Inspection Reports for Life Care Center of Seneca
512 COMMUNITY DRIVE, KS, 66538
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 2, 2025, found the facility in compliance with all regulations and no deficiencies. Prior inspections showed a pattern of deficiencies related mainly to resident dignity and privacy, medication management, infection control, and environmental safety, particularly noted in the April 30, 2025 survey. Complaint investigations in 2023 and 2019 included substantiated findings involving failure to provide adequate supervision leading to resident abuse and failure to report alleged mistreatment, respectively. Enforcement actions were noted in earlier years, including immediate jeopardy findings related to elopement risks in 2016 and a denial of payment for new admissions in 2015 due to serious deficiencies. The facility appears to have addressed recent deficiencies effectively, with multiple follow-up inspections confirming correction and no new noncompliance found.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
9.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
39 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 2, 2025
Visit Reason
An offsite revisit survey was conducted on 07/02/25 for all previous deficiencies cited on 04/30/25 to verify correction of cited deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 05/30/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 5
Apr 30, 2025
Visit Reason
The inspection was a Health Recertification Survey conducted to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy during toileting, environmental safety hazards due to unlocked chemical storage, medication management failures related to blood sugar monitoring and insulin administration, inaccurate staffing data submission, and infection prevention and control practices.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide dignified toileting care by leaving curtains and window blinds open during toileting and catheter care for residents R3, R16, and R2. | SS=D |
| Failed to ensure an environment free from chemical hazards due to unlocked housekeeping room with accessible hazardous chemicals. | SS=D |
| Failed to notify physician of blood sugars outside ordered parameters and failed to hold insulin as ordered for Resident 28. | SS=D |
| Failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ), resulting in inaccurate nurse staffing data. | SS=F |
| Failed to adhere to infection control procedures including improper use of enhanced barrier precautions for Resident 33, failure to change gloves between personal cares for Resident 2, and placing dirty dish tubs on tables while residents were eating. | SS=E |
Report Facts
Resident census: 39
Sample size: 13
Unnecessary medication blood sugar readings out of parameters: 6
PBJ Fiscal Year 2024 Quarters: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided statements on staff expectations for privacy, chemical storage, medication administration, staffing data submission, and infection control |
| Certified Nurse Aide M | Certified Nurse Aide | Observed providing care without privacy curtains and improper glove use |
| Certified Nurse Aide N | Certified Nurse Aide | Observed providing care without privacy curtains and improper glove use |
| Certified Nurse Aide O | Certified Nurse Aide | Observed improper glove use and gown removal |
| Licensed Nurse G | Licensed Nurse | Provided information on medication administration and blood sugar parameters |
| Maintenance Staff U | Maintenance Staff | Verified unlocked housekeeping room door and chemical storage |
| Certified Dietary Manager CC | Certified Dietary Manager | Commented on improper placement of dirty dish tubs on dining tables |
Inspection Report
Plan of Correction
Deficiencies: 5
Apr 30, 2025
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Seneca in response to deficiencies cited during a regulatory inspection conducted on 4/30/2025.
Findings
The plan addresses multiple deficiencies including residents' rights violations related to privacy and dignity, unsafe storage of chemicals, failure to properly manage blood sugar and insulin administration, payroll based journal concerns, and infection prevention and control issues. Corrective actions include staff education, audits, and policy reviews to ensure compliance and resident safety.
Severity Breakdown
S=D: 3
SS=F: 1
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Residents Rights/Exercise of Rights - blinds and curtains not functioning properly and residents not covered adequately during care. | S=D |
| Free of Accident Hazards/Supervision/Devices - housekeeping closet doors not locked properly. | S=D |
| Drug Regimen Is Free from Unnecessary Drugs - failure to hold insulin as ordered for residents with low blood sugar. | S=D |
| Payroll Based Journal - no immediate corrective action but staff reeducated on payroll changes. | SS=F |
| Infection Prevention & Control - staff deficient in infection control practices and PPE use. | SS=E |
Report Facts
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Dates of blood sugar issues: 8
Audit frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| LESADURYEA N066002 | Executive Director | Submitted Plan of Correction |
| DEBHARPER | Added and modified Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 4, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-08-23.
Findings
All deficiencies cited in the prior inspection were corrected as of the compliance date 2023-09-27, 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: 35
Deficiencies: 5
Aug 23, 2023
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint investigation #KS00181309 at Life Care Center of Seneca.
Findings
The facility failed to provide dignity during dining for residents R24 and R11, failed to develop and revise baseline and comprehensive care plans for residents including R89, R11, and R13, failed to provide necessary assistance with activities of daily living for residents R24 and R11, and failed to provide care and treatment in accordance with professional standards including repositioning and bruise prevention.
Complaint Details
The inspection was triggered by Complaint #KS00181309.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide dignity during dining for Resident 24 and Resident 11, including ignoring repeated requests for assistance and poor grooming. | SS=D |
| Failed to develop a baseline care plan for Resident 89 on admission for straight catheterization twice daily. | SS=D |
| Failed to revise care plans for Resident 11's refusals to be transferred and Resident 13's interventions to prevent bruising. | SS=D |
| Failed to provide required assistance with eating for Resident 24 and grooming for Resident 11. | SS=D |
| Failed to provide care and treatment in accordance with professional standards including repositioning Resident 11 and providing bruise prevention interventions for Resident 13. | SS=D |
Report Facts
Deficiency sample size: 12
Resident census: 35
Baseline care plan development timeframe: 48
Comprehensive care plan development timeframe: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide N | Certified Nurse Aide | Reported staff were to inform Resident 24 of food location and used clock method for food placement. |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted Resident 11 with ADLs and reported R11 sometimes drooled on clothing. |
| Administrative Nurse D | Administrative Nurse | Observed and assisted Resident 11 daily and commented on grooming and care plan documentation. |
| Administrative Nurse E | Administrative Nurse | Verified lack of baseline care plan for Resident 89 and lack of bruise prevention interventions for Resident 13. |
| Licensed Nurse G | Licensed Nurse | Inserted straight catheter for Resident 89 and commented on bruises for Resident 13. |
Inspection Report
Plan of Correction
Deficiencies: 5
Aug 23, 2023
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Seneca in response to deficiencies cited during the inspection conducted on August 23, 2023.
Findings
The plan addresses multiple deficiencies related to residents' rights to dignified existence, care planning accuracy, assistance with activities of daily living (ADLs), skin care, and cleanliness. The facility outlines corrective actions including staff education, audits, and quality assurance follow-up to achieve substantial compliance by September 27, 2023.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Residents requiring assistance with eating and ADLs were not consistently supported respecting personal choices. | D |
| Baseline care plans for new admissions were incomplete or inaccurate. | D |
| Care plans did not fully reflect personal preferences and interventions to reduce risk of bruising. | D |
| Dependent residents were not consistently provided with clean clothing and grooming per preference. | D |
| Skin care and protection measures for residents at risk of skin breakdown and bruising were insufficiently implemented. | D |
Report Facts
Deficiency completion date: Sep 27, 2023
Inspection date: Aug 23, 2023
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 14, 2023
Visit Reason
An offsite revisit survey was conducted on 08/14/23 to verify correction of all previous deficiencies cited on 06/28/23.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/01/23, 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: 38
Deficiencies: 1
Jun 28, 2023
Visit Reason
The inspection was conducted as a complaint survey related to allegations of abuse and neglect involving residents at the facility.
Findings
The facility failed to provide adequate supervision to prevent a resident-to-resident altercation resulting in physical abuse of Resident 1 by Resident 2. Resident 1 sustained bruising and was placed at risk for injury and adverse psychosocial effects. The facility took corrective actions including transferring Resident 2 to a behavioral unit and implementing a motion sensor alarm on Resident 2's door.
Complaint Details
The complaint survey KS00281082 and KS00181083 was substantiated with findings that Resident 2 physically abused Resident 1 on 06/25/23, including hitting Resident 1 multiple times causing bruising. The facility failed to protect Resident 1 from abuse.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide required supervision to prevent resident-to-resident abuse resulting in physical harm to Resident 1. | SS=D |
Report Facts
Census: 38
Deficiency count: 1
Incident date: Jun 25, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Involved in assessment and transfer of Resident 2 to behavioral unit |
| Certified Nurse's Aide M | Certified Nurse's Aide | Provided observations regarding Resident 2's behavior post-incident |
| Social Services Designee X | Social Services Designee | Spoke with Resident 1 about the incident and resident's feelings |
| Administrative Staff A | Administrative Staff | Conversed with Resident 1 post-incident regarding fear or anxiety |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 28, 2023
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited during a facility inspection related to an incident involving resident-to-resident altercations.
Findings
The plan addresses corrective actions taken immediately after the incident, including notification of the Director of Nursing, supervision of residents, reporting to the state agency, police involvement, and updates to care plans. Staff education and ongoing monitoring are planned to prevent future incidents.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incident involving resident-to-resident altercation requiring investigation and corrective actions. | D |
Report Facts
Complete Date for F0000: Jul 12, 2023
Complete Date for F600-D: Aug 1, 2023
Incident time: 330
Resident discharge date: Jul 13, 2023
Staff education completion date: Jul 31, 2023
Social Services interview frequency: 4
Social Services interview frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lesa Duryea | Executive Director LNHA | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 21, 2022
Visit Reason
An offsite revisit survey was conducted on 01/21/22 for all previous deficiencies cited on 12/02/21 to verify correction of prior deficiencies.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 01/07/22, 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
Census: 37
Deficiencies: 5
Dec 2, 2021
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meal service, inadequate personal hygiene care for dependent residents, failure to report and act on out-of-parameter medication pulses, and unsanitary food storage and preparation conditions.
Severity Breakdown
SS=E: 2
SS=D: 2
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to promote care in a manner to maintain and enhance dignity and respect during meal service, causing residents to wait long periods for meals. | SS=E |
| Failure to provide necessary personal hygiene and bathing services to dependent residents, resulting in poor hygiene. | SS=E |
| Consultant Pharmacist failed to report medication irregularities related to out-of-parameter pulses to the Director of Nursing, physician, and medical director. | SS=D |
| Failure to hold and report physician ordered out-of-parameter pulses for residents, placing them at risk for physical decline. | SS=D |
| Failure to store, prepare, and serve food under sanitary conditions, including lack of temperature documentation, lint accumulation, dirty equipment, and improper storage of clean items. | SS=F |
Report Facts
Census: 37
Days without temperature documentation: 22
Days without showers: 25
Days without showers: 16
Days without showers: 12
Pulse readings out of parameter: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified concerns with dining process, hygiene care, and medication irregularities |
| Licensed Nurse G | Licensed Nurse | Verified medication administration and lack of physician notification for out-of-parameter pulses |
| Certified Nurse Aide N | Certified Nurse Aide | Reported difficulties providing hygiene care to Resident 7 |
| Certified Nurse Aide O | Certified Nurse Aide | Reported reasons for missed showers and hygiene care issues |
| Dietary Staff CC | Dietary Staff | Reported slow meal service due to kitchen training |
Inspection Report
Plan of Correction
Deficiencies: 4
Dec 2, 2021
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 addresses deficiencies related to dining services, personal hygiene and bathing, medication administration according to physician orders for pulse parameters, and dietary staff compliance with cleaning and temperature documentation protocols.
Severity Breakdown
E: 2
D: 2
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Dining services did not consistently serve tablemates together and timely, with no complaints noted during survey. | E |
| Facility failed to maintain good personal hygiene including bathing and clean clothing/changes in accordance with resident rights. | E |
| Medication not held according to physician orders for pulse parameters and/or notification to physician was lacking. | D |
| Dietary staff failed to properly document refrigerator and freezer temperatures and maintain cleaning schedules for equipment. | F |
Report Facts
Frequency of audits: 5
Observation frequency: 3
Medication review frequency: 5
Cleaning monitoring frequency: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 10, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 10, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS) on 12/10/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 23, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS) on 11/23/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felicia Majewski | RN | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 23, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 26, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 26, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS) on 10/26/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 7, 2020
Visit Reason
The visit was conducted as a COVID-19 Health Survey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long-term care facilities.
Findings
The survey resulted in no deficiency citations related to the applicable regulations for long-term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 7, 2020
Visit Reason
The document is a Plan of Correction submitted in response to the COVID19 Health Survey for a long-term care facility.
Findings
The COVID19 Health Survey resulted in no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long-term care facilities.
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 1, 2020
Visit Reason
A revisit survey was conducted on 04/01/20 to verify correction of all previous deficiencies cited on 01/29/20.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 03/03/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Compliance date: Mar 3, 2020
Inspection Report
Plan of Correction
Deficiencies: 3
Mar 3, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey of the Life Care Center of Seneca.
Findings
The plan addresses deficiencies related to maintaining a safe, clean, and homelike environment, ensuring nutritive value and proper preparation of food, and installing a new exhaust fan in the beauty and barber shop. Corrective actions include repairs, staff education, audits, and monitoring to ensure compliance.
Severity Breakdown
E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Safe/Clean/Comfortable/Homelike Environment | E |
| Nutritive Value/Appearance, Palatable/Preferred Temperature | E |
| Beauty and barber shop exhaust fan | E |
Report Facts
Audit frequency: 4
Audit frequency: 3
Compliance date: Mar 3, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Olberding | Executive Director | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 1
Jan 29, 2020
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to the facility's beauty and barber shop area.
Findings
The facility failed to provide a beauty shop exhaust fan to the outside, which places residents receiving services in the beauty shop at risk for breathing problems. This was confirmed by observation and maintenance staff interview.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide a beauty shop exhaust fan to the outside. | SS=E |
Report Facts
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Staff | Verified the absence of an exhaust fan in the beauty shop |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 5, 2019
Visit Reason
An offsite revisit survey was conducted on 03/05/2019 for all previous deficiencies cited on 01/15/2019 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 01/25/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies compliance date: Jan 25, 2019
Inspection Report
Re-Inspection
Deficiencies: 1
Jan 15, 2019
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 a single isolated 'D' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective 01/25/2019.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A 'D' level deficiency, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Report Facts
Deficiency severity level: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Signed letter regarding survey results and plan of correction acceptance |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Jan 15, 2019
Visit Reason
The inspection was conducted as a Health Resurvey based on allegations of abuse, neglect, exploitation, or mistreatment involving Resident #29.
Findings
The facility failed to report an allegation of potential abuse, neglect, and/or exploitation involving Resident #29 to the State agency. The resident had a history of making false accusations against staff, but a specific incident of a nurse spitting in the resident's face was not reported to the state as required.
Complaint Details
The complaint involved an allegation that a nurse spit in Resident #29's face on 1/8/19. The facility did not report this allegation to the State agency due to the resident's history of making false accusations against staff. The allegation was substantiated as the facility confirmed the failure to report.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an allegation of potential abuse, neglect, and/or exploitation to the State agency for Resident #29. | SS=D |
Report Facts
Census: 59
Sample size: 10
BIMS score: 14
Dates: Sep 20, 2018
Dates: Oct 29, 2018
Dates: Jan 7, 2019
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 9, 2019
Visit Reason
The plan of correction addresses allegations of mistreatment by resident #29, which were investigated and reported to the state abuse hotline on 2019-01-09.
Findings
The facility implemented verbal and written education for key staff and all employees on abuse, neglect, and proper reporting protocols, with ongoing monitoring through resident interviews and quarterly in-services to ensure compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| F-609 Reporting of Alleged Violations related to mistreatment allegations of resident #29. | D |
Report Facts
Resident interviews: 5
In-service frequency: 4
Performance improvement meetings: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Noland | Director of Nursing | Received education on abuse and neglect reporting |
| Brian Olberding | Executive Director | Received education on abuse and neglect reporting and submitted the plan of correction |
| Matthew Stephenson | Regional Vice President | Provided education to DON and ED on abuse and neglect policy |
| Ginger Bellm | Regional Clinical Service Director | Provided education to DON and ED on abuse and neglect policy |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 25, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2017-11-15.
Findings
All deficiencies have been corrected as of the compliance date of 2017-11-21, 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: 2
Nov 21, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection related to medication labeling and infection control.
Findings
The plan addresses deficiencies in drug labeling, storage of narcotics, and infection control practices including sanitizing resident rooms and proper use of gloves by housekeeping staff.
Deficiencies (2)
| Description |
|---|
| Drug Records, Label/Store Drugs and Biologicals - inhalers and level 2 narcotics labeling and storage |
| Infection control, Prevent spread, linens - sanitizing resident rooms and equipment, proper hand hygiene and glove use |
Report Facts
Compliance date: Nov 21, 2017
Education completion date: Nov 20, 2017
Monitoring frequency: 4
Monitoring frequency: 3
Room cleaning audits: 1
Repeat audits: 2
Random room cleaning audits: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Olberding | Executive Director | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Nov 15, 2017
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 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 accepted, and the facility was found to be in substantial compliance effective 11/21/2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency at level "F", widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure & Certification Enforcement Manager | Named as contact and signatory related to enforcement and compliance findings. |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Nov 15, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation identified by #KS00113961 and KS00101417.
Findings
The facility failed to provide a separately locked, permanently affixed compartment for storage of Schedule II controlled medications and failed to label drugs and biologicals properly. Additionally, the facility did not effectively sanitize resident rooms and equipment, failing to clean all surfaces and not changing gloves appropriately during cleaning.
Complaint Details
The visit was complaint-related as indicated by the Health Resurvey and Complaint Investigation numbers #KS00113961 and KS00101417.
Severity Breakdown
E: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide a separately locked, permanently affixed compartment for storage of Schedule II controlled medications and failed to label drugs and biologicals in accordance with accepted professional principles. | E |
| Failed to establish an effective infection prevention and control program, including failure to properly sanitize resident rooms and equipment. | F |
Report Facts
Census: 60
Days of observation: 4
Medication carts: 2
Units: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff D | Stated nursing staff used counters on inhalers to determine disposal timing. | |
| Administrative nursing staff E | Stated facility did not date inhalers when opened and expected housekeeping staff to follow cleaning policies. | |
| Licensed nursing staff F | Stated nurses and medication aides had access to medication room keys. | |
| Housekeeping staff Y | Observed cleaning resident rooms without changing gloves and not cleaning all surfaces. | |
| Housekeeping supervisor Z | Expected housekeeping staff to change gloves after sanitizing toilet and clean all room surfaces. |
Inspection Report
Follow-Up
Deficiencies: 2
Nov 8, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The revisit report indicates that all previously cited deficiencies, including those under regulations 483.20(d), 483.20(k)(1), and 483.25(h), were corrected by 09/27/2016.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiency correction completion date: Sep 27, 2016
Inspection Report
Plan of Correction
Deficiencies: 2
Sep 27, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation related to elopement risk and safety awareness for residents.
Findings
The plan addresses deficiencies in developing comprehensive care plans and ensuring residents are free from accidents, hazards, and properly supervised, particularly focusing on elopement risk assessments and interventions including updated care plans, staff education, and monitoring procedures.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as LCC Seneca complaint 09212016.
Severity Breakdown
D: 1
J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| F-279 develop comprehensive care plans related to preventing elopement for cognitively impaired residents. | D |
| F-323 free of accident/hazards/supervision/devices related to elopement risk and safety awareness. | J |
Report Facts
Care plans reviewed monthly: 5
Review period: 3
Education completion date: Sep 9, 2016
Education completion date: Sep 18, 2016
Compliance date: Sep 27, 2016
Daily log monitoring: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Olberding | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 21, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety related to F323, "J", CFR 483.25(h). Enforcement remedies including denial of payment for new admissions were imposed.
Severity Breakdown
Level of actual harm or above: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F323, "J", CFR 483.25(h) constituting immediate jeopardy to resident health or safety. | Level of actual harm or above |
Report Facts
Denial of payment effective date: Oct 12, 2016
Provider agreement termination recommendation date: Mar 21, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to the survey findings and enforcement actions |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Sep 21, 2016
Visit Reason
Partial extended complaint investigation #105311 regarding failure to develop comprehensive care plans and ensure adequate supervision to prevent elopement of residents.
Findings
The facility failed to develop a comprehensive care plan to prevent elopement for a cognitively impaired resident exhibiting exit seeking behavior, and failed to provide adequate supervision and interventions to prevent elopement for two residents. One resident exited the facility without staff knowledge and was found outside, placing the resident in immediate jeopardy. The facility also failed to timely initiate elopement checks and adequate monitoring.
Complaint Details
Partial extended complaint investigation #105311. Substantiation status not explicitly stated but immediate jeopardy was identified due to resident elopement.
Severity Breakdown
SS=D: 1
SS=J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan to prevent elopement for one resident after exit seeking behavior was identified. | SS=D |
| Failed to ensure adequate supervision and interventions to prevent elopement for two residents, including one who exited the facility without staff knowledge and was found outside. | SS=J |
Report Facts
Census: 53
Resident sample size: 3
Elopement duration: 15
Fall risk score: 19
BIMS score: 12
BIMS score: 13
BIMS score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| KK | Outside provider | Reported resident #1 was let out of the front door and found resident outside after elopement |
| H | Licensed nursing staff | Responded to resident #1 found outside and assisted resident back inside |
| D | Administrative nursing staff | Provided statements regarding care plan updates and supervision adequacy |
| I | Licensed nursing staff | Confirmed elopement incident and elopement checklist timing |
| O | Direct care staff | Identified resident #1 as elopement risk and described interventions |
| P | Direct care staff | Identified resident #1 as elopement risk and described resident behavior |
| Q | Direct care staff | Denied resident #1 exhibited exit seeking behavior or wandered on 9/8/16 |
Inspection Report
Plan of Correction
Deficiencies: 10
Dec 21, 2015
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Seneca in response to deficiencies cited during a regulatory inspection.
Findings
The plan addresses multiple deficiencies related to care planning, medication management, infection control, noise levels, fall prevention, pressure ulcer prevention, and restorative services. The facility outlines corrective actions, education, monitoring, and compliance dates for each deficiency.
Severity Breakdown
D: 9
F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Maintenance of sound levels causing discomfort to residents | D |
| Develop comprehensive care plan addressing targeted behaviors related to medications | D |
| Right to participate in planning care with revised care plans after falls | D |
| Provide care/services for highest well being coordinating with Hospice team | D |
| Treatment/services to prevent/heal pressure ulcers with appropriate offloading | D |
| Increase/prevent decrease in Range of Motion with documentation and restorative program | D |
| Free of accident hazards/supervision/devices including fall interventions and toileting | D |
| Drug regimen free from unnecessary drugs with monitoring of psychotropic medications | D |
| Drug regimen review with pharmacy review and monitoring of psychotropic medications | D |
| Infection control to prevent spread including cleaning of frequently touched surfaces | F |
Report Facts
Education completion date: Dec 14, 2015
Compliance date: Dec 21, 2015
Audit frequency: 5
Monitoring frequency: 3
Cleaning monitoring frequency: 2
Rounds frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Olberding | Executive Director | Signed submission of Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Dec 7, 2015
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 the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 21, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter. |
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 10
Dec 7, 2015
Visit Reason
The inspection was a Health Resurvey to assess compliance with health and safety regulations at Life Care Center of Seneca.
Findings
The facility was found deficient in multiple areas including failure to maintain comfortable sound levels, develop comprehensive care plans with targeted behaviors, review and revise care plans timely, coordinate hospice care, prevent pressure ulcers, maintain restorative therapy programs, prevent falls, monitor drug regimens for unnecessary medications, and maintain infection control practices.
Severity Breakdown
SS=D: 9
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to maintain comfortable sound levels for residents #26 and #47. | SS=D |
| Failure to develop a comprehensive care plan with targeted behaviors for psychotropic medication use for resident #26. | SS=D |
| Failure to review and revise care plan timely with interventions to prevent falls for resident #26. | SS=D |
| Failure to coordinate care with hospice for resident #45. | SS=D |
| Failure to provide timely interventions to prevent development of pressure ulcer for resident #24 and inconsistent offloading of heels. | SS=D |
| Failure to maintain restorative therapy program for resident #6 resulting in decline in ADLs. | SS=D |
| Failure to implement timely and appropriate interventions to prevent falls for resident #26. | SS=D |
| Failure to ensure drug regimen free from unnecessary drugs and failure to monitor targeted behaviors for resident #26 on antianxiety medication. | SS=D |
| Failure of pharmacist to identify irregularities and recommend dose reductions for residents #10 and #26. | SS=D |
| Failure to disinfect frequently touched surfaces and follow manufacturer's instructions for cleaning solutions while cleaning a resident's room. | SS=F |
Report Facts
Census: 42
Sample size: 14
Deficiency count: 10
Fall risk scores: 9
Fall risk scores: 11
Fall risk score: 13
Fall risk score: 15
Pressure ulcer size: 1.2
Pressure ulcer size: 2
Pressure ulcer size: 1.6
Resident weight range: 139
Resident weight range: 143
Depakote dose: 750
Melatonin dose: 6
BIMS score: 12
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff X | Observed cleaning resident room without disinfecting frequently touched surfaces or following contact time | |
| Staff O | Direct Care Staff | Interviewed regarding noise complaints and restorative therapy |
| Staff P | Direct Care Staff | Interviewed regarding resident falls and restorative therapy |
| Staff Q | Direct Care Staff | Interviewed regarding resident falls and restorative therapy |
| Staff R | Direct Care Staff | Performed restorative therapy with resident #6 |
| Staff Y | Maintenance Staff | Interviewed regarding noise complaints and use of wireless headphones |
| Staff H | Licensed Nursing Staff | Interviewed regarding noise complaints, restorative therapy, and medication monitoring |
| Staff D | Administrative Nursing Staff | Interviewed regarding care plan expectations, fall protocols, hospice care, and medication monitoring |
| Staff E | Administrative Staff | Interviewed regarding cleaning procedures and manufacturer's instructions |
| Consultant Pharmacist JJ | Consultant Pharmacist | Interviewed regarding medication monitoring and dose reductions |
Inspection Report
Life Safety
Deficiencies: 1
Aug 6, 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 deficiencies to be 'F' level, widespread, with no harm but with potential for more than minimal harm, not constituting immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Life Safety Code deficiencies at 'F' level, widespread, with no harm but potential for more than minimal harm | F |
Report Facts
Denial of payments effective date: Nov 6, 2015
Provider agreement termination date: Feb 6, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report and is the 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: 1
Jul 2, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiency with regulation 483.25(h) was corrected as of 05/11/2015. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.25(h) |
Report Facts
Correction completion date: May 11, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 7, 2015
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging and 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 the most serious deficiency in the facility to be a 'G' level. Enforcement remedies including denial of payment for new Medicare admissions effective August 7, 2015, were recommended due to failure to achieve substantial compliance.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'G' level | G |
Report Facts
Denial of payment effective date: Aug 7, 2015
Termination recommendation date: Nov 7, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaline Valleray | Administrator | Facility administrator named in the report |
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
May 7, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#KS00085778) regarding a resident fall from a malfunctioning lift chair.
Findings
The facility failed to ensure the resident environment was free of accident hazards, resulting in a resident sustaining a fall and hip fracture due to a malfunctioning lift chair known to staff but not properly repaired or removed from service.
Complaint Details
The complaint investigation found that four staff members were aware of the malfunctioning lift chair controls since April 2nd or 3rd but failed to remove the chair from service or ensure timely maintenance, leading to the resident's fall and injury.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure the resident environment remained free of accident hazards; a resident fell from a malfunctioning lift chair causing a hip fracture. | SS=G |
Report Facts
Resident census: 37
Residents using lift chairs: 14
Brief Interview for Mental Status score: 12
Open scalp wound size: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 6, 2015
Visit Reason
This plan of correction was submitted in response to a complaint investigation regarding an incident involving resident #1 and the use of electric lift chairs.
Findings
The facility identified a deficiency related to inadequate supervision and assistive devices to prevent accidents involving electric lift chairs. Corrective actions included staff in-service training, review and revision of care plans, and regular equipment checks.
Complaint Details
Complaint investigation related to an incident self-reported on 2015-04-06 involving resident #1 and electric lift chairs.
Deficiencies (1)
| Description |
|---|
| Resident #1 did not receive adequate supervision and assistive devices to prevent accidents involving electric lift chairs. |
Report Facts
Dates of corrective actions: Apr 8, 2015
Dates of corrective actions: Apr 6, 2015
Dates of corrective actions: May 11, 2015
Frequency: 4
Frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaline Valleray | Executive Director | Submitted the plan of correction |
Inspection Report
Follow-Up
Deficiencies: 2
Sep 5, 2014
Visit Reason
This revisit report documents the follow-up inspection to verify that previously reported deficiencies have been corrected and the dates such corrective actions were accomplished.
Findings
The report confirms that deficiencies identified in prior surveys, specifically those referenced by regulation numbers 28-39-158(a) and 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v), were corrected as of 09/05/2014.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 28-39-158(a) |
| Deficiency related to regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) |
Inspection Report
Follow-Up
Deficiencies: 7
Sep 5, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously cited deficiencies, identified by their regulation numbers, were corrected by the revisit date of 09/05/2014.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(c) |
| Deficiency related to regulation 483.35(g) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 9
Sep 5, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a regulatory inspection of a long term care provider.
Findings
The plan addresses multiple deficiencies related to resident care plans, use and assessment of power lift chairs, behavior monitoring for residents on psychotropic medications, dietary compliance with pureed diets, assistive device provision, tuberculin vial management, laundry procedures, and staff education. Corrective actions include audits, staff education, monitoring, and ongoing performance improvement meetings.
Severity Breakdown
D: 6
E: 1
F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Resident #25 care plan was updated to reflect current seating device. | D |
| Residents with power lift chairs were assessed for safe use and care plans revised accordingly. | D |
| Behavior monitoring sheets for residents on psychotropic medications were completed and documented accurately. | E |
| Facility dietary staff are following specified recipes for residents receiving pureed diets. | D |
| Resident #20 is provided with a divided plate at every meal in compliance with care plan. | D |
| Behavior monitoring sheets for Buspar and other psychotropic medications are maintained and reviewed monthly by consulting pharmacist. | D |
| Two vials of Tuberculin were discarded and new vials ordered; education provided on vial dating and expiration checking. | D |
| Dietary Manager enrolled in certification course to ensure compliance with dietary management. | F |
| Facility laundry staff are covering soiled laundry in receiving area with education and audits in place. | F |
Report Facts
Compliance date: Sep 5, 2014
Audit frequency: 3
Audit frequency: 4
Audit frequency: 3
Audit frequency: 3
Course start date: Jun 5, 2014
Course completion date: Dec 16, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| KALINE VALLERAY | Executive Director | Submitted the Plan of Correction. |
| IRINA STRAKHOVA | Added and modified the Plan of Correction. |
Inspection Report
Enforcement
Deficiencies: 1
Aug 29, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective September 5, 2014.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and communicated the acceptance of the plan of correction. |
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 6
Aug 29, 2014
Visit Reason
The inspection was a health resurvey to evaluate compliance with regulatory requirements including care planning, accident hazards, drug regimen monitoring, dietary needs, and medication management.
Findings
The facility failed to revise comprehensive care plans, assess safety of electric recliner chairs, monitor psychotropic medication effectiveness, follow pureed diet recipes, provide assistive eating devices, and properly dispose of expired medications. The pharmacy consultant failed to identify monitoring deficiencies for psychotropic and thyroid medications.
Severity Breakdown
Level 2: 5
Level 3: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to revise comprehensive care plans for resident #35 regarding electric recliner chair riser. | Level 2 |
| Failed to assess safety and appropriateness of electric recliner chairs for residents #20 and #35. | Level 3 |
| Failed to monitor effectiveness of psychotropic medications for residents #1, #2, and #3 and failed to monitor laboratory values for thyroid medication for resident #27. | Level 2 |
| Failed to follow recipes for pureed diets, resulting in inadequate nutrition. | Level 2 |
| Failed to provide divided plate as required by care plan for resident #20. | Level 2 |
| Failed to dispose of expired Tuberculin vials in medication room. | Level 2 |
Report Facts
Census: 40
Sample size: 14
Sample size: 5
Expired medication count: 2
Psychotropic medication doses: 4
Psychotropic medication doses: 7
Psychotropic medication doses: 7
TSH lab last drawn: 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff DD | Dietary Staff | Observed preparing pureed diets and acknowledged facility did not follow specific recipes |
| Staff J | Licensed Nursing Staff | Stated nursing staff monitored resident labs on a monthly/yearly calendar |
| Staff D | Administrative Nursing Staff | Acknowledged lack of documentation for electric recliner chair assessments and lab monitoring |
| Staff K | Licensed Nursing Staff | Acknowledged expired medication in refrigerator and expected staff to follow care plans |
| Staff HH | Therapy Staff | Assessed electric recliner chair safety but could not confirm documentation |
| Staff Q | Direct Care Staff | Reported therapy assessed electric recliner chairs for safety |
| Staff R | Direct Care Staff | Reported resident behaviors and notification to nurses |
| Staff O | Direct Care Staff | Reported resident behaviors and notification to nurses |
| Staff L | Licensed Nursing Staff | Documented resident behaviors only if related to medication |
| Staff B | Social Service Staff | Reported resident behaviors and communication with nursing |
| Staff KK | Occupational Therapy Staff | Reported communication with dietary and nursing regarding special plate |
| Staff F | Administrative Nursing Staff | Expected staff to follow care plan for divided plate |
| Staff JJ | Consultant Pharmacist | Reviewed behavior monitoring sheets monthly but overlooked missing monitoring for Buspar |
Inspection Report
Life Safety
Deficiencies: 1
Jan 7, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required to address these deficiencies.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level, widespread, with no harm but potential for more than minimal harm | F |
Report Facts
Denial of payments effective date: Apr 7, 2014
Provider agreement termination date: Jul 7, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kent McGeeney | Administrator | Named as facility administrator |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 1
May 27, 2013
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to confirm the date such corrective actions were accomplished.
Findings
The report indicates that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 05/27/2013. No other deficiencies or issues were noted.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited and corrected |
Report Facts
Deficiency correction date: May 27, 2013
Inspection Report
Follow-Up
Deficiencies: 5
May 27, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that all previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(5) - (10), 483.10(b)(1) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.35(c) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 6
May 24, 2013
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 addresses multiple deficiencies including discharge procedures for Medicare services, pressure ulcer prevention interventions, preparation and choice provision for pureed diets, food storage and sanitation practices, Medical Director attendance at QAA meetings, and dietary manager certification enrollment.
Severity Breakdown
D: 2
F: 3
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Discharge procedures for residents from Skilled Medicare services lacked proper liability notices. | D |
| Pressure ulcer prevention interventions were not consistently implemented for at-risk residents. | D |
| Dietary staff did not consistently follow recipes for pureed diets or provide meal choices to residents receiving pureed diets. | F |
| Opened food containers were not properly labeled and dated; kitchen sanitation issues were noted. | F |
| Medical Director attendance at QAA meetings was not adequately documented or ensured. | E |
| Dietary Manager was not certified; facility enrolled staff in certification course. | F |
Report Facts
Audit frequency: 3
Audit duration: 4
Audit frequency: 4
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kent McGeeney | Executive Director | Named as responsible for education, monitoring, audits, and ensuring compliance in multiple corrective actions |
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 5
May 15, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to document specific skilled services on Liability Notices for residents, failure to prevent development of a pressure ulcer in one resident, failure to provide pureed diets meeting nutritional needs, failure to maintain sanitary food preparation and storage conditions, and failure to have a physician attend Quality Assessment and Assurance (QAA) meetings quarterly.
Severity Breakdown
Level D: 1
Level E: 1
Level F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to document specific skilled services residents received on Liability Notices for 3 residents. | Level D |
| Failed to prevent development of a stage II pressure ulcer for one resident and lacked adequate care plan interventions. | Level F |
| Failed to provide pureed diet that met nutritional needs, including failure to provide pureed bread, follow recipes, and offer food choices. | Level F |
| Failed to label and date food removed from original containers and maintain sanitary food preparation environment. | Level E |
| Failed to ensure a physician attended Quality Assessment and Assurance meetings at least quarterly. | — |
Report Facts
Census: 51
Residents reviewed for pressure ulcers: 1
Residents receiving pureed diet: 8
Residents reviewed: 16
Inspection Report
Plan of Correction
Deficiencies: 0
N066002 CYVT11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID CYVT11 for facility State ID N066002.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a placeholder or status page for the Plan of Correction with no records found.
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