Inspection Reports for Life Care Center of Wichita
622 N. EDGEMOOR STREET, WICHITA, KS, 67208-3602
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 27, 2018 found no deficiencies, with all prior issues corrected by the compliance date of July 11, 2018. Earlier inspections showed repeated deficiencies primarily related to timely completion of assessments, medication labeling and removal of expired medications, fall prevention interventions, and inventories of residents’ personal effects. Complaint investigations substantiated issues with fall prevention, medication errors, wound care, infection control, and resident dignity, though fines or license actions were not listed in the available reports. The facility submitted multiple plans of correction addressing these areas, including staff education, audits, and monitoring systems. The inspection history indicates improvement over time, with recent surveys showing compliance after correction of earlier cited deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
27.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
360% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
106 residents
Based on a June 2018 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 27, 2018
Visit Reason
An offsite revisit survey was conducted on 08/27/2018 for all previous deficiencies cited on 06/12/2018.
Findings
All deficiencies have been corrected as of the compliance date of 07/11/2018, 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: 4
Date: Jul 11, 2018
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita in response to deficiencies cited during a prior inspection, outlining corrective actions to address identified issues.
Findings
The Plan of Correction addresses deficiencies related to timely completion of comprehensive and quarterly MDS assessments, proper labeling and removal of expired medications including insulin pens, and completion and maintenance of residents' personal effects inventories.
Deficiencies (4)
Failure to complete timely comprehensive MDS assessments for affected residents.
Failure to complete timely quarterly MDS assessments for affected residents.
Insulin pens not labeled with open/expiration dates and expired medications not removed from medication carts.
Incomplete inventory of residents' personal effects.
Report Facts
Corrective action completion date: Jul 11, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Stephenson | Executive Director | Submitted the Plan of Correction |
Inspection Report
Census: 106
Deficiencies: 1
Date: Jun 12, 2018
Visit Reason
The inspection was a health licensure resurvey combined with complaint investigations for complaints #127573, #116987, and #115754.
Complaint Details
The visit included complaint investigations for complaints #127573, #116987, and #115754.
Findings
The facility failed to ensure staff completed an inventory of personal possessions for 4 residents in the sample. Personal inventory sheets for residents #208, #89, #62, and #45 were found to be blank and incomplete.
Deficiencies (1)
Failure to complete an inventory of personal possessions for 4 residents.
Report Facts
Census: 106
Residents with incomplete personal inventory: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff G | Interviewed regarding responsibility for completing personal inventories. | |
| administrative nursing staff B | Interviewed regarding expectations for completion of personal inventory sheets. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 8, 2018
Visit Reason
An off-site survey was conducted to address deficiencies cited on May 8, 2018.
Findings
The deficiencies cited on May 8, 2018, were corrected as of the compliance date of June 7, 2018.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 7, 2018
Visit Reason
This Plan of Correction was submitted in response to deficiencies cited related to fall prevention and care plan interventions for residents, specifically addressing issues with non-skid socks or appropriate footwear and review of prior incidents for fall risk.
Findings
The facility acknowledged deficiencies related to fall prevention and care planning for residents, and outlined corrective actions including staff education, audits of fall interventions, and root cause analysis to prevent recurrence of falls.
Deficiencies (1)
Deficient practice regarding need for non-skid socks or appropriate footwear for resident #4 and review of prior incidents for resident #3 to evaluate root cause and ensure appropriate care plan interventions.
Report Facts
Audit frequency: 3
Audit duration: 4
Incident audits: 4
Completion date: Jun 7, 2018
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 8, 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 with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 7, 2018.
Deficiencies (1)
Most serious deficiencies found to be 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
Complaint Investigation
Census: 115
Deficiencies: 1
Date: May 8, 2018
Visit Reason
The inspection was conducted as a result of complaint investigations KS00129160 and KS00128903 focusing on falls and accident hazards in the facility.
Complaint Details
The findings represent the results of complaint investigations KS00129160 and KS00128903. The facility failed to prevent falls and properly assess causal factors for falls in residents #3 and #4.
Findings
The facility failed to implement interventions to prevent falls, failed to determine the cause of falls, and failed to place appropriate interventions on the care plan for 2 of 3 residents reviewed for falls. Resident #4 fell due to not wearing non-skid socks as required by the care plan, and resident #3 had multiple falls without causal factors identified or appropriate interventions planned.
Deficiencies (1)
Failure to implement interventions to prevent falls and failure to determine causes of falls for residents #3 and #4.
Report Facts
Census: 115
Falls: 3
Falls: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff E | Reported care details for resident #4 including supervision and use of gripper socks. | |
| Licensed nurse C | Reported that residents at risk of falling needed to wear non-skid socks and described resident #4's condition. | |
| Administrative nursing staff F | Reported staff needed to check resident #4 wore non-skid socks. | |
| Direct care staff J | Reported resident #3 required total care and sometimes did not use call light. | |
| Direct care staff L | Reported on care and turning of resident #3 every 2 hours. | |
| Licensed nurse K | Reported resident #3 became confused and forgot to use call light, had falls, and nurse completed fall investigation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 16, 2018
Visit Reason
A revisit survey was conducted on 4/16-17/2018 for all previous deficiencies cited on 2/12/2018.
Findings
All deficiencies have been corrected as of the compliance date of 03/01/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Deficiency correction compliance date: Mar 1, 2018
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 16, 2018
Visit Reason
A revisit survey was conducted on 4/16-17/2018 for all previous deficiencies cited on 2/12/2018.
Findings
All deficiencies have been corrected as of the compliance date of 03/01/2018, 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
Date: Mar 1, 2018
Visit Reason
This Plan of Correction document is submitted in response to deficiencies cited during a prior survey of Life Care Center of Wichita, addressing corrective actions for skin assessments and fall prevention.
Findings
The facility identified deficiencies related to skin assessments and fall investigations for specific residents and outlined corrective actions including comprehensive assessments, staff in-service training, and ongoing audits to ensure compliance.
Deficiencies (2)
Deficiency in comprehensive skin assessment and documentation for residents #6 and #8
Deficiency in fall investigation and care plan updates for residents #5 and #3
Report Facts
Compliance date: Mar 1, 2018
In-service completion date: Apr 15, 2018
Audit duration: 4
Minimum incidents audited weekly: 4
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 3
Date: Feb 12, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers #126152, 119306, and 105231.
Complaint Details
The inspection was triggered by complaints identified by investigation numbers #126152, 119306, and 105231.
Findings
The facility failed to adequately monitor and provide appropriate interventions for resident #8's sacral flap wound, resulting in worsening skin breakdown requiring surgical debridement and wound vacuum placement. Additionally, the facility failed to properly assess and monitor multiple non-pressure skin ulcers on resident #6. The facility also failed to identify causal factors and implement effective interventions to prevent falls for residents #5 and #3.
Deficiencies (3)
Failed to ensure staff adequately monitored resident #8 for skin breakdown and provided appropriate interventions to prevent worsening of a sacral flap wound, resulting in surgical debridement and wound vacuum placement.
Failed to properly assess and monitor for effective treatment on multiple non-pressure skin ulcers on resident #6.
Failed to identify, evaluate, implement, and monitor interventions to prevent falls for residents #5 and #3.
Report Facts
Resident census: 112
Wound measurements: 11
Wound measurements: 7.5
Wound measurements: 3.2
Wound measurements: 10.2
Wound measurements: 3
Wound measurements: 0.2
Fall risk score: 22
BIMS score: 14
BIMS score: 11
BIMS score: 3
BIMS score: 13
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 6, 2017
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
All previously cited deficiencies identified by regulation numbers 483.10(a)(1), 483.10(i)(2), 483.25(c)(2)(3), and 483.25(d)(1)(2)(n)(1)-(3) were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 6, 2017
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita in response to deficiencies cited during a complaint investigation survey.
Findings
The facility addressed multiple deficiencies including dignity and respect of individuality, housekeeping and maintenance, increase/prevent decrease in range of motion, and free of accident hazards/supervision/devices. Corrective actions, education plans, and monitoring procedures were implemented to ensure compliance and prevent recurrence.
Deficiencies (4)
Dignity and Respect of Individuality - Resident #1 was provided with appropriate clothing and care plans were updated.
Housekeeping and Maintenance - Floors were swept, mopped, and scheduled for stripping/waxing; new cleaning schedule created.
Increase/Prevent Decrease in Range of Motion - Resident #1's treatment record and care plans updated to include splint wear schedule.
Free of Accident Hazards/Supervision/Devices - Correct sling placed in resident #1's room and additional slings purchased.
Report Facts
Resident rooms floors: 60
Audits per week: 10
Audit duration: 4
Audits per week: 5
Resident charts audited per week: 10
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 7, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an 'E' level deficiency 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 effective September 6, 2017.
Deficiencies (1)
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 contact and complaint coordinator related to the survey findings. |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 4
Date: Aug 7, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on allegations related to resident dignity, housekeeping, mobility treatment, and accident prevention.
Complaint Details
The complaint investigations #118019 and #118348 focused on issues including dignity and respect of residents, housekeeping and maintenance, mobility treatment, and accident prevention.
Findings
The facility failed to maintain resident dignity by not ensuring appropriate dress and privacy for a resident with Huntington's disease. Housekeeping services were inadequate, with dingy floors and dust accumulation in many rooms. The facility also failed to apply planned bilateral hand splints for a resident with limited range of motion and used an inappropriate large lift sling instead of the prescribed medium sling during transfers, posing safety risks.
Deficiencies (4)
Failure to maintain dignity for a resident by not ensuring appropriate dress and privacy during waking hours.
Failure to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior, including floor cleaning and dusting in multiple resident rooms.
Failure to apply planned bilateral hand splints for a resident with limited range of motion.
Failure to use the appropriate and planned body sling while transferring a resident, using a sling too large for the resident.
Report Facts
Residents sampled for ADL assistance: 3
Rooms with housekeeping deficiencies: 9
Rooms with housekeeping deficiencies: 8
Rooms with housekeeping deficiencies: 21
Rooms with housekeeping deficiencies: 10
Resident height: 62
Resident weight: 75
Resident weight: 77
Sling weight range medium: 100
Sling weight range medium: 200
Sling weight range large: 150
Sling weight range large: 275
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff B | Mentioned in relation to resident care, failure to dress resident properly, and use of incorrect lift sling | |
| Licensed nurse C | Mentioned in relation to resident care, failure to dress resident properly, failure to apply hand splints, and use of incorrect lift sling | |
| Administrative nurse D | Mentioned regarding expectations for resident dress and sling use | |
| Housekeeping staff G | Described cleaning procedures and dusting schedule | |
| Housekeeping staff H | Reported on floor cleaning schedule and dusting expectations | |
| Direct care staff E | Reported resident had not worn hand splints for months | |
| Direct care staff F | Assisted with resident care and observed hand spasticity | |
| Therapy staff A | Updated care plan to include wearing bilateral hand splints |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 7, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report indicates that the previously cited deficiency with regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of the revisit date. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3) previously cited and corrected
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 7, 2017
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita in response to deficiencies cited during a complaint-related survey.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation survey at Life Care Center of Wichita.
Findings
The facility was found deficient in maintaining a safe environment free of accident hazards, specifically related to resident supervision and interventions to prevent accidents. Corrective actions include implementing 3-day bladder diaries, installing grab bars, conducting audits of incontinence assessments, and performing root cause analyses for falls.
Deficiencies (1)
Failure to ensure resident environments remain free of accident hazards and provide adequate supervision and interventions to prevent accidents (F323).
Report Facts
Days for bladder diary: 3
Audit frequency: 3
Substantial compliance date: Jul 7, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| KYLE SCHAFFER | Executive Director | Submitted the Plan of Correction |
| CARYL GILL | Modified the Plan of Correction document |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 19, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious 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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction effective July 7, 2017.
Deficiencies (1)
Most serious deficiencies found to be 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
Complaint Investigation
Census: 95
Deficiencies: 1
Date: Jun 19, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#115482) focusing on the facility's failure to thoroughly investigate all causal factors related to falls for sampled residents and to develop interventions to prevent further falls.
Complaint Details
The findings represent the results of complaint investigation #115482 regarding inadequate investigation and intervention for resident falls.
Findings
The facility failed to thoroughly investigate causal factors of repeated falls for two sampled residents and did not develop adequate interventions to prevent further falls. Investigations lacked critical information such as timing of toileting assistance, use of safety devices, and environmental factors. Root cause analyses were delayed and incomplete, and care plans were not revised appropriately following assessments.
Deficiencies (1)
Failure to thoroughly investigate all causal factors related to falls and to develop interventions to prevent further falls for sampled residents.
Report Facts
Facility census: 95
Sampled residents for accidents: 3
Fall risk score: 22
Fall risk score: 24
BIMS score: 10
BIMS score: 3
Fall risk score: 14
Fall risk score: 24
Number of falls: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse J | Administrative Nurse | Provided information about facility policy on root cause analysis and confirmed deficiencies in fall investigations and interventions. |
| Licensed nurse F | Licensed Nurse | Reported resident's need for assistance and fall prevention measures. |
| Licensed nurse G | Licensed Nurse | Described fall report review process and care plan revision requirements. |
| Licensed nurse H | Licensed Nurse | Responded to resident fall and provided details about the incident. |
| Licensed nurse N | Licensed Nurse | Reported increased assistance needs of resident and more frequent staff checks. |
| Direct care staff A | Direct Care Staff | Assisted resident with transfers and described resident's fall risk. |
| Direct care staff B | Direct Care Staff | Assisted resident with transfers and applied pivot disk. |
| Direct care staff C | Direct Care Staff | Reported resident's need for assistance and fall risk behavior. |
| Direct care staff D | Direct Care Staff | New staff member who described resident's transfer needs. |
| Direct care staff E | Direct Care Staff | Reported resident's usual routine and fall risk. |
| Direct care staff L | Direct Care Staff | Reported frequent checks and assistance provided to resident. |
| Direct care staff M | Direct Care Staff | Reported changes in resident's assistance needs and toileting routine. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 9, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiency with ID Prefix F0333 related to regulation 483.25(m)(2) was corrected as of 05/27/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency with ID Prefix F0333 related to regulation 483.25(m)(2)
Report Facts
Deficiency correction date: May 27, 2016
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 27, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiency with ID Prefix F0322 related to regulation 483.25(g)(2) was corrected as of 05/27/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency with ID Prefix F0322 related to regulation 483.25(g)(2)
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 27, 2016
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita in response to deficiencies cited during a complaint-related survey.
Complaint Details
The plan addresses deficiencies cited during a complaint investigation, specifically related to medication errors affecting Resident #3 discharged for planned surgery on 5/5/16.
Findings
The facility developed and implemented a system to assure correction and continued compliance regarding medication errors, including modifications to the admissions process, staff education, and monitoring through audits.
Deficiencies (1)
Residents Free of Significant Medication Errors
Report Facts
Audit frequency: 5
Audit frequency: 5
Audit duration: 4
Performance Improvement meetings: 3
Substantial compliance date: May 27, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Director of Nursing | Responsible for providing education and monitoring medication reconciliation process |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 27, 2016
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 Wichita.
Complaint Details
This Plan of Correction is linked to a complaint investigation at Life Care Center of Wichita (complaint date 05/17/2016).
Findings
The facility developed and implemented a system to assure correction and continued compliance regarding treatment and services for residents with g-tube or peg tube sites, including education for nursing staff and monitoring through audits.
Deficiencies (1)
Failure to follow physician orders for treatment of g-tube/peg tube sites and proper documentation of treatments.
Report Facts
Audit frequency: 5
Audit frequency: 5
Audit duration: 4
Performance Improvement meetings: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Kyleschaffer | Executive Director | Submitted the Plan of Correction. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 17, 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 that constitutes no actual harm 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 the credible allegation of compliance and the plan.
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
Complaint Investigation
Census: 106
Deficiencies: 1
Date: May 17, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#0198) regarding the facility's treatment and services related to residents with feeding tubes.
Complaint Details
The complaint investigation #0198 was triggered by concerns about inadequate care of feeding tube sites, including observations of soiled dressings and signs of infection or skin breakdown.
Findings
The facility failed to provide appropriate treatment and services to prevent infection and skin breakdown at gastrostomy tube sites for 2 of 3 residents receiving feedings through a gastrostomy tube. Specifically, dressing changes were not performed as ordered, and care plans and physician orders lacked specific instructions for feeding tube site care.
Deficiencies (1)
Failed to provide appropriate treatment and services to the gastrostomy insertion site to prevent infection and skin breakdown for residents receiving feedings through a gastrostomy tube.
Report Facts
Facility census: 106
Residents in sample: 3
BIMS score: 8
BIMS score: 12
Percentage of nutrition from enteral feeding: 51
Dressing changes ordered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse F | Licensed Nurse | Observed dressing change and reported usual dressing change frequency. |
| Nurse I | Licensed Nurse | Reported observations of wound and dressing care. |
| Administrative Nurse D | Administrative Nurse | Reported expectations for dressing change orders and nursing staff compliance. |
| Physician Extender E | Physician Extender | Provided information about standing orders and dressing care practices. |
| Direct Care Staff B | Interviewed regarding resident care and dressing observations. | |
| Direct Care Staff G | Reported observations about dressing changes frequency. | |
| Direct Care Staff H | Reported no complaints of pain from resident. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 11, 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 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 the credible allegation of compliance and the plan 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 | RN, BSN, Complaint Coordinator | Named as the contact person and complaint coordinator related to the survey findings. |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 1
Date: May 11, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#99478) regarding medication errors at the facility.
Complaint Details
Complaint investigation #99478 focused on medication errors involving resident #3, who was hospitalized due to receiving triple the prescribed dose of Sensipar. The investigation found transcription errors by licensed nurses and failure to clarify orders, leading to the medication error.
Findings
The facility failed to ensure staff transcribed medication orders correctly, clarify new orders when there was a drastic change, and administer medications as ordered, resulting in a significant medication error for one resident who was hospitalized after receiving triple the prescribed dose of Sensipar.
Deficiencies (1)
Failed to ensure residents were free of significant medication errors due to incorrect transcription and administration of Sensipar medication.
Report Facts
Facility census: 113
Residents sampled for medication review: 3
Sensipar dose error: 3
Creatinine level: 6.18
Calcium level: 7.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician extender H | Physician Extender | Signed physician orders on 3/16/16 and confirmed medication error and order correction |
| Nurse D | Administrative Nurse | Entered orders into electronic system on 3/25/16; unaware of dosage error |
| Nurse A | Licensed Nurse | Entered re-admission orders on 3/31/16 with incorrect Sensipar dosage; received retraining |
| Nurse B | Licensed Nurse | Reviewed and verified orders but missed dosage error; received verbal education/retraining |
| Administrative Nurse Staff C | Administrative Nurse Staff | Aware of medication errors but had not investigated |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 1, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies related to various regulatory requirements were corrected as of the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 18, 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 Medicare and/or Medicaid.
Findings
The survey found the most serious deficiency 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 April 1, 2016.
Deficiencies (1)
Most serious deficiency found was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to enforcement and compliance findings. |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 7
Date: Mar 18, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations #96373 and 86947.
Complaint Details
The visit was triggered by complaint investigations #96373 and 86947.
Findings
The facility was found deficient in multiple areas including failure to monitor and assess a resident after dialysis, failure to prevent unnecessary drug use, failure to provide routine dental services, failure to maintain sanitary food storage and preparation areas, failure to properly label and dispose of medications, and failure to maintain infection control practices.
Deficiencies (7)
Failed to monitor and assess 1 resident upon return to the facility from dialysis.
Failed to ensure 4 of 5 residents did not receive unnecessary medications due to inadequate monitoring of blood pressure, pulses, PRN medication administration, and targeted behaviors.
Failed to provide or obtain routine dental services to meet the needs of 1 resident.
Failed to ensure the consultant pharmacist identified irregularities in medication monitoring and follow-up for residents.
Failed to establish a system to ensure resident medications had dates when opened and were disposed of when expired, including inhalers.
Failed to store, prepare and distribute food under sanitary conditions, including dirty sugar bins, greasy surfaces, and uncovered meat slicer with personal items on it.
Failed to maintain infection control by not following manufacturer recommendations for disinfectant wet times and improper cleaning procedures in resident rooms and shower room.
Report Facts
Facility census: 103
Dialysis frequency: 3
Medication monitoring failures: 28
Medication monitoring failures: 8
Medication monitoring failures: 7
Medication monitoring failures: 5
Medication monitoring failures: 4
Medication monitoring failures: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Consultant Pharmacist | Identified problems with PRN medication monitoring and lack of targeted behavior monitoring. |
| Staff D | Administrative Nurse | Reported expectations for medication monitoring and behavior documentation. |
| Staff M | Administrative Nursing Staff | Acknowledged behavior monitoring deficiencies and medication documentation irregularities. |
| Staff B | Dietary Supervisory Staff | Confirmed unsanitary conditions in food storage and preparation areas. |
| Staff E | Licensed Nurse | Removed inhalers without open dates from medication carts. |
| Staff F | Licensed Nurse | Reported lack of knowledge about inhaler dating requirements. |
| Staff S | Housekeeping Staff | Observed cleaning practices not following disinfectant wet time requirements. |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Mar 18, 2016
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita addressing deficiencies cited during a prior survey inspection conducted on 03/18/2016.
Findings
The Plan of Correction outlines corrective actions, education, and monitoring plans to address multiple deficiencies related to resident care, medication management, food sanitation, dental services, drug regimen review, medication storage, and infection control. Substantial compliance is targeted by 04/01/2016.
Deficiencies (8)
F0000: Credible Allegation of Compliance with facility-wide system to assure correction and continued compliance.
F309: Provide Care and Services for Highest Well Being, including monitoring and assessment of residents returning from dialysis.
F329: Drug Regimen Free from Unnecessary Drugs, including monitoring blood pressure, pulse, prn medications, behaviors, and sliding scale insulin administration.
F371: Food Stored/Prepared/Served Under Sanitary Conditions, including cleaning and sanitizing kitchen equipment and storage areas.
F412: Provide Routine/Emergency Dental Services, including addressing dental needs at care plan meetings and referrals.
F428: Drug Review Regimen, including monthly medication reviews by consultant pharmacist and follow-up by DON.
F431: Drug/Medication Storage, including proper labeling and dating of Advair Diskus inhalers.
F441: Infection Control, including education on proper wet times and disinfection of resident rooms and equipment.
Report Facts
Audit frequency: 5
Audit frequency: 10
Audit frequency: 3
Audit frequency: 3
Audit frequency: 10
Audit frequency: 4
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KYLESCHAFFER | Executive Director | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 11, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report documents that deficiencies identified in prior surveys under regulations 483.25(d) and 483.25(h) were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 2, 2015
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita in response to deficiencies cited during a complaint survey.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint survey for Life Care Center of Wichita.
Findings
The facility developed and implemented corrective actions to address deficiencies related to incontinence assessments and individualized toileting schedules, as well as the safe use of mechanical lifts for resident transfers. The plan includes staff education, audits, and ongoing monitoring to ensure compliance.
Deficiencies (2)
Incontinence assessment and individualized toileting schedule not properly implemented for Resident #5.
Mechanical lift use and transfer methods not properly evaluated or followed for Resident #5.
Report Facts
Residents audited: 5
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KYLESCHAFFER | Executive Director | Submitted the Plan of Correction. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 23, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.
Deficiencies (1)
Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 2
Date: Nov 23, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#KS00093374) focusing on concerns related to catheter use, urinary incontinence treatment, and safe transfer practices at the facility.
Complaint Details
The complaint investigation focused on Resident #5's care related to urinary incontinence and transfer safety. The investigation substantiated failures in providing appropriate incontinence care and safe transfer practices.
Findings
The facility failed to provide appropriate treatment and services to prevent urinary tract infections and restore bladder function for one resident, including lack of a comprehensive toileting plan and failure to offer toileting opportunities as directed by the care plan. Additionally, the facility failed to ensure safe transfers for the same resident by not following manufacturer recommendations for sit to stand lift use, including failure to fasten safety belts and use two staff as required.
Deficiencies (2)
Failure to provide appropriate treatment and services for urinary incontinence, including lack of comprehensive assessment, individualized toileting plan, and failure to offer toileting opportunities as directed by care plan for Resident #5.
Failure to ensure adequate supervision and use of assistive devices for safe transfers, including not fastening waist/chest belt and leg straps on sit to stand lift and performing mechanical lift transfers with only one staff present for Resident #5.
Report Facts
Residents in census: 114
Residents selected for sample: 6
Residents reviewed for incontinence: 3
Residents reviewed for transfers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Reported resident #5 did not have a toileting plan and staff did not toilet resident every 2 hours as directed; also reported staff do not routinely fasten waist/chest belt during transfers. |
| Direct Care Staff E | Direct Care Staff | Confirmed staff did not offer to toilet resident #5 during observation period; reported staff do not fasten waist/chest belt or use leg straps during transfers. |
| Direct Care Staff D | Direct Care Staff | Reported resident #5 preferred to stay near main entrance and staff did not toilet resident every 2 hours; reported always fastening waist/chest belt and leg straps during transfers but did not know why lift lacked leg belt. |
| Direct Care Staff F | Direct Care Staff | Reported staff 'check and change' resident #5 and do not offer toileting every 2 hours as directed. |
| Administrative Nurse B | Administrative Nurse | Confirmed facility policy requires two staff present for mechanical lift transfers and use of safety belts and leg straps as per manufacturer recommendations. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 4, 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 at 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
Most serious deficiencies found at 'F' level in Life Safety Code survey
Report Facts
Effective date for denial of payments: Feb 4, 2016
Provider agreement termination date: May 4, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 10, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously identified deficiency with ID prefix F0309 related to regulation 483.25 was corrected as of 06/10/2015.
Deficiencies (1)
Deficiency with ID prefix F0309 related to regulation 483.25
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 10, 2015
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita in response to deficiencies cited during a complaint survey.
Complaint Details
The Plan of Correction addresses deficiencies cited during a complaint survey. Resident #1 was discharged, and the facility identified potential impact on any resident with a surgical incision. The plan includes education and monitoring to prevent recurrence. Substantial compliance was noted on 6/10/15.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations related to care and services for residents with surgical incisions, including staff education and monitoring.
Deficiencies (1)
Failure to provide care/services for highest well-being related to surgical incision care and dressing changes.
Report Facts
Audits: 5
Audit duration: 4
Audit monitoring period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Kyleschaffer | Executive Director | Submitted Plan of Correction |
| Irina Strakhova | Added and modified Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 5, 2015
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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 which was accepted, resulting in a finding of substantial compliance effective June 10, 2015.
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 |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and compliance letter. |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 1
Date: Jun 5, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#6289 and #5309) regarding the facility's failure to provide necessary care and services for dressing changes for a surgical incision on a resident.
Complaint Details
The investigation was triggered by complaints regarding the lack of daily dressing changes for resident #1's surgical incision, which led to infection and hospital readmission. The complaint was substantiated by findings of missed dressing changes and infection.
Findings
The facility failed to assess and change the surgical dressing daily as ordered for resident #1, resulting in a MRSA infection and the need for a second surgical procedure (debridement). Nursing staff did not properly document or perform dressing changes, leading to delayed treatment and infection.
Deficiencies (1)
Failure to provide necessary care and services for dressing changes for a surgical incision for 1 of 3 residents reviewed.
Report Facts
Census: 116
Sample size: 3
Duration of bone stimulator use: 4
Duration of bone stimulator use: 6
Antibiotic frequency: 4
Antibiotic duration: 10
Inspection Report
Follow-Up
Deficiencies: 9
Date: Dec 12, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited with various regulatory references were corrected as of the revisit date, 12/12/2014.
Deficiencies (9)
Deficiency related to regulation 483.20(g) - (j)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.25(n)
Deficiency related to regulation 483.55(b)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Dec 12, 2014
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita addressing deficiencies cited during a prior survey.
Findings
The Plan of Correction outlines corrective actions taken for multiple deficiencies related to assessment accuracy, care plans, unnecessary drugs, immunizations, dental services, drug review regimen, medication storage, and QAA committee meetings, with education and monitoring systems implemented to prevent recurrence.
Deficiencies (10)
F0000: Credible Allegation of Compliance for cited deficiencies with facility-wide corrective system.
F278: Inaccurate assessments regarding urinary continence and dental status.
F279: Care plans not reflecting current dental status and hospice services.
F280: Care plan revisions needed to include emergency interventions for dialysis.
F329: Unnecessary drugs and inadequate monitoring/documentation of medication effects.
F334: Pneumococcal immunizations not consistently administered/documented.
F412: Dental services not adequately addressed or referred.
F428: Drug review regimen deficiencies including missing documentation and follow-up.
F431: Medication storage issues including unlabeled vials and expired medications.
F520: QAA Committee members not meeting quarterly plans, including Medical Director attendance.
Report Facts
Audit frequency: 10
Substantial compliance date: Dec 12, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| KYLE SCHAFFER | Executive Director | Submitted the Plan of Correction. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Nov 25, 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.
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 12, 2014.
Deficiencies (1)
Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kyle Schaffer | Administrator | Named as facility administrator in the report. |
| Irina Strakhova | Enforcement Coordinator | Author of the enforcement letter. |
| Carol Schiffelbein | Regional Manager | Copied on the letter as Regional Manager, Office of the Long Term Care Ombudsman. |
Inspection Report
Re-Inspection
Census: 105
Deficiencies: 9
Date: Nov 25, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements including assessment accuracy, care planning, medication management, immunizations, dental services, and quality assurance.
Findings
The facility failed to accurately assess residents' conditions, develop comprehensive care plans, monitor medication effectiveness, provide pneumococcal immunizations after consent, remove expired medications, and ensure physician attendance at quality assurance meetings.
Deficiencies (9)
Failed to accurately assess residents' urinary continence and dental status in Minimum Data Set (MDS) assessments.
Failed to develop comprehensive care plans for residents related to dental status and hospice services.
Failed to revise care plans to include emergency dialysis interventions.
Failed to ensure residents did not receive unnecessary drugs and failed to monitor effectiveness of pain medications and blood sugar levels as ordered.
Failed to provide pneumococcal immunizations to residents after consent was obtained from their legal representatives.
Failed to provide routine dental services by not identifying and notifying appropriate staff to arrange dental care for a resident with broken or loose dentures.
Failed to ensure consultant pharmacist identified drug irregularities related to pain medication follow-up and blood sugar monitoring and notify appropriate staff.
Failed to remove expired medications from medication rooms and medication carts.
Failed to ensure physician attendance at Quality Assurance meetings at least quarterly.
Report Facts
Facility census: 105
Residents in sample: 24
Incidents of urinary incontinence: 18
Days pain medication follow-up missing: 8
Days blood sugar not checked: 8
Expired medication days: 38
Expired medication days: 35
Expired medication days: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Administrative Nurse | Acknowledged inaccurate MDS assessments and expected care plans to include hospice services and dental concerns |
| Administrative nurse T | Administrative Nurse | Reported changes to bladder assessment and care plan meeting processes |
| Licensed nursing staff V | Licensed Nurse | Reported resident continence status and MDS coding errors |
| Licensed nursing staff K | Licensed Nurse | Reported dental assessments and denture care practices |
| Pharmacist R | Consultant Pharmacist | Reported failure to identify drug irregularities and pain medication follow-up issues |
| Administrative Staff P | Administrative Staff | Reported QA committee meeting frequency and lack of physician attendance |
| Administrative Staff A | Administrative Staff | Reported QA committee meeting frequency and lack of physician attendance |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 23, 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 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Aug 23, 2014
Provider agreement termination date: Nov 23, 2014
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kyle Schaffer | Administrator | Named as facility administrator in the report |
| 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: 4
Date: Dec 13, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies related to regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.20(d), 483.20(k)(1), 483.25, and 483.60(a),(b) have been corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.60(a),(b)
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Dec 13, 2013
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita in response to deficiencies cited during a complaint survey.
Complaint Details
This Plan of Correction is in response to a complaint survey. Resident #2 was discharged from the facility. The facility addressed allegations of abuse and other deficiencies cited during the complaint investigation.
Findings
The Plan of Correction addresses multiple deficiencies including failure to investigate and report allegations of abuse, care plan inaccuracies, pain assessment documentation, and pharmaceutical service procedures. The facility implemented education, monitoring, and auditing systems to ensure compliance and prevent recurrence.
Deficiencies (4)
Failure to investigate and report allegations of abuse
Inaccurate care plans, specifically regarding weight bearing status for orthopedic patients
Failure to provide services to maintain the highest wellbeing, including pain assessment and documentation
Pharmaceutical services inaccuracies, specifically in documenting administration of prn pain medications
Report Facts
Residents interviewed for abuse allegations monitoring: 5
MDS/CAAS and care plans audited: 10
Charts audited for pain assessment: 10
Charts audited for prn pain medication documentation: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KYLESCHAFFER | Executive Director | Named as responsible for submitting the Plan of Correction and involved in education and monitoring |
| MARY JANE KENNEDY | Modified the Plan of Correction | |
| IRINA STRAKHOVA | Added the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 4
Date: Dec 5, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#70373) related to allegations of neglect or abuse at the facility.
Complaint Details
The complaint investigation (#70373) focused on allegations of neglect or abuse involving 1 or 2 residents. The facility failed to immediately report the allegation involving a resident with a new left leg fracture, which required investigation to rule out abuse or neglect.
Findings
The facility failed to immediately report an allegation of possible abuse or neglect, failed to develop a comprehensive care plan for a resident with a hip fracture, failed to adequately assess and manage pain for a resident, and failed to accurately document the administration and effectiveness of narcotic pain medications.
Deficiencies (4)
Failure to immediately report allegations of abuse or neglect to officials in accordance with state law.
Failure to develop a comprehensive care plan for a resident regarding specific care status post hip fracture.
Failure to adequately assess and monitor the effectiveness of pain medications administered to a resident.
Failure to follow pharmaceutical policy and accurately document the administration and effectiveness of narcotic pain medications.
Report Facts
Facility census: 103
Residents reviewed for allegations: 2
Residents sampled for care plans: 3
PRN Lortab doses documented on MAR: 9
PRN Lortab doses removed per narcotic count sheets: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Nursing Staff | Interviewed regarding failure to immediately report abuse allegations and care plan development. |
| Staff B | Administrative Nursing Staff | Reported care plan development process and acknowledged oversight of weight bearing restrictions. |
| Staff C | Administrative Nursing Staff | Expected weight bearing restrictions to be on care plan. |
| Staff E | Direct Care Staff | Reported resident's pain complaints. |
| Staff F | Licensed Nursing Staff | Reported no knowledge of resident falls and noted increased pain and new fracture. |
| Staff G | Administrative Nursing Staff | Reported documentation expectations for pain medication administration and effectiveness. |
| Staff H | Administrative Nursing Staff | Reported documentation requirements and acknowledged lack of proper documentation. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Sep 30, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report documents that all previously cited deficiencies identified by their regulation numbers were corrected by the revisit date of 09/30/2013.
Deficiencies (4)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.55(a)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 30, 2013
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita addressing deficiencies cited during a prior survey.
Findings
The facility developed and implemented corrective actions to address deficiencies related to care plans, dental services, infection control, and performance improvement, with monitoring plans to ensure continued compliance.
Deficiencies (4)
Residents affected by incomplete comprehensive care plans; corrective actions include audits and education to ensure timely completion.
Residents with dental problems not consistently offered dental services; corrective actions include oral assessments and documentation of referrals.
Infection control deficiencies related to cleaning agents and procedures for C-diff; corrective actions include staff education and monitoring.
Quality Assurance and Performance Improvement (QAA) committee plans to address continued deficiencies with root cause analysis and monthly audits.
Report Facts
Facility staff quiz participants: 20
Audit frequency: 4
Observation frequency: 3
Plan review frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 27, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report shows that all previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected, with correction completion dates ranging from 09/26/2013 to 09/27/2013.
Report Facts
Correction completion dates: 18
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 4
Date: Sep 27, 2013
Visit Reason
This inspection was a 1st Non-Compliance Revisit to assess the facility's compliance with previously cited deficiencies.
Findings
The facility failed to complete comprehensive care plans timely for resident #331, failed to assess or offer routine dental services for resident #2, and did not ensure proper infection control practices in a Clostridium difficile precaution room. Additionally, the facility failed to monitor and ensure the effectiveness of quality assurance plans addressing these deficiencies.
Deficiencies (4)
Failed to complete the comprehensive care plan for resident #331 within the required time frame.
Failed to assess the need for or offer routine dental services for 1 of 3 residents reviewed (#2).
Failed to ensure proper cleaning and use of personal protective equipment in a Clostridium difficile precaution room to prevent spread of infection.
Failed to maintain a quality assessment and assurance committee that effectively implemented and monitored plans of action to correct identified quality deficiencies.
Report Facts
Residents sampled: 18
Residents reviewed for care plans: 3
Residents reviewed for dental services: 3
Days late for care plan completion: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Direct care staff | Reported resident #2 brushed own teeth and would notify charge nurse of dental concerns |
| Staff I | Social services staff | Reported oral/dental assessments completed on admission and quarterly |
| Staff K | Licensed nursing staff | Completed oral/dental assessments and confirmed resident #2 had a missing tooth |
| Staff L | Administrative nursing staff | Conducted oral assessments and confirmed resident #2 had no marked oral/dental issues |
| Staff M | Licensed nursing staff | Confirmed family decision not to treat resident #2's missing tooth |
| Staff A | Administrative nursing staff | Reported dental sweep and reassessment process; supervised infection control and QA |
| Staff C | Direct care staff | Observed putting on PPE for C. diff precaution room |
| Staff F | Housekeeping staff | Described cleaning procedures for C. diff precaution room |
| Staff D | Housekeeping staff | Described cleaning procedures and use of disinfectants for C. diff precaution room |
| Staff B | Housekeeping supervisor | Responsible for training housekeepers and cleaning protocols |
| Staff G | Maintenance staff | Entered C. diff precaution room without PPE |
| Staff R | Administrative staff | Reported QA committee met and developed plans of action but failed to monitor effectiveness |
| Staff H | Administrative nursing staff | Received precaution room signage |
Inspection Report
Plan of Correction
Deficiencies: 24
Date: Aug 26, 2013
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita addressing deficiencies cited during a prior survey, detailing corrective actions, education, monitoring, and compliance measures for various regulatory tags.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including rights to survey results, abuse investigations, dignity and respect, care plans, medication management, infection control, and other resident care concerns. Education, monitoring, and auditing systems have been implemented to ensure substantial compliance.
Deficiencies (24)
F0000: Credible Allegation of Compliance with facility-wide system to assure correction and continued compliance.
F167: Right to Survey Results - Survey results made accessible with education and monitoring.
F225: Investigate/Report Allegations of Abuse - Thorough investigations completed with education and monitoring.
F241: Dignity and Respect of Individuality - Measures to ensure privacy and respect with education and audits.
F242: Self-Determination & Right to Make Choices - Bathing schedule preferences honored with education and audits.
F244: Listen/Act on Group Grievances/Recommendations - Resident council meetings and complaint follow-up.
F248: Activities Meet Interests/Needs of Each Resident - Activities tailored to resident interests with education and monitoring.
F279: Care Plans - Care plans reviewed and revised with education and audits.
F280: Care Plan Revisions - Care plans revised to reflect interventions with education and audits.
F281: Professional Standards - Education and competency demonstration for medication administration.
F312: ADL's - Nail care and bathing schedules maintained with education and audits.
F314: Pressure Sores - Mandatory education and wound care rounds implemented.
F315: Catheters/Urinary Incontinence - Assessment and care plan revisions with education and audits.
F323: Accident Hazards - Fall care plans reviewed and staff educated on fall management.
F329: Unnecessary Drugs - Medication orders reviewed and education on Black Box Warnings provided.
F356: Posted Nurse Staffing Information - Staffing info posted accessibly with education and audits.
F364: Nutritive Value/Appearance/Palatable/Proper Temperature - Food temperature logs and staff education.
F371: Food Procurement, Storage, Prepared/Served Sanitary - Proper food storage and handling education and audits.
F411: Availability of Dental Service - Oral assessments and referrals with education and audits.
F425: Pharmacy Procedures - Education on physician order recap and medication review with audits.
F428: Drug Review Regimen - Medication reviews by pharmacist and nursing audits.
F431: Drug/Medication Storage - Medication storage and security education and audits.
F441: Infection Control - Cleaning protocols and staff education for C-diff prevention.
F520: QAA Committee-Members/Meet Quarterly Plans - Action plans developed and monitored for resident care concerns.
Report Facts
Education attendance: 60
Audit frequency: 10
Audit frequency: 5
Audit frequency: 3
Audit frequency: 4
Audit frequency: 12
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Farrar | Provided mandatory inservice education/training and competencies for facility management and staff | |
| KYLE SCHAFFER | Executive Director | Submitted the Plan of Correction |
Inspection Report
Annual Inspection
Census: 117
Deficiencies: 22
Date: Aug 7, 2013
Visit Reason
Annual resurvey of the facility to assess compliance with health and safety regulations, including review of allegations of abuse, resident care, medication administration, infection control, and other regulatory requirements.
Findings
The facility had multiple deficiencies including failure to make survey results accessible, inadequate investigation and reporting of abuse allegations, failure to maintain resident dignity and respect, failure to ensure resident choice in bathing, inadequate activity programming, incomplete and outdated care plans, unsafe medication administration practices, failure to monitor medications with black box warnings, improper food temperature and sanitation practices, failure to maintain infection control protocols, and failure to post nurse staffing information accessibly.
Deficiencies (22)
Failure to ensure survey results were available and readily accessible to residents, visitors, and family members.
Failure to report and thoroughly investigate allegations of abuse and neglect, including failure to report to State authorities.
Failure to maintain resident dignity by not knocking before entering rooms, not covering excrement collection bags, and undignified fall interventions.
Failure to ensure resident choice in bathing schedule and failure to provide a bathing policy.
Failure to act on grievances voiced in resident council regarding staffing and other concerns.
Failure to provide an activity program meeting resident interests and needs.
Failure to develop or revise comprehensive care plans for multiple residents including pressure ulcers, urinary incontinence, activities, dental issues, behaviors, and sleep hygiene.
Failure to revise care plans to reflect current care needs for falls, pressure ulcers, activities, and resident preferences.
Failure to safely and appropriately administer resident #110's insulin, including administration of medication drawn up by another nurse.
Failure to provide necessary assistance with bathing and nail care for residents #32 and #306.
Failure to provide services to heal existing pressure ulcers and prevent new ones for residents #21, #58, #235, and #293.
Failure to provide appropriate treatment and services to promote normal bladder function for resident #245.
Failure to provide adequate protection from hazards that could lead to accidents for residents #235, #2, and unsecured medications and chemicals for cognitively impaired residents on multiple units.
Failure to ensure medication regimen free from unnecessary drugs including lack of behavior monitoring for psychoactive medications, lack of monitoring for black box warnings, and lack of indication for use for medications.
Failure to post nurse staffing information in a prominent, accessible place and failure to post daily at the beginning of each shift.
Failure to provide palatable food served at proper temperature and failure to maintain sanitary food preparation and serving practices.
Failure to maintain an effective infection control program including failure to properly clean rooms of residents with C-diff, failure to clean reusable resident equipment, and improper glove use.
Failure to develop and implement an effective Quality Assessment and Assurance (QAA) program to address concerns and improve resident care.
Failure to provide pharmaceutical services to meet the needs of resident #3 regarding accurate administration of a PRN hypnotic medication.
Failure to identify and monitor residents for adverse side effects associated with medications with black box warnings and failure to ensure indications for use for medications.
Failure to provide pharmacy review policy and failure of pharmacist to report drug irregularities related to black box warnings and indications for use.
Failure to label medications with date opened and discard expired medications and failure to store medications securely.
Report Facts
Facility census: 117
Residents sampled: 26
Pressure ulcer stage 3 size: 0.7
Pressure ulcer stage 3 size: 0.6
Pressure ulcer stage 3 size: 0.1
Pressure ulcer stage 2 size: 0.7
Pressure ulcer stage 2 size: 0.4
Temperature: 100
Temperature: 130
Temperature: 134
Temperature: 140
Temperature: 168
Temperature: 160
Temperature: 130
Temperature: 160
Temperature: 180
Temperature: 110
Temperature: 150
Fall risk score: 24
Fall risk score: 26
Fall risk score: 22
Fall risk score: 18
Fall risk score: 26
Medication doses: 5
Medication doses: 14
Medication doses: 7
Medication doses: 7
Medication doses: 5
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 5
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Medication doses: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse P | Administrative Nurse | Named in multiple interviews regarding medication administration, infection control, and care plan reviews. |
| Licensed Nurse C | Licensed Nurse | Named in medication administration and care plan review interviews. |
| Direct Care Staff F | Direct Care Staff | Named in interviews related to resident care and medication monitoring. |
| Administrative Staff A | Administrative Staff | Named in interviews regarding policy and care plan expectations. |
| Consultant Staff EE | Consultant | Named in interviews regarding pharmacy reviews and black box warning education. |
| Licensed Nurse D | Licensed Nurse | Named in interviews regarding falls, medication monitoring, and resident care. |
| Direct Care Staff Q | Direct Care Staff | Named in interviews regarding medication side effect monitoring. |
| Licensed Nurse J | Licensed Nurse | Named in interviews regarding resident care and medication monitoring. |
| Direct Care Staff M | Direct Care Staff | Named in interviews regarding resident care and toileting. |
| Licensed Nurse BB | Licensed Nurse | Named in interviews regarding care plan and fall investigations. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 3, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report confirms that the deficiencies identified under regulations 483.10(b)(11) and 483.25 were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.25
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Date: Jul 1, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#66481) focusing on notification of changes and nursing assessment after resident falls.
Complaint Details
Complaint investigation #66481 focused on notification failures and nursing assessment after falls. The facility failed to notify family members of a resident's fall and treatment changes, and failed to properly assess a resident after a fall, risking further injury.
Findings
The facility failed to notify a resident's family about a fall and changes in treatment for one resident, and failed to properly assess and provide care to another resident after a fall, resulting in potential risk of injury and inadequate communication.
Deficiencies (2)
Failure to notify resident's family regarding a fall and changes to treatment plan for resident #2.
Failure to ensure nursing staff assessed a resident after a fall to prevent further injury for resident #3.
Report Facts
Facility census: 109
Residents reviewed for notification of change: 3
Residents investigated for nursing assessment: 3
Fall risk score: 24
Pain rating: 10
Vital signs: Blood pressure 138/85, pulse 73, respirations 16, temperature 96.8°F for resident #3 after fall
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 1, 2013
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita in response to deficiencies cited during a complaint survey.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint survey at Life Care Center of Wichita.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, including education for nursing staff on proper notification of treatment changes and assessment after resident falls, with ongoing audits and monitoring planned.
Deficiencies (2)
Failure to properly notify residents and families of changes in treatment plan or medical status.
Failure to properly assess residents after a fall.
Report Facts
Audit frequency: 10
Audit frequency: 4
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| KYLE SCHAFFER | Executive Director | Submitted Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 5, 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 confirms that the previously cited deficiency with ID prefix F0314 related to regulation 483.25(c) was corrected as of 04/10/2013.
Deficiencies (1)
Deficiency with ID prefix F0314 related to regulation 483.25(c)
Report Facts
Deficiency correction date: Apr 10, 2013
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 3, 2013
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 Wichita.
Complaint Details
The Plan of Correction addresses deficiencies cited during a complaint investigation survey.
Findings
The facility developed and implemented a system to assure correction and continued compliance related to wound care and proper use of bed linens with air mattresses. Staff education and monitoring audits were planned to ensure substantial compliance by April 10, 2013.
Deficiencies (1)
Improper use of bed linens on/between a resident and an air mattress and wound treatment application techniques.
Report Facts
Audits: 5
Audit frequency: 4
Substantial compliance date: Apr 10, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kyle Schaffer | Executive Director | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 4
Date: Apr 1, 2013
Visit Reason
The inspection was conducted as a complaint survey for complaints #64390 and #63767, focusing on issues related to pressure sores and skin integrity in residents.
Complaint Details
The survey was conducted in response to complaints #64390 and #63767 regarding pressure sore prevention and treatment.
Findings
The facility failed to ensure that a resident without pressure sores did not develop them unless unavoidable, resulting in two pressure ulcers on the resident's buttocks. The facility also failed to provide adequate treatment and pressure relief interventions, including ineffective wheelchair cushions, improper use of an air mattress, and failure to follow moisture barrier cream directions.
Deficiencies (4)
Failure to prevent development of pressure sores in a resident without prior sores unless unavoidable.
Failure to provide necessary treatment and services to promote healing and prevent infection of pressure sores.
Failure to use pressure relieving devices effectively, including inadequate wheelchair cushion and improper air mattress use.
Failure to follow directions for use of moisture barrier cream.
Report Facts
Resident sample size: 5
Residents reviewed for impaired skin integrity: 3
Pressure sore measurements: 5
Pressure sore measurements: 2.3
Pressure sore measurements: 0.7
Pressure sore measurements: 0.5
Resident census: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN A | Advanced Practice Registered Nurse | Examined resident's wounds and provided treatment orders; failed to document visit progress note timely. |
| Licensed Nurse D | Licensed Nurse | Observed and cleansed resident's wounds during inspection. |
| Administrative Nursing Staff B | Administrative Nursing Staff | Provided information about resident's history and facility policies. |
| Direct Care Staff G | Direct Care Staff | Assisted resident with repositioning and described staff education on air mattress use. |
| Direct Care Staff H | Direct Care Staff | Described facility expectations for air mattress use and resident behavior. |
| Administrative Nurse C | Administrative Nurse | Described treatment and resident compliance issues. |
| Dietary Staff E | Dietary Staff | Responsible for nutritional evaluation of residents with wounds; unaware of resident's wound status during inspection. |
| Dietary Staff I | Dietary Staff | Responsible for notifying Dietary Staff E of residents with wounds and weight loss. |
| Administrative Staff F | Administrative Staff | Discussed pressure relieving devices and wheelchair cushion issues. |
| Administrative Staff J | Administrative Staff | Confirmed lack of documentation of APRN visit progress note. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 11, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 12
Inspection Report
Plan of Correction
Deficiencies: 9
Date: May 11, 2012
Visit Reason
This document is a Plan of Correction submitted by Life Care Center of Wichita addressing deficiencies cited during a prior survey inspection.
Findings
The Plan of Correction details corrective actions taken for multiple deficiencies related to care plans, fluid restrictions, activity preferences, medication monitoring, food handling, and safety measures. It includes education plans for staff, monitoring and auditing schedules, and responsibilities assigned to facility leadership.
Deficiencies (9)
Care plans and care directives amended to reflect fluid restrictions and activity preferences; individualized toileting plans developed.
Interim care plans updated to reflect current nutrition, hydration, skin, and activity needs.
Fluid restriction care plans updated; fluid restriction flow sheets posted and staff educated.
Fingernail care provided and added to bath sheets; staff education on nail care.
Splinting schedules developed and posted; staff educated on splint use and placement.
Tape removed from janitor's closet door to ensure safety; staff educated on chemical security.
Medications with Black Box warnings reviewed and care planned; staff education and monitoring implemented.
Expired insulin vials removed; medication carts secured; staff educated on insulin handling and medication security.
Staff educated on proper collection and handling of soiled linen; monitoring of compliance implemented.
Report Facts
Care plan audits: 10
Black Box medication audits: 5
Food storage audits: 3
Food service audits: 5
Insulin vial audits: 10
Soiled linen observations: 10
Splint placement audits: 3
Inspection Report
Annual Inspection
Census: 114
Deficiencies: 10
Date: Apr 17, 2012
Visit Reason
Annual health resurvey conducted to assess compliance with regulatory requirements including care planning, medication management, infection control, and safety.
Findings
The facility failed to develop comprehensive care plans addressing residents' needs including activities, discharge planning, hydration, and incontinence. Medication management was deficient with lack of monitoring and care planning for medications with black box warnings and failure to document PRN medication administration. Infection control practices were inadequate, including improper food handling and linen management. Medication carts were left unlocked and unattended. Expired insulin vials were not discarded timely. Several residents did not receive proper grooming services. A resident with limited range of motion did not consistently have a prescribed hand splint applied.
Deficiencies (10)
Failed to develop comprehensive care plans addressing activities, discharge planning, hydration, and incontinence for sampled residents.
Failed to ensure temporary/interim care plans met residents' current needs regarding activities, skin tears, and hydration/nutrition.
Failed to maintain fluid restriction for a resident on fluid restricted diet, including lack of scheduled fluid amounts and unrestricted access to water pitcher.
Failed to provide grooming services to trim fingernails for dependent residents.
Failed to consistently apply a hand splint to a resident with limited range of motion to prevent contractures.
Failed to ensure residents' environment remained free of accident hazards by leaving janitor closet unlocked with hazardous chemicals accessible.
Failed to ensure drug regimen was free from unnecessary drugs by inadequate monitoring and care planning of medications with black box warnings and PRN medications.
Failed to store and serve food under sanitary conditions, including unsecured opened food items and improper handling of pureed food.
Failed to employ pharmacy services to ensure drug records were accurate and controlled drugs were secured; medication carts left unlocked and unattended; expired insulin vials not discarded timely.
Failed to maintain an effective infection control program to prevent contamination during linen handling and bed changes.
Report Facts
Residents on fluid restriction: 1
Residents with black box warning medications: 9
Residents on pureed diet: 8
Residents on regular diet: 78
Expired insulin vials found: 4
Residents in special care unit: 20
Residents on 400 hall: 19
Insulin dependent diabetic residents: 9
Residents sampled for unnecessary drugs: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant K | Pharmacist | Reported facility had system for black box warnings but did not assist in policy writing or education; did not check care plans personally |
| Physician J | Medical Director | Reported facility needed to follow policy on black box warnings and educate residents and staff |
| Administrative Nurse B | Administrative Nurse | Confirmed lack of black box warnings in care plans and documentation concerns |
| Licensed Nurse N | Licensed Nurse | Identified fluid restriction and documentation practices |
| Direct Care staff L | Direct Care Staff | Reported resident fluid restriction and medication knowledge |
| Direct Care staff M | Direct Care Staff | Reported resident fluid restriction and medication knowledge |
| Licensed Nurse QQ | Licensed Nurse | Left medication cart unlocked and unattended |
| Licensed Nurse F | Licensed Nurse | Left medication cart unlocked and unattended |
| Licensed Nurse UU | Licensed Nurse | Left medication cart unlocked and unattended |
| Dietary staff AA | Dietary Staff | Handled pureed food and utensils with bare hands |
| Dietary manager H | Dietary Manager | Acknowledged improper food handling technique |
| Direct Care staff X | Direct Care Staff | Carried soiled linens against uniform without bagging |
| Licensed Nurse GG | Licensed Nurse | Confirmed expired insulin vials and responsibility to reorder |
| Administrative Nurse E | Administrative Nurse | Observed resident without splint and directed staff to apply |
| Direct Care staff HH | Direct Care Staff | Observed resident with long fingernails |
| Administrative Nurse D | Administrative Nurse | Acknowledged need for nail care and splint application |
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