Inspection Reports for
Leisure Homestead at Stafford
405 GRAND AVENUE, STAFFORD, KS, 67578-2009
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
14.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
148% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
88% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
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 08/20/25.
Findings
All deficiencies from the prior inspection have been corrected as of the compliance date of 09/27/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 8
Date: Aug 28, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a regulatory inspection conducted on 08/28/2025.
Findings
The Plan of Correction addresses multiple deficiencies including psychotropic medication consent documentation, resident transfer notification, wound care management, ambulation supervision, staffing posting accuracy, kitchen sanitation, infection control practices, and equipment safety. The facility outlines corrective actions, systemic changes, and monitoring plans to achieve substantial compliance by 09/27/2025.
Deficiencies (8)
F552-D: Resident R29’s representative was notified about medication dosage changes and informed consent was obtained and documented. The facility audited psychotropic medication consents and updated policies and staff education to ensure compliance.
F628-D: Resident #38 and representative received written notice of hospital transfer and bed-hold policy. The facility audited recent transfers for proper notification and revised policies and staff training accordingly.
F686-D: Resident R1 received wound care assessment and treatment orders. Audits of residents with pressure ulcers were conducted and staff re-educated on wound care policies and documentation requirements.
F689-D: Resident R6’s ambulation orders were reviewed and staff informed. The facility reviewed and corrected discrepancies in ambulation care plans and implemented monitoring to ensure compliance.
F732-C: The facility updated and posted daily staffing sheets accurately reflecting actual hours worked and resident census. Staff were trained on posting requirements and audits established.
F812-F: Kitchen equipment and food contact surfaces were cleaned, sanitized, or replaced. Dietary staff were re-educated and cleaning schedules revised with monitoring to ensure ongoing compliance.
F880-E: Residents with catheters, nebulizers, and wounds were assessed and staff re-educated on infection control practices. Audits and policy reviews were implemented to prevent recurrence.
F908-E: Damaged sit-to-stand lifts were removed from service and replaced. Maintenance inspected all resident care equipment and implemented reporting and auditing processes to ensure safety.
Report Facts
Resident census: 35
Audit periods: 4
Audit periods: 3
Audit periods: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Younie | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Tamara Wyss | Added the Plan of Correction on 08/27/2025. | |
| Felicia Majewski | Modified the Plan of Correction on 11/19/2025. |
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 1
Date: Aug 20, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding resident notification and documentation related to bed-hold policies and hospital transfers.
Findings
The facility failed to provide Resident 38 and/or their representative with written notice specifying the duration and cost of the bed hold policy at the time of transfer to the hospital. The facility also failed to provide written notification explaining the reason for the resident's transfer in a language easy to understand.
Deficiencies (1)
F 0628: The facility did not provide required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies for Resident 38 during hospital transfer.
Report Facts
Residents present: 35
Residents reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Confirmed staff did not notify resident or representative in writing of transfer reason |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 8
Date: Aug 20, 2025
Visit Reason
The inspection was conducted as a Health Recertification Survey and complaint investigation related to multiple concerns including residents' rights, discharge process, pressure ulcer care, accident hazards, nurse staffing information, food safety, infection prevention and control, and equipment safety.
Complaint Details
The inspection included complaint investigations numbered 2585182 and 2579852, addressing concerns about residents' rights, discharge processes, pressure ulcer care, accident hazards, staffing, food safety, infection control, and equipment safety.
Findings
The facility was found deficient in multiple areas including failure to inform residents about psychotropic medication risks, inadequate discharge notifications, failure to provide weekly wound assessments, insufficient supervision to prevent falls, inaccurate nurse staffing postings, unsanitary food preparation conditions, poor infection control practices especially related to catheter care, and unsafe resident care equipment.
Deficiencies (8)
F0552: The facility failed to inform Resident 29 or representative about risks related to psychotropic medication dosage increase, lacking updated informed consent documentation.
F0628: The facility failed to provide Resident 38 or representative with written notice of bed hold policy duration and reason for hospital transfer in an understandable language.
F0686: The facility failed to provide weekly wound assessments for Resident 1 with pressure ulcers, delaying wound healing and increasing risk of injury.
F0689: The facility failed to provide necessary supervision and assistance for safe ambulation for Resident 6, placing the resident at risk for falls.
F0732: The facility failed to post accurate, publicly accessible, and identifiable nurse staffing information daily for 35 residents.
F0812: The facility failed to prepare and serve food under sanitary conditions, including unsanitizable refrigerator shelves, dirty storage racks, and heavily gouged cutting boards.
F0880: The facility failed to implement Enhanced Barrier Precautions and proper infection control practices for residents with catheters and wounds, including improper catheter bag handling and inadequate hand hygiene.
F0908: The facility failed to maintain sit-to-stand lifts in safe operating condition, with damaged pads, missing foam grips, and exposed rust, risking resident safety.
Report Facts
Resident census: 35
Sample size: 12
BIMS score: 7
BIMS score: 14
Pressure ulcer size: 2
Pressure ulcer size: 1.1
Pressure ulcer size: 2
Pressure ulcer size: 1.1
Fall risk score: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Interviewed regarding informed consent, bed hold policy, infection control, and equipment maintenance | |
| Administrative Nurse E | Interviewed regarding psychotropic consent and infection control practices | |
| Administrative Staff A | Interviewed regarding informed consent, staff expectations, and equipment maintenance | |
| Certified Nurse Aide N | CNA | Observed providing care to Resident 1 without proper PPE |
| Certified Nurse Aide O | CNA | Observed providing care to Resident 1 without proper PPE |
| Certified Medication Aide S | CMA | Reported on Resident 6's ambulation and walker use |
| Licensed Nurse G | LN | Interviewed about Resident 6's ambulation orders |
| Licensed Nurse I | LN | Observed wound care and interviewed about hand hygiene |
| Certified Medication Aide R | CMA | Reported damage to sit-to-stand lift |
| Maintenance U | Interviewed about equipment maintenance and inspections |
Inspection Report
Routine
Census: 35
Deficiencies: 8
Date: Aug 20, 2025
Visit Reason
Routine inspection of Leisure Homestead at Stafford to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to fully inform residents about psychotropic medication risks, inadequate documentation and notification related to resident transfers and bed-hold policies, insufficient pressure ulcer care, lack of proper supervision to prevent falls, incomplete nurse staffing postings, unsanitary food preparation conditions, failure to implement infection prevention protocols, and unsafe resident care equipment.
Deficiencies (8)
F 0552: The facility failed to inform Resident 29 or their representative about risks related to psychotropic medication dosage changes, lacking updated informed consent documentation.
F 0628: The facility failed to provide written notification regarding bed hold policy duration and transfer reasons to Resident 38 or their representative at hospital transfer.
F 0686: The facility failed to provide weekly wound assessments and appropriate pressure ulcer care for Resident 1, risking delayed healing and new ulcers.
F 0689: The facility failed to provide adequate supervision and assistance for safe ambulation for Resident 6, placing them at risk for falls.
F 0732: The facility failed to post accurate and complete daily nurse staffing information accessible to the public.
F 0812: The facility failed to maintain sanitary conditions in the kitchen, including unsanitizable refrigerator shelves, dirty storage racks, and heavily gouged cutting boards.
F 0880: The facility failed to implement Enhanced Barrier Precautions and proper infection control for residents with catheters and wounds, including improper catheter bag handling and inadequate hand hygiene.
F 0908: The facility failed to ensure safe and properly maintained resident care equipment, including damaged sit-to-stand lifts with exposed rust and missing foam.
Report Facts
Residents in census: 35
Residents in sample: 12
Residents reviewed for pressure ulcers: 3
Daily Staffing Sheets reviewed: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Interviewed regarding psychotropic consent, bed hold policy, wound care expectations, fall supervision, staffing sheets, infection control, and equipment maintenance | |
| Administrative Nurse E | Interviewed regarding psychotropic consent, wound care, infection control, and Enhanced Barrier Precautions | |
| Administrative Staff A | Interviewed regarding psychotropic consent, bed hold policy, fall supervision, equipment maintenance | |
| Certified Nurse Aide N | CNA | Observed and interviewed regarding catheter care and infection control |
| Certified Nurse Aide O | CNA | Observed and interviewed regarding catheter care and infection control |
| Certified Medication Aide S | CMA | Interviewed regarding Resident 6 ambulation and walker use |
| Licensed Nurse G | LN | Interviewed regarding Resident 6 ambulation orders |
| Certified Nurse Aide M | CNA | Interviewed and observed regarding catheter bag placement and infection control |
| Licensed Nurse I | LN | Observed and interviewed regarding wound dressing and infection control |
| Maintenance U | Interviewed regarding equipment maintenance and inspections |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Sep 21, 2023
Visit Reason
This document is a Plan of Correction submitted by Leisure Homestead at Stafford in response to deficiencies cited during a regulatory inspection on 2023-09-21.
Findings
The Plan of Correction addresses multiple deficiencies related to care plans, infection control, fall prevention, respiratory equipment care, linen handling, HVAC maintenance, and safety equipment installation. The facility outlines corrective actions including staff training, audits, equipment updates, and ongoing monitoring.
Deficiencies (8)
F641-D: Care plans and MDSs were corrected to reflect proper resident care. Staff received training on cleaning and storage of CPAPs and infection control.
F657-E: Resident R21's care plan and TAR were updated for ACE Wraps and TEDs. Staff education on fall prevention and intervention monitoring was implemented.
F684-D: Orders for ACE Wraps and TEDs were obtained. Random checks ensure compliance with orders and care plan audits for residents with recent falls.
F689-E: Care plans reviewed for residents at risk of falls with proper interventions. Staff receive annual safety education and quarterly care plan audits.
F695-D: Care and use of respiratory equipment added to TAR. Staff trained and monitored on proper equipment care and storage.
F880-F: PPE in laundry updated, carts replaced, and linen handling education required annually. Quarterly monitoring of linen handling and delivery established.
S1354-E: Air flow registers tested and exhaust fan switch activated in beauty shop. HVAC units maintained with annual testing.
S1358-E: Vacuum breakers installed on beauty shop and janitor closet sinks. Monthly visual inspections and annual maintenance added.
Report Facts
Deficiency tags: 8
Inspection Report
Routine
Census: 33
Deficiencies: 6
Date: Sep 21, 2023
Visit Reason
Routine inspection of Leisure Homestead at Stafford nursing home to assess compliance with care standards, including resident assessments, care planning, fall prevention, respiratory care, and infection control.
Findings
The facility failed to accurately complete resident assessments, review and revise care plans following falls, provide appropriate respiratory care including cleaning and storage of CPAP and nebulizer equipment, and maintain infection control in laundry and during linen handling. Several residents were at risk due to these deficiencies.
Deficiencies (6)
F0641: The facility failed to accurately complete the Minimum Data Set (MDS) for Resident 7 regarding CPAP use, placing the resident at risk for uncommunicated care needs.
F0657: The facility failed to review and revise care plans with interventions following falls for residents 16, 10, 32, and 21, lacking appropriate immediate interventions to prevent further falls.
F0684: The facility failed to apply TED hose every morning and remove them every night for Resident 21, placing the resident at increased risk for additional medical problems.
F0689: The facility failed to complete thorough investigations of falls and implement immediate new interventions for residents 16, 10, 7, and 32, increasing risk of injury from ongoing falls.
F0695: The facility failed to provide safe and appropriate respiratory care for residents 7, 9, and 31, including improper cleaning and storage of CPAP and nebulizer equipment, risking respiratory infections.
F0880: The facility failed to handle, store, process, and transport linens to prevent cross contamination and infection spread, and failed to perform required hand hygiene during linen delivery.
Report Facts
Residents in census: 33
Residents selected for review: 12
Falls experienced by Resident 16: 5
Falls experienced by Resident 32: 10
BIMS score for Resident 7: 15
BIMS score for Resident 9: 15
BIMS score for Resident 31: 11
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 6
Date: Sep 21, 2023
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation for multiple complaint investigations identified by KS00177457, KS00177458, and KS00180742.
Complaint Details
The inspection was triggered by complaints identified as KS00177457, KS00177458, and KS00180742. The investigation found substantiated deficiencies related to care planning, fall investigations, respiratory care, and infection control.
Findings
The facility failed to accurately complete assessments, review and revise care plans following falls, properly apply and maintain compression stockings, provide adequate respiratory care including cleaning and storage of CPAP and nebulizer equipment, and failed to prevent accident hazards including wet floor signage and proper linen handling. Fall investigations lacked thorough root cause analysis and immediate interventions to prevent further falls.
Deficiencies (6)
F641 The facility failed to accurately complete the Minimum Data Set for Resident 7 regarding CPAP use, placing the resident at risk for uncommunicated care needs.
F657 The facility failed to review and revise care plans with appropriate interventions following multiple falls for Residents 16, 10, and 32, and failed to revise the care plan for Resident 32 related to compression stockings.
F684 The facility failed to apply TED hose every morning and remove them every night for Resident 21, placing the resident at risk for additional medical problems.
F689 The facility failed to thoroughly investigate falls for Residents 16, 10, 7, and 32 to determine contributing factors and implement immediate new interventions to prevent further falls.
F695 The facility failed to properly clean and store nebulizer equipment for Residents 9 and 31 and failed to disassemble, clean, and properly store CPAP equipment and distilled water for Resident 7, inconsistent with professional standards of care.
F880 The facility failed to handle, store, process, and transport linens to prevent cross contamination and infection spread, failed to perform required hand hygiene between residents during linen delivery and ice water passing, and failed to maintain respiratory equipment to prevent infection for Residents 7, 9, and 31.
Report Facts
Resident census: 33
Residents reviewed: 12
Falls for Resident 16: 5
Falls for Resident 32: 10
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 14, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 07/15/22.
Findings
All deficiencies have been corrected as of the compliance date of 08/15/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 4
Date: Jul 15, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse, neglect, exploitation, and mistreatment involving Resident 1 (R1) and other related complaints.
Complaint Details
The investigation was triggered by multiple complaints (KS00172903, KS172920, KS00172165, KS00171730, KS00171322) involving allegations of abuse, neglect, and exploitation of Resident 1, including a medication error and delayed emergency response.
Findings
The facility failed to submit a complete and timely investigation report regarding an allegation of abuse and neglect involving R1. The facility also failed to provide timely care consistent with nursing standards when R1 showed stroke symptoms, and non-medical staff transported R1 to the ER without calling EMS. Additionally, the facility failed to ensure all clinical staff had the competencies and training to respond appropriately to resident emergencies and changes in condition.
Deficiencies (4)
F 609: The facility failed to submit the results of a completed investigation into an allegation of abuse, neglect, or exploitation involving Resident 1 within the required timeframe.
F 610: The facility failed to complete a thorough investigation into an allegation of abuse, neglect, or exploitation involving Resident 1 and did not report the results within five working days as required.
F 684: The facility failed to provide timely care consistent with nursing standards when Resident 1 showed stroke symptoms and was transported to the ER by non-medical staff without EMS assistance, causing a delay in care.
F 726: The facility failed to ensure all clinical staff had the competencies and training required to respond appropriately to a resident's change in condition and emergent situations.
Report Facts
Resident census: 39
Days past required timeframe: 3
Time delay: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Responsible for completing facility investigations and submitting paperwork to the state agency. | |
| Administrative Nurse C | Involved in assessment of Resident 1 and decision to send to ER; stated expectations for staff response to emergencies. | |
| Administrative Staff B | Non-medical staff who transported Resident 1 to the ER in a wheelchair. | |
| Licensed Nurse F | Completed assessment of Resident 1 and obtained order to send to ER. | |
| Pharmacy Consultant M | Assisted with investigation of medication error involving Resident 1. | |
| Certified Medication Aide K | Involved in medication error where Resident 1 received another resident's medication. | |
| Provider D | ER provider who received Resident 1 and initiated stroke protocol. | |
| Licensed Nurse G | Provided information about facility expectations for transporting residents to ER. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 16, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 12/08/21.
Findings
All deficiencies have been corrected as of the compliance date of 01/22/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 6
Date: Dec 8, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for Leisure Homestead at Stafford.
Complaint Details
The inspection was triggered by a complaint investigation related to medication administration, psychotropic drug use, food safety, and infection control practices.
Findings
The facility failed to ensure proper medication administration and documentation for residents, including failure to administer Tylenol and blood pressure medication as ordered, and failure to monitor and document PRN psychotropic medication use. Additionally, food safety standards were not met due to improper food storage and handling, and infection control practices were deficient with improper glove use during resident care.
Deficiencies (6)
F755 Pharmacy Services: The facility failed to document administration of Tylenol for Resident 12 as ordered by the physician.
F756 Drug Regimen Review: The facility failed to ensure the pharmacist identified and reported missing documentation of medication administration and lacked an end date for PRN psychotropic medications for Resident 22.
F757 Drug Regimen Free from Unnecessary Drugs: The facility failed to ensure blood pressure medication was administered as ordered for Resident 12 and failed to document reasons for not administering medication.
F758 Free from Unnecessary Psychotropic Medications: The facility failed to ensure Resident 22 did not receive unnecessary PRN psychotropic medication beyond 14 days without physician rationale or updated order.
F812 Food Safety: The facility failed to handle and store food in accordance with professional standards, including undated and improperly stored foods and failure to use gloves or hand hygiene appropriately during food handling.
F880 Infection Prevention and Control: The facility failed to ensure staff used personal protective equipment appropriately during toileting care for Resident 22, including failure to change gloves between tasks.
Report Facts
Resident census: 37
Days Tylenol not administered: 23
Times Metoprolol held: 11
Duration of PRN psychotropic order: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant Pharmacist C | Consultant Pharmacist | Named in failure to identify missing medication documentation and PRN psychotropic medication duration. |
| Administrative Nurse B | Administrative Nurse | Named in interviews regarding medication administration and psychotropic medication oversight. |
| Licensed Nurse G | Licensed Nurse | Named in interviews regarding medication administration and psychotropic medication regulation knowledge. |
| Certified Nurse Aide E | Certified Nurse Aide | Named in observation and interview regarding improper glove use during toileting care. |
| Certified Nurse Aide D | Certified Nurse Aide | Named in observation during toileting care of Resident 22. |
| Certified Dietary Manager O | Certified Dietary Manager | Named in observation regarding improper food storage and handling. |
| CNA F | Certified Nursing Assistant | Named in interview regarding Resident 22's behaviors and medication administration. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 6
Date: Dec 8, 2021
Visit Reason
The inspection was conducted based on complaints and concerns regarding medication administration, pharmacist oversight, psychotropic medication use, food safety, and infection control practices at the nursing home.
Complaint Details
The complaint investigation focused on medication administration errors, pharmacist oversight failures, prolonged use of psychotropic medications without proper orders, food safety violations, and improper infection control practices during resident care.
Findings
The facility failed to ensure proper administration and documentation of medications including Tylenol and blood pressure medication for Resident 12, failed to monitor and limit PRN psychotropic medication duration for Resident 22, failed to handle and store food safely, and failed to ensure appropriate use of personal protective equipment during resident care.
Deficiencies (6)
F 0755: The facility failed to document administration of Tylenol for Resident 12 as ordered by the physician, missing multiple doses over several months.
F 0756: The facility failed to ensure the consultant pharmacist identified and reported missing documentation concerning lack of administration of scheduled pain and blood pressure medications for Resident 12 and lacked an end date for PRN psychotropic medications for Resident 22.
F 0757: The facility failed to ensure efficacy of blood pressure medications for Resident 12 when staff failed to administer medication as ordered and failed to document reasons for withholding.
F 0758: The facility failed to ensure Resident 22 did not receive unnecessary psychotropic medications, administering PRN Ativan from an order dated 14 months prior without a duration or rationale.
F 0812: The facility failed to handle and store food in accordance with professional standards, including undated opened foods and improper glove use during food preparation.
F 0880: The facility failed to ensure staff changed gloves appropriately when toileting and performing peri-care for Resident 22, using the same gloves throughout the procedure.
Report Facts
Resident census: 37
Medication doses missed: 23
Blood pressure medication held: 11
Duration of PRN psychotropic medication: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Interviewed regarding medication documentation expectations and PRN medication duration | |
| Consultant Pharmacist C | Interviewed regarding medication regimen review and failure to identify missing documentation | |
| Licensed Nurse G | Interviewed regarding holding blood pressure medication and knowledge of psychotropic medication regulations | |
| Certified Dietary Manager O | Observed and interviewed regarding food handling and storage practices | |
| Certified Nurse Aide E | Observed and interviewed regarding glove use during toileting and peri-care | |
| Certified Nurse Aide F | Reported on Resident 22's behaviors and medication administration |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Dec 8, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple medication administration issues including timing conflicts, missing medication passes, and PRN antipsychotic order limits. It also covers food storage violations and infection control retraining related to glove use during perineal care.
Deficiencies (6)
F755-D: Resident R12 was often asleep during the 5:00am medication pass, leading to a physician-ordered change to administer medications with breakfast.
F756-D: Resident R12's medication order for 5:00am Tylenol was changed to morning with breakfast; physician to issue new order for PRN antipsychotic 14-day limit compliance.
F757-D: Blood pressure medication parameters for Resident R12 were clarified and entered into EMAR; staff trained on documentation requirements for medication administration.
F758-D: Resident R22's PRN psychotropic order was forwarded to physician for review to comply with 14-day limit; EMAR updated accordingly.
F812-F: All unlabeled and undated foods were discarded; dietary staff to receive Serv-Safe training and monthly inspections to ensure proper food handling.
F880-D: Direct care staff received retraining on infection control and glove use during perineal care; facility to monitor compliance and provide ongoing education.
Report Facts
Substantial compliance date: Jan 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Younie | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 5
Date: Jul 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to allegations concerning residents' rights, personal property, resident funds management, and care issues at Leisure Homestead at Stafford.
Complaint Details
The visit was triggered by complaint investigations KS00164066 and KS00160923 concerning residents' rights, personal property, resident funds management, and care practices.
Findings
The facility was found to have multiple deficiencies including failure to allow a resident to retain personal property (recliner chair), failure to provide quarterly resident funds statements to durable powers of attorney, failure to notify residents or representatives when resident funds approached SSI resource limits, failure to obtain permission before disposing of a resident's motorized scooter, and failure to develop and implement a toileting program for a resident with urinary incontinence.
Deficiencies (5)
F 557: The facility failed to allow one resident to retain and use her personal recliner chair per her desire, resulting in distress and potential skin breakdown.
F 568: The facility failed to provide quarterly resident funds statements to durable powers of attorney for two cognitively impaired residents.
F 569: The facility failed to notify residents or their representatives when resident funds balances were within $200 of the SSI resource limit for three residents.
F 602: The facility failed to obtain permission from a resident's durable power of attorney prior to disposing of the resident's motorized scooter and lacked documentation of the disposal.
F 690: The facility failed to develop and implement a toileting program for a resident with urinary incontinence to maintain or improve continence status.
Report Facts
Census: 30
Resident funds account balance: 2148.46
Resident funds account balance: 1940.24
Resident funds account balance: 1951.46
Resident funds account balance: 1975.95
Resident funds account balance: 2343.93
Resident funds account balance: 2344.05
Resident funds account balance: 2720.9
Resident funds account balance: 2586.85
Resident funds account balance: 2375.58
Resident funds account balance: 4170.62
Resident funds account balance: 4251.62
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jul 30, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies related to resident rights, personal property management, resident trust fund statements, notification of Medicaid eligibility resource limits, disposal of resident property, toileting plans, and inventory of resident personal possessions. The facility outlines corrective actions and monitoring plans to achieve substantial compliance by 09/02/2021.
Deficiencies (6)
F557: The facility removed a resident's recliner for health protection but returned it after the resident requested it. Resident rights and personal property policies will be reviewed and updated with staff training and monitoring.
F568: Quarterly statements of resident funds activity and balances were sent to resident representatives. The facility will improve documentation and compliance with financial statement distribution.
F569: Resident representatives were notified of resident trust balances near Medicaid resource limits. The facility will continue quarterly reviews and notifications to comply with regulations.
F602: The facility disposed of a resident's non-functional motorized scooter without compensation documentation. The facility will monitor resident personal property and maintain documentation of notifications and actions.
F690: The affected resident has a revised toileting plan including staff alerts. The facility will identify other residents needing toileting plans and monitor effectiveness quarterly.
S0255: The facility will update inventories of resident personal possessions annually and upon admission, ensuring compliance with statutory requirements and monitoring by designated staff.
Report Facts
Deficiencies cited: 6
Compensation offered: 500
Compliance deadline: Sep 2, 2021
Inspection Report
Routine
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
The visit was a special infection control survey for COVID-19 conducted at the facility.
Findings
The survey resulted in a finding of no deficiency citations related to infection control.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 8, 2020
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2020-02-18.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2020-03-17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 25, 2020
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 submission.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 18, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated 02/18/2020 for Leisure Homestead Stafford RS.
Findings
The plan addresses deficiencies related to grievance procedures and notification of the LTC Ombudsman for discharges and hospitalizations. The facility outlines corrective actions to ensure compliance by 03/17/2020.
Deficiencies (2)
F585-E: The facility lacked a grievance process allowing residents and visitors to file grievances anonymously. A grievance box and forms will be provided and the policy communicated to residents and staff.
F623-D: The facility did not consistently notify the LTC Ombudsman of resident discharges and hospitalizations. A policy will be implemented and notification added to monthly administrative tasks.
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 2
Date: Feb 18, 2020
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with previously identified deficiencies related to resident grievances and notice requirements before transfer or discharge.
Findings
The facility failed to ensure residents' right to file grievances anonymously due to lack of discussion, signage, and accessible grievance forms. Additionally, the facility failed to notify the Long-Term Care Ombudsman of a facility-initiated hospitalization transfer for a resident.
Deficiencies (2)
F 585 Grievances. The facility failed to ensure residents could file grievances anonymously due to lack of discussion, signage, and accessible grievance forms.
F 623 Notice Requirements Before Transfer/Discharge. The facility failed to notify the Long-Term Care Ombudsman of a facility-initiated hospitalization transfer for Resident 12.
Report Facts
Resident census: 30
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 11, 2020
Visit Reason
This document is a Plan of Correction related to deficiencies identified in a prior inspection at Leisure Homestead at Stafford on February 11, 2020.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or reference to the Plan of Correction for the previously cited deficiencies.
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 4
Date: Feb 10, 2020
Visit Reason
The inspection was a resurvey with a complaint (#144524) at the Home Plus facility conducted on February 10-11, 2020.
Complaint Details
The visit was a resurvey following a complaint (#144524).
Findings
The administrator failed to ensure certified staff were awake, responsive, and present at all times. The facility also failed to complete required medication self-administration assessments, ensure medical provider orders for all medications administered, and maintain hot water temperatures within the required range.
Deficiencies (4)
26-42-102(b) Staff Qualifications Awake & Responsive: The administrator failed to ensure certified staff were in attendance and responsive at all times, as staff were observed smoking outside and leaving the building without coverage.
26-42-205(a)(1) Medication Self Administration Assessment: The operator failed to ensure a self-administration medication assessment was completed before one resident began self-administering medications.
26-42-205(d) Facility Administration of Medications: The administrator failed to ensure each resident's record contained a medical care provider's order for all medications administered by staff.
28-39-437 Plumbing and Piping Systems: The administrator failed to maintain hot water temperatures between 98°F and 120°F at resident sinks and kitchen sink, with temperatures observed up to 135°F.
Report Facts
Census: 5
Deficiencies cited: 4
Hot water temperature: 131
Hot water temperature: 132.6
Hot water temperature: 135
Hot water temperature after adjustment: 116.5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 2, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-02-28.
Findings
All deficiencies have been corrected as of the compliance date of 2019-03-29, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 3
Date: Feb 28, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS00134223 to assess compliance with nutritional, food safety, infection control, and laundry delivery standards.
Complaint Details
The visit was triggered by a complaint investigation #KS00134223. The findings were substantiated as the facility failed to meet multiple regulatory requirements related to nutrition, food safety, and infection control.
Findings
The facility failed to ensure dietary staff followed menus for pureed diets, did not properly sanitize food preparation equipment, improperly stored food items on the floor, mishandled food with gloves, and failed to deliver resident clothing in a sanitary manner to prevent contamination.
Deficiencies (3)
F803: The facility failed to ensure dietary staff followed the menu and recipe for 2 residents on pureed diets, specifically not pureeing garlic bread as required.
F812: The facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, including food items stored on the floor and failure to sanitize kitchen appliance blades before reuse.
F880: The facility failed to maintain infection prevention and control by allowing laundry staff to deliver resident clothing in a manner that caused contact with their own clothing, risking contamination.
Report Facts
Resident census: 28
Residents on pureed diet: 2
Sample size: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff I | Observed not pureeing garlic bread and not sanitizing kitchen appliance blades; used gloved hands improperly to serve bread | |
| Administrative nursing staff J | Interviewed regarding expectations for food preparation and serving | |
| Direct care staff H | Observed delivering resident clothing improperly by holding it against own clothing | |
| Administrative staff G | Reported training on proper laundry delivery and expectations for staff |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Feb 28, 2019
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found an isolated 'D' level deficiency indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2019-03-29.
Deficiencies (1)
The facility had an isolated 'D' level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 31, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-03-22.
Findings
All deficiencies have been corrected as of the compliance date of 2018-04-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 4, 2018
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 26-42-202 (a), 26-42-206 (e), 26-42-104 (d), 26-42-102 (b), and 26-42-205 (g)(3) were corrected as of the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 22, 2018
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a single 'D' level deficiency that was isolated and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-04-18.
Deficiencies (1)
A 'D' level deficiency was cited, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 3
Date: Mar 22, 2018
Visit Reason
The inspection was conducted as a health resurvey and complaint investigations #122960 and #118761.
Complaint Details
The visit was complaint-related, investigating complaints #122960 and #118761. The facility failed to ensure proper documentation and follow-up on resident #23's resuscitation preferences and failed to maintain a grievance tracking system.
Findings
The facility failed to ensure resident #23's resuscitation preferences were documented and followed, failed to maintain a systematic grievance tracking system, and failed to administer treatments and implement interventions to prevent pressure ulcers according to care plans and physician orders.
Deficiencies (3)
F578: The facility failed to ensure resident #23's resuscitation status was documented by the resident or durable power of attorney and did not follow up on DNR status from the hospital upon admission.
F585: The facility failed to maintain a systematic grievance policy that included documentation of grievance receipt, investigation, conclusions, and corrective actions for a period of 3 years.
F686: The facility failed to administer treatments and implement interventions to prevent pressure ulcers according to the care plan and physician orders for resident #13.
Report Facts
Facility census: 26
Residents reviewed for advanced directives: 16
Residents sampled: 13
Pressure ulcer measurements: 2
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 0.2
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Mar 22, 2018
Visit Reason
This document is a Plan of Correction submitted by Leisure Home Stafford in response to deficiencies cited during a prior inspection.
Findings
The plan addresses deficiencies related to code status documentation, grievance policy compliance, and pressure ulcer prevention and treatment.
Deficiencies (3)
F578-D: The facility lacked signed DNR orders for some residents and did not verify code status documentation consistently. A process was implemented to verify and document code status for all residents.
F585-C: The grievance policy was not aligned with regulatory language and lacked a proper grievance log and tracking system. The policy was revised, a grievance log created, and notices posted to inform residents of their rights.
F686-D: The facility failed to administer treatments and interventions according to care plans and physician orders to prevent pressure ulcers. Care plans and orders were reviewed and staff educated to ensure compliance.
Inspection Report
Re-Inspection
Census: 4
Deficiencies: 5
Date: Feb 27, 2018
Visit Reason
The visit was a resurvey conducted on 2/26-27/2018 to assess compliance with previously identified deficiencies at Leisure Homestead at Stafford.
Findings
The facility was found deficient in multiple areas including incomplete negotiated service agreements, unsafe food preparation and serving temperatures, failure to conduct quarterly emergency preparedness reviews, staff not being responsive at all times, and improper labeling of over-the-counter medications.
Deficiencies (5)
26-42-202 (a) Negotiated Service Agreement: The facility failed to ensure the negotiated service agreement for one resident included a description of services, service providers, and responsible parties for payment of outside services.
26-42-206 (e) Food Preparation: Staff failed to prepare and serve food at proper temperatures, including not checking food temperatures and reheating food inadequately.
26-42-104 (d) Disaster and Emergency Preparedness Education: The facility did not provide quarterly reviews of the emergency management plan with employees and residents.
26-42-102 (b) Staff Qualifications Awake & Responsive: Certified staff were observed unresponsive and asleep during duty hours, failing to remain attentive to resident needs.
26-42-205 (g)(3) Over the counter medication: Over-the-counter medications were not labeled with the resident's full name as required.
Report Facts
Census: 4
Sample residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Named in multiple findings including failure to ensure negotiated service agreements, food safety, emergency preparedness, staff responsiveness, and medication labeling | |
| Certified staff B | Observed asleep and unresponsive during duty hours | |
| Licensed Nursing Staff D | Observed with unlabeled over-the-counter medications | |
| Administrative licensed nursing staff E | Reported completing negotiated service agreements without full understanding of requirements |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Dec 28, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited were marked as corrected and completed as of the revisit date. No uncorrected deficiencies were noted at the time of this revisit.
Deficiencies (4)
Regulation 483.13(c) deficiency was corrected and completed by 12/28/2016.
Regulations 483.20(d)(3) and 483.10(k)(2) deficiencies were corrected and completed by 12/28/2016.
Regulation 483.20(k)(3)(i) deficiency was corrected and completed by 12/28/2016.
Regulation 483.25(h) deficiency was corrected and completed by 12/28/2016.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Nov 29, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Leisure Homestead Stattford.
Complaint Details
This Plan of Correction addresses deficiencies cited in response to a complaint investigation at Leisure Homestead Stattford dated 11/29/2016.
Findings
The facility had deficiencies related to abuse, neglect, exploitation, door alarms, and elopement prevention. Corrective actions include policy revisions, staff training, risk assessments, care plan updates, and monitoring procedures to prevent wandering and elopement.
Deficiencies (4)
F226-C: The policy for Abuse, Neglect, and Exploitation was reviewed and revised, including staff training on these topics and elopement prevention.
F280-D: Door alarm codes were changed to prevent residents from exiting without staff assistance, and wander risk assessments are conducted regularly to identify at-risk residents.
F281-D: Care plans for residents at risk of wandering and elopement were updated with interventions such as wanderguard bracelets and window alarms.
F323-E: Care plans for residents were updated with elopement prevention interventions, door alarms were repaired promptly, and ongoing assessments and monitoring were implemented.
Report Facts
Complete Date: Dec 28, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Younie | CEO | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 4
Date: Nov 29, 2016
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse, neglect, and failure to implement adequate care plans and safety measures for residents at risk of elopement.
Complaint Details
The complaint investigations #108398 and #108435 triggered the survey. The complaints involved failure to protect residents' rights regarding abuse and neglect, inadequate care planning for elopement risk, and safety hazards related to door alarms and supervision.
Findings
The facility failed to train staff and contractors on abuse policies related to unauthorized photographs, did not develop adequate care plan interventions for residents at risk of elopement, and failed to ensure exit door alarms functioned properly to prevent resident elopement. Two residents at moderate risk for elopement were not properly monitored or protected, resulting in one resident eloping and sustaining injuries.
Deficiencies (4)
F226: The facility failed to train staff, contractors, and volunteers on policies prohibiting abuse related to unauthorized photographs or recordings that demean or humiliate residents.
F280: The facility failed to develop prevention interventions following a wander assessment identifying a moderate elopement risk for one resident, despite documented wandering behaviors.
F281: The facility failed to ensure staff followed professional standards by not developing interventions for elopement prevention after assessing a resident as moderate risk on admission.
F323: The facility failed to ensure the resident environment was free of accident hazards by not developing interventions for elopement prevention for two residents and failed to ensure an exit door alarm sounded when opened.
Report Facts
Residents at risk for elopement: 9
Residents sampled for elopement risk: 3
Resident census: 28
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 29, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 28, 2016.
Deficiencies (1)
The facility had an "E" level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as the complaint coordinator and contact for questions regarding the survey. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 9, 2016
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the previously cited deficiency with ID Prefix S0835 and regulation 28-39-161 was corrected as of 02/09/2016. No other deficiencies are noted.
Deficiencies (1)
Deficiency with ID Prefix S0835 and regulation 28-39-161 was corrected as of 02/09/2016.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Feb 9, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.
Findings
The plan outlines corrective actions for deficiencies related to psychotropic medication monitoring, food labeling and storage, medication chart reviews, housekeeping glove use, and laundry water temperature control.
Deficiencies (5)
F329-D: The facility will care plan targeted behaviors of residents on psychotropic drugs and document indications and effectiveness of PRN medications with monthly reviews by licensed nurses.
F371-F: Unlabeled and undated food items have been disposed; the facility will label and date all food items before storage and ensure sanitary handling of dishes and utensils.
F428-D: The pharmacist will review charts of residents on PRN medications monthly to identify irregularities and ensure proper monitoring of medication use and behavior logs.
F441-F: Housekeeping staff will be trained on proper glove use to prevent cross contamination, with monitoring by maintenance supervisor and administrator.
S0835-F: Temperature gauges will be installed to ensure wash-water temperature does not fall below 72 degrees, with daily recording and staff training on chemical usage and monitoring.
Report Facts
Corrective action completion date: Feb 9, 2016
Temperature threshold: 72
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 11, 2016
Visit Reason
The visit 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 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the plan of correction. |
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 1
Date: Jan 11, 2016
Visit Reason
The visit was a Health Licensure Resurvey to assess compliance with infection control and other regulatory requirements.
Findings
The facility failed to perform and record daily hot water temperature checks for the laundry area as required, instead recording temperatures weekly. This noncompliance had the potential to affect all 28 residents.
Deficiencies (1)
KAR 28-39-161(5)(F) The facility failed to perform daily water temperature monitoring for the laundry area, recording temperatures weekly instead. This did not meet the facility policy requiring daily monitoring to ensure hot water temperatures of at least 160 degrees Fahrenheit.
Report Facts
Facility census: 28
Water temperature range: 162
Water temperature range: 184
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff | Interviewed regarding laundry water temperature monitoring |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 24, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied 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, widespread, with no harm but potential for more than minimal harm, and not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Dec 24, 2015
Provider agreement termination date: Mar 24, 2016
IDR request deadline: 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 process. |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Jan 29, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report confirms that all previously identified deficiencies have been corrected as of the revisit date.
Deficiencies (6)
Regulation 483.25(h) deficiency was corrected by 01/29/2015.
Regulation 483.35(d)(1)-(2) deficiency was corrected by 01/29/2015.
Regulation 483.35(i) deficiency was corrected by 01/29/2015.
Regulation 483.65 deficiency was corrected by 01/29/2015.
Regulation 483.70(h) deficiency was corrected by 01/29/2015.
Regulation 483.75(o)(1) deficiency was corrected by 01/29/2015.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 29, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-09-25.
Findings
All previously reported deficiencies identified by regulation numbers F0323, F0364, F0371, F0441, F0465, and F0520 were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 3, 2014
Visit Reason
This document reports the results of a first revisit conducted on December 3, 2014, to verify compliance with Federal requirements following a September 25, 2014 health survey of a nursing home facility.
Findings
The revisit found the most serious deficiencies to be 'F' level deficiencies. Based on these deficiencies, denial of payment for new Medicare/Medicaid admissions was imposed effective December 25, 2014, and termination of the provider agreement was recommended.
Report Facts
Denial of Payment effective date: Dec 25, 2014
Provider agreement termination date: Mar 25, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 3, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date of 12/03/2014.
Report Facts
Deficiencies corrected: 10
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 3, 2014
Visit Reason
The revisit was conducted to verify that the facility had achieved and maintained compliance with Federal requirements following the September 25, 2014 health survey.
Findings
The revisit found the most serious deficiencies to be 'F' level deficiencies. Based on these deficiencies, denial of payment for new Medicare/Medicaid admissions was imposed effective December 25, 2014, and termination of the provider agreement was recommended.
Deficiencies (1)
The revisit identified 'F' level deficiencies indicating serious noncompliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Report Facts
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter. |
| Sherriann Pater | Branch Manager Associate Regional Administrator | Authorized the letter for the Division of Medicaid and State Operations. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 3, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by the revisit date of 12/03/2014.
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 6
Date: Nov 25, 2014
Visit Reason
Revisit inspection to verify correction of previously cited deficiencies related to safety, food preparation, sanitation, infection control, environment, and quality assurance.
Findings
The facility failed to maintain a safe environment by not securing chemicals behind locked doors, failed to prepare pureed food according to dietician-approved recipes, failed to store food under sanitary conditions with undated open food items, failed to use effective germicidal chemicals, and failed to maintain a clean food preparation environment. Additionally, a resident's pet dog was allowed in the dining room during meal time. The quality assessment and assurance committee did not develop or implement plans to correct these deficiencies.
Deficiencies (6)
483.25(h) The facility failed to maintain a safe environment by not securing chemicals behind locked doors accessible to residents.
483.35(d)(1)-(2) The facility failed to prepare pureed food as recommended in the dietician approved recipe, adding unmeasured liquids and not conserving nutritive value.
483.35(i) The facility failed to store food under sanitary conditions by having undated open food items with no use by date in the walk-in refrigerator and dry storage.
483.65 The facility failed to provide a safe and sanitary environment by using chemicals that did not effectively kill bacteria and improper cleaning practices.
483.70(h) The facility failed to provide a safe, functional, sanitary, and comfortable environment by not thoroughly cleaning food preparation equipment and allowing a resident's pet dog in the dining room during meal time.
483.75(o)(1) The facility failed to ensure the quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies.
Report Facts
Residents affected: 32
Residents cognitively impaired and independently mobile: 12
Residents receiving pureed diets: 4
Deficiency severity E: 2
Deficiency severity F: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping staff C | Reported cleaning practices and use of unlabeled cleaning solutions | |
| Dietary staff F | Observed preparing pureed food with unmeasured liquids | |
| Dietary staff G | Interviewed about food storage and preparation practices | |
| Maintenance staff E | Interviewed about locked chemical storage | |
| Administrative nurse A | Interviewed about chemical storage and pet dog in dining room | |
| Administrative staff B | Interviewed about chemical storage, cleaning products, and infection control | |
| Consultant H | Interviewed about pureed food preparation standards |
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Oct 7, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including Medicare non-coverage notices, incident reporting, abuse policy updates, comprehensive resident assessments, care plan revisions, skin assessments, kitchen door security, food preparation, infection control, call light maintenance, and facility cleanliness.
Deficiencies (14)
F156-D: The liability notice form has been revised to include the QIO phone number and will be monitored for proper notice documentation.
F225-D: Incident reports and resident injuries will be reviewed and reported as required, with mandatory in-service training on abuse, neglect, and exploitation.
F226-E: The Abuse Policy has been updated per S&C letter 11-30 and includes reference checks for new hires, with monitoring to ensure compliance.
F279-D: Comprehensive assessments will be conducted on admission and as needed to develop care plans addressing resident needs with measurable goals.
F280-D: Care plans have been revised to reflect changes in resident assistance needs and toileting plans, with ongoing assessments and nurse responsibilities.
F281-D: Initial/temporary care plans will be developed upon admission with shift reports to convey new admission information.
F314-G: Skin assessments and Braden Scale will be done on admission, quarterly, or with significant changes, including wound documentation and physician notification.
F323-E: Two kitchen doors will be kept closed and locked with key access and keypad alarms to protect residents from hazards and unauthorized exit.
F364-E: Pureed foods will be prepared as directed with nutritional liquids to conserve nutritive value, monitored by dietary staff.
F371-F: Food items will be discarded by expiration dates, and food preparation equipment will be cleaned and monitored for chemical effectiveness.
F411-D: The facility will assist residents in arranging dental appointments with in-house dental services provided every six months.
F441-F: Staff have been educated on chemical wet times, with policies to prevent infection spread and monitoring by maintenance and administration.
F463-E: Call lights will be checked twice monthly and repaired as needed, with monitoring and maintenance alerts documented.
F465-F: Kitchen maintenance issues have been addressed, and a pet policy prohibiting dogs in the dining room during meals has been updated and enforced.
Report Facts
Plan of Correction completion dates: 10
Dental service frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Younie | Administrator | Submitted the Plan of Correction |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 29, 2014
Visit Reason
The inspection was a licensure survey for the facility named Leisure Homestead at Stafford.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 14
Date: Sep 25, 2014
Visit Reason
Health resurvey inspection of Leisure Homestead at Stafford nursing facility to assess compliance with federal regulations.
Findings
The facility had multiple deficiencies including failure to provide proper liability notices, inadequate abuse investigation and reporting, incomplete care plans especially for pressure ulcers and urinary incontinence, unsafe environment hazards including hot water and chemical access, unsanitary food preparation and storage, failure to maintain call light systems, and unsanitary dining environment with pets roaming during meal service.
Deficiencies (14)
F156: Facility failed to include the name and phone number of the Quality Improvement Organization on liability notices for two residents to file an immediate appeal.
F225: Facility failed to immediately report an allegation of abuse and injury of unknown origin, conduct a thorough investigation, and report results timely to the State survey agency for one resident.
F226: Facility failed to adequately screen 5 newly hired employees by completing reference checks and failed to update abuse policy with current reporting requirements.
F279: Facility failed to develop a comprehensive care plan with measurable goals and individualized interventions for pressure ulcer treatment and prevention for one resident.
F280: Facility failed to update and revise the plan of care to reflect changes in urinary incontinence status for one resident.
F281: Facility failed to develop an initial/temporary care plan upon admission for one resident.
F314: Facility failed to prevent avoidable pressure ulcers after admission for one resident and failed to provide adequate treatment and documentation.
F323: Facility failed to maintain a safe environment by propping open kitchen doors allowing resident access to hot water over 150°F and hazardous chemicals, and allowed unalarmed exit door access to outside.
F364: Facility failed to conserve nutritive value of pureed pork by thinning with water instead of nutritional liquid.
F371: Facility failed to store and prepare food under sanitary conditions including expired foods, improper cleaning and sanitizing of food equipment, and food residue on kitchen appliances.
F411: Facility failed to promptly refer a resident to a dentist after loss of a partial dental plate for at least four months.
F441: Facility failed to follow manufacturer instructions for wet times of cleaning chemicals and lacked chemicals effective against C-difficile spores, compromising infection control.
F463: Facility failed to maintain resident call light systems in working order for five resident rooms.
F465: Facility failed to maintain a safe and sanitary environment in the kitchen and dining room, including broken kitchen equipment and allowing two dogs to roam the dining room during meal service, one of which defecated on the floor.
Report Facts
Residents present: 32
Residents sampled: 22
Residents reviewed for pressure ulcers: 1
Residents reviewed for urinary incontinence: 2
Residents receiving pureed diet: 5
Expired yogurt containers: 2
Expired cranberry sauce containers: 5
Inspection Report
Enforcement
Deficiencies: 1
Date: Sep 25, 2014
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be at a 'G' level related to pressure ulcers. Due to noncompliance, enforcement remedies including denial of payment for new Medicare admissions were imposed effective December 25, 2014.
Deficiencies (1)
F314 Pressure Ulcers: The facility failed to implement corrective actions to prevent avoidable pressure ulcers and to provide appropriate care to prevent worsening of existing pressure ulcers.
Report Facts
Denial of payment effective date: Dec 25, 2014
Compliance deadline: Mar 25, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gillespie | Administrator | Named as facility administrator in the report |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement report |
Inspection Report
Enforcement
Deficiencies: 1
Date: Sep 25, 2014
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be a 'G' level. Due to noncompliance with F314 related to pressure ulcers, enforcement remedies including denial of payment for new Medicare admissions were imposed.
Deficiencies (1)
F314 Pressure Ulcers: The facility failed to implement corrective actions to prevent avoidable pressure ulcers and to provide appropriate care to prevent worsening of existing pressure ulcers.
Report Facts
Denial of payment effective date: Dec 25, 2014
Compliance deadline: Mar 25, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gillespie | Administrator | Named as facility administrator in report header |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement report |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 18, 2014
Visit Reason
A Life Safety Code survey was conducted 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, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
The facility was found to have 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Jun 18, 2014
Provider agreement termination date: Sep 18, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 18, 2014
Visit Reason
A Life Safety Code survey was conducted 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, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Jun 18, 2014
Effective date for provider agreement termination: Sep 18, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Kansas Department for Aging and Disability Services |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 1, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-06-18.
Findings
The report confirms that the previously identified deficiencies, including those under regulation 483.65, were corrected as of 2013-07-01.
Deficiencies (1)
Regulation 483.65 deficiency previously cited was corrected by 2013-07-01.
Report Facts
Date of Revisit: Jul 1, 2013
Date of Original Survey: Jun 18, 2013
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 1, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected.
Findings
The report confirms that the deficiencies previously cited were corrected as of the revisit date.
Deficiencies (1)
Regulation 483.65 deficiency with ID prefix F0441 was corrected on 07/01/2013.
Report Facts
Deficiency correction date: Jul 1, 2013
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 1
Date: Jun 18, 2013
Visit Reason
The visit was a health resurvey to assess compliance with infection control requirements following previous deficiencies.
Findings
The facility failed to maintain proper infection control practices, specifically in cleaning glucometers between uses and properly storing oxygen administration equipment, which could lead to the spread of infection among residents.
Deficiencies (1)
F 441 Infection Control: The facility failed to cleanse glucometers before and after use for residents #7, #17, and #26, risking infection spread. The facility also failed to properly store oxygen tubing and masks for residents #9 and #20, exposing equipment to contamination.
Report Facts
Census: 29
Sample size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Observed performing blood sugar checks without cleansing glucometer | |
| Nurse A | Verified glucometer cleaning procedures and oxygen equipment storage requirements |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 30, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of the revisit date of 04/30/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 30, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of the revisit date. The report lists multiple regulation citations with correction completion dates of 04/30/2012.
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 7
Date: Apr 2, 2012
Visit Reason
The visit was a Health Resurvey to evaluate compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to conduct criminal record checks for new staff, inaccurate resident assessments, inadequate care and services for residents, failure to prevent urinary tract infections, unsafe environmental hazards, unsanitary food handling practices, and poor infection control procedures.
Deficiencies (7)
F 226: The facility failed to conduct criminal record checks for 1 of 5 staff hired since the last survey, violating abuse and neglect policies.
F 278: The facility failed to accurately assess the status and activities of daily living for 2 of 9 sampled residents.
F 309: The facility failed to provide necessary care and services to maintain the highest well-being for 1 of 9 sampled residents, including failure to reassess positioning needs in a Broda chair.
F 315: The facility failed to provide appropriate toileting services to prevent urinary tract infection and maintain bladder function for 1 resident.
F 323: The facility failed to adequately assess a large gap in a positioning rail, creating a potential accident hazard for 1 resident.
F 371: The facility failed to prepare, distribute, and serve food under sanitary conditions, including dietary staff not fully covering hair during meal service.
F 441: The facility failed to maintain infection control practices by not requiring hand washing after resident contact and improperly handling soiled linens.
Report Facts
Resident census: 29
Sample size: 9
Staff missing criminal record check: 1
Washcloth bucket usage: 5
Washcloth bucket usage: 6
Gap size in positioning rail: 20
Gap size in positioning rail: 8
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N093002 POC 41SU11
Visit Reason
This document is a Plan of Correction submitted by the facility to address previously identified deficiencies.
Findings
The plan addresses deficiencies related to cleaning and disinfection of glucometers and proper storage of oxygen concentrators and related equipment to prevent contamination.
Deficiencies (2)
F0000 The facility will take the statement of deficiencies to the QA committee on 7-17-13.
F441-E All licensed nurses will be inserviced on cleaning and disinfection of glucometers. The DON will monitor weekly to ensure compliance. All resident oxygen concentrators will be fitted with protective cloth bags and staff will be trained on proper storage to prevent contamination.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N093002 POC 14DY11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior inspection at the facility.
Findings
No specific findings are detailed in this document. It serves as a corrective action plan linked to a previous deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N093002 POC KF9T11
Visit Reason
This document is a Plan of Correction related to a previous inspection or deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N093002 POC 14DY12
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N093002 POC MPD212
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies related to environmental safety, food preparation, food storage, chemical handling, and cleaning practices. Corrective actions include installation of self-locking door knobs, staff training, competency checks, and ongoing monitoring by supervisors and consultants.
Deficiencies (6)
F323-E: Janitor closet and chemical storage doors now have self-locking door knobs and signs to ensure they remain locked to protect residents from chemical exposure.
F364-E: Pureed foods will be prepared as directed on the menu and recipe, with measured portions and use of nutritional liquids to maintain consistency and nutritive value.
F371-F: All food storage areas and refrigerators/freezers have been cleaned and organized with proper labeling, dating, and removal of expired or dented food items.
F441-F: Chemicals on housekeeping carts have been replaced with original containers, and wet times updated to reflect changes in chemicals used.
F465-F: Refrigerator and freezer doors, food processing machine, and stove burners have been cleaned; dietary staff educated on cleaning schedules and responsibilities.
F520-F: The Quality Assurance/Assessment Committee met to review deficiencies and develop plans of correction, with ongoing quarterly monitoring and staff training on Root Cause Analysis.
Report Facts
Competency and compliance check dates: Multiple dates listed for competency and compliance checks between 12/09/2014 and 01/06/2015
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N093002 POC OZ6E11
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 addresses deficiencies related to dietary staff training on menus and pureed diets, safe food storage and handling, and laundry personnel training on safe handling and processing of linens and clothing. The facility outlines corrective actions and monitoring plans to achieve substantial compliance by March 29, 2019.
Deficiencies (3)
F803-D Dietary staff will receive extra training on menus, nutrition, and pureed foods to ensure residents on pureed diets are offered what is on the menu. Diet orders will be monitored by nursing and dietary staff to identify residents needing altered diets.
F812-D The facility purchased a dunnage rack for temporary food storage and will train dietary staff on safe food storage, sanitizing, handling, and glove use. Annual mandatory training will be assigned to all dietary staff.
F880-D Laundry personnel will receive additional training on safe handling, storing, processing, and transporting linens and clothing. Annual mandatory training will be assigned to all laundry personnel.
Report Facts
Residents on puree diet: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Younie | Administrator | Submitted the Plan of Correction |
| Diana Melander | Added the Plan of Correction | |
| Lacey Hunter | Modified the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: N093002 POC TBGL11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction addresses multiple deficiencies including incomplete criminal background checks for staff, inadequate restorative and therapy services for residents, improper use of positioning devices, individualized toileting plans, bed rail safety, dietary staff hygiene, and proper handling of soiled linen.
Deficiencies (7)
F226-D: The facility failed to obtain timely criminal background check results for a dietary staff member and will ensure all new employees have completed background checks before file completion.
F278-D: Residents #4 and #20 were not consistently receiving restorative assistance and therapy referrals; documentation and monitoring procedures will be improved.
F309-D: Resident #15 required proper positioning in a Broda chair to prevent sliding; monitoring for positioning and therapy referrals will be enhanced.
F315-D: Resident #6 will have an individualized toileting plan developed and monitored to ensure cleanliness and dryness.
F323-D: Resident #20 was provided with bed rails and repositioning aids; bed rail use and safety will be monitored regularly.
F371-E: Dietary staff were re-educated on hair covering requirements; compliance will be monitored weekly.
F441-E: Procedures for warming wet wash cloths and handling soiled linen were improved with staff education and monitoring.
Report Facts
Complete Date: Apr 3, 2012
Complete Date: Apr 30, 2012
Complete Date: Apr 10, 2012
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N093002 POC VSNE11
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for the facility Leisure Stafford.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N093002 POC ZO6E11
Visit Reason
This document is a plan of correction related to a prior inspection event identified as ZO6E11 for the facility with State ID N093002.
Findings
No deficiency details or findings are included in this document. It serves solely as a record of the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N093002 POC ZVYD11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 07-15-22.
Findings
The plan addresses multiple deficiencies related to abuse, neglect, exploitation prevention and intervention, EMS notification protocols, resident assessment, and staffing adequacy. The facility outlines corrective actions including staff training, policy review, monitoring, and quality assurance activities to achieve substantial compliance by 08/15/2022.
Deficiencies (4)
F609: The administrator will review abuse, neglect, and exploitation prevention and intervention and share information with staff on identifying and reporting incidents. Monitoring and reporting to the State Survey Agency will be conducted.
F610: The administrator will review abuse, neglect, and exploitation prevention and intervention, study surveyor training, and ensure thorough investigation and reporting of all alleged violations.
F684: Nursing staff will review EMS notification protocols for emergencies, update policies and care plans, and monitor changes quarterly.
F726: The administrator and QA nurse will update the facility assessment to assure adequate staffing numbers and competencies, with quarterly reviews by the QA committee.
Report Facts
Deficiency completion dates: Aug 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Younie | Administrator | Submitted the Plan of Correction |
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