Inspection Reports for
Logan County Senior Living Inc
615 PRICE AVE, OAKLEY, KS, 67748
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
13.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
123% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
90% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: Feb 17, 2025
Visit Reason
The inspection was conducted following a complaint regarding staff physically forcing a resident (R1) to take medications against her will.
Complaint Details
The complaint was substantiated based on witness statements, video evidence, and staff interviews confirming that Licensed Nurse G physically forced Resident 1 to take medications despite her refusal. Licensed Nurse G was suspended pending investigation and corrective actions were implemented.
Findings
The facility failed to prevent staff from physically forcing R1 to take medications despite her refusal, resulting in actual harm and psychosocial risk. The investigation included witness statements, review of medical records, and video footage confirming the incident.
Deficiencies (1)
F 0600: The facility failed to protect residents from abuse by allowing staff to physically force Resident 1 to take medications against her will, causing actual harm and psychosocial distress.
Report Facts
Residents present: 27
Brief Interview for Mental Status (BIMS) score: 3
Mood severity score: 15
Date of incident: Dec 15, 2024
Date of survey completion: Feb 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in medication forcing abuse finding and suspended pending investigation |
| Certified Nurse's Aide M | Certified Nurse's Aide | Intervened to encourage Resident 1 to take medications without force |
| Certified Nurse's Aide N | Certified Nurse's Aide | Witnessed incident and reported to Administrative Nurse D |
| Administrative Nurse D | Administrative Nurse | Received reports of incident, conducted investigation, and oversaw corrective actions |
| Administrative Staff A | Administrative Staff | Notified and involved in investigation and review of camera footage |
Inspection Report
Routine
Census: 27
Deficiencies: 12
Date: Apr 4, 2024
Visit Reason
Routine inspection of Logan County Senior Living Inc to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to ensure mail delivery on Saturdays, improper use of Medicare ABN forms, inadequate dementia care planning, unsafe wound care practices, unsafe use of assistive devices, failure to assess safe smoking practices, inadequate mental health services, failure to notify physician of out-of-parameter blood sugars, failure to date insulin pens, lack of coordinated hospice care plan, inaccurate staffing data submission, and inadequate infection control during wound care.
Deficiencies (12)
F 0576: The facility failed to ensure residents received their mail on Saturdays as required by policy.
F 0582: The facility failed to provide residents R5, R19, and R79 the correct Medicare ABN Form 10055, placing them at risk for uninformed decisions about skilled services.
F 0657: The facility failed to develop and implement an individualized dementia treatment plan for Resident R22 with dementia and behaviors.
F 0684: The facility failed to follow acceptable wound care practices for Resident R79, risking delayed healing and infection.
F 0689: The facility failed to ensure a safe environment for Residents R9 and R18, including unsafe electric wheelchair use and lack of smoking safety assessment.
F 0742: The facility failed to assess, monitor, and provide mental health services for Resident R2 after verbalized suicidal thoughts.
F 0744: The facility failed to develop and implement individualized interventions for Resident R22 with dementia and behaviors, placing the resident at risk for abuse and decreased quality of life.
F 0757: The facility failed to notify the physician of out-of-parameter blood sugars for Resident R18, risking unnecessary medication side effects.
F 0761: The facility failed to date Resident R11's insulin flex pen, risking ineffective medication administration.
F 0849: The facility failed to coordinate care between hospice and facility staff for Resident R3, risking inappropriate end-of-life care.
F 0851: The facility failed to submit accurate Payroll Based Journal staffing data, risking unidentified and ongoing inadequate nurse staffing.
F 0880: The facility failed to ensure adequate infection control measures during wound care for Resident R79, risking wound infection and cross contamination.
Report Facts
Residents census: 27
Out-of-parameter blood sugar readings: 11
PBJ missing licensed nurse coverage days: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Verified mail delivery process, Medicare ABN form usage, hospice care plan absence, and PBJ data submission issues. | |
| Administrative Nurse D | Observed and verified wound care infection control deficiencies and unsafe wheelchair and smoking assessments. | |
| Licensed Nurse G | Provided information on Resident R22's behaviors and Resident R9's wheelchair use. | |
| Certified Medication Aide R | Reported on Resident R22's behaviors and Resident R9's condition. | |
| Social Services X | Verified provision of incorrect Medicare ABN forms. |
Inspection Report
Routine
Census: 27
Deficiencies: 12
Date: Apr 4, 2024
Visit Reason
Routine inspection of Logan County Senior Living Inc to assess compliance with regulatory requirements related to resident care, safety, medication management, infection control, and staffing.
Findings
The facility had multiple deficiencies including failure to deliver mail on Saturdays, improper use of Medicare ABN forms, inadequate dementia care planning, unsafe wound care practices, unsafe use of assistive devices, failure to assess safe smoking practices, inadequate behavioral health services, failure to notify physician of out-of-parameter blood sugars, failure to date insulin pens, lack of coordinated hospice care plan, inaccurate staffing data submission, and inadequate infection control during wound care.
Deficiencies (12)
F 0576: The facility failed to ensure residents received their mail on Saturdays as required by policy.
F 0582: The facility failed to provide residents R5, R19, and R79 the correct Medicare ABN Form 10055, placing them at risk for uninformed decisions about skilled services.
F 0657: The facility failed to develop and implement an individualized dementia treatment plan for Resident R22 with dementia and behaviors, placing the resident at risk for abuse and decreased quality of life.
F 0684: The facility failed to follow acceptable wound care practices for Resident R79 with an infected wound, risking delayed healing and complications.
F 0689: The facility failed to ensure a safe environment for Residents R9 and R18 by not assessing safe use of an electric wheelchair and safe smoking practices, placing them at risk for accidents and injury.
F 0742: The facility failed to provide necessary behavioral health services and monitoring for Resident R2 who expressed suicidal thoughts, placing her at risk for impaired quality of life.
F 0744: The facility failed to develop and implement individualized interventions for Resident R22 with dementia and behaviors, placing the resident at risk for abuse and decreased quality of life.
F 0757: The facility failed to notify the physician when Resident R18's blood sugar readings were out of ordered parameters, placing the resident at risk for unnecessary medication side effects and complications.
F 0761: The facility failed to date Resident R11's insulin flex pen, risking ineffective medication administration.
F 0849: The facility failed to coordinate care between hospice and facility staff for Resident R3 receiving hospice services, placing her at risk for inappropriate end-of-life care.
F 0851: The facility failed to submit accurate Payroll Based Journal staffing data, placing residents at risk for unidentified and ongoing inadequate nurse staffing.
F 0880: The facility failed to ensure adequate infection control during wound care for Resident R79, risking continued wound infection and cross contamination.
Report Facts
Resident census: 27
Out-of-parameter blood sugar readings: 11
PBJ inaccurate reporting days: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Verified mail delivery issues, Medicare ABN form usage, hospice care plan absence, and PBJ data inaccuracies | |
| Administrative Nurse D | Observed and verified wound care infection control deficiencies and unsafe wound care practices | |
| Licensed Nurse G | Provided information on Resident R22's behaviors and blood sugar notification practices | |
| Certified Medication Aide R | Reported on Resident R22's behaviors and Resident R9's condition |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 1
Date: Dec 28, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding a fall incident involving Resident 1 (R1) who fell out of her wheelchair when staff failed to place foot pedals on the wheelchair before assisting her outside.
Complaint Details
The investigation was triggered by a complaint after R1 fell out of her wheelchair when LN G pushed her down a sloped sidewalk without foot pedals on the wheelchair. The fall caused serious injuries including a cervical fracture. The complaint was substantiated with findings of deficient practice by staff.
Findings
The facility failed to prevent a fall out of a wheelchair by not placing foot pedals on the wheelchair before assisting R1 outside. This resulted in R1 sustaining a forehead hematoma, laceration requiring sutures, abrasions, and a cervical fracture of the first vertebrae, causing increased pain and impaired mobility.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. Staff did not place foot pedals on R1's wheelchair before assisting her outside, leading to a fall and serious injury.
Report Facts
Residents present: 24
Date of fall incident: Dec 15, 2023
Pain scale rating: 4
Length of hospital medication course: 7
Laceration size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in the fall incident involving R1 and failure to place foot pedals on wheelchair |
| Administrative Nurse D | Administrative Nurse | Involved in investigation and communication with hospital regarding R1's fall |
| LN H | Licensed Nurse | Witnessed and assisted during fall incident investigation |
| Administrative Staff A | Administrative Staff | Participated in investigation and scene evaluation of fall incident |
Inspection Report
Census: 23
Deficiencies: 1
Date: Nov 29, 2023
Visit Reason
The inspection was conducted to investigate a deficiency related to the facility's failure to follow Resident 1's care plan requiring two staff for transfers with a sit to stand lift, which resulted in a significant skin tear.
Findings
The facility failed to follow Resident 1's care plan requiring two staff for transfers using a sit to stand lift, resulting in a large skin tear to the resident's left posterior calf. The skin tear was documented with detailed wound assessments and the facility reeducated staff on proper transfer procedures.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision and adherence to Resident 1's care plan requiring two staff for transfers with a sit to stand lift, resulting in a significant skin tear measuring 4.5 cm by 3 cm to the resident's left posterior calf. This deficient practice placed the resident at risk for skin tears, pain, and delayed healing.
Report Facts
Residents present: 23
Skin tear size: 4.5
Skin tear size: 3
Blister size: 7.5
Blister size: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in the finding for transferring Resident 1 alone, causing the skin tear |
| Licensed Nurse G | Licensed Nurse | Reported the skin tear to Administrative Nurse and applied dressing |
| Administrative Nurse D | Administrative Nurse | Notified about the skin tear and reeducated staff on transfer procedures |
| Administrative Staff A | Administrative Staff | Commented on CNA M not following care plan during transfer |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Date: Sep 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate antibiotic treatment and care to Resident 1 (R1) following hospital discharge.
Complaint Details
The complaint investigation found that the facility failed to follow the infectious disease physician's antibiotic orders for Resident 1, administering only seven days instead of four weeks. This failure was substantiated and resulted in immediate jeopardy to the resident's health and safety.
Findings
The facility failed to ensure staff implemented care and treatment consistent with standards when they did not provide R1 with the full four-week antibiotic regimen ordered by the infectious disease physician, instead administering only seven days. This failure resulted in R1's condition worsening, transfer to a higher level of care, and eventual death.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, resulting in immediate jeopardy to resident health or safety. Staff did not ensure R1 received the full four-week antibiotic treatment as ordered, leading to deterioration and death.
Report Facts
Resident census: 25
Antibiotic treatment duration: 7
Vital signs: 92
Vital signs: 53
Vital signs: 124
Oxygen saturation: 71
Oxygen saturation: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in relation to failure to clarify antibiotic orders and nurse-to-nurse report |
| Administrative Staff A | Administrative Staff | Commented on Administrative Nurse D's actions during the incident |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 2
Date: Aug 15, 2023
Visit Reason
The inspection was conducted due to allegations of verbal and mental abuse by a licensed nurse towards residents, triggered by a complaint and subsequent investigation.
Complaint Details
The complaint involved allegations that Licensed Nurse G verbally abused Resident R1 by yelling and threatening her, and also verbally abused Resident R2. The facility failed to immediately report the abuse to the administrator. The investigation confirmed the allegations, and the nurse was suspended and terminated. The facility took corrective actions including staff education and reporting improvements.
Findings
The facility failed to ensure residents R1 and R2 were free from verbal and mental abuse by staff, specifically Licensed Nurse G, who was found to have yelled and used inappropriate language towards residents. The facility also failed to immediately report the abuse allegations to the administrator. The nurse was suspended and later terminated. Corrective actions were implemented to educate staff on abuse reporting and to improve safety.
Deficiencies (2)
F 0600: The facility failed to protect residents from verbal and mental abuse by staff, including a nurse who yelled and threatened a resident. This placed residents in immediate jeopardy.
F 0609: The facility failed to timely report suspected abuse and the results of the investigation to proper authorities, placing residents in immediate jeopardy.
Report Facts
Resident census: 24
Residents reviewed for abuse and neglect: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in findings for verbal abuse and mistreatment of residents, suspended and terminated |
| CNA M | Certified Nurse Aide | Witnessed abuse and reported incident |
| Administrative Nurse D | Administrative Nurse | Conducted investigation, interviewed residents and staff, filed police report, and reported to licensing board |
| LN H | Licensed Nurse | Received abuse report from CNA M |
| CNA N | Certified Nurse Aide | Witnessed incident and spoke with CNA M about reporting |
| Administrative Staff A | Administrative Staff | Informed Administrative Nurse D of report and expressed regret about hiring LN G |
Inspection Report
Routine
Census: 27
Deficiencies: 4
Date: Apr 5, 2022
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident safety, medication management, infection control, and behavioral health monitoring.
Findings
The facility failed to adequately assess the safety of side rails for one resident, failed to ensure appropriate diagnosis and monitoring for antipsychotic medication use in three residents, and failed to properly disinfect blood glucose testing equipment and store oxygen tubing and nasal cannulas, placing residents at risk for injury, inappropriate medication use, and infection.
Deficiencies (4)
F 0700: The facility failed to assess Resident 25's side rail for safe use, and the side rail was improperly installed and not attached to the bed, placing the resident at risk for injury.
F 0756: The facility failed to ensure the Consultant Pharmacist identified and reported inappropriate diagnoses for the use of antipsychotic medications for Residents 12 and 17, placing them at risk for inappropriate medication use.
F 0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions for Residents 12 and 17, and failed to monitor behavioral symptoms for Resident 18, placing residents at risk for adverse effects from psychotropic medications.
F 0880: The facility failed to properly disinfect the blood glucose meter between uses and failed to store oxygen tubing and nasal cannulas in a sanitary manner for Residents 1, 7, 21, 22, and 28, placing residents at risk for infection.
Report Facts
Residents in census: 27
Residents in sample: 12
Residents reviewed for unnecessary medications: 5
Dates missing behavioral documentation: 10
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 4
Date: Aug 18, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely notify the physician and state agency about a resident's second degree burn and failure to provide adequate supervision and care.
Complaint Details
The complaint investigation focused on Resident 12's second degree burn caused by hot food. The facility was found to have failed in timely physician notification, state agency reporting, routine assessment, and adequate supervision during meals.
Findings
The facility failed to timely notify Resident 12's physician and the state agency about a second degree burn to her left hand. The facility also failed to adequately assess and treat the burn and did not provide adequate supervision during meals, resulting in the injury.
Deficiencies (4)
The facility failed to notify Resident 12's physician in a timely manner of a facility-acquired second degree burn to her left hand.
The facility failed to report Resident 12's second degree burn to the state agency as required.
The facility failed to routinely assess Resident 12's second degree burn to the top of her left hand.
The facility failed to provide adequate supervision with meals for Resident 12, resulting in a second degree burn from hot food.
Report Facts
Resident census: 19
Blister size: 0.5
Blister size: 0.5
Burn scab size: 2
Burn scab size: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in failure to timely notify physician and in care related to Resident 12's burn |
| CNA M | Certified Nurse Aide | Noted blisters on Resident 12's hand and involved in care |
| Administrative Nurse D | Administrative Nurse | Verified failure to timely notify physician and state hotline |
| Physician GG | Physician | Resident 12's physician who found wounds during rounds and expected timely reporting |
| LN I | Licensed Nurse | Physician GG's nurse who reported expectations for timely reporting |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Nov 7, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection of the facility.
Findings
The plan addresses multiple deficiencies including cleaning practices in the dining room, use of table cloths, medication orders for antipsychotic drugs, preparation of pureed diets, and consultant pharmacist review processes. Corrective actions include staff education, policy development, and random audits to ensure compliance.
Deficiencies (5)
F241-E: Regular sweeping and mopping will no longer be done after breakfast due to residents' open dining policy. Staff will spot clean as needed without disturbing residents except for safety spills.
F252-E: Table cloths will be added to the assisted dining tables to address deficient practice affecting residents who sit there.
F329-D: Medication orders for antipsychotic drugs were missing appropriate diagnoses; orders have been updated and a new policy is being developed with staff education and audits.
F364-E: A new policy for pureed diets includes expectations for bread inclusion; dietary staff will be educated and audits performed.
F428-D: Consultant pharmacist was given SOM Appendix PP and expectations for notification of inappropriate psychotropic medication diagnoses; new policy development and audits planned.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Date: Nov 7, 2017
Visit Reason
The inspection was a Health Resurvey and complaint investigation #116516 to assess compliance with regulatory requirements.
Complaint Details
The visit was triggered by a complaint investigation #116516.
Findings
The facility failed to maintain resident dignity during dining, provide a homelike environment for residents requiring assistance with meals, ensure appropriate diagnoses for antipsychotic medication use, provide adequate nutritive value in pureed diets, and act on pharmacist recommendations regarding medication diagnoses.
Deficiencies (5)
F241: The facility failed to maintain an environment promoting resident dignity during dining by mopping floors while residents were eating and moving residents away from tables.
F252: The facility failed to provide a homelike environment by not placing tablecloths on the table where 6 residents requiring assistance ate meals.
F329: The facility failed to ensure appropriate diagnoses for the use of Seroquel for two residents, placing them at risk for incorrect side effect monitoring and adverse effects.
F364: The facility failed to provide bread as part of the pureed diet for 4 residents, risking inadequate nutrition.
F428: The facility failed to act on pharmacist recommendations regarding inappropriate diagnoses for antipsychotic medication use for two residents, risking incorrect side effect monitoring.
Report Facts
Resident census: 37
Sample size: 12
Residents requiring assistance at table: 6
Residents reviewed for unnecessary medications: 5
Residents with inappropriate diagnosis for Seroquel: 2
Seroquel dosage Resident #20: 25
Seroquel dosage Resident #2: 25
Seroquel dosage Resident #2 revised: 12.5
Pureed diets prepared: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Verified inappropriate dining and medication diagnoses findings | |
| Housekeeper A | Observed mopping during meals and moving residents | |
| Housekeeping Supervisor B | Verified inappropriate mopping during meals | |
| Dietary Staff F | Prepared pureed diets without bread | |
| Dietary Manager E | Commented on lack of tablecloth and pureed bread | |
| Dietary Manager G | Stated bread should be included in pureed diets | |
| Registered Dietician H | Confirmed expectation of bread in pureed diets | |
| Pharmacist I | Addressed inappropriate diagnosis for Resident #20's Seroquel use | |
| Pharmacist K | Stated vascular dementia was not appropriate diagnosis for Resident #2's Seroquel use | |
| Nurse Aide D | Explained reason for no tablecloth at assisted dining table |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 3, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.10(b)(11), 483.15(a), and 483.60(a),(b) have been corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 5, 2016
Visit Reason
The visit was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found isolated 'D' level deficiencies that constitute no actual harm but have the potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated findings and compliance status. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 5, 2016
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 addresses deficiencies related to medication administration and vital signs practices, including staff re-education, policy revisions, and ongoing audits to ensure compliance.
Deficiencies (3)
F157-D: Staff will be re-educated on notifying the provider when medication is unavailable. The Medication Administration policy was revised to include notification procedures and audits will ensure compliance.
F241-D: Vital signs will no longer be obtained in the dining hall during meal times. The policy was updated and audits will monitor adherence to this change.
F425-D: Medications previously unavailable have been obtained and are administered as ordered. The Medication Administration policy was revised and audits will continue to ensure 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 previously identified deficiencies.
Findings
The facility failed to timely obtain and administer physician-ordered medications for one resident and failed to notify the physician of these issues. Additionally, the facility did not promote resident dignity during care activities such as taking blood pressures and oxygen saturation at the dining table.
Deficiencies (3)
F157: The facility failed to notify the physician and legal representatives of a resident's significant change and failed to administer physician-ordered medications timely for Resident #30.
F241: The facility failed to maintain resident dignity by obtaining blood pressures and oxygen saturation levels at the dining table during meals for Residents #19, #4, and #3.
F425: The facility failed to provide pharmaceutical services ensuring accurate acquisition and timely administration of medications for Resident #30.
Report Facts
Resident census: 36
Missed medication doses: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Administrative Nurse | Verified medication administration failures and dignity concerns |
| Nurse A | Observed obtaining blood pressure at dining table | |
| Nurse B | Observed obtaining blood pressure and pulse oximeter readings at dining table |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 8, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously identified deficiencies, including those under regulation 483.25(h), have been corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 01/08/2016.
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 'D' level, indicating no harm with potential for more than minimal harm and no immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility had deficiencies identified at the 'D' level in the Life Safety Code survey, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payment for new admissions: Apr 6, 2016
Effective date for termination of provider agreement: Jul 6, 2016
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 15, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies found during a complaint investigation at Logan Co Manor LTCU.
Complaint Details
This Plan of Correction is related to a complaint investigation at Logan Co Manor LTCU.
Findings
The plan addresses issues related to alarm placement and resident safety, including staff education and ongoing audits to ensure compliance with alarm safety protocols.
Deficiencies (1)
F323-D: Alarm placement and resident safety issues were identified. Administrative staff educated nursing staff on proper alarm use and will continue audits until compliance is achieved.
Report Facts
Plan of Correction completion date: Jan 8, 2016
Staff in-service date: Jan 24, 2016
Audit start date: Nov 19, 2015
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Dec 10, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#93967) regarding the facility's failure to implement care plan interventions to prevent resident falls.
Complaint Details
The complaint investigation (#93967) substantiated that the facility failed to implement fall prevention measures for Resident #2, leading to two falls due to personal alarms not being properly connected or activated.
Findings
The facility failed to ensure staff implemented fall prevention interventions as care planned for one resident, resulting in two falls related to personal alarms not being properly connected or activated.
Deficiencies (1)
F 323 483.25(h) The facility failed to ensure placement and activation of Resident #2's personal alarms as care planned, resulting in two falls when alarms were not connected properly or activated.
Report Facts
Resident census: 37
Sample size: 3
Falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide A | Nurse Aide | Verified staff had to ensure alarms were on and noted resident's cognitive and physical decline |
| Nurse B | Nurse | Verified alarms were not connected properly and staff education was provided |
| Administrative Nurse C | Administrative Nurse | Verified Resident #2 had two falls related to personal alarms not connected properly |
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 a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility was cited with a 'D' level deficiency indicating no actual harm but 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 for questions concerning the survey findings. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 28, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously reported deficiencies identified by regulation or Life Safety Code provisions have been corrected as of the revisit date.
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, 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 the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
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.
Findings
The plan addresses multiple deficiencies related to medication availability and administration, care plan updates after falls, and 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)
F157-D: Medications that were not available have been obtained and are being administered as ordered. A new medication administration policy has been written and nursing staff will be in-serviced on expectations and provider notification when medications are not received.
F280-D: Care plans for residents described in the deficiencies have been updated. A new MDS Coordinator has been hired to oversee care plan updates after falls, with audits performed to ensure compliance.
F281-D: The fall policy is being revised and nursing staff will be educated on revisions. Care plans are being updated and audited to ensure appropriate interventions after falls.
F323-D: Interim care plan processes have been changed to be viewed as actual care plans. A new policy on supervision levels for resident ADLs is being developed and staff will be in-serviced accordingly.
F425-D: Medications that were not available have been obtained and are being administered as ordered. A new medication administration policy has been written and nursing staff will be in-serviced on the process when medications are not available.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Date: Sep 28, 2015
Visit Reason
Complaint investigations #90733 and #91553 were conducted to evaluate concerns related to medication administration, fall prevention, and resident care.
Complaint Details
The investigation was triggered by complaints #90733 and #91553 regarding medication administration failures and fall prevention issues.
Findings
The facility failed to notify the physician about missed medication doses for Resident #1, failed to implement individualized fall prevention interventions 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 did not obtain physician-ordered medications in a timely manner for Resident #1.
Deficiencies (5)
483.10(b)(11) The facility failed to notify the physician that Resident #1 did not receive or was not administered several ordered medications during the first week after admission.
483.20(d)(3), 483.10(k)(2) The facility failed to develop and revise a comprehensive care plan with individualized interventions to prevent further falls for Resident #1 after multiple falls and injuries.
483.20(k)(3)(i) The facility failed to implement care plan interventions to prevent falls for Resident #1, who was at high risk and sustained a head injury from a fall.
483.25(h) The facility failed to provide adequate supervision and assistive devices to prevent accidents for Residents #1 and #2, resulting in falls and injuries including a hip fracture.
483.60(a),(b) The facility failed to obtain physician-ordered medications in a timely manner for Resident #1, resulting in missed doses of multiple medications during the first week after admission.
Report Facts
Resident census: 37
Missed medication doses: 8
Missed medication doses: 6
Missed medication doses: 5
Missed medication doses: 14
Missed medication doses: 30
Fall risk scores: 55
Fall risk scores: 70
Fall risk scores: 105
Fall risk scores: 30
Fall risk scores: 70
Fall risk scores: 80
Fall risk scores: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Verified failure to notify physician about missed medications and lack of individualized fall prevention interventions. | |
| Nurse G | Verified incomplete initial care plan and lack of individualized fall prevention interventions for Resident #1. | |
| Nurse A | Provided information about Resident #1's unsteady gait and falls. | |
| Nurse C | Reported Resident #1's unsteady mobility and lack of mental changes between falls. | |
| Nurse Aide B | Reported Resident #1's ability to disable alarms and refusal of assistance. | |
| Housekeeping Staff H | Witnessed Resident #1 fall from a step stool in the dining room. | |
| Housekeeping Staff E | Witnessed Resident #1 fall while walking without walker. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 12, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report lists multiple regulation citations with correction completion dates of 09/12/2015.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 6
Date: Aug 13, 2015
Visit Reason
Complaint investigation #89459 regarding failure to investigate and report a choking episode and other care and medication management concerns.
Complaint Details
Complaint investigation #89459 focused on failure to investigate and report a choking incident and other care deficiencies.
Findings
The facility failed to thoroughly investigate and report a choking incident, develop and revise comprehensive care plans for residents with behavioral issues, provide adequate supervision during meal times, and prevent unnecessary use of antipsychotic medications for a resident with dementia.
Deficiencies (6)
F225: The facility failed to thoroughly investigate and report a choking episode involving Resident #2 to the state agency within 5 working days.
F279: The facility failed to develop a comprehensive care plan to instruct staff on managing increasing behaviors of Resident #1.
F280: The facility failed to review and revise Resident #3's care plan to adequately instruct staff on managing increased behaviors.
F309: The facility failed to provide care and services to adequately manage behaviors for Resident #1.
F323: The facility failed to provide adequate supervision during meal times in the dining room, leaving residents unattended for 2-5 minutes at a time.
F329: The facility failed to prevent unnecessary medications by administering Seroquel to Resident #1 for a contraindicated diagnosis of dementia.
Report Facts
Resident census: 35
Residents sampled: 3
Duration of residents left unattended: 2
Duration of residents left unattended: 5
Seroquel dosage: 25
Seroquel dosage: 50
Seroquel dosage: 100
Haldol dosage: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Verified staff presence and described choking incident response. | |
| Nurse Aide C | Verified staff absence in dining room during meals. | |
| Administrative Staff A | Verified failure to investigate and report choking incident and supervision concerns. | |
| Administrative Nurse E | Verified lack of comprehensive care plans and behavior management. | |
| Nurse Aide G | Reported difficulty managing Resident #1's behaviors. | |
| 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. | |
| Nurse Aide H | Reported Resident #1's behaviors and facility staffing concerns. | |
| Nurse Aide F | Reported performing 15-minute checks on Resident #1. |
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, resulting in a finding of substantial compliance effective September 12, 2015.
Deficiencies (1)
The facility was cited for an "E" level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 20, 2015
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected as of 02/20/2015.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 20, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented in the Plan of Correction.
Findings
All deficiencies previously reported were corrected as of the revisit date. The report lists multiple regulation citations with correction completion dates.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Jan 28, 2015
Visit Reason
This document is a Plan of Correction submitted by Logan County Manor LTCU in response to deficiencies identified during a prior inspection.
Findings
The Plan of Correction addresses multiple deficiencies including fall management, 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 monitoring to achieve substantial compliance.
Deficiencies (9)
F225-D: Resident fall resulted in injury; resident assessed and placed on 30-minute checks. Fall policy revised to include injury of unknown origin and reporting requirements.
F309-D: Pain management orders updated; staff educated on pain management policy; audits to ensure effectiveness planned.
F315-D: Catheter care policy reviewed; staff trained on proper catheter care and prevention of catheter bag dragging; audits scheduled.
F323-D: Sani Wipes secured in locked cabinets with childproof locks; staff educated on chemical storage; audits planned.
F329-D: Medication Administration Records reviewed for vital sign parameters and bowel regimen; staff in-serviced on reporting vital signs and bowel movement issues; audits to continue.
F371-F: Dietary staff hairnets replaced with bonnets; refrigerator thermometers relocated and batteries changed; staff educated on temperature monitoring; audits ongoing.
F428-D: Medication Administration Records reviewed for vital signs and bowel movement monitoring; Director of Nursing to coordinate pharmacist review; audits ongoing.
F431-E: Investigation of controlled substances in unlocked cabinet; medications awaiting destruction secured; policy revised; staff educated; audits planned.
F441-F: Resident moved to private room with contact isolation; biohazard receptacle obtained; infection control practices reinforced; audits to ensure compliance.
Report Facts
Complete Date: Jan 28, 2015
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 9
Date: Jan 22, 2015
Visit Reason
The visit was a health resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to report an unwitnessed fall with injury, inadequate pain management, improper catheter care, unsafe environment hazards, failure to monitor medications and vital signs properly, unsanitary food preparation practices, improper medication storage and disposal, and inadequate infection control practices.
Deficiencies (9)
F225: The facility failed to report an unwitnessed fall with a nasal fracture of Resident #7 to the State agency within required timeframes.
F309: The facility failed to provide adequate pain management during wound care for Resident #9, who exhibited verbal and non-verbal signs of pain.
F315: The facility failed to provide appropriate catheter care and failed to justify the use of an indwelling catheter for Resident #1 and Resident #24, leading to risk of infection.
F323: The facility failed to maintain an environment free from accident hazards, including unsecured germicidal wipes accessible to residents.
F329: The facility failed to follow physician's orders for pulse monitoring and bowel management for Resident #31, and failed to provide timely interventions.
F371: The facility failed to prepare and serve food under sanitary conditions and maintain food at adequate temperatures; staff hair was not fully contained in hairnets.
F428: The facility's consultant pharmacist failed to identify and address failures in pulse and bowel monitoring for Resident #31.
F431: The facility failed to properly store and dispose of medications, including controlled substances, and maintain accurate reconciliation records.
F441: The facility failed to maintain infection control practices including contact isolation procedures, proper care of urinary catheter drainage bags, blood glucose equipment disinfection, and oxygen equipment storage.
Report Facts
Resident census: 32
Sample size: 13
Pulse readings >85: 25
Pulse readings >85: 29
Pulse readings >85: 35
Pulse readings >85: 18
Pulse readings >85: 25
Pulse readings >85: 16
No bowel movement days: 7
No bowel movement days: 6
Temperature range: 42
Temperature range: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide J | Assisted Resident #9 with transfer and was observed not following contact isolation procedures | |
| Administrative Nurse C | Verified multiple findings including failure to report fall, catheter care issues, infection control lapses, and medication storage problems | |
| Nurse Aide B | Observed emptying catheter bag without wiping drainage spout and allowing bag to touch floor | |
| Physical Therapist K | Verified dressing changes and pain management issues for Resident #9 | |
| Medication Aide G | Observed cleaning glucometer improperly and stated wipes were not available | |
| Registered Pharmacist H | Registered Pharmacist | Verified improper medication storage and disposal in medication room |
| Infection Control Nurse D | Verified infection control deficiencies including lack of biohazard receptacle and improper roommate placement |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 22, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 22, 2015
Visit Reason
A Health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 27, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied 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 to address these deficiencies.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
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
Informal Dispute Resolution 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. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 27, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied 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 to address these deficiencies.
Deficiencies (1)
The facility was cited for 'F' level deficiencies related to Life Safety Code compliance, which were widespread and posed potential for more than minimal harm without immediate jeopardy.
Report Facts
Denial of payment effective date: Nov 27, 2014
Termination effective date: Feb 27, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process and appeals. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 18, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the Plan of Correction.
Findings
All previously reported deficiencies identified on the CMS-2567 have been corrected as of the dates listed in the report.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 11
Date: Oct 23, 2013
Visit Reason
Health resurvey inspection to evaluate compliance with federal regulations including resident rights, physical restraints, housekeeping, care planning, pain management, accident prevention, infection control, medication management, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, improper use of physical restraints, unsanitary conditions, inadequate care plan revisions after falls, insufficient pain management, inadequate supervision to prevent accidents, bed rail entrapment risks, improper linen processing, contaminated medication handling, and failure to act on quality assurance findings.
Deficiencies (11)
F 167: The facility failed to post the survey results in an area readily accessible to residents, obstructed by a coat rack and placed too high for wheelchair access.
F 221: The facility failed to ensure a resident remained free of physical restraints not medically required, using a lap table as a restraint without proper justification or consistent care plan instructions.
F 253: The facility failed to maintain a sanitary and comfortable interior, with dust accumulation on bathroom ceiling vents and unrepaired gouges in resident room walls.
F 280: The facility failed to review and revise comprehensive care plans related to falls for two residents, lacking implementation of new interventions after multiple falls.
F 309: The facility failed to provide necessary pain management to maintain highest well-being for a resident, including failure to follow up on effectiveness of pain medications.
F 323: The facility failed to ensure adequate supervision and assistive devices to prevent accidents for residents at high risk of falls, failed to prevent entrapment risk from bed rails with large gaps, and stored hazardous chemicals accessible to residents.
F 325: The facility failed to maintain acceptable nutritional status for a resident by not following consulting dietician recommendations for nutritional supplements despite significant weight loss.
F 329: The facility failed to ensure residents did not receive unnecessary drugs by failing to monitor effectiveness of as needed medications for three residents.
F 371: The facility failed to serve food under sanitary conditions by using contaminated gloves while assisting residents with eating.
F 441: The facility failed to prevent spread of infection by improper linen processing and contaminated medication handling during administration.
F 520: The facility failed to develop and implement an action plan to correct identified quality deficiencies in the Quality Assessment and Assurance committee meetings.
Report Facts
Resident census: 39
Weight loss: 25
Weight loss: 30
Medication administration: 62
Medication administration: 49
Medication administration: 26
Medication administration: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nursing Staff | Named in relation to physical restraint findings, care plan revisions, medication monitoring, and QAA committee |
| Licensed Nursing Staff H | Licensed Nurse | Named in relation to physical restraint findings, care plan revisions, medication monitoring, and fall prevention |
| Consultant X | Consultant Pharmacist | Named in relation to medication monitoring irregularities |
| Direct Care Staff I | Direct Care Staff | Named in relation to resident pain complaints and assistance |
| Licensed Nursing Staff R | Licensed Nurse | Named in relation to pain medication administration and monitoring |
| Dietary Staff F | Dietary Staff | Named in relation to dietary recommendations and food service |
| Staff E | Housekeeping/Laundry Staff | Named in relation to laundry processing and chemical handling |
| Staff S | Licensed Nursing Staff | Named in relation to medication handling contamination |
| Direct Care Staff P | Direct Care Staff | Named in relation to resident pain complaints |
| Direct Care Staff C | Direct Care Staff | Named in relation to QAA committee participation |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Oct 17, 2013
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 documentation practices. The Quality Committee will oversee compliance and monitor progress.
Deficiencies (12)
F167-C: The survey was moved to a location accessible to all residents and staff to ensure visibility and accessibility.
F221-D: Measures will be implemented to remove a lap tray restraint and assess the resident for proper positioning; restraint policy will be reviewed and staff educated.
F253-E: Bathroom ceiling vents were cleaned and walls repaired; housekeeping and maintenance procedures were updated to maintain cleanliness and repair.
F280-D: Nurses will be educated to update care plans with interventions after falls; audits will ensure compliance.
F309-D: Nurses and CMAs will be educated on pain control expectations; a pain policy will be developed and audits conducted.
F323-G: A fall team was established; an unsafe bed was removed; door latch repaired; maintenance will monitor door latches weekly.
F325-D: Resident charts reviewed for nutritional recommendations; dietician involvement and audits will ensure follow-up.
F329-D: Medication regimen reviewed by social worker; education on pain control and psychotropic drug reduction audits will be conducted.
F371-D: Staff will be educated on infection control for food handling; observations will be conducted to ensure compliance.
F428-D: Nurses and CMAs will be educated on documenting responses to PRN medications; audits will monitor compliance.
F441-F: Laundry staff educated on sanitizer use; nurses and CMAs educated on infection control; monthly checks and med pass observations will be reported.
F520-F: The Quality Committee will oversee regulatory compliance and quality improvement projects, reviewing data monthly until substantial compliance is achieved.
Report Facts
Audit frequency: 3
Audit frequency: 3
Observation frequency: 3
Monthly checks: 3
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 18, 2012
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
All deficiencies previously reported on the CMS-2567 have been corrected as of the revisit date 09/18/2012.
Inspection Report
Follow-Up
Deficiencies: 8
Date: Sep 18, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by the revisit date of 09/18/2012.
Deficiencies (8)
Regulation 483.15(a) deficiency was corrected by 09/18/2012.
Regulations 483.20(d) and 483.20(k)(1) deficiencies were corrected by 09/18/2012.
Regulation 483.25(h) deficiency was corrected by 09/18/2012.
Regulations 483.35(d)(1)-(2) deficiencies were corrected by 09/18/2012.
Regulation 483.35(i) deficiency was corrected by 09/18/2012.
Regulations 483.60(a) and (b) deficiencies were corrected by 09/18/2012.
Regulation 483.65 deficiency was corrected by 09/18/2012.
Regulation 483.70(g) deficiency was corrected by 09/18/2012.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Aug 22, 2012
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 feeding residents with dignity, updating care plans for activities, ensuring proper door locking for chemical storage, measuring food temperatures, sanitary food service, medication administration accuracy, glucometer cleaning, and bedside table placement. Corrective actions include staff inservice, monitoring, policy development, and monthly reporting to the Quality Assurance Committee.
Deficiencies (8)
F241-D: Staff were instructed on feeding residents with dignity, including positioning and isolation signage removal. Monitoring of dining room compliance will occur three times weekly.
F279-D: Resident care plans were updated to include accurate activity descriptions and measurable goals. Staff were educated on care plan expectations with quarterly reviews.
F323-E: Doors to chemical storage areas were fixed to close and lock properly. Staff were inserviced on chemical storage and maintenance will perform weekly checks.
F364-D: Dietary staff were instructed to measure temperatures of pureed and ground foods to ensure safety. Food temperature charts were revised and will be reviewed monthly.
F371-F: Nursing and dietary staff were instructed on sanitary food service. Observations of dining room and dietary service will occur three times weekly with monthly QA reporting.
F425-D: Medication administration records for sliding scale insulin were reviewed and staff inserviced. Chart audits will be performed with monthly QA reporting.
F441-E: Nursing staff were inserviced on glucometer cleaning. A sink was ordered for the whirlpool room. Monitoring of cleaning will occur three times weekly with monthly QA reporting.
F464-D: Staff arranged bedside table placement for resident comfort and updated care plans. Monitoring will occur three times weekly with monthly QA reporting.
Report Facts
Complete Date: Sep 18, 2012
Plan of Correction submission date: Aug 31, 2012
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 8
Date: Aug 20, 2012
Visit Reason
Health resurvey inspection to assess compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during dining, inadequate comprehensive care plans for resident activities, unsafe storage of hazardous chemicals, improper food temperature monitoring, unsanitary food handling practices, failure to administer prescribed medications, inadequate infection control measures, and insufficient furnishings to accommodate resident dining needs.
Deficiencies (8)
F241: The facility failed to maintain residents' dignity during dining by staff using a spoon to wipe food from resident's mouth and improper seating and interaction with residents during meals.
F279: The facility failed to develop comprehensive care plans with measurable objectives and timetables addressing residents' individual activity interests for 2 sampled residents.
F323: The facility failed to ensure the environment was free of accident hazards by storing hazardous chemicals in unlocked, accessible areas to cognitively impaired residents.
F364: The facility failed to provide palatable food at proper temperatures for residents receiving pureed diets, with food served below safe temperature levels.
F371: The facility failed to prepare, distribute, and serve food under sanitary conditions, including staff handling food with contaminated gloves and bare hands.
F425: The facility failed to provide pharmaceutical services by not administering sliding scale insulin as ordered for a resident with elevated blood sugar levels.
F441: The facility failed to maintain infection control by lacking a handwashing sink in the west hall whirlpool room and failing to clean glucometers between resident use.
F464: The facility failed to provide adequate furnishings to accommodate the dining needs of a resident, including improper positioning during meals and inadequate bedside table placement.
Report Facts
Deficiencies cited: 8
Residents sampled: 19
Residents cognitively impaired and independently mobile: 11
Residents receiving pureed diet: 2
Residents with medication administration issue: 1
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, care plan audits, surveillance, and education to ensure compliance.
Deficiencies (6)
F225-D: A resident choked on a piece of meat; the diet was changed to ground meat and no further choking occurred. The incident was not reported to Risk Management, so no investigation was done.
F279-D: The care plan of the resident involved was updated; new residents are expected to have a temporary care plan within 24 hours and a complete plan within 21 days.
F280-D: A resident with psychiatric diagnoses was in an inpatient geropsychiatric unit and passed away; psychotherapy notes will be given to the DON to update care plans and educate staff.
F309-D: A resident was admitted to a geropsychiatric unit for medication adjustment; the facility will work with the family to determine appropriate placement and educate staff if the resident returns.
F323-E: At least one nurse will be stationed in the dining room before and during meals until tables are cleared; weekly surveillance will be conducted and reported to the Quality Committee.
F329-D: Education was provided about atypical antipsychotic medications for dementia; medication reviews and audits will be conducted to ensure appropriate use and staff education.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N055002 POC WJWU11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by Event ID WJWU11.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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