission for residents R101 and R102.
26-41-202(d) Negotiated Service Agreement for resident R103 was not reviewed and revised at least once every 365 days.
26-41-202(h) Negotiated Service Agreement for residents R101 and R102 was not signed by all individuals involved, including the nurse who developed the NSA.
26-41-204(d) Negotiated Service Agreement did not identify the licensed nurse responsible for implementation and supervision of health care services for residents R102 and R103.
26-41-205(g)(3) Over-the-counter medications were not labeled with resident names and were used as stock medications.
26-41-104(b) Written Emergency Plan did not include information on missing residents and natural gas leak.
26-41-104(d) Disaster and Emergency Preparedness lacked quarterly reviews of the emergency management plan with employees and residents including all required topics.
26-41-207(b)(5-6)(c) Infection Control Policies failed to ensure compliance with tuberculosis guidelines, including two-step TB skin testing for residents and new employees.
Report Facts
Resident census: 24
Number of residents in sample: 3
Number of unlabeled OTC medication containers: 4
Number of new employee records reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Provided statements regarding functional capacity screening and negotiated service agreements |
| Administrative Staff C | Administrative Staff | Acknowledged deficiencies in emergency plan reviews and staff education |
| Certified Medication Aide B | Certified Medication Aide | Observed handling of unlabeled over-the-counter medications |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 19, 2022
Visit Reason
This document represents the plan of correction submitted following a resurvey of an assisted living facility conducted on October 19-20, 2022.
Findings
The document summarizes the findings from the resurvey but does not detail specific deficiencies or findings within this text.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 17, 2021
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
All previously reported deficiencies identified by regulation numbers 26-41-202(a), 26-41-204(e), 26-41-205 a(4), 26-41-205(h), 26-41-207 (b)(5-6)(c), and 28-39-254 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 3, 2021
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a record of the Plan of Correction status.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 23, 2021
Visit Reason
This document is a Plan of Correction related to deficiencies identified during an inspection of Kearny County Hospital Assisted Living on February 23, 2021.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 6
Date: Feb 17, 2021
Visit Reason
The visit was a resurvey of the assisted living facility conducted on 2-17, 2-18, and 2-22-2021 to assess compliance with previously cited deficiencies.
Findings
The facility failed to ensure negotiated service agreements included all required services, failed to properly delegate nursing duties for blood glucose monitoring, failed to label prefilled medication containers correctly, improperly stored insulin medications, failed to comply with tuberculosis screening guidelines, and failed to secure chemicals to maintain resident safety.
Deficiencies (6)
KAR 26-41-202 (a)(1)(2) The facility failed to ensure negotiated service agreements included descriptions of all services residents would receive and identification of service providers, including blood glucose monitoring and use of assistive devices.
KAR-26-41-204 (e) The facility failed to delegate the nursing procedure of blood sugar monitoring to certified medication aides according to the Kansas nurse practice act.
KAR 26-41-205 (a)(4) The facility failed to ensure a prefilled medication container used by a resident who self-administered medications was labeled with the resident's name and the date it was prefilled.
KAR 26-41-205 (h)(1) The facility failed to store insulin medications in a locked medication room, cabinet, or cart and failed to label insulin pens with resident names and dates of first use.
K.A.R 26-41-207(c) The facility failed to comply with tuberculosis screening guidelines for residents and newly hired employees, missing initial and annual TB symptom screens and second TB skin tests.
KAR 28-39-254 (a) The facility failed to secure chemicals in locked cabinets, exposing residents to potential hazards.
Report Facts
Census: 31
Residents in sample: 3
Focused record reviews: 2
Newly hired employee files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Confirmed failures in negotiated service agreements, training, and medication storage | |
| Licensed nursing staff D | Licensed Nurse | Reported on medication administration and TB screening compliance |
| Certified staff B | Certified medication aide lacking training for blood sugar monitoring | |
| Certified staff C | Certified medication aide lacking training for blood sugar monitoring |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
The visit was a special infection control survey for COVID-19 conducted at the facility.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document. It serves only as a record of the plan of correction submission.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Sep 5, 2018
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (4)
Regulation 26-41-201 (a) (b) deficiency was corrected by 09/05/2018.
Regulation 26-41-202 (a) deficiency was corrected by 09/05/2018.
Regulation 26-41-204 (d) deficiency was corrected by 09/05/2018.
Regulation 26-41-104 (d) deficiency was corrected by 09/05/2018.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 4
Date: Aug 7, 2018
Visit Reason
The visit was a resurvey conducted on 8/6 and 8/7/2018 to assess compliance with previously identified deficiencies at Kearny County Hospital Assisted Living.
Findings
The facility failed to ensure functional capacity screens included all required elements, negotiated service agreements lacked descriptions of services and responsible providers, and did not name the licensed nurse responsible for health service plans. Additionally, the facility failed to conduct quarterly reviews of the emergency management plan with employees and residents.
Deficiencies (4)
KAR 26-41-201(a) Functional capacity screens on admission lacked required elements such as medical treatments, resident demographics, and screening for various functional and behavioral aspects for 3 residents.
KAR 26-41-202(a) Negotiated service agreements for 3 residents failed to provide descriptions of services, identify service providers, and specify meals provided.
KAR 26-41-204(d) Negotiated service agreements for 3 residents lacked the name of the licensed nurse responsible for implementation and supervision of the health service plan.
KAR 26-41-104(d)(3) The facility failed to ensure quarterly review of the emergency management plan with employees and residents.
Report Facts
Census: 83
Sample size: 3
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 23, 2017
Visit Reason
This revisit inspection was conducted to verify that previously cited deficiencies at Kearny County Hospital Assisted Living were corrected.
Findings
All previously reported deficiencies identified by regulation numbers 26-39-101(h), 28-39-158(g), and 26-41-102(d) were corrected as of the revisit date.
Deficiencies (3)
Regulation 26-39-101(h) deficiency was corrected by the revisit date.
Regulation 28-39-158(g) deficiency was corrected by the revisit date.
Regulation 26-41-102(d) deficiency was corrected by the revisit date.
Inspection Report
Plan of Correction
Capacity: 35
Deficiencies: 4
Date: Jun 1, 2017
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a regulatory inspection of the facility.
Findings
The plan addresses deficiencies related to licensed capacity increase, food safety practices including expiration date monitoring and temperature controls, and verification of staff credentials before employment.
Deficiencies (4)
Licensed capacity has been increased from 30 residents to 35 residents. The Director of Nursing or designee will monitor facility census monthly to ensure compliance with licensed capacity.
Dietary staff will be educated on First in First Out Policy to manage food expiration. Staff will check and document expiration dates daily and discard expired food during daily checks.
Dietary staff will monitor freezer and refrigerator temperatures daily and record them. Temperatures out of FDA guidelines will be adjusted and rechecked, with maintenance contacted if issues persist.
Human Resource Director will verify all certified and licensed staff credentials before employment. Verification forms will be attached to applications and checked monthly for compliance.
Report Facts
Licensed capacity: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Stingley | Chief Nursing Officer | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Re-Inspection
Deficiencies: 3
Date: May 30, 2017
Visit Reason
The inspection was conducted as an Assisted Living Licensure Resurvey to evaluate compliance with licensing requirements and facility regulations.
Findings
The facility was found to have exceeded its licensed capacity by housing 32 residents instead of the licensed 30 without applying for a capacity change. Additionally, sanitary violations were noted including failure to discard expired food and monitor refrigerator/freezer temperatures. Staff qualification deficiencies were also identified related to incomplete nurse aide registry and background checks prior to staff providing care.
Deficiencies (3)
26-39-101 (h) Change of Resident Capacity: The facility failed to apply for a license capacity change when their census increased from 30 to 32 residents.
28-39-158(g) Sanitary Conditions: The facility failed to discard expired food and monitor refrigerator/freezer temperatures, risking resident safety.
26-41-102 (d) Staff Qualifications Employee Records: The facility failed to complete nurse aide registry and criminal background checks prior to direct care staff providing resident care.
Report Facts
Facility census: 32
Licensed capacity: 30
Expired cookies: 8
Missing temperature record dates: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff D | Direct Care Staff | Named in deficiency for providing care prior to completion of nurse aide registry and background checks |
| Dietary staff E | Dietary Staff | Confirmed presence of expired cookies in kitchen |
| Dietary staff F | Dietary Staff | Interviewed regarding food removal and temperature monitoring procedures |
| Administrative staff A | Administrative Staff | Interviewed about staff hiring and background check procedures |
| Administrative staff B | Administrative Nursing Staff | Interviewed about knowledge of background check compliance |
| Administrative staff C | Administrative Staff | Interviewed about licensed bed capacity and census |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 7, 2016
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously reported deficiencies listed by regulation numbers were corrected as of 10/30/2015. The report confirms completion of corrective actions for each cited deficiency.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Oct 2, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of the assisted living facility.
Findings
The Plan of Correction addresses multiple deficiencies including pressure ulcer prevention, wound assessment, functional capacity screening, and completion of negotiated service agreements. Several corrective actions and monitoring plans are outlined to ensure compliance and resident safety.
Deficiencies (9)
Tag S0135-D: Resident #3 will have a pressure reducing mattress placed on his bed and a roho cushion placed in his chair. A wound assessment flowchart will be built in the EHR to assist nursing staff with accurate wound assessments and education will be provided on wound care and non-use of donut cushions.
Tag S3055-C: No Plan of Correction required for this deficiency.
Tag S3081-D: Resident #2 will have a Functional Capacity Screen completed. Functional Capacity Screens will be completed annually, after significant changes, and quarterly if assistance with eating is provided. Staff will be educated and monitoring will occur quarterly.
Tag S3085-D: Resident #1 will have a Negotiated Service Agreement completed by qualified staff. All agreements will be reviewed and revised in collaboration with residents. Quarterly reviews will ensure compliance.
Tag S3171-G: No Plan of Correction required for this deficiency.
Tag S3215-D: No Plan of Correction required for this deficiency.
Tag S3225-F: No Plan of Correction required for this deficiency.
Tag S3285-C: No Plan of Correction required for this deficiency.
Tag S3305-E: No Plan of Correction required for this deficiency.
Inspection Report
Re-Inspection
Census: 25
Deficiencies: 9
Date: Oct 2, 2015
Visit Reason
Health Licensure Resurvey to assess compliance with state regulations and previous deficiencies.
Findings
The facility failed to notify a physician of worsening pressure ulcers for one resident, failed to provide adequate treatment and monitoring for pressure ulcers, failed to serve food in a sanitary manner, failed to ensure expired medications were removed, failed to make the most recent survey report available to residents, failed to ensure medication regimen review variances were reported to medical providers, failed to make the emergency management plan available to residents and visitors, failed to complete an annual functional capacity screen for one resident, and failed to ensure qualified staff developed negotiated service agreements.
Deficiencies (9)
26-39-103 (h) Resident Right Notification of Changes: The facility failed to notify the physician of worsening pressure ulcers for resident #3.
28-39-152(c) Pressure Ulcers: The facility failed to provide treatment and services to promote healing and prevent new pressure ulcers for resident #3.
28-39-158(g) Sanitary Conditions: The facility failed to serve foods in a sanitary manner in the 300 hall dining room.
26-43-101 (l) Survey Report: The facility failed to ensure the most recent survey report was accessible to residents and others.
26-43-205 (h) Medication Storage: The facility failed to ensure expired medications were not available for use in the 300 hall medication cart.
26-43-205 (k)(2) Medication Regimen Review Variance Report: The facility failed to ensure the consultant pharmacist reported medication regimen variances to residents' medical care providers.
26-43-104 (e) Emergency Plan Available: The facility failed to make the emergency management plan available to residents and visitors.
26-41-201 (c) Functional Capacity Screen Reassessment: The facility failed to complete an annual functional capacity screen for resident #2 within 365 days.
26-41-202 (a) Negotiated Service Agreement: The facility failed to ensure qualified staff developed the negotiated service agreement in collaboration with the resident.
Report Facts
Census: 25
Expired medication count: 2
Pressure ulcer measurements: 0.4
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 3
Pressure ulcer measurements: 1
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 1
Functional Capacity Screen date: 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Licensed Nurse | Named in findings related to failure to notify physician and treatment of pressure ulcers for resident #3 |
| Administrative Nurse A | Administrative Nurse | Interviewed regarding awareness of pressure ulcers, medication reviews, emergency plan, and functional capacity screening |
| Staff B | Director of Assisted Living Facility | Signed negotiated service agreement without operator certification |
| Staff G | Dietary Staff | Observed serving food in unsanitary manner |
| Staff E | Direct Care Staff | Observed medication cart and discussed expired medications |
| Staff D | Direct Care Staff | Interviewed about resident assistance and medication expiration checks |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 3, 2014
Visit Reason
This is a follow-up visit to verify correction of previously reported deficiencies at Kearny County Hospital Assisted Living.
Findings
The report confirms that previously identified deficiencies under regulations 26-43-101(g), 26-41-204(a), and 28-39-256 have been corrected as of the revisit date.
Deficiencies (3)
Regulation 26-43-101(g): Previously cited deficiency has been corrected as of 07/03/2014.
Regulation 26-41-204(a): Previously cited deficiency has been corrected as of 07/03/2014.
Regulation 28-39-256: Previously cited deficiency has been corrected as of 07/03/2014.
Inspection Report
Renewal
Census: 30
Deficiencies: 3
Date: Jun 11, 2014
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with assisted living facility regulations and licensing requirements.
Findings
The facility failed to post a notice of availability of policies and procedures, did not update a resident's health service plan after a physician ordered a back brace requiring staff assistance, and failed to maintain hot water temperatures within the required range in resident areas.
Deficiencies (3)
26-43-101(g) Availability of policies and procedures. The facility failed to post a notice of availability of policies and procedures in a place accessible to residents and the public.
26-41-204 (a) Health Care Services. The facility failed to update resident #1's health service plan after a physician ordered a back brace that required staff assistance for application.
28-39-256 Mechanical requirements. The facility failed to maintain hot water temperatures between 98 and 120 degrees Fahrenheit in resident areas on the 300 hallway.
Report Facts
Resident census: 30
Residents sampled: 3
Water temperature: 137.2
Water temperature: 136.1
Water temperature: 135
Water temperature: 130.2
Water temperature: 134.7
Water temperature: 134.5
Water temperature: 124.6
Water temperature: 107.4
Water temperature: 107.9
Water temperature range: 123
Water temperature range: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse E | Licensed Nurse | Verified resident #1 required assistance with back brace application and confirmed lack of health service plan revision |
| Maintenance staff D | Checked water temperatures and reported to supervisor | |
| Maintenance staff C | Made adjustments to hot water heater and called plumber | |
| Administrative staff A | Confirmed failure to post notice of policies and procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N047002 POC PO0I11
Visit Reason
This document is a Plan of Correction related to a prior inspection of Kearny County Assisted Living dated 8/7/2018.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N047002 POC UWD111
Visit Reason
This document is a plan of correction related to a previous inspection of the Kearney County Hospital Assisted Living facility concerning COVID-19.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a plan of correction submission referencing a prior deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N047002 POC G09P11
Visit Reason
This document is a Plan of Correction submitted by Kearny Co Hospital Assisted Living in response to deficiencies identified in a prior inspection.
Findings
The Plan of Correction outlines corrective actions including posting policy notices, educating nursing staff on updating resident health service plans, and implementing a Quality Assurance/Quality Improvement project to monitor compliance over the next 12 months.
Deficiencies (2)
S2030 Availability of Policies and Procedures: Notices were posted in both Assisted Living halls informing residents and the public that facility policies and procedures are available for review in the Assisted Living facility Operator's office.
S3155 Health Care Services: The Director of Nursing or designee will educate full-time staff nurses on updating resident health service plans by 06/24/2014 and monitor compliance through a QA/QI project for the next 12 months.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Twilleger | RN/DON | Submitted the Plan of Correction. |
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