Inspection Reports for Life Care Center of Burlington

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 12/11/24.

All previously cited deficiencies have been corrected as of the compliance date of 01/16/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Life Care Center of Burlington in response to deficiencies cited during a survey conducted on December 11, 2024.

The Plan of Correction addresses multiple deficiencies related to abuse, neglect, reporting of alleged violations, bed hold policy, activities of daily living, qualified dietary staff, hospice services, and infection prevention and control. The facility has implemented corrective actions including staff education, audits, monitoring, and system improvements to ensure compliance and prevent recurrence.

The inspection was conducted as a health resurvey and complaint investigation related to allegations of resident abuse and other regulatory compliance issues.

The facility was found deficient in multiple areas including failure to prevent resident-to-resident abuse, failure to report and investigate abuse allegations timely, failure to provide required written notices for resident transfers and discharges, failure to employ a certified dietary manager, failure to ensure collaboration with hospice providers, failure to provide necessary assistance with activities of daily living, and failure to maintain an effective infection prevention and control program.

The visit was complaint-related, triggered by allegations of resident abuse and other regulatory concerns. The facility was found to have failed in preventing abuse, reporting abuse incidents timely, investigating abuse, and other compliance issues.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-09-25.

All deficiencies cited in the prior inspection have been corrected as of the compliance date 2023-10-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The document is a Plan of Correction submitted in response to deficiencies cited during a survey of Life Care Center of Burlington conducted on 9.25.23.

The plan addresses deficiencies related to resident falls and safe use of mechanical lifts, including staff education, resident assessments, equipment safety checks, and ongoing audits to ensure compliance and safety.

The inspection was conducted as a complaint investigation based on multiple complaint investigation numbers (#KS00182892, #KS00182556, #KS00182433, and #KS00182824).

The facility failed to ensure safe transfers for two residents (R1 and R2) who required mechanical lifts and assistance of two staff members. Both residents experienced falls during transfers when only one staff member assisted, placing them at risk for injury.

The visit was complaint-related involving four complaint investigation numbers. The findings substantiated that the facility did not follow proper transfer protocols, leading to resident falls.

This document is a Plan of Correction submitted by Life Care Center of Burlington in response to deficiencies cited during a survey conducted on 07/17/2023.

The facility had deficiencies related to infection control practices, including PPE use, respiratory infection isolation, hand hygiene, and environmental services such as linen handling. The Plan of Correction outlines systemic changes, staff education, auditing procedures, and monitoring to achieve substantial compliance by 08/11/2023.

A complaint survey was conducted on 07/13/23 and 07/17/23 for complaint #180749. Additionally, a Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess infection control practices related to COVID-19.

The facility was found to be in compliance with all regulations related to the complaint. However, the facility failed to utilize appropriate infection control practices to prevent transmission of COVID-19, failed to monitor residents who tested positive for COVID-19, failed to ensure visitors were aware of the COVID-19 outbreak, failed to ensure staff wore appropriate PPE including eye protection, failed to ensure proper signage for transmission-based precautions, and failed to ensure linens were transported properly. These failures increased the risk of spreading COVID-19 infection.

The complaint survey was conducted for complaint #180749. The allegations were reviewed with no noncompliance found related to the complaint itself. The infection control survey identified deficiencies related to COVID-19 infection prevention and control.

A revisit survey was conducted on 03/27/23 through 03/28/23 for all previous deficiencies cited on 01/31/23.

All deficiencies have been corrected as of the compliance date of 02/28/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Life Care Center of Burlington in response to deficiencies cited during a survey conducted on 01.31.23.

The Plan of Correction addresses multiple deficiencies related to comprehensive care plans, ADL care, treatment and prevention of pressure ulcers, bowel/bladder incontinence care, drug regimen management, psychotropic medication use, dietary staff qualifications, and food safety. The facility has implemented audits, staff re-education, monitoring, and ongoing reviews to ensure compliance and correction of cited deficiencies.

The inspection was a Health Resurvey to assess compliance with previously identified deficiencies and overall regulatory requirements at Life Care Center of Burlington.

The facility was found deficient in multiple areas including care plan timing and revision, ADL care provision, pressure ulcer prevention and treatment, catheter care, medication management, dietary staffing qualifications, and food safety practices. Several residents had unmet care needs placing them at risk for complications.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-10-12.

All deficiencies cited in the prior inspection have been corrected as of the compliance date 2022-11-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies cited during a survey of Life Care Center of Burlington conducted on 10/12/2022.

The facility developed and implemented a system to assure correction and continued compliance with regulations related to meal time delivery and service. Actions include ordering additional meal trays, posting meal times, monitoring meal delivery timeliness and quality, staff education, and ongoing audits.

The inspection was conducted as a complaint investigation (#174535) regarding the timeliness of meal service to residents.

The facility failed to ensure meals were served to residents within the scheduled meal service times, with observations and resident reports indicating meals were served up to one and one-half hours late. Staff acknowledged the delays and inability to consistently serve meals on time.

Complaint investigation #174535 focused on meal service timeliness. Residents and staff reported meals were served late, sometimes up to one and one-half hours after scheduled times. Administrative staff verified the issue.

A revisit resurvey was conducted to verify correction of all previous deficiencies cited on 07/14/2022.

All deficiencies have been corrected as of the compliance date of 07/29/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted as a complaint investigation covering multiple complaint investigation numbers related to the facility.

The facility was found deficient in ensuring resident safety related to fall prevention and medication administration. One resident suffered a right shoulder fracture due to inadequate ambulatory assistance without use of a gait belt. Another resident was administered incorrect medications due to failure to follow the five rights of medication administration.

The investigation included multiple complaint investigation numbers (#171542, #171941, #172161, #172153, #172286, #172410, #171944, #171907, and #172129). The findings were based on these complaints.

This document is a Plan of Correction submitted by Life Care Center of Burlington in response to deficiencies cited during a survey conducted on 7.13.22.

The facility developed and implemented a system to assure correction and continued compliance with regulations, including education of nursing staff on safe ambulation and medication administration, auditing resident needs, and ongoing monitoring by the DON and QAPI committee.

An offsite revisit survey was conducted on 06/23/2022 for all previous deficiencies cited on 05/05/2022.

All deficiencies have been corrected as of the compliance date of 05/26/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report for LCC Burlington.

The Plan of Correction includes corrective actions cross-referenced to specific deficiencies identified in the linked deficiency report 45LC11.

The inspection was conducted as a complaint investigation based on complaint investigation numbers KS00169161, KS00170883, and KS171413.

The facility failed to monitor and maintain an infection control program to prevent the spread of infection to 42 residents by not ensuring tuberculosis (TB) screening for newly hired employees who worked with those residents.

The complaint investigation found that newly hired employees lacked timely tuberculosis screening, with interviews confirming delays in TB testing and documentation. The facility acknowledged short staffing and procedural lapses in screening new hires.

An offsite revisit survey was conducted on 04/13/2022 for all previous deficiencies cited on 02/07/2022.

All deficiencies have been corrected as of the compliance date of 02/28/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey at Life Care Center of Burlington, specifically addressing issues related to quality of care following resident falls.

The plan addresses a deficiency where a resident experienced a fall resulting in a change of condition, diagnostic testing, and delayed physician response. The facility implemented systemic changes including staff education, monitoring compliance, and auditing physician notifications to ensure timely follow-up and correction.

The inspection was conducted as a result of complaint investigations identified by case numbers KS 00167367, KS 00168770, KS 0016049, and KS 0016001.

The facility failed to ensure timely follow-up and communication with the physician after a resident (R1) fell and sustained a fractured right clavicle. There was an 11-day delay between the x-ray report and obtaining physician orders for treatment, indicating a failure in the facility's follow-up procedures.

The report represents findings from complaint investigations # KS 00167367, KS 00168770, KS 0016049, and KS 0016001. The complaint was substantiated as the facility failed to timely communicate with the physician following a resident's fall and fracture.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2021-08-31.

All deficiencies cited in the prior inspection have been corrected as of the compliance date 2021-09-24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2021-07-22.

All deficiencies cited in the prior inspection have been corrected as of the compliance date 2021-08-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted as a complaint investigation based on complaint investigation numbers KS 00164293, KS 00164443, and KS 00165024.

The facility failed to provide adequate supervision to prevent elopement of residents, including Resident 4, who exited the building during a fire drill without staff knowledge. The doors automatically unlocked during the fire alarm, and staff were insufficient to monitor residents, placing them at risk for accidents outside the facility.

The visit was triggered by complaints identified as KS 00164293, KS 00164443, and KS 00165024. The complaint was substantiated by findings of inadequate supervision leading to elopement risk.

An offsite revisit survey was conducted on 08/24/2021 for all previous deficiencies cited on 07/12/2021 to verify correction of cited deficiencies.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/06/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Life Care Center of Burlington addressing deficiencies cited during a prior survey.

The plan outlines corrective actions for multiple deficiencies including failure to obtain signed bed hold agreements, incomplete discharge summaries and medication reconciliation, improper labeling of insulin pens, maintenance issues in the laundry area, and lack of required Abuse, Neglect, and Exploitation training for staff. The facility commits to education, audits, and systemic changes to ensure compliance by 08/06/2021.

The document is a Plan of Correction submitted in response to deficiencies cited during a survey at Life Care Center of Burlington, specifically addressing issues related to resident supervision and elopement risk.

Resident R4 required staff supervision for daily living and safety; deficiencies included inadequate monitoring during fire alarms and elopement risk assessments. The facility implemented systemic changes including updated assessments, staff education, and monitoring protocols to ensure compliance.

This Plan of Correction addresses deficiencies cited during a survey conducted at Life Care Center of Burlington, specifically related to routine nail care for residents.

The facility was found deficient in providing routine nail care to residents dependent on staff for physical needs, with corrective actions implemented to ensure compliance and ongoing monitoring.

The inspection was conducted as a complaint investigation (#163900) to evaluate allegations related to the care provided to residents, specifically focusing on activities of daily living.

The facility failed to ensure one dependent resident received proper personal hygiene care, specifically toenail care. Observations, interviews, and record reviews showed the resident's toenails were overgrown and untrimmed for an extended period, and staff lacked a system to monitor nail care.

Complaint investigation #163900. The deficiency was substantiated based on observations, interviews, and record reviews indicating failure to provide proper toenail care.

The inspection was conducted as a Health Resurvey and Complaint Investigation #KS00163832 to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including failure to provide bed-hold policy notification upon resident transfer, incomplete discharge summaries, inaccurate labeling of insulin pens for diabetic residents, unsafe and unsanitary laundry conditions, and failure to ensure required abuse, neglect, exploitation, and misappropriation training for staff.

The visit was triggered by a complaint investigation identified as #KS00163832.

A revisit survey was conducted on 05/26/21 to verify correction of all previous deficiencies cited on 03/04/21.

All deficiencies cited in the prior inspection were corrected as of 03/19/21, and no new non-compliance was found. The facility is in compliance with all regulations surveyed.

The document is a Plan of Correction submitted in response to deficiencies cited during a survey of Life Care Center of Burlington, addressing issues related to resident care including urinary catheter management and pressure ulcer treatment.

Deficiencies involved alleged deficient practices affecting residents with urinary catheter management and pressure ulcer care. The facility implemented corrective actions including audits, staff education, and monitoring to ensure compliance and prevent recurrence.

The inspection was conducted as a complaint investigation related to failure to identify lack of urinary output, timely physician notification, collection of urine sample, and failure to start antibiotic treatment for a resident, placing the resident in immediate jeopardy.

The facility failed to identify lack of urinary output and notify the physician timely for Resident 1, failed to collect a urine sample as ordered, and delayed antibiotic administration by three days. Additionally, the facility failed to monitor healing and perform neurochecks after falls for Residents 1 and 3. For Resident 2, the facility failed to complete a comprehensive wound assessment upon readmission, failed to provide ordered treatment for an unstageable pressure ulcer, and failed to have appropriate linens and mattress settings.

The complaint investigation included allegations #160499, #160500, and #160569. Immediate jeopardy was identified related to Resident 1's urinary care but was abated on 03/04/21 after the facility implemented corrective actions.

An offsite revisit was conducted on 10/23/2020 for all previous deficiencies cited on 09/09/2020.

All deficiencies have been corrected as of the compliance date of 10/09/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Life Care Center of Burlington in response to deficiencies cited during a survey conducted on 09/09/2020.

The Plan of Correction addresses deficiencies related to accuracy of assessments, development and implementation of comprehensive care plans, and increasing/preventing decrease in range of motion/mobility. The facility has implemented audits, education, and monitoring to ensure compliance and correction of these issues.

The inspection was conducted as a complaint investigation (#155647) to evaluate the facility's compliance with regulatory requirements related to resident care and assessments.

The facility failed to complete accurate comprehensive assessments for residents who refused care, failed to develop and implement accurate care plans for restorative services, and failed to provide appropriate treatment and services to maintain or increase range of motion for residents, resulting in potential decreased range of motion and unmet individual care needs.

The visit was triggered by complaint investigation #155647. The facility was found noncompliant in areas related to accuracy of assessments, care planning, and restorative services for residents who refused care or had limited mobility.

A non-compliance revisit for the Targeted Infection Control/Covid-19 survey was conducted on 7/28, 7/29 and 8/3/2020 for all previous deficiencies cited on 4/21/2020.

All deficiencies have been corrected as of the compliance date of 5/20/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Life Care Center of Burlington in response to deficiencies cited during a COVID-19 related survey conducted on April 21, 2020.

The plan addresses multiple deficiencies including investigation and prevention of alleged violations, supervision and accident hazards, and infection prevention and control. The facility implemented systemic changes such as staff education, audits, and updated care plans to ensure compliance and resident safety.

A COVID-19 Focused Infection Control Survey and a Focused Abuse Abbreviated Survey were conducted following multiple complaints involving abuse investigations and supervision to prevent accidents.

The facility failed to thoroughly investigate allegations of abuse including rape and resident altercations, failed to implement individualized care plans to prevent falls resulting in a resident's death, and failed to maintain an effective infection control program including incomplete tracking of COVID-19 cases among residents and staff.

The investigation was triggered by complaints KS00151120, KS00151166, KS00151366, and KS00150409 involving abuse allegations and supervision failures to prevent accidents. The facility failed to thoroughly investigate these complaints, including failure to interview multiple residents, failure to obtain hospital records, and failure to notify the State Agency of a resident's death.

An offsite revisit was conducted on 11/13/19 for all previous deficiencies cited on 09/23/19 to verify correction of cited deficiencies.

All deficiencies have been corrected as of the compliance date of 10/23/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Life Care Center of Burlington addressing deficiencies cited during a prior survey conducted on 9/23/2019.

The plan outlines corrective actions for multiple deficiencies including baseline care plans, pharmacy services, drug regimen reviews, menu preparation, food safety, infection prevention and control, and antibiotic stewardship. The facility has implemented audits, education, and monitoring to ensure compliance and prevent recurrence.

The inspection was conducted as a Health Resurvey and Complaint Investigation covering multiple complaint investigation numbers.

The facility was found deficient in multiple areas including failure to provide baseline care plan summaries to residents and representatives, failure to ensure availability and administration of medications as ordered, failure to timely act on pharmacist recommendations regarding unnecessary medications, failure to follow dietary recipes and serve food at proper temperatures, failure to maintain sanitary food storage and preparation areas, failure to maintain infection control procedures including proper disinfection of glucometers and unlabeled personal hygiene items, and failure to implement an effective antibiotic stewardship program.

This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.

The report indicates that all previously reported deficiencies identified by regulation numbers 483.12(c)(1)(4), 483.21(b)(2)(i)-(iii), and 483.25(d)(1)(2) were corrected as of 04/13/2019.

The document is a Plan of Correction submitted by Life Care Center of Burlington in response to deficiencies cited during a prior inspection, addressing corrective actions for identified issues.

The Plan of Correction addresses deficient practices related to incident investigations, abuse and neglect reporting, and fall management, including revisions to care plans and staff education to prevent future occurrences.

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.

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 reviewed and accepted, resulting in a finding of substantial compliance effective April 13, 2019.

The inspection was conducted as a complaint investigation (#138098) related to allegations of neglect involving a resident who fell and fractured a wrist while attempting to remove another resident from his/her bed.

The facility failed to report an incident of neglect to the state agency as required, failed to revise the care plan with new interventions following the resident's fall, and failed to ensure adequate supervision and assistive devices to prevent further falls. The resident with severe cognitive impairment fell while trying to remove another resident from his/her bed, resulting in a fractured wrist.

The complaint investigation (#138098) found that the facility did not report an incident of neglect involving resident #2 who fell and fractured a wrist while attempting to remove another resident from his/her bed. The facility concluded there was no abuse or neglect substantiated and did not report the incident to the state agency.

A revisit survey was conducted on 1/16/19 and 1/17/19 to verify correction of all previous deficiencies cited on 11/19/18.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 12/18/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Life Care Center of Burlington in response to deficiencies cited during a survey conducted on 11/19/2018.

The Plan of Correction addresses multiple deficiencies including environmental maintenance, baseline care plans, respiratory care, pain management, dialysis care, nurse aide performance, drug regimen management, psychotropic medication use, medication error rates, medication storage, food procurement and sanitary practices, and dietary services. The facility has implemented education, audits, and monitoring systems to ensure compliance and prevent recurrence.

The inspection was conducted as a Health Resurvey and Complaint Investigation related to dietary services at the facility.

The facility failed to retain the services of a full-time certified dietary manager to oversee the dietary department. Dietary staff reported not being certified or scheduled for the certification exam.

The visit included complaint investigations #134987, #135133, and #135272.

A Health Resurvey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and Medicaid programs.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to prior noncompliance on 06/07/2018, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.

A revisit survey was conducted on 8/8/18 to verify correction of all previous deficiencies cited on 6/7/18.

All deficiencies cited in the previous inspection have been corrected as of 6/27/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Life Care Center of Burlington in response to deficiencies cited in a prior inspection related to incident investigations and elopement policies.

The Plan of Correction addresses deficiencies related to incident investigations and elopement procedures, including staff education, audits, and ongoing compliance monitoring to prevent future occurrences.

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.

The survey found that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety related to F689; "J", CFR 483.25(d)(1)(2). Enforcement remedies including denial of payment for new admissions were imposed.

Complaint investigation #KS00130106 regarding an allegation of elopement and failure to thoroughly investigate the incident.

The facility failed to thoroughly investigate an elopement incident involving Resident #1, who exited the building without staff knowledge and was found outside approximately 30 to 45 minutes later. The facility also failed to ensure adequate supervision and training of staff, including agency personnel, regarding elopement risks and alarm procedures.

Complaint investigation #KS00130106 focused on an elopement incident involving Resident #1 who exited the facility without staff knowledge. The facility initially did not report the incident to the state agency, failed to identify the resident as an elopement risk, and had untrained agency staff unaware of elopement procedures. The resident was found outside by a bystander and returned to the facility.

The document is a Plan of Correction related to complaint investigations #124559 and #129615 for the facility.

The complaint investigations resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

Complaint investigations #124559 and #129615 were conducted and found no deficiencies.

The visit was conducted as a complaint investigation for complaint numbers 124559 and 129615 at the facility.

The complaint investigation resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

Complaint investigation #124559 and #129615 resulted in no deficiency citations.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at Life Care Center of Burlington.

The facility was cited for failing to transcribe and administer respiratory medication as ordered. The Plan of Correction outlines actions taken including medication transcription audits, education for licensed nurses, and ongoing admission audits to ensure compliance.

This Plan of Correction is related to a complaint investigation survey identified as LCC Burlington complaint 01172018.

The inspection was conducted as a result of complaint investigations #124968 and #125314 regarding pharmacy services and medication administration.

The facility failed to transcribe and administer respiratory medication as ordered to one resident, resulting in missed doses of Albuterol Sulfate/Ipratropium. The transcription error was not caught by the admitting nurse or the second nurse who checked the orders.

The findings represent the results of complaint investigations #124968 and #125314.

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.

The survey found the most serious deficiencies to be 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 February 15, 2018.

This document is a Plan of Correction submitted by Life Care Center of Burlington addressing deficiencies cited during a prior survey inspection.

The Plan of Correction details corrective actions, education, monitoring, and prevention measures for multiple deficiencies including housekeeping, care planning, medication administration, infection control, resident call systems, and facility policies. Substantial compliance dates are noted as 09/26/2017 for all items.

An offsite visit was completed on 10/19/2017 to verify correction of previous deficiencies cited on 08/28/2017.

The deficiencies previously cited have been corrected and no new non-compliance was found. The facility is in compliance with all regulations surveyed.

A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found a most serious deficiency at level "F", 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 reviewed and accepted, resulting in a finding of substantial compliance effective 09/26/2017.

The inspection was conducted as a Health Resurvey and Complaint Investigations #113193, #115877 and #116365.

The facility was found deficient in multiple areas including housekeeping and maintenance services, care plan revisions, medication administration and monitoring, infection control, call light functionality, sanitary conditions in laundry and medication rooms, staffing requirements, and medical record completeness.

This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 and Plan of Correction.

The revisit confirmed that the deficiencies previously cited under regulations 483.10(g)(14) and 483.24, 483.25(k)(l) were corrected as of 12/27/2016.

The inspection was conducted as a complaint investigation (#108065) focusing on the facility's failure to notify the physician timely regarding significant changes in a resident's condition.

The facility failed to notify the physician in a timely manner for a resident who experienced a fall with a hip fracture and pain, and a respiratory infection with fever. The resident remained in the facility approximately 19 hours before being sent to the emergency room. Additionally, the facility failed to provide timely and appropriate assessments and physician notification for the resident's ongoing fever and respiratory status.

The complaint investigation (#108065) found the facility failed to notify the physician timely for one sampled resident who had a fall with hip fracture and pain and a respiratory infection with fever. The resident was not sent to the hospital until approximately 19 hours after the fall. The facility also failed to appropriately assess and notify the physician regarding the resident's ongoing fever and respiratory status.

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.

The survey found the most serious deficiency to be 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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.

This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.

The plan addresses medication availability and administration deficiencies involving residents #1, 2, 3, and 4, with corrective actions including nurse education and monitoring of medication administration records.

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.

The report indicates that all previously cited deficiencies have been corrected as of the revisit date.

The inspection was conducted as a complaint investigation (#103916) regarding concerns about the timely delivery and administration of medications to residents.

The facility failed to ensure timely delivery and administration of medications for four residents reviewed, with multiple missed doses due to medications being unavailable or delayed delivery from an out-of-town pharmacy. The facility's policy lacked guidance on timely delivery of routine and stat medications, and there was no documented investigation or physician notification for missed doses.

Complaint investigation #103916 focused on medication administration delays and failures for four residents.

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.

The survey found the most serious deficiency to be an "E" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.

The Plan of Correction addresses multiple deficiencies related to fall prevention, resident wandering and fear, wound care orders, and care plan updates, with detailed corrective actions and compliance dates.

This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.

All previously cited deficiencies related to various regulatory requirements were corrected as of the revisit date, with corrections completed and verified for multiple identified items.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and plan of correction.

The inspection was a Health Resurvey conducted to assess compliance with previously cited deficiencies and overall facility regulatory requirements.

The facility was found deficient in multiple areas including failure to revise care plans after resident falls, inadequate management of resident behaviors related to wandering, failure to provide necessary care to prevent pressure ulcers, and failure to implement timely interventions to prevent repeated falls for a resident.

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.

The survey found the most serious deficiency to be an "F" level deficiency, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit confirmed that all previously reported deficiencies, identified by their regulation numbers, were corrected as of the revisit date.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to achieve compliance with Federal Medicare and Medicaid requirements.

The plan addresses multiple deficiencies including restorative services, resident safety related to hazardous equipment and chemicals, medication administration and monitoring, nurse staffing records, and glucose monitoring practices. The facility describes education, training, auditing, and monitoring activities to ensure compliance and resident safety.

A Health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found 'E' level deficiencies 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, resulting in a finding of substantial compliance effective October 17, 2014.

The inspection was conducted as a Health Resurvey and complaint investigations #79442 and #79454.

The facility was found deficient in multiple areas including failure to provide appropriate range of motion treatment, inadequate supervision leading to resident elopement, unsafe use of enabler bars with entrapment risk, unsecured hazardous chemicals, failure to monitor effectiveness of PRN medications, failure to maintain posted nurse staffing data, failure to act on pharmacist recommendations regarding medication monitoring, and inadequate sanitization of glucometers.

The inspection included complaint investigations #79442 and #79454.

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.

The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, 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.

This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The report documents that the deficiency identified under regulation 483.25(c) with ID prefix F0314 was corrected as of 07/19/2013.

This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection, specifically addressing treatment and services to prevent and heal pressure sores.

The plan outlines corrective actions including continued treatment for resident #62, staff education on pressure sore prevention and treatment, competency checks, and regular observations to ensure care plan interventions are followed.

The inspection was a Health Resurvey conducted to assess compliance with treatment and services to prevent and heal pressure sores in residents.

The facility failed to provide adequate treatment and services to promote healing and prevent infection for a resident (#62) who developed an avoidable stage 3 pressure ulcer on the left heel. Observations revealed failure to follow the care plan, improper wound care aseptic technique, and failure to use pressure relieving devices as ordered.

This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The report shows that the previously cited deficiency with ID prefix F0328 related to regulation 483.25(k) was corrected as of 08/20/2012.

The document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection, specifically addressing treatment and care for special needs related to physician recommendations and resident refusal of Bipap therapy.

The facility identified an issue where a resident refused Bipap therapy despite physician recommendation, and the Director of Nursing provided education and follow-up. The plan includes staff education, routine auditing of physician orders, and review by the Quality Assurance committee.

The inspection was conducted as a complaint investigation (#58745) regarding the facility's failure to follow-up on a physician recommendation for special respiratory equipment for one resident.

The facility failed to follow-up with the physician to clarify orders for a BIPAP machine for a resident with respiratory impairment, resulting in the resident not receiving the recommended respiratory equipment for nearly a month after returning from a hospital appointment.

The complaint investigation (#58745) found that the facility did not follow-up on a physician's recommendation for a BIPAP machine for a resident with chronic obstructive bronchitis and shortness of breath. The resident returned from a hospital appointment on 7/9/12 with orders for the machine, but the facility failed to clarify the order or ensure the resident received the equipment until questioned on 8/7/12.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to address identified issues.

The Plan of Correction details multiple areas requiring improvement including resident rights to visitor access, investigation and reporting of abuse allegations, individualized activities, housekeeping and maintenance, comprehensive resident assessments, urinary incontinence management, nutrition status, drug regimen monitoring, infection control, and facility maintenance such as ventilation and handrails.

The visit was a health re-survey to assess compliance with previously cited deficiencies and to verify correction of issues.

The facility was found deficient in multiple areas including failure to inform residents of their rights to contact the state ombudsman, inadequate investigation and reporting of abuse and neglect, failure to provide individualized activity programs, maintenance and housekeeping deficiencies, incomplete comprehensive assessments, failure to monitor medications with black box warnings, improper medication storage and handling, infection control lapses, inadequate ventilation in the beauty shop, and unsecured handrails in hallways.

This document is a Plan of Correction submitted in response to deficiencies identified in a prior complaint investigation at the facility.

The plan addresses deficiencies related to timely notification of changes in resident condition and provision of care and services to ensure the highest well-being of residents, including education, monitoring, and auditing processes.

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