Inspection Reports for Logan County Senior Living Inc
615 PRICE AVE, OAKLEY, KS, 67748
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 3, 2016, found that all previously cited deficiencies had been corrected. Earlier inspections showed recurring issues primarily related to medication administration, resident dignity during care, and fall prevention interventions. Complaint investigations substantiated concerns about missed medications, inadequate fall prevention, and supervision, as well as a choking incident that was not properly reported. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record indicates ongoing efforts to address deficiencies, with improvements noted in follow-up inspections verifying correction of prior issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
22.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
270% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
36 residents
Based on a April 2016 inspection.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 3, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.10(b)(11), 483.15(a), and 483.60(a),(b) were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.60(a),(b)
Inspection Report
Deficiencies: 1
Date: Apr 5, 2016
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 isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective May 3, 2016.
Deficiencies (1)
Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date of substantial compliance: May 3, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to enforcement and compliance |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 3
Date: Apr 5, 2016
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements following prior findings.
Findings
The facility failed to timely obtain and administer physician-ordered medications for one resident, failed to notify the physician of missed medications, and failed to maintain resident dignity by conducting certain assessments at the dining table. Multiple deficiencies related to medication administration and resident dignity were cited.
Deficiencies (3)
Failed to notify resident, physician, or family of significant changes including missed medication administration.
Failed to promote care that maintains or enhances residents' dignity and respect, including conducting blood pressure and oxygen saturation measurements at the dining table during meals.
Failed to provide pharmaceutical services ensuring accurate acquiring, receiving, dispensing, and administering of medications, including failure to obtain and administer physician-ordered medications in a timely manner.
Report Facts
Resident census: 36
Days medication not administered: 2
Days medication not administered: 3
Days medication not administered: 2
Doses medication not administered: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Administrative Nurse | Verified missed medication administration and lack of physician notification; confirmed dignity concerns regarding assessments at dining table |
| Nurse A | Observed obtaining blood pressure at dining table | |
| Nurse B | Observed asking resident about pain and placing pulse oximeter at dining table; unsure about appropriateness of assessments at dining table |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 8, 2016
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 revisit report confirms that the previously cited deficiency under regulation 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
Deficiency under regulation 483.25(h) corrected
Report Facts
Deficiency correction date: Jan 8, 2016
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 6, 2016
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 at a 'D' level, indicating no harm with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
Most serious deficiencies found at 'D' level
Report Facts
Denial of payment effective date: Apr 6, 2016
Termination effective date: Jul 6, 2016
Plan of correction submission timeframe: 10
IDR submission timeframe: 10
Fair hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 11, 2015
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation related to alarm placement and resident safety at Logan Co Manor LTCU.
Complaint Details
This Plan of Correction is linked to a complaint investigation at Logan Co Manor LTCU.
Findings
The facility identified deficiencies related to improper alarm placement affecting resident safety. Administrative staff have educated nursing staff and are conducting audits and staff in-service training to ensure compliance and safety.
Deficiencies (1)
Deficiency related to alarm placement and resident safety
Report Facts
Date of Quality Committee review: Dec 23, 2015
Date correction will be in place: Jan 8, 2016
Date of staff in-service: Jan 24, 2016
Date random audits began: Nov 19, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 10, 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 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 which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted 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 |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Dec 10, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#93967) to evaluate the facility's compliance with accident hazard prevention and supervision requirements.
Complaint Details
The complaint investigation (#93967) found that Resident #2 had two falls related to personal alarms not being connected properly, despite care plans and staff education.
Findings
The facility failed to ensure staff implemented care plan interventions for one resident at high risk for falls, resulting in two falls due to personal alarms not being properly activated or connected.
Deficiencies (1)
Failure to ensure staff implemented interventions as care planned for a resident at high risk for falls, resulting in continued falls.
Report Facts
Census: 37
Sample size: 3
Falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide A | Nurse Aide | Verified staff had to ensure resident's bed and chair alarms were on and noted resident's recent cognitive and physical decline |
| Nurse B | Nurse | Verified alarms were not connected properly at time of resident fall and staff education was provided |
| Administrative Nurse C | Administrative Nurse | Verified resident had two falls related to personal alarms not connected properly |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Oct 28, 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 revisit report shows that all previously identified deficiencies with ID prefixes F0157, F0280, F0281, F0323, and F0425 were corrected as of 10/28/2015.
Deficiencies (5)
Deficiency with ID prefix F0157 related to regulation 483.10(b)(11)
Deficiency with ID prefix F0280 related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency with ID prefix F0281 related to regulation 483.20(k)(3)(i)
Deficiency with ID prefix F0323 related to regulation 483.25(h)
Deficiency with ID prefix F0425 related to regulations 483.60(a) and (b)
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Sep 28, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Logan County Hospital LTCU.
Complaint Details
This plan of correction is in response to a complaint investigation at Logan County Hospital LTCU.
Findings
The plan addresses multiple deficiencies including medication availability and administration, updating care plans after falls, revising fall policies, and improving interim care plan processes. Corrective actions include policy revisions, staff in-service training, audits by the Director of Nursing or designee, and ongoing Quality Committee oversight until substantial compliance is achieved.
Deficiencies (5)
Medications that were not available have been obtained and are being administered as ordered.
Care plans for residents at high risk for falls have been updated and oversight improved.
Fall policy is being revised and nursing staff educated on revisions.
Process for interim care plans changed to be viewed as actual care plans with new policy development.
Medications not available have been obtained and administered; policy revised and staff in-serviced.
Report Facts
Plan of Correction completion date: Oct 28, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 28, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Deficiencies (1)
Deficiencies cited at 'D' level that constitute 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 person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Date: Sep 28, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers #90733 and #91553.
Complaint Details
The inspection was conducted as a result of complaint investigations #90733 and #91553.
Findings
The facility failed to notify the physician about missed medication doses for Resident #1, failed to provide individualized care plans and interventions to prevent falls for Resident #1 who sustained multiple falls and injuries, and failed to provide adequate supervision and assistive devices to prevent accidents for Residents #1 and #2. Additionally, the facility failed to obtain physician-ordered medications in a timely manner for Resident #1.
Deficiencies (5)
Failed to notify the physician that Resident #1 had not received and administered several medications as ordered.
Failed to care plan appropriate interventions to prevent further falls for Resident #1.
Failed to provide services meeting professional standards by not implementing fall prevention interventions for Resident #1.
Failed to ensure the resident environment was free of accident hazards and provide adequate supervision and assistive devices to prevent accidents for Residents #1 and #2.
Failed to provide pharmaceutical services assuring accurate acquiring, receiving, dispensing, and administering of medications; specifically failed to obtain physician ordered medications in a timely manner for Resident #1.
Report Facts
Census: 37
Medication doses missed: 8
Medication doses missed: 6
Medication doses missed: 5
Medication doses missed: 14
Medication doses missed: 30
Fall risk scores: 55
Fall risk scores: 70
Fall risk scores: 30
Fall risk scores: 70
Fall risk scores: 80
Fall risk scores: 90
Fall risk scores: 90
Fall risk scores: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified failure to notify physician of missed medications and lack of individualized fall prevention interventions. |
| Nurse G | Nurse | Verified Resident #1's initial care plan had not been completed and lacked individualized fall prevention interventions. |
| Housekeeping Staff H | Housekeeping Staff | Witnessed Resident #1 fall from a step stool on 8/6/15. |
| Housekeeping Staff E | Housekeeping Staff | Witnessed Resident #1 fall on 9/14/15 and noted resident walking without walker. |
| Nurse A | Nurse | Reported Resident #1 was unsteady and ambulated with walker, and described falls. |
| Nurse Aide B | Nurse Aide | Reported Resident #1 disabled alarms and walked independently. |
| Nurse C | Nurse | Reported Resident #1 was unsteady and used wheelchair after fall, and Resident #2 was independent with quad cane but fell and broke hip. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 12, 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
All previously cited deficiencies identified by regulation numbers were corrected as of the revisit date.
Report Facts
Deficiency corrections completed: 6
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 6
Date: Aug 13, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#89459) focusing on allegations of abuse, neglect, and mistreatment, including a choking episode and behavior management concerns.
Complaint Details
Complaint investigation #89459 focused on allegations of abuse, neglect, and mistreatment including a choking episode where a visitor performed the Heimlich maneuver on Resident #2.
Findings
The facility failed to thoroughly investigate and report a choking incident, did not develop or revise comprehensive care plans for residents with behavioral issues, failed to provide adequate supervision during meal times, and administered unnecessary antipsychotic medications to a resident with dementia.
Deficiencies (6)
Failed to thoroughly investigate and report a choking episode involving Resident #2.
Failed to develop a comprehensive care plan to manage behaviors for Resident #1.
Failed to review and revise Resident #3's care plan to manage increased behaviors.
Failed to provide care and services to adequately manage behaviors for Resident #1.
Failed to provide adequate supervision during meal times in the dining room.
Failed to prevent unnecessary medications by administering Seroquel to Resident #1 with a contraindicated diagnosis of dementia.
Report Facts
Census: 35
Residents sampled: 3
Heimlich maneuver count: 3
Seroquel dosage: 50
Haldol dosage: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Witnessed the Heimlich maneuver and verified staff presence issues in the dining room. | |
| Administrative Staff A | Verified the facility did not investigate or report the choking incident and confirmed supervision requirements in the dining room. | |
| Nurse Aide C | Verified staff absence in the dining room during meals. | |
| Administrative Nurse E | Verified lack of comprehensive care plan for Resident #1 and inadequate staff guidance for behavior management. | |
| Nurse Aide G | Reported difficulty managing Resident #1's behaviors and lack of adequate training and staffing. | |
| Nurse D | Verified Resident #1's behaviors are hard to manage and administered Haldol injection. | |
| Nurse Aide J | Reported fear of Resident #1 due to verbal and physical abuse. | |
| Nurse Aide I | Verified Resident #1's aggressive behavior and use of cuss words. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 13, 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 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 12, 2015.
Deficiencies (1)
Most serious deficiency found to be an 'E' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 9
Date: Feb 20, 2015
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, February 20, 2015.
Deficiencies (9)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jan 28, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection of Logan County Manor LTCU.
Findings
The Plan of Correction addresses multiple deficiencies including resident falls, pain management, catheter care, chemical storage, medication administration, dietary staff hygiene, medication destruction, and infection control practices. Corrective actions include policy revisions, staff education, audits, and ongoing monitoring by the Quality Committee.
Deficiencies (8)
Resident fall resulting in injury; resident requires assist with ambulation and uses a walker.
Pain management regimen reviewed and updated with orders for liquid morphine and fentanyl patch.
Catheter care policy reviewed; mechanism applied to prevent catheter bags from dragging on floor.
Chemical storage improved with locked areas and childproof locks applied to cabinets.
Medication Administration Record reviewed for pulse parameters and bowel regimen; staff in-serviced.
Dietary staff hairnets replaced with bonnets; refrigerator thermometers checked and repositioned.
Medication destruction procedures revised; controlled substances secured in double-locked cabinet.
Resident moved to private room with contact isolation; infection control practices enhanced including biohazard disposal and glucometer cleaning.
Report Facts
Dates of corrective action completion: Feb 20, 2015
Date Quality Committee reviewed Statement of Deficiencies: Jan 28, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Patschippers | Administrative Assistant | Submitted the Plan of Correction to KDADS |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 9
Date: Jan 22, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements including investigation and reporting of abuse allegations, care and services, catheter care, accident hazards, medication management, infection control, and other related areas.
Findings
The facility was found deficient in multiple areas including failure to report an unwitnessed fall with injury to the state agency, inadequate pain management during wound care, improper catheter care and lack of medical justification for catheter use, unsafe environment with accessible hazardous materials, failure to follow medication orders and monitor residents properly, unsanitary food preparation and storage practices, inadequate medication storage and disposal, and failure to maintain infection control procedures.
Deficiencies (9)
Failure to notify the appropriate state agency of an unwitnessed fall with a nasal fracture for Resident #7.
Failure to ensure adequate pain management during wound care for Resident #9.
Failure to provide appropriate catheter care to prevent infections and lack of medical justification for catheter use for Residents #24 and #1.
Failure to provide an environment free from accident hazards; unlocked cabinet with hazardous wipes accessible to residents.
Failure to ensure drug regimen is free from unnecessary drugs; failure to follow physician's orders for pulse monitoring and bowel management for Resident #31.
Failure to prepare and serve food under sanitary conditions and maintain food at adequate temperatures.
Failure of pharmacist consultant to identify and address failure to follow physician's orders for pulse and bowel monitoring for Resident #31.
Failure to maintain proper drug records, label, and storage of controlled substances; unsecured medications and improper disposal of narcotics.
Failure to establish and maintain an infection control program to prevent spread of infection, including improper contact isolation, urinary catheter care, blood glucose equipment cleaning, and oxygen equipment storage.
Report Facts
Residents present: 32
Residents sampled: 13
Pulse readings >85: 193
Days without bowel movement: 7
Days without bowel movement: 6
Medication bottles: 55
Medication bubble packs: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide J | Assisted Resident #9 with transfer and involved in infection control deficiencies | |
| Administrative Nurse C | Verified multiple deficiencies including failure to report fall, catheter care issues, infection control, and medication storage | |
| Nurse Aide B | Observed providing catheter care improperly | |
| Nurse D | Verified catheter bag should not touch floor and bowel monitoring procedures | |
| Medication Aide G | Observed cleaning glucometer improperly | |
| Registered Pharmacist H | Registered Pharmacist | Verified medication storage deficiencies |
| Infection Control Nurse D | Verified infection control policy violations |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 22, 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 'F' level deficiencies, 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 based on the credible allegation of compliance and the submitted plan.
Deficiencies (1)
Deficiencies cited on the survey with 'F' level severity, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter as Enforcement Coordinator related to the plan of correction acceptance. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 27, 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 deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payment for new admissions and termination of provider agreement were outlined if substantial compliance was not achieved.
Deficiencies (1)
Most serious deficiencies found were 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: Nov 27, 2014
Termination effective date: Feb 27, 2015
Plan of correction submission timeframe: 10
Fair hearing request timeframe: 60
IDR submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution and appeals related to deficiencies. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated survey certification. |
Inspection Report
Follow-Up
Deficiencies: 12
Date: Dec 18, 2013
Visit Reason
This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that all previously identified deficiencies listed with their regulation numbers were corrected by 11/20/2013, confirming compliance with the cited regulations.
Deficiencies (12)
Deficiency related to regulation 483.10(g)(1)
Deficiency related to regulation 483.13(a)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.75(o)(1)
Report Facts
Correction completion date: Nov 20, 2013
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 12
Date: Oct 16, 2013
Visit Reason
Health resurvey inspection conducted to evaluate compliance with federal regulations and verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, improper use of physical restraints, unsanitary conditions, incomplete care plan revisions related to falls, inadequate pain management, insufficient supervision to prevent accidents, bed rail entrapment risks, failure to follow dietary recommendations, failure to monitor effectiveness of medications, unsanitary food service practices, improper medication handling, and failure to implement quality assurance corrective actions.
Deficiencies (12)
Failed to post survey results in an area readily accessible to residents.
Failed to ensure a resident remained free of physical restraints not medically justified.
Failed to maintain sanitary and comfortable interior; dust accumulation on bathroom vents and gouges in walls.
Failed to review/revise comprehensive care plans related to falls for 2 residents.
Failed to provide necessary care and services for pain management for 1 resident.
Failed to ensure adequate supervision and assistive devices to prevent accidents/falls for 2 residents.
Failed to ensure resident environment free from entrapment risk due to bed rails with large gaps.
Failed to maintain acceptable nutritional status for 1 resident due to failure to follow dietician recommendations.
Failed to ensure drug regimen free from unnecessary drugs by not monitoring effectiveness of medications for 3 residents.
Failed to serve food under sanitary conditions; used contaminated gloves while assisting residents with eating.
Failed to prevent spread of infection during medication administration; touched resident's medication with bare hands.
Failed to develop and implement action plan to correct identified quality deficiencies in QAA committee meetings.
Report Facts
census: 39
deficiency count: 12
weight loss percentage: 18.6
bed rail gap size: 10
bed rail gap size: 5.625
fall risk score: 19
PRN medication monitoring failures: 22
PRN medication monitoring failures: 14
PRN medication monitoring failures: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Interviewed regarding survey results posting, restraint use, care plan revisions, pain management, fall prevention, and QAA committee |
| Licensed Nursing Staff H | Licensed Nurse | Interviewed regarding restraint use, care plan revisions, fall prevention, pain management, and medication monitoring |
| Consultant X | Consultant Pharmacist | Reported irregularities in medication monitoring to facility administration |
| Direct Care Staff I | Direct Care Staff | Observed assisting resident with ambulation and reporting pain complaints |
| Direct Care Staff P | Direct Care Staff | Observed assisting resident with ambulation and reporting pain complaints |
| Dietary Staff F | Dietary Staff | Interviewed regarding dietary recommendations and food service practices |
| Licensed Nursing Staff S | Licensed Nurse | Observed medication administration with improper infection control |
| Direct Care Staff C | Direct Care Staff | Reported on QAA committee participation and reporting |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Sep 18, 2012
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers F0241, F0279, F0323, F0364, F0371, F0425, F0441, and F0464 were corrected as of the revisit date.
Deficiencies (8)
Deficiency related to regulation 483.15(a)
Deficiency related to regulations 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.35(d)(1)-(2)
Deficiency related to regulation 483.35(i)
Deficiency related to regulations 483.60(a),(b)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.70(g)
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Aug 22, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of Logan Co Manor LTCU.
Findings
The Plan of Correction addresses multiple deficiencies including feeding residents with dignity, updating care plans for activities, ensuring doors close and lock properly for chemical storage, measuring food temperatures, sanitary food service, medication administration accuracy, glucometer cleaning, and appropriate bedside table placement. Corrective actions include staff inservice, monitoring, policy development, and reporting to the Quality Assurance Committee.
Deficiencies (8)
Feeding residents in a dignified manner and proper isolation signage.
Care plans updated to include accurate descriptions and measurable goals for activities.
Doors leading to chemical storage fixed to close and lock properly; staff inserviced on chemical storage.
Dietary staff instructed to measure temperatures of pureed and ground foods to ensure safety.
Nursing and dietary staff instructed on sanitary food service; policy development underway.
Medication administration records reviewed for sliding scale insulin accuracy; staff inserviced.
Nursing staff inserviced on glucometer cleaning; sink ordered for whirlpool room installation.
Appropriate bedside table placement for resident ensured and monitored.
Report Facts
Meals observed per week: 3
Compliance deadline: Sep 18, 2012
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 8
Date: Aug 20, 2012
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 maintain resident dignity during care, inadequate comprehensive care plans for activities, unsafe storage of hazardous chemicals, failure to serve food at proper temperatures and under sanitary conditions, failure to administer medications as ordered, inadequate infection control practices, and insufficient furnishings to accommodate resident dining needs.
Deficiencies (8)
Failure to promote care that maintained or enhanced residents' dignity and respect during dining and in posting signs indicating special precautions.
Failure to develop comprehensive nursing care plans with measurable objectives and timetables to meet residents' medical, nursing, mental, and psychosocial needs related to individual activity interests.
Failure to ensure the environment remained free of accident hazards for cognitively impaired, independently mobile residents due to storage of hazardous chemicals in accessible areas.
Failure to provide palatable food at the proper temperature for residents receiving pureed diets.
Failure to prepare, distribute, and serve food under sanitary conditions, including staff contamination of food by bare hands or contaminated gloves.
Failure to provide pharmaceutical services including administering all drugs and biologicals as ordered, specifically failure to give sliding scale insulin to a resident as ordered.
Failure to maintain infection control by not providing a handwashing sink in the west hall whirlpool room and failure to clean glucometers between resident use.
Failure to provide adequate furnishings to accommodate the dining needs of a resident, including improper positioning and lack of appropriate dining furniture.
Report Facts
Residents receiving pureed diet: 2
Residents cognitively impaired and independently mobile: 11
Residents sampled for review: 19
Blood sugar levels requiring insulin units: 200
Temperature of pureed pork chops: 109.9
Temperature of pureed green bean casserole: 122.4
Temperature of pureed potatoes: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff J | Named in dignity deficiency for feeding resident #5 improperly. | |
| Administrative Nurse B | Interviewed regarding dignity, care plans, hazardous chemical storage, glucometer cleaning, and insulin administration deficiencies. | |
| Direct Care Staff G | Observed and interviewed regarding dignity and sanitary food handling deficiencies. | |
| Dietary Staff L | Observed and interviewed regarding improper food temperature monitoring. | |
| Licensed Nurse C | Interviewed regarding lack of individualized activity care plans. | |
| Direct Care Staff N | Observed and interviewed regarding sanitary food handling deficiencies. | |
| Dietary Staff T | Observed and interviewed regarding sanitary food handling deficiencies. | |
| Dietary Staff R | Observed regarding sanitary food handling deficiencies. | |
| Dietary Staff S | Observed and interviewed regarding sanitary food handling deficiencies. | |
| Licensed Nursing Staff P | Observed failing to clean glucometer between resident use. | |
| Maintenance Staff F | Confirmed lack of handwashing sink in west hall whirlpool room. | |
| Direct Care Staff H | Interviewed regarding hand hygiene practices in whirlpool room. | |
| Licensed Nurse I | Confirmed lack of handwashing sink in west hall whirlpool room. |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: N055002 POC 9ORR11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan outlines corrective actions for multiple deficiencies including survey accessibility, restraint use, environmental repairs, fall prevention, pain management, medication review, infection control, and quality committee oversight. Each corrective action includes timelines and monitoring plans to ensure compliance.
Deficiencies (12)
Survey was not accessible to all residents; moved to accessible location.
Improper use of lap tray restraint; measures to remove and assess resident.
Bathroom ceiling vents unclean and room walls damaged; cleaned and repaired.
Care plans not updated with fall interventions; education and audits planned.
Inadequate pain control and documentation; education and pain policy development.
Fall hazards including malfunctioning door and old bed; removal and repairs done.
Resident nutritional intake and weight concerns; dietician involvement and audits.
Psychotropic medication regimen review and drug reduction audits planned.
Improper infection control in food handling; staff education and observations planned.
Inadequate documentation of response to prn medications; education and audits planned.
Laundry staff and medication handlers not following infection control; education and monitoring.
Quality Committee oversight of regulatory compliance and quality improvement plans.
Report Facts
Residents audited for prn pain medication: 3
Frequency of food service observations: 3
Med passes monitored weekly: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for auditing prn pain medication administration, care plan updates, drug reduction audits, and monitoring med passes. | |
| Licensed Clinical Social Worker | Reviewed medication regimen and made recommendations regarding drug reduction. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N055002 POC BU4K11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to medication administration and vital signs monitoring practices, including re-education of staff, policy revisions, and ongoing audits to ensure compliance.
Deficiencies (3)
Failure to notify provider when medication is not available.
Vital signs were being obtained in the dining hall during meal times.
Medications were not available and not administered as ordered.
Report Facts
Plan of correction completion date: May 3, 2016
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N055002 POC FROU11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including choking incidents, care plan updates, psychiatric resident management, medication reviews, and staff education. Corrective actions include staffing changes, policy revisions, audits, and education to ensure compliance.
Deficiencies (6)
Resident choking incident in dining room and failure to report to Risk Management
Care plan of resident involved was not updated timely
Inadequate management of residents with psychiatric diagnoses and behaviors
Resident admitted to geropsychiatric unit for medication adjustment and placement evaluation
Nurse staffing in dining room insufficient during meals
Inappropriate use of antipsychotic medications for residents with dementia behaviors
Report Facts
Plan of correction completion date: Sep 12, 2015
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