Inspection Reports for Life Care Center of Andover
621 W. 21ST STREET, ANDOVER, KS, 67002
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 17, 2020 found the facility in compliance with all regulations and no deficiencies were cited. Prior inspections showed a pattern of deficiencies related mainly to resident care planning, assistance with activities of daily living, pain management, safe transfer techniques, and medication management, including failure to act on pharmacist recommendations. Complaint investigations substantiated issues such as inadequate supervision leading to resident elopements and delays in reporting and investigating neglect. Enforcement actions included denial of payment for new Medicare and Medicaid admissions due to pressure ulcer care deficiencies and immediate jeopardy findings related to resident safety, but these were resolved in subsequent inspections. The facility’s record shows improvement over time, with all deficiencies corrected by the most recent survey.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
42.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
605% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
71 residents
Based on a January 2020 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 17, 2020
Visit Reason
A revisit survey was conducted on 02/17/2020 and 02/18/2020 for all previous deficiencies cited on 01/15/2020.
Findings
All deficiencies have been corrected as of the compliance date of 02/05/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 9
Date: Jan 15, 2020
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving multiple complaint numbers.
Complaint Details
The visit was triggered by multiple complaints as indicated by complaint investigation numbers #146783, #142970, #145913, #144810, #149246, and #149196.
Findings
The facility was found deficient in multiple areas including failure to include responsible parties in care planning, failure to review and revise care plans, inadequate discharge summaries, insufficient assistance with activities of daily living, failure to provide restorative nursing services, unsafe transfer techniques, failure to ensure safe transport, failure to provide adequate pain management, and failure to act on pharmacist recommendations regarding medication orders.
Deficiencies (9)
Failed to include resident's responsible party in development of comprehensive care plan.
Failed to review and revise plan of care for residents with pain and contractures.
Failed to complete discharge summary for a resident as required.
Failed to provide necessary assistance with activities of daily living including bathing, shaving, and nail care for multiple residents.
Failed to provide restorative nursing services and adaptive equipment to prevent contractures and maintain mobility.
Failed to ensure residents remained free from accidents related to improper transfer techniques and unsafe wheelchair transport.
Failed to provide pain relieving interventions for a resident with pain due to contractures.
Failed to act on pharmacist's recommendation regarding lack of stop order date on PRN Lorazepam medication.
Failed to ensure resident remained free from unnecessary psychotropic medication related to lack of stop order date on PRN Lorazepam.
Report Facts
Residents reviewed: 21
Residents reviewed for ADL: 10
Bathing opportunities: 21
Baths received: 11
Pain medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Confirmed care plan reviews, restorative program reorganization, and failure to act on pharmacist recommendations. |
| Consulting Therapist HH | Consulting Therapist | Reevaluated residents for therapy/restorative needs and confirmed discharge instructions were not communicated. |
| Licensed Nurse G | Licensed Nurse | Observed resident's pain and contractures, confirmed care plan deficiencies. |
| Certified Nurse Aide O | Certified Nurse Aide | Provided passive range of motion and attempted pain relief interventions. |
| Certified Nurse Aide M | Certified Nurse Aide | Observed resident transported without foot pedals on wheelchair. |
| Certified Nurse Aide QQ | Certified Nurse Aide | Reported resident's nails were long, broken, and chipped. |
| Licensed Nurse HH | Licensed Nurse | Assessed resident after fall and confirmed use of full body lift was required. |
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Jan 15, 2020
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited in a prior survey report dated 1/15/2020.
Findings
The facility was found deficient in multiple areas including failure to include responsible parties in care plans for cognitively impaired residents, failure to review and revise care plans for pain relief and splint use, incomplete discharge summaries, inadequate routine assistance with bathing, nail care and shaving, inadequate restorative nursing and adaptive equipment provision, improper transfer techniques, failure to provide pain management interventions, failure to act timely on pharmacy recommendations, and failure to ensure stop orders for psychotropic medications.
Deficiencies (9)
Failed to include responsible party in development of comprehensive care plan for cognitively impaired resident.
Failed to review/revise care plans to include interventions for pain relief and splints.
Failed to complete discharge summary for discharged resident.
Failed to provide routine assistance with bathing, nail care, and shaving for multiple residents.
Failed to provide adequate restorative nursing and ensure adaptive equipment.
Failed to provide proper transfer technique and safe transport for residents.
Failed to provide interventions for pain management during range of motion.
Failed to act timely on pharmacy recommendations.
Failed to have a stop order after 14 days for PRN psychotropic medication.
Report Facts
Residents affected: 6
Pharmacy recommendations audited monthly: 5
Audit frequency: 3
Audit duration: 4
Pain monitoring frequency: 2
PRN psychotropic drug use limit: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniella Laffery | Administrator | Submitted the Plan of Correction. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 22, 2019
Visit Reason
A revisit survey was conducted on 07/22/2019 for all previous deficiencies cited on 06/24/2019.
Findings
All deficiencies have been corrected as of the compliance date of 06/28/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 3
Date: Jun 24, 2019
Visit Reason
Partial extended survey conducted for complaint investigations #KS00142441 and #KS00142612 regarding allegations of neglect and elopement of resident #1.
Complaint Details
The complaint investigation was triggered by allegations that resident #1 eloped from the facility on 5/3/19 without staff knowledge. The facility failed to timely report the incident, failed to thoroughly investigate it, and failed to provide adequate supervision to prevent the elopement. The resident was found by off-duty staff wandering outside the facility. The family was not notified until the next day.
Findings
The facility failed to timely report an allegation of neglect when resident #1 eloped from the building on 5/3/19, failed to thoroughly investigate the allegation, and failed to provide adequate supervision to prevent the resident from exiting the building, placing the resident in immediate jeopardy. The resident was found wandering outside by off-duty staff after staff failed to properly respond to an alarm and conduct a thorough search.
Deficiencies (3)
Failed to timely report an allegation of neglect to the State agency when resident #1 eloped from the building on 5/3/19.
Failed to thoroughly investigate an allegation of neglect when resident #1 eloped from the building on 5/3/19.
Failed to ensure adequate supervision to prevent resident #1 from exiting through a secured door triggering an alarm, resulting in the resident wandering outside unsupervised.
Report Facts
Census: 73
Date of elopement incident: May 3, 2019
Date of survey completion: Jun 24, 2019
Date of report sent: Jun 25, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Direct care staff who found resident #1 outside and escorted him/her back to the nursing station; wrote a notarized witness statement. | |
| Staff E | Direct care staff who found resident #1 outside and escorted him/her back to the nursing station; wrote a notarized witness statement. | |
| Staff G | Licensed nursing staff who responded to the door alarm but failed to thoroughly search the area; documented investigation; unavailable for interview. | |
| Staff C | Licensed nursing staff who was notified of resident elopement; wrote a notarized witness statement; could not recall filling out an incident report. | |
| Staff A | Administrative staff | Notified of resident elopement; involved in investigation and statements. |
| Staff B | Administrative nursing staff | Notified of resident elopement; involved in investigation and statements. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jun 24, 2019
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited in a prior survey related to allegations of neglect and inadequate supervision involving resident #1 who eloped.
Findings
The facility failed to report and thoroughly investigate an incident of alleged neglect when resident #1 eloped, and failed to provide adequate supervision to prevent the elopement. The facility has educated staff on reporting, investigation, and response procedures and will conduct ongoing reviews and drills to ensure compliance.
Deficiencies (3)
Failure to report an incident of alleged neglect related to resident #1 eloping.
Failure to thoroughly investigate an allegation of neglect related to resident #1 eloping.
Failure to provide adequate supervision to prevent resident #1 from exiting the facility with only one staff member responding to the alarm.
Report Facts
Deficiencies cited: 3
Plan of Correction completion date: Jun 28, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniella Ffery | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 12, 2019
Visit Reason
A revisit survey was conducted on 6/10-6/12/2019 for all previous deficiencies cited on 4/17/19 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 5/15/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Compliance date: May 15, 2019
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 12, 2019
Visit Reason
A second non-compliance revisit survey was conducted on 6/10-6/12/2019 for all previous deficiencies cited on 4/17/19.
Findings
All deficiencies have been corrected as of the compliance date of 5/15/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Dates of previous deficiencies and compliance: Apr 17, 2019
Compliance date: May 15, 2019
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 15, 2019
Visit Reason
This Plan of Correction document responds to deficiencies cited in a prior survey of Life Care Centers of Andover, addressing issues such as failure to notify physicians of changes in resident health status, failure to report and investigate suspected neglect, failure to develop individualized care plans, failure to provide adequate social services, medication administration errors, and failure to provide physician-ordered diets.
Findings
The facility submitted corrective actions for multiple deficiencies including failure to notify physicians and residents of changes, failure to report and investigate neglect, failure to develop individualized care plans for certain residents, failure to provide adequate social services related to grief counseling, medication administration errors, and failure to provide physician-ordered diets. The facility implemented staff education, daily reviews, audits, and monitoring to ensure compliance and planned to achieve substantial compliance by 5/15/2019.
Deficiencies (7)
Failure to notify resident #35's physician of declining health status and failure to notify resident #29 of a medication change
Failure to report an incident of suspected neglect related to resident #35
Failure to investigate an alleged incident of neglect for resident #35
Failure to develop individualized care plans for residents #29, #35, and #49
Failure to ensure adequate social services for resident #29 in relation to grief counseling
Failure to ensure only physician-ordered medications were administered to residents #29 and #49
Failure to provide physician-ordered diets to residents #29, #40, and #87
Report Facts
Date for substantial compliance: May 15, 2019
Resident IDs referenced: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 15, 2019
Visit Reason
This document is a Plan of Correction submitted by Life Care Centers of Andover in response to a survey report dated 4/17/2019, addressing deficiencies cited during the inspection.
Findings
The facility failed to develop and implement baseline care plans, review and revise care plans after assessments, develop discharge plans, provide treatment and care according to professional standards, ensure fall interventions, maintain an effective quality assessment and assurance program, and implement an antibiotic stewardship program. The facility has taken corrective actions including audits, staff education, and monitoring to achieve substantial compliance by 5/15/2019.
Deficiencies (7)
Failed to complete baseline care plans for residents #356, #357, and #358.
Failed to review and revise care plans for residents #35, #94, and #77 related to falls and diet progression.
Failed to develop discharge plans for residents #77 and #359.
Failed to provide treatment and care in accordance with professional standards for residents #35, #49, #29, #362, and #152.
Failed to ensure fall interventions were in place for residents #35 and #94.
Failed to maintain an effective quality assessment and assurance program.
Failed to implement and maintain an antibiotic stewardship program including proper tracking and monitoring.
Report Facts
Deficiencies cited: 7
Dates of resident discharge: 4
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 8
Date: Apr 17, 2019
Visit Reason
Complaint investigations were conducted based on multiple complaint numbers regarding concerns at Life Care Center of Andover.
Complaint Details
The complaint investigations involved multiple complaint numbers (KS00140239, KS00140085, KS00139981, KS00139154, KS00138559, KS00138565) related to resident care concerns including neglect, medication errors, and care planning.
Findings
The facility failed to ensure timely physician notification for resident decline, failed to notify a resident of medication changes, failed to report and investigate neglect allegations, failed to develop individualized care plans, failed to provide timely social services, failed to prevent significant medication errors, and failed to provide diets per physician orders.
Deficiencies (8)
Failed to notify physician timely when resident experienced significant decline and hospitalization.
Failed to notify resident of medication change.
Failed to report alleged neglect incident to state agency within required timeframe.
Failed to thoroughly investigate alleged neglect incident.
Failed to develop individualized care plans for dietary needs, pain management, grief counseling, and oxygen use.
Failed to provide timely medically-related social services for grief counseling.
Failed to prevent significant medication errors including administration of another resident's medications and failure to remove discontinued medication from cart.
Failed to provide therapeutic diets as prescribed by physician including failure to provide mechanically soft diet and appropriate diet condiments.
Report Facts
Residents reviewed for sample: 28
Residents reviewed for medication accuracy: 3
Residents reviewed for diet: 5
Potassium level: 6.1
Blood sugar: 285
Medication error blood pressure monitoring: 3
Resident census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff M | Nurse | Named in medication error involving administration of wrong resident's medications |
| Licensed nursing staff Z | Nurse | Involved in resident #35 care during decline and hospital transfer |
| Administrative nursing staff C | Administrator/Nursing Staff | Provided expectations for monitoring and reported on investigation and care plan reviews |
| Licensed nursing staff Y | Nurse | Involved in resident #35 lab refusals and family communications |
| Direct care staff N | CNA | Assisted resident #29 with transfer |
| Direct care staff T | CNA | Assisted resident #29 with transfer |
| Direct care staff V | CNA | Reported on resident #29 care needs and behaviors |
| Licensed nursing staff B | Nurse | Verified care plan reviews and medication delays |
| Dietary staff F | Dietary Staff | Reported on dietary stock and ordering |
| Direct care staff S | CNA | Administered discontinued medication to resident #49 |
| Licensed nursing staff Q | Nurse | Reported medication removal and documentation procedures |
| PCP X | Primary Care Physician | Provided orders and medical opinions related to medication errors and resident care |
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 11
Date: Apr 17, 2019
Visit Reason
A Non-Compliance Revisit and partial extended survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS to verify correction of previous deficiencies and assess compliance.
Findings
The facility was found not in substantial compliance with 42 CFR 483 subpart B, with deficiencies in baseline care plans, care plan timing and revision, discharge planning, quality of care including failure to maintain airway and oxygenation, medication errors, wound care, fall prevention, quality assurance program, and antibiotic stewardship.
Deficiencies (11)
Failure to complete baseline care plans for residents to ensure staff, resident, and representative awareness of medication, dietary instructions, services and treatments.
Failure to review and revise care plans for residents with changes in condition, including fall risk and feeding tube progression.
Failure to develop and implement effective discharge planning process focusing on resident goals, preparation for post-discharge care, and reduction of preventable readmissions.
Failure to ensure residents received treatment and care in accordance with professional standards, including failure to maintain airway and oxygenation for resident #35, resulting in hospitalization and death.
Failure to timely and thoroughly assess residents for changes in condition, including following medication errors and skin condition treatments.
Failure to monitor blood pressure per physician orders following medication error for resident #29.
Failure to assess resident following administration of medication to which resident was allergic.
Failure to ensure proper hand hygiene and glove use during wound care to prevent infection spread.
Failure to ensure fall interventions were in place and followed to prevent falls for residents with history of falls.
Failure to maintain an effective quality assessment and assurance program to develop and monitor corrective action plans for identified deficiencies.
Failure to accurately identify facility or community acquired infections, monitor antibiotic use, and document infection resolution to prevent spread of infections.
Report Facts
Resident census: 89
Fall risk evaluation score: 26
Fall risk evaluation score: 22
Blood sugar levels: 499
Blood sugar levels: 128
Potassium level: 6.5
BIMS score: 10
BIMS score: 8
BIMS score: 7
BIMS score: 15
BIMS score: 15
Blood pressure readings: 153
Blood pressure readings: 81
Fall interventions count: 8
Residents with infections: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Licensed Nursing Staff | Named in medication error finding and failure to monitor blood pressure |
| Staff O | Licensed Nursing Staff | Named in wound care hand hygiene deficiency |
| Staff Z | Licensed Nursing Staff | Named in failure to monitor resident with critical potassium level |
| Staff Y | Licensed Nursing Staff | Named in failure to monitor resident with critical potassium level and medication error follow-up |
| Staff L | Direct Care Staff | Named in fall prevention deficiency |
| Staff P | Direct Care Staff | Named in fall prevention deficiency |
| Staff N | Direct Care Staff | Named in fall prevention deficiency |
| Administrative Staff C | Administrative Nursing Staff | Named in discharge planning and quality assurance program findings |
| Administrative Staff A | Administrative Staff | Named in quality assurance program findings |
| PCP X | Primary Care Physician | Named in quality of care and medication error findings |
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 9
Date: Apr 17, 2019
Visit Reason
A Non-Compliance Revisit and partial extended survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS to verify correction of previous deficiencies and assess compliance with federal regulations.
Findings
The facility was found not in substantial compliance with multiple deficiencies including failure to complete baseline care plans, failure to revise care plans timely, inadequate discharge planning, failure to provide quality care resulting in immediate jeopardy, failure to prevent falls, and failure to maintain an effective quality assurance program including antibiotic stewardship.
Deficiencies (9)
Failure to complete baseline care plans for 3 residents to ensure staff, resident, and representative awareness of medication, dietary instructions, services, and treatments.
Failure to review and revise care plans timely for 3 residents including fall risk and diet progression.
Failure to develop and implement an effective discharge planning process for 2 residents to ensure transition to post-discharge care and reduce preventable readmissions.
Failure to provide appropriate and timely assessments and treatments to ensure resident #35 maintained a secure airway with adequate oxygenation, resulting in immediate jeopardy and resident death.
Failure to timely and thoroughly assess residents for changes in condition following medication errors for residents #29 and #49.
Failure to provide appropriate treatment to promote healing and prevent infection for residents #362 and #152 including improper hand hygiene and wound care technique.
Failure to ensure fall interventions were in place and followed to prevent falls for residents #94 and #35.
Failure to maintain an effective quality assessment and assurance program to develop and monitor corrective action plans for identified deficiencies.
Failure to accurately identify facility or community acquired infections, monitor infections, document antibiotic susceptibility, and resolution of infections to prevent spread among residents.
Report Facts
Resident census: 89
Fall risk evaluation score: 26
Fall risk evaluation score: 22
Blood sugar levels: 499
Blood sugar levels: 128
Critical potassium level: 6.5
Potassium level: 6.1
Blood pressure: 153
Blood pressure: 81
Fall investigation times: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Licensed Nursing Staff | Named in medication error and failure to monitor blood pressure |
| Staff Z | Licensed Nursing Staff | Named in resident #35 respiratory decline and failure to document assessments |
| Staff O | Licensed Nursing Staff | Named in wound care hand hygiene failure |
| Staff C | Administrative Nursing Staff | Responsible for social services and discharge planning |
| Staff P | Direct Care Staff | Named in fall prevention failure and resident transfer assistance |
| Staff L | Direct Care Staff | Named in fall prevention failure and resident transfer assistance |
Inspection Report
Plan of Correction
Deficiencies: 25
Date: Mar 8, 2019
Visit Reason
This document is a Plan of Correction submitted by Life Care Centers of Andover in response to a survey identifying multiple deficiencies in care, environment, documentation, and staffing.
Findings
The facility was found deficient in multiple areas including privacy during care, cleanliness, misappropriation of property, documentation of discharge information, care planning, nursing assessments, medication management, staffing sufficiency, and infection control. The facility has implemented corrective actions including staff education, audits, and policy revisions to achieve substantial compliance by 3/8/2019.
Deficiencies (25)
Failed to pull privacy curtain while providing incontinent care for resident #53.
Dirty urinals, missing tile, discolored areas, and unclean common areas.
Failed to ensure resident #69 was free of misappropriation of property.
Failed to document information communicated to receiving health care facility for resident #102.
Failed to provide written notification of hospital transfer to resident #93 representative and long-term care Ombudsman.
Failed to provide written notification regarding facility’s bed-hold policy for resident #93.
Failed to develop baseline care plans for residents #151 and #152 including key instructions.
Failed to review and revise care plans for residents #36 and #60 after assessments.
Failed to develop discharge plan for resident #102.
Failed to provide oral care, shaving, clean clothing, bathing, and meal assistance for various residents.
Failed to monitor respiratory status, vital signs, and skin conditions for residents #201, #93, #36, and #94.
Failed to provide interventions to prevent stage II pressure ulcer for resident #60.
Failed to remove splint/brace as ordered for resident #31.
Failed to ensure non-skid socks were in place for resident #94.
Failed to keep catheter bag below bladder level and properly anchor catheter for residents #60 and #36.
Failed to provide sufficient nursing staff to assure resident safety.
Three nurse aides lacked annual competency evaluations.
Failed to provide 12 hours of individualized training for 2 nurse aides.
Failed to ensure resident #98 did not receive psychotropic medication beyond 14 days without reevaluation.
Observed unlabeled and undated items and expired medication vial in medication room refrigerator.
Failed to provide appropriate fitting partial/dentures for resident #60.
Failed to maintain food temperatures during serving for resident #83.
Failed to provide clean podus boots for resident #39.
Failed to log antibiotics and monitor antibiotic use as part of antibiotic stewardship program.
Products improperly stored on floor and discolored spot above door in linen closet.
Report Facts
Date of substantial compliance: Mar 8, 2019
Number of nurse aides lacking annual evaluation: 3
Number of nurse aides lacking 12 hours training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniella Ffery | Executive Director | Submitted the Plan of Correction to KDADS. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 6, 2019
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and constituted Immediate Jeopardy, Past Non-compliance to resident health or safety for F689, CFR 483.25(d)(1)(2). Enforcement remedies will be recommended and the facility will not be given an opportunity to correct deficiencies before remedies are imposed.
Deficiencies (1)
Facility was not in substantial compliance with participation requirements constituting Immediate Jeopardy, Past Non-compliance to resident health or safety for F689, CFR 483.25(d)(1)(2).
Report Facts
Provider Number: 175157
Days to request IDR: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Laffery | Administrator | Facility administrator named in report |
| Caryl Gill | Complaint Coordinator | Named in report as complaint coordinator |
| Patty Brown | Interim Commissioner | Named as contact for informal dispute resolution |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 6, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior complaint investigation.
Findings
The plan indicates that the deficiencies identified as F0000 and F689-J were past noncompliance issues for which no plan of correction was required.
Deficiencies (2)
F0000 Past noncompliance: no plan of correction required.
F689-J Past noncompliance: no plan of correction required.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Mar 6, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#138867) regarding a resident elopement incident where the facility failed to provide adequate supervision to prevent a resident from exiting the building unnoticed.
Complaint Details
Complaint investigation #138867. The resident exited the facility without staff knowledge at approximately 9:45 pm, walked to the assisted living facility next door in 26 degree Fahrenheit weather. The facility failed to respond to the exit door alarm in a timely manner.
Findings
The facility failed to respond timely to a door alarm, resulting in a cognitively impaired resident exiting the building and walking to a neighboring assisted living facility in cold weather, placing the resident in immediate jeopardy. The facility conducted an investigation, implemented corrective actions including elopement drills, staff education, and updated care plans and assessments.
Deficiencies (1)
Failed to provide adequate supervision and/or assistive devices to prevent a resident from eloping the facility unnoticed.
Report Facts
Census: 101
Elopement risk residents: 7
Residents reviewed: 3
Temperature: 26
Deficiency correction completion date: Mar 1, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Staff E | Licensed Nursing Staff | Reported hearing the alarm but was too busy to respond |
| Licensed Nursing Staff F | Licensed Nursing Staff | Documented staff assisted resident back and performed assessment |
| Licensed Nursing Staff D | Licensed Nursing Staff | Witnessed resident at assisted living facility and verified statements |
| Direct Care Staff B | Direct Care Staff | Found resident missing and assisted in locating resident |
| Direct Care Staff C | Direct Care Staff | Assisted resident at assisted living facility and coordinated return |
| Administrative Nursing Staff A | Administrative Nursing Staff | Received calls about elopement and coordinated investigation |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 22
Date: Feb 7, 2019
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to evaluate compliance with resident rights, safe environment, free from misappropriation, transfer and discharge requirements, resident care, and infection control.
Complaint Details
The visit was complaint-related as indicated by the Health Resurvey and Complaint Investigation #137208.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during care, unsafe and unsanitary environment conditions, failure to protect residents from misappropriation of property, inadequate transfer and discharge documentation and notification, incomplete baseline and comprehensive care plans, insufficient assistance with activities of daily living, inadequate nursing assessments following changes in condition, failure to prevent pressure ulcers, improper catheter care, insufficient nursing staff, incomplete nurse aide evaluations and training, improper medication storage, failure to provide appropriate dental care, serving food at improper temperatures, and ineffective infection prevention and control practices.
Deficiencies (22)
Failure to maintain resident dignity during incontinent care by not pulling privacy curtain or closing door.
Failure to provide a safe, clean, comfortable, and homelike environment; dirty shower rooms and dining room sink.
Failure to ensure resident's right to be free from misappropriation of property.
Failure to document and communicate transfer and discharge information properly.
Failure to provide written notice of transfer and bed-hold policy to resident and representative.
Failure to develop baseline care plan including initial goals, medication, dietary instructions, and provide summary to resident/representative.
Failure to review and revise care plans timely to include individualized interventions for yeast infections, pressure ulcers, and resident preferences.
Failure to provide adequate assistance with activities of daily living including oral care, shaving, bathing, grooming, and feeding.
Failure to assess and monitor respiratory status and vital signs after change in condition with low oxygen saturation and pneumothorax.
Failure to prevent development of stage II pressure ulcer due to inadequate interventions.
Failure to follow physician orders for splint/brace use to prevent contractures.
Failure to ensure fall interventions including non-skid socks and call light use were effective to prevent falls.
Failure to provide appropriate catheter care including maintaining drainage bag below bladder level and proper anchoring to prevent trauma and infection.
Insufficient nursing staff to provide timely and adequate care including answering call lights, bathing, grooming, and feeding assistance.
Failure to complete annual nurse aide evaluations and provide required in-service training.
Failure to limit timeframe for PRN psychotropic medication to 14 days without physician reevaluation.
Failure to monitor medication expiration dates and improper storage of medications and staff food in medication refrigerator.
Failure to provide appropriate fitting partial dentures.
Failure to serve food at palatable temperatures and in a timely manner.
Failure to maintain resident care equipment in a sanitary manner to prevent infection.
Failure to implement an effective antibiotic stewardship program including monitoring antibiotic use and documentation.
Failure to maintain a sanitary, orderly, and comfortable environment including dirty floors, equipment on floor, and wet spots in linen closet.
Report Facts
Residents reviewed: 26
Residents with pressure ulcers reviewed: 5
Residents reviewed for ADLs: 7
Residents reviewed for urinary catheters: 2
Residents reviewed for dental: 2
Residents receiving antibiotics: 33
Residents receiving antibiotics: 37
Residents receiving antibiotics: 32
Residents receiving antibiotics: 35
Residents receiving antibiotics: 41
Residents receiving antibiotics: 34
Staff files reviewed: 5
Staff lacking annual evaluation: 3
Staff lacking 12 hours in-service training: 2
Residents with food temperature complaints: 50
Food temperature measured: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Nursing Staff | Confirmed failure to complete nurse aide evaluations and training, and lack of follow-up on respiratory status |
| Staff B | Licensed Nursing Staff | Confirmed failure to notify resident or representative of transfers and bed-hold policy, and lack of discharge plan documentation |
| Staff U | Direct Care Staff | Observed and reported resident dignity violation during care |
| Staff P | Direct Care Staff | Reported catheter bag placement above bladder level during transfer |
| Staff E | Licensed Staff | Confirmed catheter bag should be below bladder level and podus boots needed cleaning |
| Staff M | Licensed Nursing Staff | Noted medication refrigerator issues and confirmed lidocaine vial use |
| Staff G | Licensed Nursing Staff | Observed podus boots with crusted drainage |
| Staff H | Licensed Nursing Staff | Confirmed resident yeast infection and treatment |
| Staff C | Licensed Nursing Staff | Confirmed resident oral care needs and debris buildup |
| Staff Q | Direct Care Staff | Reported resident fall risk and non-use of call light |
| Staff W | Direct Care Staff | Reported insufficient staffing and missed baths |
| Staff X | Direct Care Staff | Reported insufficient staffing and missed baths |
| Staff DD | Direct Care Staff | Reported resident hygiene care and clothing changes |
| Staff FF | Direct Care Staff | Described bathing schedule and documentation |
| Staff EE | Direct Care Staff | Confirmed bathing schedule and documentation |
| Staff N | Licensed Nursing Staff | Confirmed responsibility for shaving resident |
| Staff R | Direct Care Staff | Reported grooming schedule for resident facial hair |
| Staff O | Direct Care Staff | Reported oral care schedule |
| Staff Y | Certified Nurse Aide | Lacked annual evaluation |
| Staff Z | Certified Nurse Aide | Lacked annual evaluation |
| Staff AA | Certified Nurse Aide | Lacked annual evaluation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 6, 2019
Visit Reason
A desk review was conducted for the deficiencies cited on 2019-01-22 to verify the facility's compliance.
Findings
The deficiencies cited on 2019-01-22 were placed back into substantial compliance based upon the facility's compliance date effective 2019-01-24.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 13, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective January 24, 2019.
Deficiencies (1)
A 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Date: Dec 13, 2018
Visit Reason
The inspection was conducted as a result of complaint investigations #135013 and #135487 to assess compliance with care plan development and pressure ulcer treatment requirements.
Complaint Details
The findings represent the results of complaint investigations #135013 and #135487.
Findings
The facility failed to develop comprehensive care plans that included residents' activity preferences for 2 of 4 sampled residents and failed to provide necessary treatment and monitoring to promote healing of pressure ulcers for 2 of 4 sampled residents. Deficiencies included lack of activity care plans and delayed wound measurement and treatment.
Deficiencies (2)
Failed to develop a comprehensive care plan including provision of activities for 2 of 4 sampled residents.
Failed to provide necessary treatment and services to promote healing of pressure ulcers for 2 of 4 sampled residents.
Report Facts
Census: 89
Residents sampled for review: 4
BIMS score: 7
BIMS score: 15
Pressure ulcer measurement: 8
Pressure ulcer measurement: 5
Pressure ulcer measurement: 0.1
Pressure ulcer measurement: 4.5
Pressure ulcer measurement: 5.5
Pressure ulcer measurement: 4.5
Pressure ulcer measurement: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity staff E | Reported completing activity evaluations and resident attendance at activities. | |
| Administrative nursing staff C | Verified lack of activity care plans and care plan completion responsibilities. | |
| Administrative nursing staff A | Verified expectations for activity care plans and wound measurement/treatment. | |
| Licensed nursing staff H | Verified failure to measure wounds and put interventions in place promptly. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 13, 2018
Visit Reason
This Plan of Correction is submitted in response to deficiencies cited in the Life Care Centers of Andover inspection report dated 12/13/2018, addressing care plan and pressure ulcer prevention deficiencies.
Findings
The facility was found deficient in ensuring care plans included resident preferences and in providing care to reduce the risk of pressure ulcers. Specific residents were identified with deficiencies in activity care plans and pressure ulcer care.
Deficiencies (2)
Care plans did not consistently include resident preferences for activities.
Failure to ensure care to reduce risk of pressure ulcers, including measurement and notification protocols.
Report Facts
Residents affected: 2
Residents affected: 2
Care plan audits: 5
Medical record audits: 3
Audit duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Cave | Executive Director | Submitted the Plan of Correction |
| Diana Melander | Added Plan of Correction | |
| Caryl Gill | Modified Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 27, 2018
Visit Reason
An off-site survey was conducted to address deficiencies cited on May 23, 2018.
Findings
The deficiencies cited during the prior survey were corrected as of the compliance date of June 27, 2018.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 27, 2018
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited related to medication administration and transcription.
Findings
The facility identified issues with medication dosage information, route of administration, and transcription errors. Corrective actions include clarifying orders, reviewing medication orders, implementing double check systems, and providing staff education to prevent future occurrences.
Deficiencies (1)
Deficient practice noted in F757 related to medication dosage, route of administration, and transcription errors.
Report Facts
Audit frequency: 4
Audit duration: 4
Pharmacy recommendation audit duration: 2
Plan of Correction completion date: Jun 27, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Cave | Executive Director | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 23, 2018
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 a "D" level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 27, 2018.
Deficiencies (1)
Most serious deficiency was a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 3
Date: May 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#129501) to review concerns related to medication administration and ensure compliance with drug regimen requirements.
Complaint Details
The visit was triggered by complaint investigation #129501 regarding medication administration errors and failure to follow physician orders.
Findings
The facility failed to ensure that three residents received medications as ordered by the physician, including incorrect dosages, improper routes of administration, and unclear medication orders, potentially risking adverse effects and ineffective treatment.
Deficiencies (3)
Resident #1 received incorrect doses of Fluticasone nasal spray (12 incorrect doses) due to inconsistent medication administration record and medication labeling.
Resident #2 did not receive Ondansetron via the sublingual route as ordered; the medication administration record did not specify the orally dissolving tablet route.
Resident #3's physician order for Dorzolamide ophthalmic eye drops did not specify which eye to treat, and the facility failed to clarify this, risking inaccurate administration.
Report Facts
Resident census: 86
Incorrect doses: 12
Residents reviewed: 3
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 3, 2018
Visit Reason
A revisit survey was conducted on 05/03/18 to verify correction of all previous deficiencies cited on 03/06/18.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 04/11/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 3, 2018
Visit Reason
A revisit survey was conducted on 05/03/18 to verify correction of all previous deficiencies cited on 03/06/18.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 04/11/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Deficiencies (1)
All previous deficiencies cited on 03/06/18 have been corrected.
Report Facts
Deficiency correction compliance date: Apr 11, 2018
Inspection Report
Plan of Correction
Deficiencies: 24
Date: Mar 6, 2018
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a state and federal inspection conducted on March 6, 2018.
Findings
The Plan of Correction addresses multiple deficiencies across various regulatory tags including resident rights, advance directives, environmental cleanliness, staff reference checks, comprehensive resident assessments, care planning, restorative services, medication management, staffing, dietary services, infection control, and equipment maintenance. The facility outlines corrective actions, education plans, audits, and ongoing monitoring to ensure compliance and prevent recurrence.
Deficiencies (24)
Failure to periodically review resident rights
Issues related to advance directives and code status
Provision of a home-like environment including dining room cleanliness
Incomplete reference checks for staff
Inadequate comprehensive, accurate, standardized assessments of residents' functional capacity
Lack of comprehensive person-centered care plans
Care plans not reviewed and revised after assessments
Lack of ADL care plans and restorative/maintenance programs
Inadequate assistance with resident hygiene and bathing preferences
Pressure ulcer prevention and treatment plan deficiencies
Inadequate restorative and maintenance programs for residents at risk
Inadequate supervision and use of assistive devices to prevent falls
Incontinence assessment and care planning deficiencies
Nutritional interventions and care planning deficiencies
Staffing needs and clinical staffing hours review deficiencies
Nurse aide training and competency requirements not met
Staff posting information incomplete or inaccurate
Medication management including black box warnings not properly documented or monitored
Dietary staffing and support deficiencies
Snack and meal provision not meeting regulatory requirements
Food safety and sanitation issues in kitchen and storage areas
Housekeeping and maintenance of outside areas inadequate
Infection control and antibiotic stewardship deficiencies
Dishwasher not functioning properly
Report Facts
Audit duration: 2
Audit frequency: 2
Audit frequency: 4
Audit frequency: 2
Audit frequency: 3
Audit frequency: 1
Audit frequency: 2
Audit frequency: 2
Audit frequency: 2
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Cave | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added Plan of Correction | |
| Lori Mouak | Modified Plan of Correction | |
| Regional Director of Clinical Services | Responsible for education on antibiotic stewardship | |
| Clinical Reimbursement Specialist | Responsible for reviewing care plans and reporting to Quality Assurance Committee | |
| MDS Coordinator | Responsible for assessments and reporting to Quality Assurance Committee | |
| Administrative Nurse | Responsible for weekly care plan reviews | |
| Dietary Manager | Responsible for dietary staffing and meal/snack provision education and audits | |
| Executive Director | Responsible for multiple education and audit activities |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 20
Date: Mar 6, 2018
Visit Reason
Health Resurvey and Complaint Investigation with multiple complaint numbers, including review of resident rights, advance directives, safe environment, staff employment screening, comprehensive assessments, care planning, activities of daily living, medication regimen, and infection control.
Complaint Details
Complaint investigation included multiple complaint numbers and focused on resident rights, advance directives, safe environment, staffing, care planning, medication management, infection control, and dietary services.
Findings
The facility had multiple deficiencies including failure to periodically review resident rights, failure to maintain advance directives documentation, unsafe and unclean dining environment, failure to obtain reference checks for new employees, incomplete comprehensive assessments and care plans, inadequate restorative nursing services, insufficient staffing, failure to monitor medications with black box warnings, failure to provide adequate toileting and hygiene care, failure to maintain kitchen sanitation and equipment, and failure to implement an antibiotic stewardship program.
Deficiencies (20)
Failure to periodically review resident rights with residents.
Failure to maintain advance directives documentation and obtain informed consent for code status.
Unsafe and unclean dining environment with food debris on floor and lack of home-like dining atmosphere.
Failure to obtain reference checks for new employees to ensure residents remain free of abuse, neglect, and exploitation.
Failure to complete comprehensive assessments and care area assessments for multiple residents.
Failure to develop and implement comprehensive care plans including restorative programs and ambulation plans.
Failure to provide restorative services to maintain or improve resident mobility and range of motion.
Failure to provide necessary assistance to maintain personal hygiene and grooming, including bathing and hand hygiene.
Failure to provide planned interventions for prevention of pressure ulcers and failure to maintain multipodus boots properly.
Failure to provide appropriate toileting and perineal care for incontinent residents and failure to provide proper catheter care.
Failure to provide ordered nutritional supplements and monitor weight loss.
Insufficient dietary support staff to safely and effectively carry out dietary functions.
Failure to provide residents with at least 3 meals daily at regular times and failure to provide snacks at non-traditional times.
Failure to maintain a clean and sanitary kitchen environment including storage, preparation, and serving of food.
Failure to properly dispose of garbage and refuse, resulting in debris and soiled gloves in garbage area.
Failure to develop, promote, and implement an antibiotic stewardship program to monitor antibiotic use and effectiveness.
Failure to maintain kitchen equipment in safe operating condition, including dishwasher not reaching required temperature.
Failure to provide sufficient nursing staff to ensure nursing and related services to attain or maintain highest practicable well-being.
Failure to post nurse staffing information including actual hours worked as required.
Failure to identify and monitor residents for adverse consequences associated with administration of medications with black box warnings.
Report Facts
Residents reviewed: 31
Residents with deficiencies: 5
Residents with deficiencies: 4
Residents with deficiencies: 3
Residents with deficiencies: 2
Residents with deficiencies: 1
Residents with deficiencies: 2
Residents with deficiencies: 2
Residents with deficiencies: 5
Residents with deficiencies: 5
Residents with deficiencies: 2
Staff hours missing: 5
In-service hours missing: 5
Dishwasher temperature: 110.6
Weight loss: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff UU | Activities Staff | Failed to review resident rights during resident council meetings |
| Staff Q | Administrative Staff | Unable to locate advance directives for resident #27 |
| Staff J | Administrative Nursing Staff | Confirmed lack of advance directives and restorative program |
| Staff VV | Housekeeper | Confirmed food debris on dining room floor |
| Staff YY | Administrative Staff | Confirmed missing reference checks for employees |
| Staff W | Administrative Staff | Confirmed responsibility for reference checks |
| Staff TT | Consultant Pharmacist | Identified lack of monitoring of black box warnings |
| Staff A | Administrative Nursing Staff | Confirmed lack of restorative program and failure to monitor black box warnings |
| Staff CC | Licensed Nursing Staff | Unaware of black box warnings and restorative program |
| Staff M | Therapy Staff | Confirmed resident #27 stopped therapy and did not know if restorative program was provided |
| Staff N | Dietary Staff | Reported lack of 2 full-time cooks and failure to distribute snacks |
| Staff OO | Administrative Staff | Unaware of requirement to post actual staff hours worked |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 16, 2018
Visit Reason
An off-site survey was conducted to review the deficiencies cited on December 29, 2017.
Findings
The deficiencies cited in the prior survey were corrected as of the compliance date of February 6, 2018.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Feb 6, 2018
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a complaint survey.
Findings
The Plan of Correction addresses multiple deficiencies including environmental concerns, care plan updates for residents with special dietary and dialysis needs, bathing assistance, catheter care, and toileting provision. The facility has implemented corrective actions such as audits, staff education, and ongoing monitoring to ensure compliance.
Deficiencies (5)
Environmental deficiency involving odor and cleanliness related to floor tiles and floor cleaning machine.
Care plan deficiency for resident #1 regarding proper diet for dependent resident and dialysis care.
Deficient bathing assistance and care planning.
Treatment administration record and care plan deficiency related to catheter and leg bag care.
Care plan deficiency for resident #1 regarding diet for dependent resident receiving dialysis.
Report Facts
Audit frequency: 2
Audit duration: 4
Audit frequency: 1
Audit frequency: 2
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 29, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an 'E' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective February 6, 2018.
Deficiencies (1)
Most serious deficiency was an 'E' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 5
Date: Dec 29, 2017
Visit Reason
The inspection was conducted based on complaint investigations #124422 and #125155 to assess compliance with regulations related to safe environment, care planning, ADL care, incontinence care, and dietary needs.
Complaint Details
The inspection was triggered by complaints #124422 and #125155 regarding sanitation, care planning, personal hygiene, catheter care, bowel management, toileting, and dietary compliance.
Findings
The facility failed to maintain a clean and sanitary environment affecting the assisted dining area, failed to properly review and revise care plans for therapeutic diets, failed to provide adequate bathing and personal hygiene care for dependent residents, failed to provide appropriate urinary catheter and bowel care, failed to provide toileting opportunities as planned, and failed to provide the ordered renal diet to a dialysis resident.
Deficiencies (5)
Failed to ensure a clean and sanitary environment in janitor's closet causing foul odor in assisted dining area.
Failed to review and revise care plan for therapeutic diet for resident #1.
Failed to provide bathing and personal hygiene care as expected for 3 residents (#1, 5, and 7).
Failed to provide urinary catheter care and bowel maintenance for resident #5; failed to provide toileting opportunities for residents #2 and #4.
Failed to provide the ordered renal diet to resident #1 receiving dialysis.
Report Facts
Census: 80
Bathing opportunities missed: 20
Dialysis frequency: 2
Weight gain: 6
Bowel movements missed: 18
Baths provided: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Housekeeping staff who identified foul odor source in janitor's closet | |
| Staff D | Licensed nursing staff | Verified resident #1 received Nepro supplement not with meals |
| Staff V | Consulting staff | Reported resident #1 had complicated diet and was involved in dietary review |
| Staff M | Direct care staff | Failed to provide personal hygiene care to resident #1 |
| Staff H | Direct care staff | Attempted to feed resident #1 and reported care provided |
| Staff P | Direct care staff | Reported bath aides rarely complete all baths due to other duties |
| Staff J | Direct care staff | Reported resident #5 totally dependent for ADL care |
| Staff U | Direct care staff | Reported resident #7 shower schedule and bathing concerns |
| Staff G | Licensed nursing staff | Provided digital stimulation to resident #5 and verified lack of catheter care orders |
| Staff A | Administrative staff | Verified bathing and dietary concerns and plans for correction |
| Staff C | Administrative nursing staff | Verified bathing and catheter care deficiencies |
| Staff B | Administrative nursing staff | Verified late care plan and bathing documentation issues |
| Staff L | Direct care staff | Assisted with resident #2 incontinent care |
| Staff E | Licensed nursing staff | Applied skin barrier for resident #2 |
| Staff K | Direct care staff | Reported resident #2 incontinent care practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 12, 2017
Visit Reason
An off-site survey was conducted to review deficiencies cited on 2017-10-13 and verify their correction by the compliance date of 2017-10-31.
Findings
The deficiencies cited on 2017-10-13 were corrected as of the compliance date of 2017-10-31.
Report Facts
Deficiency citation date: Oct 13, 2017
Compliance date: Oct 31, 2017
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Oct 31, 2017
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a complaint survey (Complaint 101317).
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation (Complaint 101317).
Findings
The facility identified deficiencies related to assistance with activities of daily living (ADLs) including bathing and oral care, bowel and bladder assessments, and timely dental services. The plan outlines corrective actions including audits, education, and care plan updates to ensure compliance and prevent recurrence.
Deficiencies (4)
Deficient practice in providing bathing assistance according to resident preferences and documentation of refusals.
Deficient practice in oral care assistance and oral assessments.
Deficient practice in bowel and bladder assessments and care planning to prevent infections and maintain function.
Deficient practice in ensuring residents receive dental services in a timely manner.
Report Facts
Audit frequency: 5
Audit frequency: 3
Audit frequency: 3
Audit frequency: 3
Audit frequency: 3
Dental appointment date: Dental appointment scheduled for 2017-10-12 and rescheduled for 2017-11-15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Cave | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 13, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective October 31, 2017.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Date: Oct 13, 2017
Visit Reason
Complaint investigation #121437 was conducted to assess the facility's compliance with regulations related to activities of daily living care, urinary continence, and dental services for dependent residents.
Complaint Details
Complaint investigation #121437 focused on personal hygiene care, urinary continence management, and dental services for dependent residents.
Findings
The facility failed to ensure adequate personal hygiene assistance and bathing opportunities for dependent residents, failed to provide individualized toileting plans to maintain normal bladder function and prevent urinary tract infections, and failed to provide timely dental health services for a resident with decayed teeth requiring extraction.
Deficiencies (3)
Failed to ensure 2 sampled residents received adequate personal hygiene assistance including bathing and oral hygiene care.
Failed to ensure 2 residents received individualized toileting plans to maintain normal urinary elimination and prevent urinary tract infections.
Failed to provide timely dental health services to a resident with decayed teeth requiring extraction.
Report Facts
Residents sampled for ADL care: 3
Residents reviewed for urinary incontinence: 4
Days delay for dental appointment: 194
Resident census: 72
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 2, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report indicates that all previously cited deficiencies were corrected as of the dates listed, with no uncorrected deficiencies remaining at the time of the revisit.
Deficiencies (1)
Deficiency with ID Prefix F0314 related to regulation 483.25(b)(1)
Report Facts
Deficiency correction date: Jul 3, 2017
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 3, 2017
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a prior survey, specifically addressing pressure ulcer prevention and treatment.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations related to pressure ulcer care, including staff education, skin assessments for all residents, and ongoing audits to ensure proper documentation and treatment.
Deficiencies (1)
Failure to ensure residents receive care consistent with professional standards to prevent pressure ulcers and provide appropriate treatment.
Report Facts
Audit duration: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Cave | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Caryl Gill | Modified the Plan of Correction document |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 27, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be F314, related to pressure ulcers, at a level of actual harm that is not immediate jeopardy. Due to the facility's history of noncompliance, no opportunity to correct deficiencies before remedies are imposed was given, resulting in enforcement actions including denial of payment for new Medicare and Medicaid admissions.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers, indicating actual harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: Jul 18, 2017
Previous survey date: Nov 9, 2016
Compliance deadline: Dec 27, 2017
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named in relation to complaint coordination and instructions for dispute resolution |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: Jun 27, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#117173) related to pressure ulcer care and treatment at the facility.
Complaint Details
The visit was triggered by complaint investigation #117173. The complaint involved inadequate care for pressure ulcers, including failure to assess, monitor, and treat wounds properly, and failure to use pressure relieving devices and positioning to prevent ulcer worsening.
Findings
The facility failed to ensure one resident admitted with pressure ulcers received adequate care to prevent recurrence and worsening of pressure ulcers. The resident developed multiple recurring and new pressure ulcers due to failures in assessment, monitoring, use of pressure relieving devices, proper positioning, and availability of physician-ordered treatments.
Deficiencies (1)
Failure to ensure care and services to prevent recurrence and worsening of pressure ulcers for resident #1.
Report Facts
Census: 65
Residents reviewed for pressure ulcers: 3
Pressure ulcers on resident #1: 4
Pressure ulcers on resident #1: 1
Pressure ulcers on resident #1: 2
Braden Scale Risk Assessment scores: 17
Braden Scale Risk Assessment scores: 18
Pressure ulcer measurements: 1
Inspection Report
Follow-Up
Deficiencies: 6
Date: Dec 21, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.25, 483.25(d), 483.25(l), 483.60(a),(b), and 483.65 were corrected as of the revisit date.
Deficiencies (6)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.60(a),(b)
Deficiency related to regulation 483.65
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 9, 2016
Visit Reason
This document reports on a revisit conducted on November 9, 2016, following a September 6, 2016 health survey, to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Complaint Details
The action is based on deficiencies found on the current revisit survey and a complaint survey conducted on September 28, 2016.
Findings
The revisit found the most serious deficiency to be a 'G' level deficiency, indicating a level of actual harm or above. As a result, a denial of payment for new Medicare and Medicaid admissions was imposed effective September 28, 2016, and a recommendation for termination of the provider agreement was made if substantial compliance is not achieved by March 6, 2017.
Deficiencies (1)
Most serious deficiency found was a 'G' level deficiency.
Report Facts
Denial of payment effective date: Sep 28, 2016
Recommended termination date: Mar 6, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Administrator | Named as facility administrator in the report. |
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed the letter and provided contact information. |
Inspection Report
Follow-Up
Deficiencies: 16
Date: Nov 9, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers and identification prefix codes were marked as corrected and completed as of the revisit date.
Deficiencies (16)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.15(c)(6)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.15(h)(5)
Deficiency related to regulation 483.20(g) - (j)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(k)
Deficiency related to regulation 483.30(a)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 16
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 9, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Life Care Center of Andover were corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 26-40-303 (b)(c), 26-40-305 (c)(1)(2), 26-40-305 (3), and 28-39-163 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Nov 9, 2016
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a survey conducted on November 9, 2016.
Findings
The facility developed and implemented corrective actions addressing deficiencies related to urinary catheter care, fluid restriction and medication administration, prevention of urethral trauma, monitoring of bowel movements and blood glucose, pain medication administration, and infection control. The plan includes education for licensed nurses and monitoring of corrective actions through audits and committee reviews.
Deficiencies (6)
Individualized plan of care for urinary catheter to prevent trauma and infection.
Discontinuation of fluid restriction and monitoring of weight and medication administration.
Catheter care to prevent urethral trauma and ongoing assessments with urologist consultation.
Monitoring of bowel movements, blood glucose levels, blood pressure, and medication administration.
Administration of pain medication and clarification of physician orders for bronchospasm medication.
Maintenance of infection control program to prevent and control infections within the facility.
Report Facts
Audit frequency: 3
Audit frequency: 2
Audit frequency: 2
Audit frequency: 5
Audit frequency: 12
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 6
Date: Nov 9, 2016
Visit Reason
The inspection was a non-compliance revisit and complaint investigation #106957 to assess regulatory compliance related to care planning, quality of care, medication administration, infection control, and other related concerns.
Complaint Details
The visit was triggered by a complaint investigation #106957 and a non-compliance revisit.
Findings
The facility failed to develop comprehensive care plans, provide necessary care to prevent catheter trauma and infections, monitor residents' weights and fluid intake, administer medications as ordered, and maintain an effective infection control program including surveillance and antibiotic use tracking.
Deficiencies (6)
Failed to develop a comprehensive, individualized plan of care for a resident's urinary catheter to prevent trauma and infection.
Failed to ensure quality of care for residents including failure to monitor fluid intake/output and weights, and failure to administer medication as ordered.
Failed to provide catheter care to prevent urethral trauma and failed to follow up timely with consulting urologist.
Failed to ensure residents' drug regimens were free from unnecessary drugs including failure to monitor blood glucose, blood pressure, and medication administration as ordered.
Failed to provide pharmaceutical services including accurate medication administration and clarification of physician orders.
Failed to maintain an infection control program including failure to trend infections, pathogens, antibiotic use, and data analysis.
Report Facts
Residents reviewed: 14
Residents with urinary catheters/urostomy reviewed: 3
Days without bowel movement: 3
Morphine doses administered: 27
Morphine doses administered: 30
Residents with infections treated with antibiotics: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Staff I | Interviewed regarding incomplete intake and output sheets. | |
| Licensed Nursing Staff M | Interviewed regarding catheter anchoring device and resident pain. | |
| Licensed Nursing Staff J and G | Observed providing treatment to resident's pressure ulcer and catheter care. | |
| Administrative Nursing Staff P | Interviewed regarding care plan updates for catheter anchoring device. | |
| Administrative Nursing Staff B | Interviewed regarding monitoring of weights, intake/output, medication administration, and infection control. | |
| Nurse Practitioner Consultant Staff H | Interviewed regarding catheter trauma and medication administration. | |
| Licensed Nursing Staff F | Interviewed regarding appointment scheduling and transportation. | |
| Consulting Urologist | Interviewed regarding resident's urethral erosion and catheter positioning. | |
| Consulting Pharmacy Staff Q | Interviewed regarding medication order and delivery failure. | |
| Administrative Staff A | Interviewed regarding medication administration and appointment scheduling. | |
| Administrative Nursing Staff G | Interviewed regarding infection control log and surveillance. |
Inspection Report
Plan of Correction
Deficiencies: 31
Date: Oct 6, 2016
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover addressing deficiencies cited during a prior survey. It outlines corrective actions, systemic changes, and monitoring plans to achieve substantial compliance.
Findings
The Plan of Correction details multiple deficiencies related to resident care, safety, medication management, environmental conditions, staffing, infection control, and policy compliance. It includes specific resident cases, systemic education and training, and monitoring strategies to ensure correction and ongoing compliance.
Deficiencies (31)
Falls investigated with root cause analysis completed for residents #35 and #45; resident #32 no longer in facility.
Residents receiving appropriate assistance and care plan updates related to dining, positioning, and dignity.
Resident bathing preferences and care plans updated; staff educated on resident rights and bathing schedules.
Resident council concerns addressed; staff educated on grievance procedures and call light response.
Environmental repairs and cleaning completed in therapy and resident areas.
Adequate lighting provided; staff educated on environmental concerns and monitoring.
MDS corrections made for residents; staff educated on assessment and documentation of oral and respiratory status.
Care plans updated for ADL needs, toileting, oral care; staff educated on incontinent care and bathing preferences.
Care plans revised for use and monitoring of oxygen and Bipap devices; staff education and audits planned.
Lab collections and pain documentation completed; staff educated on pain assessment and monitoring.
Bathing, oral care, and peri care provided per resident choice; staff education and observation audits planned.
Pressure ulcer treatment and wound care education provided; audits planned.
Urostomy appliance management to prevent infection; staff education and audits planned.
Falls investigated; chemical storage corrected; staff trained on fall prevention and mechanical lifts.
Respiratory therapy orders reviewed and updated; staff educated on respiratory care and medication administration.
Medication reviews by pharmacist; staff educated on medication monitoring and administration.
Staffing maintained to ensure quality care; education on acuity-based staffing and monitoring implemented.
Food service and kitchen sanitation improved; staff trained on protocols and cleaning schedules.
Medication storage and labeling corrected; staff education and audits planned.
Drug regimen reviews completed; new pharmacist engaged; staff education and monitoring planned.
Medication storage secured; medication room door repaired; staff education and audits planned.
Infection control improvements including cleaning, hand hygiene, and staff education; monitoring planned.
Facility leadership reviewed policies and procedures; education and monitoring of policy access implemented.
Certified Nursing Assistant training and evaluation files reviewed; in-service calendar updated and monitored.
Laboratory agreement obtained and monitored by Executive Director.
Bio-Terrorism Response plan updated and monitored by Executive Director.
Quality Assurance/Performance Improvement policies education provided; monitoring of corrective actions planned.
Door alarms and delayed mag locks installed for resident safety; staff educated and environmental rounds conducted.
Exhaust vent installed in beauty shop; staff educated and environmental rounds conducted.
Ground fault circuit interrupter installed in therapy area; staff educated and environmental rounds conducted.
Certified Nursing Assistant education and evaluation tracking improved; monitoring planned.
Report Facts
Residents affected: 14
Environmental rounds frequency: 2
Environmental rounds frequency: 3
Environmental rounds frequency: 8
Audit frequency: 3
Audit frequency: 12
Audit frequency: 8
Certified Nursing Assistant in-service hours: 12
Certified Nursing Assistant audit frequency: 3
Certified Nursing Assistant observation frequency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Executive Director | Submitted the Plan of Correction and named in multiple corrective action monitoring roles |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Enforcement
Deficiencies: 2
Date: Sep 6, 2016
Visit Reason
A Health survey was conducted on September 6, 2016, by the Kansas Department for Aging and Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Complaint Details
The enforcement action references deficiencies found on the current survey and a complaint survey conducted on February 24, 2016, indicating a history of noncompliance.
Findings
The survey found serious deficiencies at a level of actual harm that is not immediate jeopardy, with a history of noncompliance from a prior abbreviated survey on February 24, 2016. Enforcement remedies include denial of payment for new Medicare and Medicaid admissions effective September 28, 2016, until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (2)
Noncompliance with F314, Pressure Ulcers, indicating avoidable pressure ulcers occurred and inadequate care and services to prevent pressure ulcers.
Noncompliance with F323, Substandard Quality of Care as defined at CFR 488.301.
Report Facts
Denial of payment effective date: Sep 28, 2016
Noncompliance history date: Feb 24, 2016
Compliance deadline: Mar 6, 2017
Civil Money Penalty minimum amount: 5000
Hearing request deadline days: 60
Informal Dispute Resolution request deadline days: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Administrator | Facility administrator named in the report |
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed the enforcement letter |
Inspection Report
Census: 74
Deficiencies: 18
Date: Sep 6, 2016
Visit Reason
The inspection was a Health Resurvey, an Extended Health Resurvey and Complaint investigations related to multiple resident incidents and facility compliance.
Findings
The facility had multiple deficiencies including failure to thoroughly investigate and report resident falls with injuries, failure to promote resident dignity and respect, inadequate environmental cleanliness, insufficient lighting, incomplete resident assessments and care plans, failure to provide adequate bathing and oral care, pressure ulcer prevention and treatment deficiencies, inadequate respiratory care, medication administration errors, insufficient nursing staff, unsanitary food handling, and lack of updated facility policies and quality assurance oversight.
Deficiencies (18)
Failure to thoroughly investigate and report to the state agency 3 residents who experienced falls and injuries including head lacerations and fractures.
Failure to promote care for residents in a manner that maintains or enhances dignity and respect, including residents sleeping at dining tables, improper positioning, and inadequate clothing coverage.
Failure to maintain a clean, sanitary, and homelike environment in multiple resident hallways and common areas.
Failure to maintain adequate lighting in resident rooms and dining areas.
Failure to complete accurate comprehensive assessments for residents, including failure to document use of CPAP and dental status.
Failure to develop individualized care plans for urinary incontinence and ADL needs.
Failure to review and revise care plans for pressure ulcers and respiratory care.
Failure to provide bathing and oral hygiene opportunities as scheduled and needed.
Failure to provide care and services to assist with attaining or maintaining highest practicable physical level, including failure to obtain ordered labs and monitor pain and weights.
Failure to provide adequate supervision and assistive devices to prevent falls and accidents, including improper use of mechanical lifts and unsafe environment for cognitively impaired residents.
Failure to provide respiratory care services in a sanitary manner including maintenance and cleaning of oxygen and CPAP/BiPAP equipment.
Failure to ensure drug regimens are free from unnecessary drugs due to lack of monitoring, missing labs, conflicting orders, and failure to discontinue unused medications.
Failure to provide sufficient nursing staff to meet resident needs and ensure highest practicable well-being.
Failure to store, prepare, and serve food under sanitary conditions including expired food, unlabeled food, and improper handling of food and utensils.
Failure to provide pharmaceutical services with accurate acquiring, receiving, dispensing, and administering of drugs including expired medications and unlabeled or improperly stored medications.
Failure to maintain an infection control program including trending infections, proper hand hygiene, proper disposal of contaminated items, and proper cleaning and laundry procedures.
Failure of the governing body to review and implement facility policies and procedures in a timely manner.
Failure to conduct annual nurse aide performance reviews and provide required in-service education.
Report Facts
Resident census: 74
Number of residents reviewed: 32
Number of nurse aides reviewed: 5
Number of infections reported: 15
Number of infections reported: 16
Number of infections reported: 6
Number of infections reported: 5
Number of infections reported: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Named in fall investigation and oversight of infection control and medication administration |
| Staff E | Administrative Licensed Nursing Staff | Named in medication and infection control oversight |
| Staff D | Administrative Nursing Staff | Named in medication and respiratory care oversight |
| Staff C | Administrative Nursing Staff | Named in staffing and medication oversight |
| Staff I | Licensed Nursing Staff | Named in fall investigation and medication monitoring |
| Staff L | Licensed Nursing Staff | Named in fall investigation and medication administration |
| Staff RR | Direct Care Staff | Named in fall investigation and resident care |
| Staff AA | Direct Care Staff | Named in fall investigation and resident care |
| Staff QQ | Direct Care Staff | Named in resident care and bathing |
| Staff CC | Direct Care Staff | Named in resident care and fall risk |
| Staff ZZ | Direct Care Staff | Named in fall investigation for improper mechanical lift use |
| Staff KK | Pharmacy Consultant | Named in medication monitoring oversight |
| Staff GG | Housekeeping/Laundry Staff | Named in infection control and environmental cleanliness |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 20, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at the 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jul 20, 2016
Provider agreement termination date: Oct 20, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for informal dispute resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 12, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) was corrected as of 03/11/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency under regulation 483.25(h)
Report Facts
Deficiency correction date: Mar 11, 2016
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 12, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that all previously cited deficiencies were corrected as of 03/11/2016, with no uncorrected deficiencies remaining.
Deficiencies (3)
Deficiency with regulation 483.25 corrected
Deficiency with regulation 483.25(a)(3) corrected
Deficiency with regulation 483.30(a) corrected
Report Facts
Date of correction: Mar 11, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 11, 2016
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a prior survey related to falls and resident care.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations regarding fall prevention. Staff education and monitoring of care plan interventions for residents at risk of falls were emphasized.
Deficiencies (1)
Care plan reviewed and revised as needed for falls; interventions in place and followed by staff.
Report Facts
Observations of residents at risk for falls: 10
Compliance date: Mar 11, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Feb 24, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers 95422, 96693, and 96724.
Complaint Details
The visit was triggered by complaint investigations #95422, 96693, and 96724. The complaint was substantiated as the facility failed to prevent a fall for a high-risk resident, resulting in injury.
Findings
The facility failed to provide planned interventions to prevent falls for one cognitively impaired resident, resulting in a fall with a head laceration requiring three staples. The resident was left unattended in a wheelchair in their room despite care plans directing staff not to leave the resident alone, indicating inadequate supervision and failure to follow care plans.
Deficiencies (1)
Failure to provide planned interventions to prevent falls for a cognitively impaired resident, resulting in a fall with head laceration requiring three staples.
Report Facts
Resident census: 66
Fall Risk Assessment score: 22
Number of staples: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Direct care staff | Involved in pushing the resident to their room and leaving the resident unattended in the wheelchair |
| Administrative nursing staff B | Administrative nursing staff | Provided information about the resident's behaviors and falls in December |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 16, 2016
Visit Reason
Two separate abbreviated surveys were conducted on February 16, 2016 and February 24, 2016 to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The surveys found the most serious deficiency in the facility to be a 'G' level cited on February 24, 2016, resulting in enforcement remedies including a denial of payment for new Medicare and Medicaid admissions effective May 16, 2016 until substantial compliance is achieved.
Deficiencies (1)
Most serious deficiency cited at 'G' level on February 24, 2016
Report Facts
Denial of Payment for New Admissions Effective Date: May 16, 2016
Termination Recommendation Date: Aug 16, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 16, 2016
Visit Reason
Two separate abbreviated surveys were conducted on February 16, 2016 and February 24, 2016 to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The surveys found the most serious deficiency in the facility to be a 'G' level cited on February 24, 2016. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective May 16, 2016 until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Most serious deficiency cited at 'G' level on February 24, 2016
Report Facts
Denial of Payment for New Admissions Effective Date: May 16, 2016
Termination Recommendation Date: Aug 16, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 3
Date: Feb 16, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#95681 and 96112) regarding concerns about medication administration, bathing care, and staffing adequacy at the facility.
Complaint Details
The complaint investigation (#95681 and 96112) was substantiated with findings of medication administration failures, inadequate bathing care, and insufficient staffing.
Findings
The facility failed to ensure timely administration of pain medications for one resident, failed to provide bathing as planned for three residents, and lacked sufficient nursing staff to meet the physical, mental, and psychosocial needs of all 74 residents. Multiple observations and interviews confirmed inadequate staffing, delayed responses to call lights, and insufficient care provision.
Deficiencies (3)
Failure to ensure timely administration of PRN and routine pain medications for a resident.
Failure to provide bathing as planned for dependent residents, with some residents going 5 to 11 days without bathing.
Failure to provide sufficient 24-hour nursing staff to meet resident care needs, resulting in delayed care and unmet needs.
Report Facts
Census: 74
Residents requiring mechanical lift: 23
Staffing shortfall days: 13
Staffing shortfall hours: 43.16
Bathing opportunities for resident #4: 28
Bathing opportunities for resident #2: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff C | Licensed Nursing Staff | Named in medication administration delay and pain medication failure. |
| Administrative nursing staff A | Administrative Nursing Staff | Reported complaints regarding medication administration and provided staffing information. |
| Administrative nursing staff B | Administrative Nursing Staff | Reported on bathing care expectations and staffing adequacy. |
| Administrative nursing staff L | Administrative Nursing Staff | Confirmed staffing equation and staffing shortfalls. |
| direct care staff E | Direct Care Staff | Reported staffing shortages and impact on bathing and call light response. |
| direct care staff D | Direct Care Staff | Reported resident independence and staffing challenges. |
| direct care staff M | Direct Care Staff | Reported insufficient staffing on day shift. |
| licensed nursing staff G | Licensed Nursing Staff | Reported staffing adequacy concerns. |
| direct care staff F | Direct Care Staff | Reported challenges with bathing and repositioning due to staffing. |
| direct care staff I | Direct Care Staff | Reported call light delays and staffing shortages. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Feb 16, 2016
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a complaint investigation survey conducted on February 16, 2016.
Complaint Details
This Plan of Correction is in response to a complaint investigation survey conducted on February 16, 2016, at Life Care Center of Andover.
Findings
The plan addresses deficiencies related to timely administration of pain medication, bathing schedules, and adequate staffing to meet resident needs including timely call light response and removal of trays. The facility implemented education, audits, interviews, and compliance rounds to assure correction and continued compliance.
Deficiencies (3)
Failure to administer scheduled and prn pain medication in a timely manner.
Failure to provide baths per residents' desired schedules.
Inadequate staffing resulting in delays in bathing, repositioning, medication administration, call light response, and tray removal.
Report Facts
Resident interviews: 5
MARS reviews: 5
Bath audits: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Executive Director | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 29, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the deficiencies previously cited under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.60(a),(b) were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.60(a),(b)
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 29, 2015
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a complaint investigation survey.
Findings
The facility developed and implemented corrective actions to address medication administration errors and timely receipt of medications from the pharmacy, including staff education, competency audits, and monitoring through random observations and logs.
Deficiencies (2)
Medication error involving Resident #1; nurse educated and competency audited; no further neglect instances.
Issues with timely receipt of medications for Resident #1 and Resident #2; education and follow-up procedures implemented.
Report Facts
Random observations of medication pass: 10
Observation period: 3
Plan of correction submission date: Jun 29, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Executive Director | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 15, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 29, 2015.
Deficiencies (1)
Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Date: Jun 15, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#87713 and #87726) related to allegations of neglect and medication errors at the facility.
Complaint Details
The complaint investigation found substantiated neglect related to medication errors, including insulin administration to a non-diabetic resident and failure to report the incident to the state agency.
Findings
The facility failed to report a medication error involving insulin administration to a non-diabetic resident, and failed to provide ordered medications in a timely manner for newly admitted residents. There were errors in medication administration, including administering insulin to a resident without physician orders and borrowing medications from another resident. The facility also failed to report the medication error to the state agency as required.
Deficiencies (2)
Failed to report to the state agency an incident of neglect related to a medication error where insulin was administered to a non-diabetic resident without physician orders.
Failed to provide ordered medications in a timely manner on admission for two residents and failed to provide the correct physician ordered medication for one resident.
Report Facts
Census: 88
Residents sampled: 4
Units of insulin administered in error: 2
Medications not administered on admission: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Staff C | Licensed Nurse | Administered insulin to the wrong resident and confirmed the error |
| Administrative Nursing Staff B | Administrative Nursing Staff | Investigated the insulin error, counseled nurse C, and confirmed failure to report the incident |
| Administrative Staff A | Administrative Staff | Reported failure to report the insulin medication error to the state agency |
Inspection Report
Follow-Up
Deficiencies: 13
Date: May 8, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provision numbers were corrected as of the revisit date of 05/08/2015.
Deficiencies (13)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.15(f)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.20(k)(3)(i)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(e)(2)
Deficiency related to regulation 483.30(a)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.70(h)
Report Facts
Deficiencies corrected: 13
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Apr 27, 2015
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a prior survey.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies related to resident care, including notification of changes in resident status, bathing and waking schedules, skin care, urinary incontinence, restorative care, staffing, infection control, and facility grounds maintenance. The facility describes education, audits, monitoring, and performance improvement activities to ensure compliance and ongoing quality.
Deficiencies (13)
Failure to notify family and physician of changes in resident status and timely treatment initiation.
Resident bathing and waking schedules not aligned with resident preferences.
Provision of activities without interruption and adjustment of bathing times.
Care plan revisions to reflect current skin status and interventions.
Interim care plan completion upon admission and care plan updates.
Coordination of care for residents with pacemakers and dialysis.
Resident bathing and oral care per resident choice and care plan.
Management of skin integrity including repositioning and documentation.
Urinary incontinence program including assessment and documentation.
Provision of restorative range of motion as ordered and staffing for restorative duties.
Staffing levels and patterns to ensure nursing and related services are provided as ordered.
Infection log completeness including resolution dates, cultures, antibiotics, and tracking.
Maintenance of facility grounds to ensure safe, functional, sanitary, and comfortable environment.
Report Facts
Resident interviews: 5
Care plan audits: 5
Pacemaker audits: 1
Pre-Post Dialysis audits: 3
Oral care audits: 25
Restorative records audits: 3
Skin assessments audits: 5
Staff interviews: 5
Family interviews: 5
Infection log audits: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Executive Director | Submitted the Plan of Correction. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Apr 16, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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, resulting in a finding of substantial compliance effective May 8, 2015.
Deficiencies (1)
Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter related to the survey findings. |
Inspection Report
Census: 86
Deficiencies: 14
Date: Apr 16, 2015
Visit Reason
The inspection was a Health Resurvey and complaint investigations related to multiple citations including failure to notify physician timely, failure to provide resident choices, failure to provide ongoing activities, failure to revise care plans, failure to meet professional standards, failure to provide necessary care and services, insufficient nursing staff, infection control deficiencies, and environmental safety concerns.
Findings
The facility was cited for multiple deficiencies including failure to timely notify physician of a pressure ulcer, failure to provide resident choices for bathing and wake time, failure to provide ongoing activities, failure to revise care plans after significant changes, failure to develop interim care plans, failure to provide pacemaker checks, failure to coordinate dialysis care, failure to provide adequate oral hygiene and bathing, failure to provide range of motion therapy as ordered, insufficient nursing staff to meet resident needs, failure to monitor and treat pressure ulcers adequately, failure to provide timely toileting and peri-care, failure to maintain infection control program and failure to maintain safe and stable parking lot and entrance areas.
Deficiencies (14)
Failure to notify physician timely of a facility acquired stage I pressure ulcer and failure to develop care plan interventions for the pressure ulcer.
Failure to provide resident choices for bathing type and wake time.
Failure to provide ongoing activities for residents.
Failure to revise care plan following discovery of pressure ulcer.
Failure to develop interim care plan for newly admitted residents including urinary incontinence.
Failure to provide pacemaker checks from admission until discovered months later.
Failure to coordinate dialysis care including incomplete pre/post dialysis documentation.
Failure to provide dependent residents with necessary oral hygiene and bathing.
Failure to provide restorative range of motion therapy as ordered resulting in risk of further contractures.
Insufficient nursing staff to provide care and services to maintain highest practicable well-being of residents.
Failure to maintain an effective infection control program including lack of infection tracking and trending.
Failure to maintain safe, functional, and stable parking/resident pick up area with cracked and broken concrete and curbs.
Failure to provide timely repositioning and treatment of pressure ulcers for residents at risk.
Failure to check and change incontinent resident timely and failure to assess and provide appropriate urinary care.
Report Facts
Resident census: 86
Resident sample size: 23
Pressure ulcer size: 4
Pressure ulcer size: 1
Pressure ulcer size: 3
Pressure ulcer size: 0.5
Braden scale score: 12
Braden scale score: 17
Braden scale score: 18
Restorative therapy missed days: 48
Pacemaker check dates missed: 11
Wet brief duration: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Licensed Nursing Staff | Reported discovery of pressure ulcer and failure to notify physician timely |
| Staff F | Administrative Nursing Staff | Verified failure to notify physician timely and assessed pressure ulcer |
| Staff B | Administrative Nursing Staff | Verified failure to notify physician timely and failure to develop care plan |
| Staff O | In House Nurse Practitioner | Reported first notification of pressure ulcer and ordered treatment |
| Staff J | Licensed Nursing Staff | Verified lack of interim care plan and inadequate toileting care |
| Staff GG | Direct Care Staff | Reported bathing schedule and resident preferences |
| Staff HH | Direct Care Staff | Reported bathing schedule and resident preferences |
| Staff D | Direct Care Staff | Reported restorative therapy not completed due to staffing |
| Staff CC | Direct Care Staff | Reported restorative therapy not completed due to staffing |
| Staff EE | Direct Care Staff | Reported repositioning schedule and bathing delays |
| Staff Y | Licensed Administrative Staff | Discovered resident had pacemaker after altercation |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 8, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be isolated 'D' level deficiencies 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)
Isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy
Report Facts
Effective date for denial of payments: Jul 8, 2014
Effective date for provider agreement termination: Oct 8, 2014
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hall | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 21, 2014
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
The report confirms that the previously cited deficiency identified by regulation 28-39-149 with ID prefix S0235 was corrected as of 01/21/2014.
Deficiencies (1)
Deficiency identified under regulation 28-39-149 with ID prefix S0235
Report Facts
Deficiencies corrected: 1
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 21, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that all previously cited deficiencies have been corrected as of the revisit date, with each deficiency fully identified by regulation number and correction completion date.
Report Facts
Deficiencies corrected: 12
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Jan 21, 2014
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover addressing deficiencies cited during a prior survey and outlining corrective actions to ensure compliance with regulations.
Findings
The plan details corrective actions for multiple deficiencies including replacement of missing resident items, environmental repairs, assessment corrections, care plan revisions, pressure ulcer prevention, catheter management, medication administration, and infection control measures. The facility has implemented education, audits, and monitoring processes to maintain compliance.
Deficiencies (12)
Missing shoes and razor for Resident #54 were replaced and personal inventory sheet updated.
Hallways and resident rooms repaired to assure sanitary, orderly, and comfortable environment.
Resident #63 assessment corrected to identify dialysis status.
Resident #69 placed on Walk to Dine program and care plan revised.
Resident #69 care plan updated to assist staff in maintaining optimum function.
Pressure reduction cushion placed in Resident #27 wheelchair.
Resident #152 had catheter discontinued; education and audits planned for catheter management.
Resident #148 to receive appropriate treatment to prevent aspiration during feeding tube medication administration.
Resident #27 fitted with hip protectors to prevent falls; staff education and monitoring planned.
Discontinued medications counted and returned to pharmacy with audits and education.
Glucometers sanitized per infection control recommendations with staff education and audits.
Resident records updated with complete inventory of personal belongings.
Report Facts
Audit frequency: 3
Audit frequency: 5
Audit frequency: 2
Audit frequency: 4
Audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamelahall | Executive Director | Named as responsible for oversight and plan revision in multiple corrective actions |
| Director of Nursing | Responsible for education, audits, and monitoring related to assessments, catheter management, medication administration, and care plans | |
| Restorative Nurse | Responsible for ambulation program implementation and education | |
| Assistant Director of Nursing | Involved in monitoring pressure ulcer prevention measures | |
| Wound Nurse | Conducts audits and monitoring related to wound assessments and pressure ulcer prevention | |
| Weekend Nurse Manager | Checks residents at risk for pressure ulcers during rounds | |
| Staff Development Nurse | Performs competency checks and education on medication administration and infection control | |
| Director of Rehab | Educates therapy staff regarding communication on ambulation changes |
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 11
Date: Dec 26, 2013
Visit Reason
The inspection was a health resurvey of the Life Care Center of Andover to assess compliance with regulatory requirements including resident rights, housekeeping, assessment accuracy, care planning, treatment services, infection control, and medication management.
Findings
The facility was found deficient in multiple areas including failure to safeguard resident property, maintain a sanitary environment, accurately complete resident assessments, develop comprehensive care plans, provide appropriate treatment to maintain or improve resident abilities, prevent pressure ulcers, ensure medical justification for catheters, check feeding tube placement before medication administration, prevent repeated falls, properly store medications for destruction or return, and maintain infection control during blood glucose testing.
Deficiencies (11)
Failed to safeguard one resident's personal property.
Failed to maintain a sanitary, orderly, and comfortable interior environment on all hallways.
Failed to accurately complete resident assessments reflecting dialysis and pressure ulcer status.
Failed to develop comprehensive care plans including interventions for ambulation after discharge from therapy.
Failed to provide appropriate treatment and services to maintain or improve ambulation for a resident.
Failed to ensure pressure reducing cushion was in place for a resident at risk for pressure ulcers.
Failed to ensure medical need and physician order for indwelling urinary catheter.
Failed to check feeding tube placement prior to medication administration.
Failed to ensure residents received care and services to prevent repeated falls, including use of hip protectors.
Failed to adequately store medications held for destruction or return to pharmacy with proper accounting.
Failed to adequately sanitize common use glucometer and failed to follow infection control measures during blood glucose testing.
Report Facts
Residents reviewed: 22
Residents requiring blood sugar monitoring: 37
Residents with medications held for return/destruction: 14
Fall risk assessment scores: 22
Fall risk assessment scores: 24
BIMS score: 13
BIMS score: 14
BIMS score: 13
Wound measurement: 3
Wound measurement: 3.2
Medication dose: 5
Water flush volume: 30
Water flush volume: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Social Service Staff | Unaware of lost items reported by resident #54 |
| Staff M | Direct Care Staff | Did not recall resident #54 reporting missing items |
| Staff A | Administrative Staff | Reported inventory process and replacement of lost items |
| Staff P | Licensed Staff | Verified dialysis omission on resident #63 assessment and lack of restorative program for resident #69 |
| Staff O | Licensed Staff | Reported restorative services process and lack of restorative program for resident #69 |
| Staff Z | Direct Care Staff | Reported resident #69 required assistance and wheelchair for mobility |
| Staff I | Licensed Staff | Verified care plan changes and restorative program list absence for resident #69 |
| Staff Q | Licensed Nursing Staff | Reported wound care and pressure cushion needs for resident #27 and catheter removal |
| Staff U | Direct Care Staff | Assisted resident #27 without hip guards |
| Staff V | Direct Care Staff | Assisted resident #27 without hip guards |
| Staff W | Direct Care Staff | Reported resident #152 catheter removal and resident #55 fall risk care |
| Staff X | Licensed Staff | Lacked knowledge of medication return logging process |
| Staff F | Licensed Nursing Staff | Observed blood glucose testing without gloves or sanitizing glucometer |
| Staff G | Licensed Nursing Staff | Observed blood glucose testing without sanitizing glucometer between residents |
| Staff H | Licensed Nursing Staff | Observed blood glucose testing and sanitized glucometer |
| Staff I | Licensed Nursing Staff | Observed blood glucose testing and sanitized glucometer |
| Staff B | Licensed Administrative Staff | Reported medication return process and glucometer sanitizing policy |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 20, 2012
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 09/20/2012.
Deficiencies (1)
Deficiency under regulation 28-39-158(a) previously cited and corrected.
Report Facts
Deficiency correction date: Sep 20, 2012
Inspection Report
Follow-Up
Deficiencies: 3
Date: Sep 20, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiencies identified by regulation numbers 483.35(i), 483.60(b),(d),(e), and 483.65 have been corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 7, 2012
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Andover in response to deficiencies cited during a survey inspection.
Findings
The facility developed and implemented corrective actions to address deficiencies related to dietary department sanitation, medication expiration monitoring, safe handling of linens to prevent infection spread, and ensuring a qualified dietary manager. The plan includes staff inservices, cleaning schedules, audits, and ongoing monitoring by designated staff.
Deficiencies (4)
Failure to maintain a clean and sanitary dietary department for storage, preparation, and serving of food products.
Failure to ensure medications are monitored for expiration on an ongoing basis.
Failure to ensure safe handling of linens to prevent the spread of infections to residents.
Failure to have a qualified dietary manager to assure a clean and sanitary dietary department.
Report Facts
Dates of corrective action completion: Sep 20, 2012
Audit frequency: 1
Competency tests: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Allen | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 4
Date: Sep 4, 2012
Visit Reason
The inspection was conducted as an annual survey to assess compliance with dietary services regulations, including staffing, food safety, and sanitation in the dietary department.
Findings
The facility failed to retain a certified dietary manager and did not maintain adequate sanitation in the dietary department. Food was served at unsafe temperatures, and multiple areas in the kitchen exhibited grime, food residue, and poor cleaning practices.
Deficiencies (4)
Failure to retain the services of a certified dietary manager to oversee dietary staff and maintain a clean and sanitary dietary department.
Serving chicken salad sandwiches at unsafe temperatures (60-64 degrees Fahrenheit), risking foodborne illness.
Multiple sanitation issues including dried food on equipment, blackened crumbs in toaster, food crumbs on floor and under equipment, grime on microwave interior, sticky preparation tables, dirty floor fan, dirt/grime in kitchen gaps, sticky warmer door, food particles on walls, dirty walk-in refrigerator, grime on roller carts, broken drawer, and mop bucket with muddy water.
Dietary cleaning schedule for August 2012 lacked initials for numerous dates, indicating incomplete cleaning documentation.
Report Facts
Census: 93
Number of sandwiches served at unsafe temperature: 9
Date of temperature observations: Aug 29, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff A | Reported lack of knowledge on keeping food cold and identified lack of certified dietary manager | |
| Dietary staff K | Observed serving chicken salad sandwiches at unsafe temperatures | |
| Consultant I | Reported limited time to check the kitchen | |
| Administrative staff J | Identified current dietary manager lacked certification |
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