Inspection Reports for Life Care Center of Burlington
601 CROSS STREET, BURLINGTON, KS, 66839-1105
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 23, 2025 found no deficiencies, confirming the facility was in compliance with all regulations surveyed. Prior inspections showed a pattern of deficiencies related mainly to resident abuse prevention and reporting, assistance with activities of daily living, dietary staff qualifications, infection prevention and control, and safe resident transfers. Several complaint investigations substantiated issues such as failure to prevent and investigate resident-to-resident abuse, delayed reporting of incidents, inadequate supervision leading to falls, and lapses in infection control practices. Enforcement actions including immediate jeopardy findings related to urinary care in 2021 and denial of payment for new admissions in 2018 were noted, but no fines or license suspensions were listed in the available reports. The facility appears to have addressed many prior deficiencies through corrective actions and staff education, with recent inspections showing improvement and no new citations.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
17.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
190% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
74 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 12/11/24.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Dec 11, 2024
Visit Reason
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.
Findings
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.
Deficiencies (9)
F0000 Credible Allegation of Compliance: Facility-wide system to assure correction and continued compliance with regulations.
F600 D-Free of Abuse, Neglect, and Exploitation: Updated care plans, staff education, and monitoring to prevent abuse and neglect.
F609 D-Reporting of Alleged Violations: Updated care plans and staff education on reporting suspected abuse and neglect.
F610 D-Investigate/Prevent/Correct Alleged Violation: Updated care plans, staff education, and monitoring to investigate and prevent violations.
F625 D-Notice of Bed Hold Policy Before/Upon Transfer: Staff education and audits on written notification for facility-initiated transfers.
F676 D-Activities Daily Living (ADL) Maintain Abilities: Staff education and audits on feeding assistance and dining room supervision.
F801 F-Qualified Dietary Staff: Dietary manager continuing certification course and monitoring progress.
F849 D-Hospice Services: Staff education and audits to ensure collaboration of care with hospice providers.
F880 F-Infection Prevention and Control: Staff education and audits on catheter care, barrier precautions, and water management.
Report Facts
Date of Compliance: 2025
Staff education frequency: 5
Audit frequency: 5
Audit frequency: 3
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 8
Date: Dec 11, 2024
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation related to allegations of resident abuse and other regulatory compliance issues.
Complaint Details
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.
Findings
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.
Deficiencies (8)
The facility failed to ensure all residents remained free from abuse when Resident 17 stomped on Resident 8's foot, placing residents at risk for injury and ongoing abuse.
The facility failed to report immediately to the administrator a resident-to-resident abuse incident when Resident 17 stomped on Resident 8's foot.
The facility failed to investigate and provide protective measures for an incident of resident-to-resident abuse by Resident 17.
The facility failed to provide written notification for facility-initiated transfers and failed to notify the Long-Term Care Ombudsman for residents discharged to hospitals.
The facility failed to ensure Resident 47 received assistance eating her breakfast meal, placing her at risk for choking, impaired nutrition, and further decline in ADL ability.
The facility failed to employ a full-time certified dietary manager to oversee nutritional services for 73 residents.
The facility failed to ensure collaboration between the hospice provider and the facility for Resident 45, regarding the plan of care and services provided.
The facility failed to maintain an infection prevention and control program, including failure to provide sanitary catheter care and implement Enhanced Barrier Precautions for Resident 40, and failed to implement an adequate water management program.
Report Facts
Residents in sample: 18
Residents reviewed for hospitalization: 3
Residents reviewed for ADLs: 2
Residents reviewed for hospice services: 1
Residents reviewed for infection control: 1
Facility census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Mentioned in relation to abuse reporting, investigation, and ADL assistance findings |
| Administrative Nurse E | Administrative Nurse | Mentioned in relation to abuse reporting and infection control findings |
| Certified Nurse Aide M | Certified Nurse Aide | Mentioned in relation to resident behaviors and meal assistance |
| Consultant GG | Mentioned in relation to abuse incident investigation | |
| Dietary Staff BB | Dietary Staff | Dietary manager without certification |
| Social Services Staff X | Social Services Staff | Mentioned in relation to failure to notify LTCO of resident transfers |
| Licensed Nurse H | Licensed Nurse | Mentioned in relation to meal assistance and resident feeding |
| Certified Nurse Aide N | Certified Nurse Aide | Mentioned in relation to infection control and catheter care |
| Licensed Nurse G | Licensed Nurse | Mentioned in relation to infection control and catheter care |
| Administrative Staff A | Administrative Staff | Mentioned in relation to LTCO notification and water management |
| Maintenance Staff V | Maintenance Staff | Mentioned in relation to water management and Legionella testing |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-09-25.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 25, 2023
Visit Reason
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.
Findings
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.
Deficiencies (1)
Accidents related to resident falls and safe transfer using mechanical lifts.
Report Facts
Audit frequency: 3
Audit duration: 60
Plan of Correction completion date: Oct 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Stockebrand | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint investigation numbers (#KS00182892, #KS00182556, #KS00182433, and #KS00182824).
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure staff transferred residents requiring mechanical lifts with assistance of two staff members, resulting in falls.
Report Facts
Census: 64
Residents reviewed for accidents: 2
Residents selected for review: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | On duty when R1 fell; stated staff transferred R1 by herself against protocol. |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted R1 during transfer when fall occurred; lacked additional staff assistance. |
| Administrative Staff A | Administrative Staff | Stated expectation of two staff members assisting with mechanical lifts. |
| Licensed Nurse H | Licensed Nurse | Documented transfer attempt of R2 with sit to stand lift resulting in fall. |
| Certified Nurse Aide N | Certified Nurse Aide | Reported R2 fall during sit to stand lift transfer; stated it was unsafe to use the lift alone. |
| Certified Nurse Aide O | Certified Nurse Aide | Assisted in lifting R2 off the floor after fall. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 17, 2023
Visit Reason
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.
Findings
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.
Deficiencies (3)
Deficiencies cited related to infection control and respiratory infection isolation practices.
Deficiencies related to hand hygiene and personal protective equipment (PPE) availability and use.
Deficiencies related to environmental services including proper transportation and storage of clean linens.
Report Facts
Audit frequency: 5
Audit frequency: 3
Compliance target date: Aug 11, 2023
Audit frequency: 5
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Stockebrand | Executive Director | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to utilize appropriate infection control practices to prevent transmission of COVID-19 throughout the facility and failure to monitor residents who tested positive for COVID-19.
Report Facts
Residents tested positive for COVID-19: 27
Residents on memory care unit: 20
Residents positive for COVID-19 on memory care unit: 12
Current residents with active COVID-19: 5
Residents on isolation for at least: 10
Residents census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Provided information on respiratory symptom screening, PPE use, and isolation procedures. |
| Licensed Nurse G | Licensed Nurse | Responsible for residents on memory care unit; described PPE practices and isolation procedures. |
| Administrative Nurse D | Administrative Nurse | Discussed respiratory assessments, signage, and PPE requirements. |
| Certified Medication Aide R | Certified Medication Aide | Reported not being instructed to wear protective eyewear in memory care unit. |
| Certified Nurse Aide M | Certified Nurse Aide | Reported eyewear use only when COVID-19 was 'really bad'. |
| Administrative Nurse F | Administrative Nurse | Observed assisting COVID-19 positive resident without full PPE. |
| Housekeeping Staff U | Observed transporting uncovered linens and stated linens should be covered during transport. | |
| Housekeeping Staff V | Stated linens should be covered during transport and was unaware visitors should wear masks. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
A revisit survey was conducted on 03/27/23 through 03/28/23 for all previous deficiencies cited on 01/31/23.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jan 31, 2023
Visit Reason
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.
Findings
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.
Deficiencies (8)
Comprehensive Care Plans related to skin integrity concerns and nutritional support.
ADL Care Provided for Dependent Residents including bathing and personal hygiene assistance.
Treatment/Services to Prevent/Heal Pressure Ulcer including wound assessment and monitoring.
Bowel/Bladder Incontinence, Catheter, UTI care and monitoring.
Drug Regimen is Free from Unnecessary Drugs including blood glucose monitoring.
Free from Unnecessary Psychotropic Meds/PRN Use including medication review and physician notification.
Qualified Dietary Staff enrollment in certification course.
Food Procurement, Store/Prepare/Serve-Sanitary practices including discarding undated and unsealed food.
Report Facts
Audit frequency: 5
Compliance date: Feb 28, 2023
Survey date: Jan 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Stockebrand | Executive Director | Submitted the Plan of Correction. |
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 8
Date: Jan 31, 2023
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously identified deficiencies and overall regulatory requirements at Life Care Center of Burlington.
Findings
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.
Deficiencies (8)
Failure to review and revise Resident 49's care plan to prevent and promote healing of a facility acquired stage three pressure ulcer.
Failure to provide consistent bathing services for four sampled residents, placing them at risk for complications related to poor hygiene.
Failure to provide necessary treatment and services to prevent and promote healing of pressure ulcers for Residents 49 and 53.
Failure to provide appropriate catheter care for Resident 35, placing the resident at risk for urinary tract infection.
Failure to report blood sugars outside physician ordered parameters for Residents 5 and 9, placing them at risk for physical decline and complications related to hyperglycemia.
Failure to obtain a stop date for Resident 48's PRN antianxiety medication and failure to ensure appropriate diagnosis for antipsychotic medication use.
Failure to ensure the director of food and nutrition services had required qualifications as a certified dietary manager.
Failure to ensure food items stored in refrigerators were properly labeled and dated, risking foodborne illness.
Report Facts
Census: 60
Sample size: 15
Residents reviewed for ADLs: 5
Days without bathing for Resident 5: 35
Days without bathing for Resident 17: 5
Days without bathing for Resident 23: 30
Days without bathing for Resident 54: 89
Stage three pressure ulcer size: 4
Stage three pressure ulcer size: 3.5
Stage three pressure ulcer size: 0.2
Stage two pressure ulcer size: 5.9
Stage two pressure ulcer size: 3.6
Stage two pressure ulcer size: 0.1
Blood sugar: 419
Blood sugar: 440
Blood sugar: 409
Blood sugar: 419
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant GG | Consultant | Verified care plan deficiencies and bathing service issues; provided expert opinion on catheter care and medication management |
| Licensed Nurse G | Licensed Nurse | Provided observations and statements regarding resident care and wound management |
| Certified Nurse Aide M | Certified Nurse Aide | Provided statements regarding bathing refusals and shower sheet documentation |
| Dietary BB | Dietary Staff | Stated lack of certification as dietary manager and described food storage practices |
| Certified Nurse Aide N | Certified Nurse Aide | Observed providing catheter care with improper glove use |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 28, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-10-12.
Findings
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.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 12, 2022
Visit Reason
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.
Findings
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.
Deficiencies (1)
Meal time delivery was found to be unsatisfactory and in need of improvement.
Report Facts
Audit frequency: 5
Audit frequency: 2
Audit frequency: 1
Audit review period: 3
Plan completion date: Nov 11, 2022
Date ordered: Oct 11, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Stockebrand | Executive Director | Submitted the Plan of Correction |
| Teresa Edwards | Added the Plan of Correction | |
| Evelyn Lacey | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Date: Oct 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation (#174535) regarding the timeliness of meal service to residents.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure meals served within the facility's scheduled meal service times to residents.
Report Facts
Census: 59
Scheduled meal times: 3
Meal delay duration: 1.5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 16, 2022
Visit Reason
A revisit resurvey was conducted to verify correction of all previous deficiencies cited on 07/14/2022.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Jul 14, 2022
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint investigation numbers related to the facility.
Complaint Details
The investigation included multiple complaint investigation numbers (#171542, #171941, #172161, #172153, #172286, #172410, #171944, #171907, and #172129). The findings were based on these complaints.
Findings
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.
Deficiencies (2)
Failure to ensure Resident 2, assessed as a fall risk, remained free from accident hazards when staff failed to properly provide ambulatory assistance during toileting, resulting in a right shoulder fracture.
Failure to follow the five rights for administration of medication when staff administered incorrect medications to Resident 7 as prescribed by the physician.
Report Facts
Resident census: 55
Fall Risk Assessment score: 22
Medication error date: Jul 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Assisted Resident 2 without using a gait belt, contributing to the fall and injury. |
| CMA R | Certified Medication Aide | Administered incorrect medications to Resident 7. |
| LN I | Licensed Nurse | Assessed Resident 2 after the fall and called EMS. |
| LN G | Licensed Nurse | Notified of medication error and monitored Resident 7. |
| Administrative Staff A | Documented facility investigation of Resident 2's fall and reported medication error. | |
| Administrative Nurse E | Administrative Nurse | Interviewed regarding expectations for gait belt use. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 13, 2022
Visit Reason
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.
Findings
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.
Deficiencies (2)
Resident 2 no longer resides at the facility. Licensed and certified nursing staff will be educated regarding assistance required to achieve and maintain safety with ambulation.
Resident 7’s physician was notified of a medication error on 7.12.22 with no new orders received. Licensed and certified nursing staff will be educated regarding Oral Medication Standard of Care.
Report Facts
Audit frequency: 2
QAPI review frequency: 1
Dates of education completion: Jul 27, 2022
Date of survey: Jul 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Simon Madondo | Executive Director | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 23, 2022
Visit Reason
An offsite revisit survey was conducted on 06/23/2022 for all previous deficiencies cited on 05/05/2022.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 5, 2022
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report for LCC Burlington.
Findings
The Plan of Correction includes corrective actions cross-referenced to specific deficiencies identified in the linked deficiency report 45LC11.
Report Facts
Deficiency report ID: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Johnson | Executive Director | Submitted the Plan of Correction |
| Teresa Edwards | Added the Plan of Correction | |
| Evelyn Lacey | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: May 5, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers KS00169161, KS00170883, and KS171413.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure tuberculosis screening for newly hired employees, including Certified Medication Staff S, Certified Nurse Aide M, and Certified Medication Aide R.
Report Facts
Resident census: 53
Residents in main units: 42
Number of complaint investigations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Spoke with employees about TB testing delays and acknowledged screening failures |
| Certified Medication Staff S | Certified Medication Staff | Hired 01/02/22, lacked TB screening |
| Certified Nurse Aide M | Certified Nurse Aide | Hired early April 2022, lacked TB screening until 05/05/22 |
| Certified Medication Aide R | Certified Medication Aide | Hired November 2021, lacked TB screening until 05/05/22 |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
An offsite revisit survey was conducted on 04/13/2022 for all previous deficiencies cited on 02/07/2022.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 7, 2022
Visit Reason
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.
Findings
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.
Deficiencies (1)
Resident experienced a fall with delayed physician response and follow-up orders.
Report Facts
Audit frequency: 5
Audit frequency: 3
Date of fall: Dec 12, 2021
Date of audit: Feb 14, 2022
Compliance target date: Feb 28, 2022
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Feb 7, 2022
Visit Reason
The inspection was conducted as a result of complaint investigations identified by case numbers KS 00167367, KS 00168770, KS 0016049, and KS 0016001.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure necessary treatment and care in accordance with professional standards for a resident who fell and sustained a fractured right clavicle, including delayed follow-up with the physician for orders after the x-ray results.
Report Facts
Resident census: 62
Days delay in physician follow-up: 11
Resident falls reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Confirmed lack of follow-up by facility staff related to the resident's fall and fracture |
| Administrative Nurse D | Administrative Nurse | Reported facility sent x-ray results fax on 12/18/21 and did not receive physician communication until 12/29/21 |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 14, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2021-08-31.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 9, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2021-07-22.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Aug 31, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers KS 00164293, KS 00164443, and KS 00165024.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to provide adequate supervision to prevent residents, including Resident 4, from exiting the facility during a fire drill without staff knowledge.
Report Facts
Census: 62
Elopement risk residents: 14
Temperature: 94
BIMS score: 5
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Documented health status note and interviewed regarding Resident 4's elopement. |
| Dietary Aide BB | Dietary Aide | Observed Resident 4 outside during elopement and reported incident. |
| Administrative Staff A | Administrative Staff | Interviewed regarding staff presence and elopement incident. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 24, 2021
Visit Reason
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.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Aug 6, 2021
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Burlington addressing deficiencies cited during a prior survey.
Findings
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.
Deficiencies (5)
Failure to obtain a signed bed hold for resident transfers to hospital or therapeutic leave.
Failure to complete discharge summary/recapitulation of stay and medication reconciliation for discharged residents.
Insulin pens were not appropriately labeled during survey.
Environmental maintenance issues including exposed bare wood, missing/broken tiles, and improper storage in laundry area.
Certified staff identified as not having required Abuse, Neglect, & Exploitation training.
Report Facts
Audit period for transfers and discharges: 60
Audit period for staff education: 90
Audit frequency for insulin pen labeling: 60
Audit frequency for environmental rounds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gingerbellm | Executive Director | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 30, 2021
Visit Reason
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.
Findings
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.
Deficiencies (1)
Resident R4 was affected by deficient practice related to supervision and elopement risk.
Report Facts
Date of corrective actions: Jul 30, 2021
Plan completion date: Sep 24, 2021
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ginger Bellm | Executive Director | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 22, 2021
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to provide routine nail care to resident R1 who was dependent on staff for physical needs.
Report Facts
Audit frequency: 5
Audit duration: 12
Audit frequency: 5
Routine nail care frequency: 2
Audit date: Aug 6, 2021
Plan completion date: Aug 13, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ginger Bellm | Executive Director | Submitted the Plan of Correction |
| Teresa Edwards | Added the Plan of Correction | |
| Evelyn Lacey | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Jul 22, 2021
Visit Reason
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.
Complaint Details
Complaint investigation #163900. The deficiency was substantiated based on observations, interviews, and record reviews indicating failure to provide proper toenail care.
Findings
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.
Deficiencies (1)
Failure to provide proper toenail care to a dependent resident requiring assistance with personal cares.
Report Facts
Resident census: 56
Days toenails not trimmed: 40
Days toenails not trimmed: 60
BIMS score: 3
BIMS score: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Reported trimming resident's toenails unless resident would not hold still |
| CMA N | Certified Medication Aide | Reported staff should do fingernail care every two weeks but did not trim toenails; stated podiatrist should trim toenails |
| CNA O | Certified Nurse Aide | Reported staff should trim toenails during resident showers and document on shower sheet |
| LN G | Licensed Nurse | Verified resident's toenails were curved over toes and stated staff should trim toenails as part of shower care |
| Administrative Nurse D | Administrative Nurse | Reported expectation for staff to check nails every bath but lacked monitoring system |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 5
Date: Jul 12, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS00163832 to assess compliance with regulatory requirements.
Complaint Details
The visit was triggered by a complaint investigation identified as #KS00163832.
Findings
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.
Deficiencies (5)
Failure to provide bed-hold policy notification for a resident transferred to hospital.
Failure to complete a discharge summary including recapitulation of stay and medication reconciliation for a discharged resident.
Failure to ensure accurate labeling of seven insulin pens for five diabetic residents.
Failure to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the laundry.
Failure to provide required abuse, neglect, exploitation and misappropriation training for two of three selected staff.
Report Facts
Census: 56
Sample size: 15
Insulin pens without accurate labeling: 7
Missing/broken floor tiles: 60
Staff files missing abuse training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Interviewed regarding failure to provide bed hold form and medication labeling. | |
| Administrative Nurse D | Interviewed regarding bed hold policy and medication labeling. | |
| Administrative Staff A | Verified failure to complete discharge summary and abuse training. | |
| Licensed Nurse I | Reported staff practice of writing resident names on insulin pens. | |
| Licensed Nurse G | Advised on risks of medication errors without prescription labels on insulin pens. | |
| Consultant GG | Reported pharmacy practice of placing only one label on insulin pen boxes. | |
| Housekeeping Staff V | Provided observations of laundry area conditions. | |
| Maintenance Staff U | Verified laundry area deficiencies. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 26, 2021
Visit Reason
A revisit survey was conducted on 05/26/21 to verify correction of all previous deficiencies cited on 03/04/21.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 4, 2021
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficient practice related to urinary catheter management and follow-up on falls with injury for residents R1 and R3.
Deficient practice related to pressure ulcer assessment and treatment for resident R2 and others readmitted with pressure ulcers.
Report Facts
Audit frequency: 5
Compliance date: Mar 19, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gingerbellm | Administrator | Submitted the Plan of Correction |
| Janice Vangotten | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Mar 4, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to identify lack of urinary output, timely physician notification, collection of urine sample, and delayed antibiotic administration for Resident 1.
Failure to monitor healing progression and perform neurochecks following falls for Residents 1 and 3.
Failure to complete comprehensive wound assessment, provide ordered treatment, and maintain appropriate linens and mattress settings for Resident 2's unstageable pressure ulcer.
Report Facts
Census: 51
Urinary output gap: 48
Urinary output gap: 15
Delay in antibiotic administration: 3
Pressure ulcer measurement: 11
Pressure ulcer measurement: 13.5
Pressure ulcer measurement: 6
Pressure ulcer measurement: 2.3
Pressure ulcer measurement: 3
Pressure ulcer measurement: 4.5
Pressure ulcer measurement: 3.7
Pressure ulcer measurement: 3.4
Resident weight: 134
Air mattress setting: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Notified of immediate jeopardy related to Resident 1's care | |
| Licensed Nurse J | Licensed Nurse | Revealed she did not change Resident 1's catheter on 02/15/21 as indicated |
| Licensed Nurse K | Licensed Nurse | Changed Resident 1's catheter on 02/20/21 and reported catheter issues |
| Administrative Nurse D | Administrative Nurse | Revealed staff did not collect urine sample as ordered and should have notified physician by phone |
| Consulting Physician GG | Consulting Physician | Reported catheter was falling apart and antibiotic should have been started sooner |
| Licensed Nurse H | Licensed Nurse | Reported neurochecks were done after Resident 1's fall but initial neurochecks were missed |
| Licensed Nurse G | Licensed Nurse | Described Resident 2's wound and treatment orders |
| Administrative Nurse E | Administrative Nurse | Responsible for infection control, unaware of antibiotic order for Resident 1 |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 23, 2020
Visit Reason
An offsite revisit was conducted on 10/23/2020 for all previous deficiencies cited on 09/09/2020.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Sep 9, 2020
Visit Reason
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.
Findings
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.
Deficiencies (3)
Accuracy of Assessments - Updated quarterly MDS assessment scheduled for resident #2 to reflect refusals of care.
Develop/Implement Comprehensive Care Plan - Care plans for residents #4 and #5 updated to include restorative services.
Increase/Prevent Decrease in ROM/Mobility - Care plans updated to include restorative services and audits to ensure compliance.
Report Facts
Audit frequency: 3
Audit duration: 3
Substantial compliance date: Oct 9, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Stockebrand | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Date: Sep 9, 2020
Visit Reason
The inspection was conducted as a complaint investigation (#155647) to evaluate the facility's compliance with regulatory requirements related to resident care and assessments.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to complete an accurate comprehensive assessment for a resident with refusals of care.
Failed to develop and implement a comprehensive person-centered care plan for residents to meet their individual needs, including restorative services.
Failed to provide appropriate treatment and services to increase or maintain range of motion to prevent further decrease in range of motion.
Report Facts
Census: 59
Residents reviewed: 5
Restorative services days provided for Resident 4: 7
Restorative services days provided for Resident 4: 3
Restorative services days provided for Resident 4: 5
Restorative services days provided for Resident 5: 0
Restorative services days provided for Resident 5: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Provided statements regarding residents rejecting care and restorative services not being provided as ordered. | |
| Certified Nurse Aide N | Certified Nurse Aide | Observed resident rejecting repositioning care. |
| CNA M | Certified Nurse Aide | Confirmed resident frequently refused care and repositioning. |
| Licensed Nurse G | Licensed Nurse | Confirmed resident frequently refused care. |
| Direct care staff P | Reported restorative services were not provided as ordered due to staff being pulled to floor duties. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 28, 2020
Visit Reason
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.
Findings
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.
Report Facts
Inspection dates: 3
Previous deficiency citation date: Apr 21, 2020
Compliance date: May 20, 2020
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 21, 2020
Visit Reason
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.
Findings
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.
Deficiencies (3)
Investigate/Prevent/Correct Alleged Violation related to resident incidents including an alleged rape and resident altercations.
Free of Accident Hazards/Supervision/Devices related to fall risk interventions and individualized care plans.
Infection Prevention & Control deficiencies involving resident and staff infections and infection control line listing.
Report Facts
Date for substantial compliance: May 20, 2020
Audit timeframes: 30
Fall risk score threshold: 10
Investigation completion timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Stockebrand | Executive Director | Named as Executive Director reviewing findings and submitting the Plan of Correction |
| Janice VanGotten | Added and modified the Plan of Correction document | |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 3
Date: Apr 21, 2020
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to thoroughly investigate allegations of rape and abuse involving multiple residents, including failure to obtain hospital records and notify the State Agency of a resident's death.
Failed to develop and implement individualized care plan interventions to prevent falls for a cognitively impaired resident, resulting in a fall with major injury and subsequent death.
Failed to maintain an effective infection prevention and control program that identified, tracked, and trended infections including residents affected by COVID-19; residents and staff with COVID-19 were not properly documented on infection control logs.
Report Facts
Resident census: 52
Number of residents tested positive for COVID-19: 31
Resident temperature readings: 99.6
Resident temperature readings: 102.3
Resident temperature readings: 103.4
Oxygen saturation: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Authored nursing note documenting resident R3's fall and failed to return calls during investigation |
| MA1 | Medication Aide | Assisted resident R3 prior to fall and failed to return calls during investigation |
| Administrator | Indicated investigation deficiencies and failure to notify State Agency of resident death | |
| Director of Nursing | Director of Nursing (DON) | Indicated fall care plan was inappropriate and confirmed failures in infection control log documentation |
| NA1 | Nurse Aide | Reported elevated temperature on 3/20/20 and was sent home; not tested for COVID-19 at that time |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 13, 2019
Visit Reason
An offsite revisit was conducted on 11/13/19 for all previous deficiencies cited on 09/23/19 to verify correction of cited deficiencies.
Findings
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.
Report Facts
Previous deficiencies correction compliance date: Oct 23, 2019
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Sep 23, 2019
Visit Reason
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.
Findings
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.
Deficiencies (8)
Baseline Care Plan deficiencies requiring new care plan meetings and audits.
Pharmacy Services/Procedures deficiencies related to medication administration and audits.
Drug Regimen Review deficiencies involving pharmacy consultant recommendations and physician review.
Menus not meeting resident needs or preparation/follow-up issues.
Nutritive value, appearance, palatability, and temperature of food issues.
Food procurement, storage, preparation, and sanitary deficiencies including outdated food and equipment cleanliness.
Infection Prevention and Control issues including unlabeled personal hygiene products and glucometer cleaning.
Antibiotic Stewardship Program monitoring and education deficiencies.
Report Facts
Audit frequency: 3
Audit frequency: 5
Audit frequency: 10
Audit frequency: 10
Audit frequency: 3
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Stockebrand | Executive Director | Submitted the Plan of Correction |
Inspection Report
Census: 66
Deficiencies: 8
Date: Sep 23, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation covering multiple complaint investigation numbers.
Findings
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.
Deficiencies (8)
Failed to provide resident and representative a summary of the baseline care plan.
Failed to ensure medications were available and administered as ordered by the physician for residents R18 and R44.
Failed to timely act upon pharmacist recommendations to discontinue PRN lorazepam for Resident R27.
Failed to follow recipe for pureed Salisbury steak and bread for Resident R44 on pureed diet.
Failed to serve food at palatable temperature to residents.
Failed to maintain clean and sanitary dietary department for food storage, preparation, and serving.
Failed to maintain infection control procedures including unlabeled personal hygiene items in shower room and improper disinfection of glucometers.
Failed to develop and implement an antibiotic stewardship program to monitor antibiotic use, culture and sensitivity, and effectiveness.
Report Facts
Residents reviewed: 21
Residents on pureed diet: 1
Residents requiring blood glucose testing: 8
Food temperatures: 132
Food temperatures: 128
Food temperatures: 94
Food temperatures: 105.6
Food temperatures: 86.9
Food temperatures: 109
Food temperatures: 114
Food temperatures: 120
Food temperatures: 84
Food temperatures: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Reported staff failed to administer medications if unavailable and failed to look in overflow for extra medications. |
| Administrative Nurse D | Administrative Nurse | Reported failure to administer medications due to unavailability and failure to provide care plan summaries. |
| Consultant GG | Consultant Pharmacist | Reported pharmacy delivers medications after order received and noted delay in physician response to medication recommendations. |
| Dietary Staff CC | Dietary Staff | Failed to follow recipe for pureed Salisbury steak and bread. |
| Dietary Staff BB | Dietary Staff | Reported awareness of food temperature issues and unsanitary kitchen conditions. |
| Licensed Nurse L | Licensed Nurse | Failed to adequately disinfect glucometer after blood sugar testing. |
| Licensed Nurse H | Licensed Nurse | Placed glucometer on floor and medication cart without barrier and failed to disinfect. |
| Administrative Nurse F | Administrative Nurse | Reported on antibiotic stewardship and infection control procedures. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 15, 2019
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
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.
Deficiencies (3)
Deficiency related to regulation 483.12(c)(1)(4)
Deficiency related to regulation 483.21(b)(2)(i)-(iii)
Deficiency related to regulation 483.25(d)(1)(2)
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 13, 2019
Visit Reason
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.
Findings
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.
Deficiencies (3)
Deficient practice noted in F609 involving resident #2, related to incident investigation and reporting.
Deficient practice noted in F657 involving resident #1, related to fall care plan revision and fall review process.
Deficient practice noted in F689 involving resident #1, related to fall care plan revision and staff education on fall reporting.
Report Facts
Complete Date: Apr 13, 2019
Incident Review Period: 30
Fall Date: Jan 22, 2019
Education Date: Mar 13, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Stockebrand | Executive Director | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 13, 2019
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 reviewed and accepted, resulting in a finding of substantial compliance effective April 13, 2019.
Deficiencies (1)
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 the contact person and signatory of the report letter. |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 3
Date: Mar 13, 2019
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to report an incident of neglect involving a resident's fall resulting in a fractured wrist.
Failure to review and revise the care plan with new interventions following the resident's fall.
Failure to ensure adequate supervision and assistive devices to prevent further falls after the resident's fall.
Report Facts
Resident census: 61
Fall risk assessment score: 13
Number of residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Direct Care Staff | Reported resident ambulated without devices and assisted resident during toileting |
| Staff K | Direct Care Staff | Reported close observation of residents but unsure of new interventions after fall |
| Staff G | Direct Care Staff | Provided written statement regarding resident's location prior to fall |
| Staff D | Licensed Nursing Staff | Reported neuro-checks after unwitnessed falls and verified presence of another resident in bed at time of fall |
| Staff R | Administrative Nursing Staff | Verified care plan lacked intervention following resident's fall |
| Staff A | Administrative Staff | Reviewed fall investigation and explained facility's rationale for not reporting incident to state agency |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 17, 2019
Visit Reason
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.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Nov 19, 2018
Visit Reason
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.
Findings
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.
Deficiencies (13)
Safe/Clean/Comfortable/Homelike Environment - issues with torn wheelchair arm rests, damaged shower door, built-up soap and floor tile repairs.
Baseline Care Plan - failure to update care plan for resident #167 to include respiratory care needs.
Respiratory/Tracheostomy Care and Suctioning - care plans and nebulizer storage/cleaning deficiencies.
Pain Management - inadequate monitoring of pain medication effectiveness for resident #167.
Dialysis - inadequate assessment of resident #47's dialysis shunt.
Nurse Aide Performance Review - failure to complete required skills evaluations for clinical associates.
Drug Regimen is Free from Unnecessary Drugs - monitoring and documentation deficiencies for residents #5 and #21.
Free from Unnecessary Psychotropic Meds/PRN Use - behavior monitoring sheets not properly utilized for residents #5, #10, #12, and #21.
Free of Medication Error Rates of 5 Percent or More - medication error notification and monitoring for resident #21.
Residents are Free of Significant Med Errors - medication error notification and monitoring for resident #21.
Label/Store Drugs and Biologicals - medication room audits revealed issues with staff drinks, storage, dating, and expired medications.
Food Procurement, Store/Prepare/Serve-Sanitary - kitchen cleanliness and repairs needed for countertops and cabinet doors.
Dietary Services - dietary manager certification in progress.
Report Facts
Deficiencies cited: 13
Plan of Correction completion date: Dec 18, 2018
Dietary Manager certification completion date: May 31, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Stockebrand | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction | |
| Lacey Hunter | Modified Plan of Correction |
Inspection Report
Census: 60
Deficiencies: 1
Date: Nov 19, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to dietary services at the facility.
Complaint Details
The visit included complaint investigations #134987, #135133, and #135272.
Findings
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.
Deficiencies (1)
Failure to employ a full-time certified dietary manager to oversee the dietary department.
Report Facts
Census: 60
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 19, 2018
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiencies constituting a level of actual harm that is not immediate jeopardy were found.
Report Facts
Denial of payment effective date: Dec 28, 2018
Previous noncompliance date: Jun 7, 2018
Civil Money Penalty amount: 10483
Timeframe for substantial compliance: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Coordinator | Contact person regarding instructions and enforcement actions. |
| Benton Williams | CMS Regional Office Contact | Contact person for questions regarding the matter. |
| Patty Brown | Interim Commissioner | Recipient of written requests for Informal Dispute Resolution. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 8, 2018
Visit Reason
A revisit survey was conducted on 8/8/18 to verify correction of all previous deficiencies cited on 6/7/18.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jun 27, 2018
Visit Reason
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.
Findings
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.
Deficiencies (3)
Deficient practice noted in F610 involving incident investigation and interventions to prevent recurrence.
Deficient practice noted in F689 related to elopement policy, alarm response procedures, and staff education.
Deficient practice noted in F726 related to elopement policy, alarm response procedures, and staff education.
Report Facts
Compliance timeframe: 4
Compliance deadline: Jun 27, 2018
Date submitted: Jun 15, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Bingham | Interim Executive Director | Submitted the Plan of Correction. |
| Jennifer Reed | Added the Plan of Correction on June 13, 2018. | |
| Caryl Gill | Modified the Plan of Correction on February 18, 2019. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 7, 2018
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 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.
Deficiencies (1)
Noncompliance with F689; "J", CFR 483.25(d)(1)(2) related to substandard quality of care
Report Facts
Denial of payment effective date: Jun 29, 2018
Provider agreement termination date: Dec 7, 2018
Civil Money Penalty minimum amount: 10483
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Bingham | Administrator | Named as facility administrator |
| Caryl Gill | Complaint Coordinator | Signed letter as Complaint Coordinator |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 3
Date: Jun 7, 2018
Visit Reason
Complaint investigation #KS00130106 regarding an allegation of elopement and failure to thoroughly investigate the incident.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to thoroughly investigate an allegation of elopement and determine causal factors.
Failed to ensure resident environment was free of accident hazards and provide adequate supervision to prevent elopement.
Failed to maintain adequately trained nursing staff and agency personnel to ensure resident safety and care needs.
Report Facts
Census: 65
Resident elopement distance: 320
Alarm duration: 15
Visual checks frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Nursing Staff | Reported being the only nurse on duty during elopement incident and managed resident care. |
| Staff A | Administrative Staff | Involved in decision not to report elopement initially and acknowledged failures in investigation. |
| Staff B | Administrative Nursing Staff | Involved in decision not to report elopement initially and acknowledged failures in investigation. |
| Staff E | Direct Care Staff | Reported working during elopement incident and noted agency staff were untrained on elopement procedures. |
| Staff J | Direct Care Staff | Reported hearing alarm for at least 15 minutes but was unable to respond due to assisting another resident. |
| Staff P | Agency Direct Care Staff | Reported not knowing alarm codes and lack of training on elopement procedures. |
| Ancillary Staff R | Orientation Staff | Responsible for orientation but does not provide education to agency staff. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 22, 2018
Visit Reason
The document is a Plan of Correction related to complaint investigations #124559 and #129615 for the facility.
Complaint Details
Complaint investigations #124559 and #129615 were conducted and found no deficiencies.
Findings
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 22, 2018
Visit Reason
The visit was conducted as a complaint investigation for complaint numbers 124559 and 129615 at the facility.
Complaint Details
Complaint investigation #124559 and #129615 resulted in no deficiency citations.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 19, 2018
Visit Reason
An off-site survey was conducted to review deficiencies cited on January 17, 2018.
Findings
The deficiencies cited during the prior survey were corrected as of the compliance date of February 15, 2018.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 17, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at Life Care Center of Burlington.
Complaint Details
This Plan of Correction is related to a complaint investigation survey identified as LCC Burlington complaint 01172018.
Findings
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.
Deficiencies (1)
Failing to transcribe and administer respiratory medication as ordered
Report Facts
Admission records audit: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Tracy Bartley | Executive Director | Submitted the Plan of Correction |
| Caryl Gill | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Jan 17, 2018
Visit Reason
The inspection was conducted as a result of complaint investigations #124968 and #125314 regarding pharmacy services and medication administration.
Complaint Details
The findings represent the results of complaint investigations #124968 and #125314.
Findings
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.
Deficiencies (1)
Failed to transcribe and administer respiratory medication as ordered to one resident.
Report Facts
Resident census: 60
Residents sampled for respiratory needs: 3
Missed medication doses: 5
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 17, 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 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.
Deficiencies (1)
Most serious deficiencies found were 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 and signatory related to the survey findings and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 16
Date: Sep 26, 2017
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Burlington addressing deficiencies cited during a prior survey inspection.
Findings
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.
Deficiencies (16)
Housekeeping and Maintenance Services deficient
Right to Participate Planning Care deficient
Services Provided Meet Professional Standards deficient
No Catheter, Prevent UTI, Restore Bladder deficient
Drug Regimen is Free from Unnecessary Drugs deficient
Free From Medication Error Rates of 5% or More deficient
Waiver—RN 8 Hours 7 Days/ Week, Full Time DON deficient
Food Procure, Store / Prepare / Serve – Sanitary deficient
Provide / Obtain Specialized Rehab Services deficient
Drug Regimen Review deficient
Infection Control deficient
Resident Call System – Rooms / Toilet / Bath deficient
Safe / Functional / Sanitary / Comfortable Environment Bath deficient
Governing Body-Facility Policies/Appoint Administration deficient
Nurse Aide Perform Review deficient
Res Records – Complete / Accurate / Accessible deficient
Report Facts
Residents affected by call light issue: 15
Cleaning schedule items deficient: 16
Audit frequency: 3
Audit frequency: 4
Medication administration audit frequency: 2
Staff interviews: 2
Skills evaluations completed: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Bartley | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added Plan of Correction on 02/06/2016 | |
| Lori Mouak | Modified Plan of Correction on 02/26/2021 | |
| Social Service Director | Responsible for specialized rehab services and PASRR letters | |
| Dietary Manager | Responsible for kitchen cleaning and audits | |
| Maintenance Director | Responsible for call light repairs and audits | |
| Director of Nursing (DON) | Responsible for multiple education and monitoring activities | |
| Assistant Director of Nursing (ADON) | Assists with housekeeping and behavior documentation monitoring | |
| Health Information Management Director (HIMD) | Responsible for resident records audits and progress notes | |
| Pharmacy consultant | Reviews policies and education related to medication usage |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 26, 2017
Visit Reason
An offsite visit was completed on 10/19/2017 to verify correction of previous deficiencies cited on 08/28/2017.
Findings
The deficiencies previously cited have been corrected and no new non-compliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 28, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensing and Certification Enforcement Manager | Signed letter regarding acceptance of plan of correction and compliance status. |
Inspection Report
Census: 61
Deficiencies: 16
Date: Aug 28, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #113193, #115877 and #116365.
Findings
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.
Deficiencies (16)
Failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in multiple resident rooms, bathrooms, dining rooms, and nurses stations.
Failed to appropriately review and revise the care plan for 3 sampled residents including nutrition needs, supervision, and family participation.
Failed to ensure signed physician admission orders for a resident to ensure appropriate medication, care and services.
Failed to implement individualized toileting plans for 2 residents with urinary incontinence to maintain or improve bladder function.
Failed to ensure medication regimen free from unnecessary drugs by not monitoring/responding to vital signs for antihypertensive medication administration.
Failed to ensure medication error rates below 5%, with 3 medication errors observed for 2 residents.
Failed to maintain RN coverage for at least 8 consecutive hours a day on 6/3/17 and 6/4/17.
Failed to store and prepare foods under sanitary conditions in the kitchen and maintain sanitary medication rooms and laundry area.
Failed to provide specialized rehabilitation services for mental health as recommended in the PASRR determination letter for a resident with mental illness.
Pharmacist failed to identify irregularity of facility failure to monitor elevated vital signs for antihypertensive medication administration for a resident.
Failed to monitor and maintain an infection control program to prevent spread of infection, including lack of tracking and trending infections and documenting antibiotic effectiveness.
Failed to provide functioning call lights for 15 resident rooms to ensure adequate staff assistance.
Failed to provide a sanitary environment in the laundry and in 2 of 3 medication rooms.
Failed to conduct an annual review of facility policies and procedures by all members of the governing body including the director of nursing and medical director.
Failed to ensure direct care staff received annual performance reviews to identify weaknesses and provide further education.
Failed to maintain complete and accurate medical records including physician progress notes and behavior documentation for sampled residents.
Report Facts
Residents present: 61
Medication error rate: 9.375
RN coverage hours missed: 2
Residents sampled: 17
Residents reviewed for unnecessary medications: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff W | Licensed Nursing Staff | Named in medication administration deficiency for inhalers |
| Staff X | Licensed Nursing Staff | Named in medication administration and monitoring deficiency |
| Staff B | Administrative Nursing Staff | Named in multiple findings including care plan, RN coverage, infection control, call light system, and policy review |
| Staff A | Administrative Staff | Named in policy review and staff performance evaluation deficiency |
| Staff E | Housekeeping Staff | Named in housekeeping and medication room cleaning deficiencies |
| Staff F | Maintenance Staff | Named in housekeeping and call light system deficiencies |
| Staff Y | Administrative Staff | Named in medical record completeness deficiency |
| Staff M | Direct Care Staff | Named in staff performance evaluation deficiency |
| Staff O | Direct Care Staff | Named in staff performance evaluation deficiency |
| Staff Q | Direct Care Staff | Named in staff performance evaluation deficiency |
| Staff U | Direct Care Staff | Named in staff performance evaluation deficiency |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 27, 2016
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 483.10(g)(14)
Deficiency related to regulations 483.24 and 483.25(k)(l)
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Dec 8, 2016
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to notify the physician timely of a resident's significant change in condition related to a fall with hip fracture and pain, and a respiratory infection accompanied by fever.
Failure to provide timely and appropriate assessments and physician notification for a resident experiencing significant change in condition and pain, including unresolved fever and respiratory infection.
Report Facts
Resident census: 39
Time delay: 19
Resident sample size: 3
Resident ID: 1
Temperature: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff E | Licensed Nursing Staff | Verified the resident had occasionally complained of hip pain after the fall. |
| Licensed nursing staff B | Licensed Nursing Staff | Verified the nurse on the health unit had responsibility for overseeing the locked unit. |
| Licensed nursing staff C | Licensed Nursing Staff | Verified the nurse on the health unit had responsibility for overseeing the locked unit. |
| Administrative staff A | Administrative Staff | Verified the licensed nurse previously in the locked unit had left employment and had not been replaced. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be 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.
Deficiencies (1)
Most serious deficiency found 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 and signatory related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 18, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Findings
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.
Deficiencies (1)
Medications ordered for residents #1, 2, 3, and 4 are available and administered as ordered by the physician.
Report Facts
Audit frequency: 5
Audit frequency: 2
Performance Improvement meetings: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Bartley | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 18, 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 indicates that all previously cited deficiencies have been corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 4
Date: Aug 12, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#103916) regarding concerns about the timely delivery and administration of medications to residents.
Complaint Details
Complaint investigation #103916 focused on medication administration delays and failures for four residents.
Findings
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.
Deficiencies (4)
Failure to administer multiple medications on time for Resident #1 due to medication unavailability.
Failure to provide the 2 PM dose of Gabapentin for Resident #2 on 8/3/16.
Failure to administer multiple doses of medications on admission day and subsequent days for Resident #3, including missed doses of Zithromax, Sinemet, Gabapentin, MS Contin ER, Domperidone, and nebulizer treatments.
Failure to administer Potassium Chloride and Mirtazapine as ordered for Resident #4, with delays and lack of documentation for missed doses.
Report Facts
Resident census: 51
Number of residents reviewed: 4
Days medication delayed: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff G | Reported admission medication ordering and delivery process. | |
| Administrative nursing staff C | Reported use of out-of-town pharmacy and medication delivery timing. | |
| Licensed nursing staff F | Reported medication delivery timing and breakthrough pain for a resident. | |
| Administrative nursing staff B | Reported medication delivery timing and stat delivery availability. | |
| Licensed nursing staff E | Reported routine delivery times and stat delivery expectations. | |
| Licensed nursing staff D | Reported stat delivery window does not usually occur as planned. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 12, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency 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.
Deficiencies (1)
Most serious deficiency found to be an "E" 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 the contact person regarding the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jan 29, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The Plan 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.
Deficiencies (4)
Care plan reviewed and revised for Resident #57 to reflect current interventions for falls.
Resident #57 wanders into various rooms on the dementia unit; education and monitoring implemented to address resident fear.
System change developed for faxed requests for new wound care orders to ensure prompt physician response.
Care plan reviewed and revised for Resident #57 to reflect current interventions for falls with interdisciplinary team involvement.
Report Facts
Compliance date: Jan 29, 2016
Care plan audits: 5
Observations: 5
Resident interviews: 5
Staff interviews: 5
Faxed request reviews: 5
Resident audits: 5
Falls reviewed quarterly: 5
Inspection Report
Follow-Up
Deficiencies: 5
Date: Jan 29, 2016
Visit Reason
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.
Findings
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.
Deficiencies (5)
Deficiency related to 483.13(b), 483.13(c)(1)(i)
Deficiency related to 483.13(c)(1)(i)-(iii), (c)(2)-(4)
Deficiency related to 483.20(d)(3), 483.10(k)(2)
Deficiency related to 483.25(c)
Deficiency related to 483.25(h)
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 13, 2016
Visit Reason
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.
Findings
The survey found isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and plan of correction.
Deficiencies (1)
'D' level deficiencies, isolated, 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 decision letter. |
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 4
Date: Jan 13, 2016
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
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.
Deficiencies (4)
Failure to review and revise the care plan for a resident after multiple falls.
Failure to provide necessary care and services to manage inappropriate behavior related to wandering and resident safety.
Failure to provide preventative interventions and physician-ordered treatment for a resident with pressure ulcers.
Failure to ensure resident environment free of accident hazards and provide adequate supervision to prevent repeated falls.
Report Facts
Census: 51
Residents sampled: 14
Falls: 5
Fall Risk Assessment Score: 19
Fall Risk Assessment Score: 15
Pressure ulcer size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Mentioned in relation to expectations for fall investigations and care plan updates |
| Staff L | Licensed Nursing Staff | Mentioned regarding incident with resident #57 and failure to document or report resident fears |
| Staff F | Licensed Nursing Staff | Assisted resident #57 and involved in care and assessment related to falls and pressure ulcer |
| Staff D | Social Service Staff | Provided information about resident fears and care plan meetings |
| Staff E | Licensed Nursing Staff | Described fall assessment and notification procedures |
| Staff C | Administrative Nursing Staff | Recalled resident #57's aggression and staff efforts to keep others safe |
| Staff A | Administrative Staff | Unaware of incident details and investigation |
| Staff H | Direct Care Staff | Described resident behavior and dressing related to pressure ulcer |
| Staff G | Licensed Nursing Staff | Discussed orders and documentation for pressure ulcer treatment |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 30, 2015
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 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.
Deficiencies (1)
Most serious deficiency found was an "F" level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Dec 30, 2015
Provider agreement termination date: Mar 30, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Oct 17, 2014
Visit Reason
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.
Findings
The revisit confirmed that all previously reported deficiencies, identified by their regulation numbers, were corrected as of the revisit date.
Deficiencies (6)
Deficiency related to regulation 483.25(e)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.30(e)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Oct 17, 2014
Visit Reason
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.
Findings
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.
Deficiencies (6)
Restorative plan reviewed and revised; restorative services provided as planned.
Resident safety ensured by removing unsafe bed rails and securing chemicals; education provided to staff and family.
PRN medication administration and bowel movement monitoring with documentation and staff education.
Nurse staffing records to be maintained and monitored for compliance.
PRN medication and bowel movement monitoring with pharmacist involvement and physician communication.
Glucose monitoring provided according to policy with staff re-education and competency checks.
Report Facts
Completion Date: Oct 17, 2014
Number of aides trained: 3
Frequency of audits: 7
Frequency of audits: 4
BM monitoring book initiation date: Oct 9, 2014
Random spot checks duration: 3
Glucose monitoring observation duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Bartley | Executive Director | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 3, 2014
Visit Reason
A Health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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.
Deficiencies (1)
'E' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Date of survey: Oct 3, 2014
Plan of correction effective date: Oct 17, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 6
Date: Oct 3, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations #79442 and #79454.
Complaint Details
The inspection included complaint investigations #79442 and #79454.
Findings
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.
Deficiencies (6)
Failure to provide appropriate range of motion treatment and services to maintain or improve range of motion for a resident with contractures and dementia.
Failure to maintain resident safety including inadequate supervision leading to elopement, use of unsafe positioning bar with entrapment risk, and unsecured hazardous chemicals accessible to residents.
Failure to ensure residents' drug regimens were free from unnecessary drugs due to lack of adequate monitoring of PRN medication effectiveness and bowel movement monitoring.
Failure to maintain posted daily nurse staffing data for a minimum of 18 months as required.
Failure to act upon pharmacist recommendations to follow-up on medication effectiveness and failure of pharmacist to identify inadequate bowel movement monitoring.
Failure to adequately sanitize glucometers per manufacturer's recommendations, risking infection transmission.
Report Facts
Resident census: 46
Residents reviewed for range of motion: 3
Residents receiving restorative services: 13
Days resident was outside: 3
Enabler bar opening size: 9.75
Enabler bar opening size: 12.75
BIMS score: 8
BIMS score: 0
Days without bowel movement: 7
PRN medication administration dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Administrative Staff | Reported on restorative aide workload and staffing, nurse staffing data maintenance, and follow-up on PRN medications. |
| Staff G | Licensed Nursing Staff | Observed performing glucometer testing and cleaning. |
| Staff H | Licensed Nursing Staff | Observed performing glucometer testing and cleaning. |
| Staff L | Licensed Nursing Staff | Involved in resident elopement incident and investigation. |
| Staff O | Licensed Nursing Staff | Reported on bowel movement monitoring and interventions. |
| Staff P | Direct Care Staff | Reported on bowel movement charting. |
| Staff C | Administrative Nursing Staff | Reported on glucometer cleaning procedures. |
| Consultant Staff N | Consultant | Reported on review of resident bowel movement records. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 11, 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 '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.
Deficiencies (1)
Deficiencies found at 'E' level, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: May 11, 2014
Provider agreement termination date: Aug 11, 2014
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter Mungai | 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
Follow-Up
Deficiencies: 1
Date: Aug 13, 2013
Visit Reason
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.
Findings
The report documents that the deficiency identified under regulation 483.25(c) with ID prefix F0314 was corrected as of 07/19/2013.
Deficiencies (1)
Deficiency under regulation 483.25(c) identified by prefix F0314
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 19, 2013
Visit Reason
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.
Findings
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.
Deficiencies (1)
Treatment and services to prevent and heal pressure sores were deficient, particularly related to resident #62.
Report Facts
Compliance date: Jul 19, 2013
Observation frequency: 5
Observation duration: 4
Treatment observations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Petermungai | Executive Director | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 1
Date: Jun 20, 2013
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with treatment and services to prevent and heal pressure sores in residents.
Findings
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.
Deficiencies (1)
Failure to provide treatment and services to promote healing and prevent infection for a resident with pressure ulcers who developed an avoidable stage 3 pressure ulcer.
Report Facts
Census: 51
Pressure ulcer measurements: 3.8
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 1.2
Pressure ulcer duration: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse A | Documented pressure ulcer status record and provided wound care assessment | |
| licensed nurse C | Observed providing dressing change and improper aseptic technique | |
| certified nursing staff D | Acknowledged resident did not always wear ordered pressure relieving boots | |
| certified nursing staff F | Reported resident was not taken back to bed since shift change | |
| licensed wound nurse A | Provided wound assessment and measurement |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 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 had been corrected.
Findings
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.
Deficiencies (1)
Deficiency with ID prefix F0328 related to regulation 483.25(k)
Report Facts
Deficiency correction date: Aug 20, 2012
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 17, 2012
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to follow up on physician recommendations/orders regarding Bipap therapy for Resident #1 who refused treatment.
Report Facts
Complete date for correction: Aug 20, 2012
Number of orders audited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Peter Mungai | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Aug 10, 2012
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to follow-up on physician recommendation for special respiratory equipment (BIPAP machine) for one resident.
Report Facts
Resident census: 67
Residents sampled: 3
Resident admission date: Jan 16, 2012
Significant change MDS date: Jun 29, 2012
Hospital appointment date: Jul 9, 2012
Inspection visit date: Aug 7, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social services staff A | Provided information about the ALS program and motorized wheelchair. | |
| Licensed nursing staff B | Verified the resident received an order for a BIPAP machine. | |
| Administrative nursing staff C | Verified resident returned with BIPAP order and acknowledged failure to follow-up. | |
| Licensed nursing staff D | Reported understanding that ALS program would provide BIPAP machine and wheelchair. |
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Mar 1, 2012
Visit Reason
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.
Findings
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.
Deficiencies (15)
Right to/Facility Provision of Visitor Access
Investigate/Report Allegations/Individuals
Activities Meet Interests/Needs of each Resident
Housekeeping and Maintenance Services
Comprehensive Assessments
Right to Participate Planning Care-Revise Care Plan
No Catheter, Prevent UTI, Restore Bladder
Maintain Nutrition Status Unless Unavoidable
Drug Regimen is Free From Unnecessary Drugs
Food procure, Store/prepare/serve-sanitary
Drug Regimen Review, Report Irregular, Act On
Drug Records, Label/Store Drugs & Biologicals
Infection Control, Prevent Spread, Linens
Adequate outside ventilation - Window/mechanic
Corridors have firmly secured handrails
Report Facts
Interviews conducted: 5
Investigations reviewed: 1
Activity care plans reviewed: 2
Observations of activities: 5
Assessments reviewed: 3
Incontinence plans reviewed: 2
Nutrition plans reviewed: 2
Residents audited for Black Box warnings: 5
Residents audited for psychoactive meds effectiveness: 2
Med room inspections: 2
Observations of soiled linens handling: 5
Audits during dining room and housekeeping services: 5
Compliance review meetings: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PETERMUNGAI | Executive Director | Named as responsible for monitoring compliance and submitting the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 14
Date: Feb 29, 2012
Visit Reason
The visit was a health re-survey to assess compliance with previously cited deficiencies and to verify correction of issues.
Findings
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.
Deficiencies (14)
Failed to ensure residents remained knowledgeable and informed of their right to have accessibility to the state ombudsman.
Failed to thoroughly investigate and report incidents of alleged abuse or neglect, including failure to report a hot coffee burn and unwitnessed fall.
Failed to provide an ongoing activity program designed to meet interests and needs of residents with cognitive impairment.
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, including window repairs.
Failed to conduct comprehensive individualized assessments addressing all resident needs and strengths, including care area assessments (CAAs).
Failed to review and revise the activity care plan for a resident to include individualized activities.
Failed to provide appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.
Failed to ensure a resident maintained acceptable nutritional status and failed to provide necessary services to prevent weight loss.
Failed to ensure drug regimens were free from unnecessary drugs, including failure to monitor and identify adverse effects of medications with black box warnings and failure to monitor effectiveness of psychotropic medications.
Failed to procure, store, prepare, distribute and serve food under sanitary conditions, including improper handling of glasses and condiment containers.
Failed to ensure drug records were in order and that controlled drugs were properly accounted for, including failure to remove expired medications and properly log discontinued medications.
Failed to establish and maintain an infection control program to prevent spread of infection, including improper handling and transport of soiled linens and contaminated clothing.
Failed to provide adequate outside ventilation in the facility beauty shop due to a non-functioning exhaust fan covered with debris.
Failed to equip corridors with firmly secured handrails on each side, with one hallway lacking a handrail on one side and the other side obstructed by equipment.
Report Facts
Resident weight loss: 14
Expired vaccine vials: 4
Residents affected by unsecured handrails: 17
Residents in dining area affected by unsanitary food service: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Nursing Staff | Reported not fully using pharmacy black box warning list and not including side effects on care plans. |
| Staff E | Activity/Social Services Staff | Reported lack of individualized activity care plans and incomplete quarterly assessments. |
| Staff Q | Direct Care Staff | Observed placing urine wet clothing on floor without sanitizing. |
| Staff L | Licensed Nursing Staff | Reported resident activity and toileting practices. |
| Staff M | Licensed Nursing Staff | Observed resident behavior and medication use. |
| Staff G | Dietary Staff | Reported improper handling of condiments and glasses. |
| Staff I | Housekeeping/Maintenance/Laundry Staff | Confirmed non-functioning ventilation fan and window repair needs. |
| Staff B | Administrative Nursing Staff | Described medication return process and investigation of abuse. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N016001 POC 1N0M11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior complaint investigation at the facility.
Findings
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.
Deficiencies (2)
Failure to notify of changes in resident condition in a timely manner (F157)
Failure to provide care and services to ensure highest well-being of residents (F309)
Report Facts
Compliance deadline: Dec 27, 2016
Audit/tracking period: 3
QAPI presentation frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Bartley | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
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