Inspection Reports for
Lone Tree Retirement Community, LLC
801 E GRANT, MEADE, KS, 67864
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
73% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/21/25.
Findings
All deficiencies from the prior inspection have been corrected as of the compliance date 10/01/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 8
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as a Health Recertification Survey and complaint investigation regarding allegations in KS00194531.
Complaint Details
The complaint investigation was related to allegations in KS00194531, including concerns about resident dignity, discharge processes, assessment accuracy, food safety, waste disposal, staffing data accuracy, infection control practices, and infection preventionist qualifications.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and privacy, failure to provide a written discharge summary, inaccurate resident assessments, unsanitary food storage and preparation practices, improper garbage disposal, incomplete staffing data submission, inadequate infection prevention and control practices, and lack of a qualified infection preventionist.
Deficiencies (8)
Resident Rights: The facility failed to treat Resident 4 with dignity by providing care without privacy during mechanical lift use, leaving doors and curtains open.
Discharge Process: The facility failed to provide a written discharge summary or recapitulation of stay for Resident 37, risking impaired continuity of care.
Accuracy of Assessments: The facility failed to accurately complete Minimum Data Set assessments for five residents related to alarms, pressure ulcers, medications, dental status, and diet.
Food Procurement, Storage, Preparation, and Service: The facility failed to store and prepare food under sanitary conditions, including unsealed food items, food stored on the floor, unlabeled items, and dirty kitchen equipment.
Garbage and Refuse Disposal: The facility failed to properly maintain and dispose of kitchen garbage, with uncovered garbage cans present in the kitchen.
Payroll Based Journal: The facility failed to submit complete and accurate staffing information to CMS, incorrectly reporting licensed nursing coverage on multiple dates.
Infection Prevention and Control: The facility failed to use Enhanced Barrier Precautions for Resident 5, ensure adequate hand hygiene during care for Residents 5 and 32, and deliver food in a sanitary manner.
Infection Preventionist Qualifications: The facility failed to designate a qualified Infection Preventionist with specialized training in infection prevention and control.
Report Facts
Resident census: 33
Dates with no licensed nursing coverage reported in PBJ: 12
Weight of flour bag stored on floor: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Infection Preventionist | Named as facility IP without health-related degree or specialized infection prevention training |
| Administrative Nurse D | Administrative Nurse | Assisted with infection prevention tasks and confirmed deficiencies in infection control and discharge summary |
| Certified Dietary Manager BB | Certified Dietary Manager | Reported on food storage and sanitation issues in kitchen |
| Consultant Staff GG | Consultant | Provided input on infection control expectations and IP qualifications |
| Licensed Nurse G | Licensed Nurse | Confirmed infection control expectations and PPE use |
| Certified Nurse Aide M | Certified Nurse Aide | Observed failing to provide privacy and inadequate hand hygiene |
| Certified Nurse Aide S | Certified Nurse Aide | Observed failing to provide adequate hand hygiene during care |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Aug 19, 2025
Visit Reason
The document is a Plan of Correction submitted in response to an Annual and Complaint Survey conducted from August 19, 2025 to August 21, 2025 at Lone Tree Retirement Community.
Findings
The Plan of Correction addresses multiple deficiencies identified during the Annual and Complaint Survey, including resident rights, discharge process, accuracy of assessments, food procurement and sanitation, garbage disposal, payroll based journal accuracy, infection prevention and control, and infection preventionist qualifications.
Deficiencies (8)
F550: Resident Rights/Exercise of Rights. Staff involved were immediately counseled and re-educated; resident dignity was protected. Facility-wide audits and staff re-education were conducted to prevent recurrence.
F628: Discharge Process. Discharge summaries were completed and provided; staff were educated and a discharge checklist implemented. Audits will monitor compliance.
F641: Accuracy of Assessments. Identified residents' MDS were corrected and transmitted to CMS. Staff were re-educated and audits scheduled to ensure ongoing accuracy.
F812: Food Procurement, Store/Prepare/Serve-Sanitary. Food items were stored properly or discarded; kitchen sanitized. Staff re-educated and audits planned to ensure compliance.
F814: Dispose Garbage and Refuse Property. Garbage cans were lidded or removed; staff re-educated and signage posted. Regular inspections and audits scheduled.
F851: Payroll Based Journal. Missing days corrected and resubmitted; staff re-educated on reporting requirements. Ongoing audits planned to ensure accuracy.
F880: Infection Prevention & Control. Staff counseled and re-educated; facility-wide observations conducted. Hand hygiene competency completed and audits scheduled.
F881: Infection Preventionist Qualifications Role. DON assumed responsibility and is enrolled in certification course. Compliance and documentation will be maintained and reviewed.
Report Facts
Survey dates: Annual and Complaint Survey conducted from 2025-08-19 to 2025-08-21
Plan of Correction submission deadline: Submission by September 14th, 2025
Plan of Correction compliance date: Date of compliance for all deficiencies is October 1, 2025
Number of identified residents with MDS corrections: 5
Missing PBJ days corrected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CASANDRA MITTLIEDER | LNHA | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| FELICIA MAJEWSKI | Modified the Plan of Correction on 11/19/2025 | |
| CPATTERSON | Added the Plan of Correction on 08/28/2025 |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-08-30.
Findings
All deficiencies have been corrected as of the compliance date of 2023-09-26, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Aug 30, 2023
Visit Reason
This document is a Plan of Correction submitted by Meade District Hospital LTCU in response to deficiencies cited during the inspection on 2023-08-30.
Findings
The Plan of Correction addresses multiple deficiencies including nebulizer treatment policies, food storage and safety, staffing information reporting, infection control education, and dishwasher sanitization procedures.
Deficiencies (6)
F0000: The facility will review the statement of deficiencies at the Managers meeting and QAPI meeting, with minutes provided to the Governing Board.
F695-D: The facility updated the nebulizer treatment policy to include cleaning and storage, and will ensure oxygen saturation is assessed before and after treatments.
F812-F: Food services will maintain clean food storage areas, inspect food upon delivery, and ensure proper labeling and temperature monitoring of refrigerated and non-refrigerated foods.
F851-C: The policy for mandatory submission of staffing information has been reviewed, with the Director of Nursing responsible for timely reporting of PBJ data.
F880-D: Nursing staff receive education on infection control, specifically peri-care and hand hygiene, with annual training and check-offs scheduled and ongoing.
F908-F: Dishwasher parts were installed and chemical concentration for dish sanitization will be logged in place of water temperature when using the three-sink method.
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 5
Date: Aug 30, 2023
Visit Reason
The inspection was a health resurvey to evaluate compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility failed to provide proper respiratory care and cleaning of nebulizer equipment for residents, failed to maintain sanitary food storage and dish sanitization practices, failed to submit complete staffing data, failed infection control practices including hand hygiene, and failed to maintain a functioning dish machine.
Deficiencies (5)
F695 Respiratory care: The facility failed to provide respiratory care consistent with professional standards for Residents 26 and 27 regarding nebulizer use and cleaning.
F812 Food safety: The facility failed to store foods safely and ensure proper sanitization and food handling practices to prevent foodborne illness.
F851 Payroll Based Journal: The facility failed to submit complete and accurate direct care staffing information to CMS, missing licensed nursing coverage data on multiple dates.
F880 Infection Control: The facility failed to maintain a sanitary environment by not cleaning nebulizer equipment between uses and failing hand hygiene during incontinent care for Resident 16.
F908 Essential Equipment: The facility failed to maintain mechanical and patient care equipment in safe operating condition by having a non-functioning dish machine since 08/08/23.
Report Facts
Resident census: 27
Sanitizing sink chlorine concentration: 100
Deficiency severity counts: 5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 5, 2022
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2021-11-16.
Findings
All deficiencies have been corrected as of the compliance date of 2021-12-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Dec 11, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection report.
Findings
The plan outlines corrective actions including development and communication of a new Bed Hold Policy, updating resident care plans for oxygen use, and revising policies for oxygen delivery equipment cleaning and storage.
Deficiencies (6)
F0000 The facility will present the statement of deficiencies to management and QAPI meetings with minutes provided to the Governing Board.
F550-D The facility developed a new Bed Hold Policy requiring verbal and written notification to residents or representatives about transfers and therapeutic leave, including State Ombudsman contact information.
F572-E This tag was removed and replaced with a revised deficiency report attached.
F625-D The facility must provide written notice of the Bed Hold policy at transfer or therapeutic leave with signed receipt by resident or representative, including emergency transfer procedures.
F657-D Resident care plans will be updated with current oxygen orders and documentation tabs added to the computer program.
F695-E The oxygen delivery equipment policy will be updated to include cleaning, storage, and dating of tubing and nebulizer equipment.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Date: Nov 16, 2021
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation for the facility.
Complaint Details
The inspection included a complaint investigation as indicated by the report stating findings from a health resurvey and complaint investigation KS00156100.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with dignity by not providing a privacy bag for an indwelling catheter, failure to provide bed-hold policy upon hospital transfer, failure to revise care plans to include oxygen care, and failure to properly clean and store oxygen and nebulizer equipment for several residents.
Deficiencies (4)
F 550 Resident Rights: The facility failed to ensure Resident 6 was treated with dignity by not providing a privacy bag for an indwelling catheter bag.
F 625 Notice of Bed Hold Policy: The facility failed to provide Resident 26 or the resident representative with a bed-hold policy upon transfer to a hospital.
F 657 Care Plan Timing and Revision: The facility failed to revise care plans for Residents 9 and 28 to include care of the oxygen both residents were receiving.
F 695 Respiratory/Tracheostomy Care: The facility failed to ensure routine changing and sanitary storage of oxygen tubing and nebulizer equipment for Residents 9, 17, 25, and 28.
Report Facts
Facility census: 33
Sample size: 12
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
A revisit survey was conducted on 11/18/20 and 11/19/20 for all previous deficiencies cited on 10/13/20 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 10/30/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Oct 30, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior survey, addressing fall prevention and resident safety.
Findings
The facility identified deficiencies related to fall prevention, including lack of staff adherence to resident care plans and environmental factors contributing to falls. Corrective actions include staff education, updated care plans for high-risk residents, and ongoing assessments to prevent accidents.
Deficiencies (6)
F0000: Deficiencies from the survey were reviewed in QAPI and Risk Management meetings to address standards of care for staff involved in incidents. F-689: The facility will provide a safe environment by assessing resident needs and ensuring supervision to prevent accidents.
F689-G: All falls are evaluated to identify residents at higher risk. Each resident will have a Fall Risk Predictive Factors Assessment completed at scheduled times including admission and quarterly reviews.
Resident #6's fall was due to staff not following the care plan to remain with the resident. The care plan was updated to avoid assisting the resident to a recliner when restless.
Resident #7's fall was related to inadequate visual monitoring due to seating. The care plan was updated to assist the resident to a specific recliner for improved monitoring.
Resident #8's fall was due to being up without a walker. The care plan was updated to include evaluation for physical therapy and assistance of two staff.
Resident #10's fall was environmental and related to bladder incontinence. The care plan includes education on call light use and assistance type. The resident is on hospice care with a new diagnosis of colon cancer.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dr. Schowengardt | Medical Director | Attended QAPI meeting reviewing deficiencies |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Oct 13, 2020
Visit Reason
The inspection was conducted as a complaint investigation involving multiple complaint numbers related to resident falls and supervision issues.
Complaint Details
The complaint investigation involved multiple complaint numbers related to falls and supervision failures at the facility.
Findings
The facility failed to adequately supervise residents at high risk for falls and failed to thoroughly investigate falls to determine root causes and implement appropriate interventions. Several residents experienced fractures due to falls, and the facility's fall investigations and interventions were delayed or insufficient. Staffing shortages were noted as a contributing factor to inadequate supervision.
Deficiencies (1)
F 689: The facility failed to thoroughly investigate resident falls for Residents 6, 7, 8, and 10 to determine root causes and tailor interventions, resulting in fractures and injuries.
Report Facts
Facility census: 33
Fall incidents: 6
Days delay: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Named in fall incident involving Resident 6 and failure to provide adequate supervision | |
| Administrative Nurse A | Reviewed fall video and identified supervision failures for Resident 6 | |
| LN D | Licensed Nurse | Involved in fall investigation and care for Resident 6 |
| CNA B | Provided information on fall interventions for Resident 6 and Resident 8 | |
| CNA C | Reported fall and bruise findings for Resident 6 and staffing concerns | |
| CNA P | Reported bruise findings for Resident 6 and staffing concerns | |
| CNA I | Reported on toileting and fall interventions for Resident 8 and Resident 10 | |
| LN M | Licensed Nurse | Reported staffing difficulties on evening shifts |
| CNA E | Reported pain and assisted Resident 8 after fall | |
| LN H | Certified Medication Aide | Administered pain medication to Resident 8 |
| CNA T | Assisted Resident 8 to bed | |
| CNA G | Assisted Resident 8 to bed and reported pain | |
| CNA O | Reported lack of communication about residents' toileting needs | |
| LN J | Licensed Nurse | Reported on fall interventions and resident condition for Resident 10 |
| LN K | Licensed Nurse | Reported on toileting diaries and assistance for Resident 10 |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 9, 2020
Visit Reason
The inspection was conducted as a health survey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations, indicating full compliance with the applicable long term care regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 9, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a health survey inspection of a long term care facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Inspection Report
Deficiencies: 0
Date: Jan 17, 2019
Visit Reason
The health survey was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations with respect to the applicable regulations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 17, 2019
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of a long term care facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 17, 2017
Visit Reason
This document is a plan of correction related to a facility inspection conducted at Meade District Hosp LTCU DBA Lone Tree Retirement.
Findings
The document contains a statement of deficiencies and a plan of correction but does not provide specific findings or deficiency details.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 17, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection.
Findings
The document contains no specific deficiencies or findings detailed; it serves as a template for corrective actions related to previously identified deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Sep 13, 2017
Visit Reason
The document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection, aiming to ensure a safe and sustained environment for residents.
Findings
The plan addresses multiple deficiencies including medication error rates, food procurement and storage, narcotics security, and call system maintenance. The facility outlines corrective actions and staff education to resolve these issues.
Deficiencies (6)
F0000 The facility will take statement of deficiencies to the September 13, 2017 QAPI meeting to provide a safe and sustained environment for each resident. Meeting minutes will be provided to the Governing Board on September 21, 2017.
F332-D The facility will ensure the Medication Error Rate is less than 5% by clarifying conflicting orders with providers and updating medication administration policies. Nursing staff will be educated on the policy at the next monthly meeting.
F371-E The facility will ensure foods are procured from approved sources and stored, prepared, and served under sanitary conditions. Staff will be educated on food handling and documentation, with monitoring reported at the next QAPI meeting.
F431-E The facility will secure narcotics in separately locked, permanently affixed compartments under a double lock system. Nursing staff have been educated on these changes and interventions will be reviewed at the next QAPI meeting.
S0000 The facility will take statement of deficiencies to the September 13, 2017 QAPI meeting to provide a safe and sustainable environment for each resident. Meeting minutes will be provided to the Governing Board on September 21, 2017.
S1164-F The facility will perform weekly preventative maintenance of the call system to verify functionality. A log of testing will be maintained and reported at monthly QAPI meetings.
Report Facts
Medication Error Rate: 5
Inspection Report
Renewal
Census: 35
Deficiencies: 1
Date: Aug 21, 2017
Visit Reason
The inspection was a licensure resurvey to assess compliance with nursing facility regulations.
Findings
The facility failed to ensure weekly testing of the call light system, performing only monthly checks. This deficiency potentially affected all 35 residents.
Deficiencies (1)
26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) Nursing facility support system. The facility failed to perform weekly preventative maintenance on the call light system to verify it remained functional. Staff only checked the call lights monthly.
Report Facts
Residents present: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| J | Maintenance Staff | Interviewed regarding call light system testing frequency |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 27, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were corrected as of May 3, 2017, with no uncorrected deficiencies noted at the time of this revisit.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: May 3, 2017
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 outlines corrective actions to address deficiencies related to resident confidentiality, abuse prevention and reporting, staff education, investigation procedures, and nurse aide competency verification.
Deficiencies (8)
F0000 The facility will review statements of deficiencies at QAPI and Medical Directors meetings to ensure ongoing compliance.
F164-D The facility will safeguard all resident records and prevent confidentiality breaches, including social media use, through staff in-service training.
F223-K The facility will educate all staff on Abuse, Neglect and Exploitation policies, reporting requirements, and consequences of abuse.
F225-L All reports of abuse, neglect, or injuries of unknown source will be thoroughly investigated by Risk Management staff with appropriate documentation and reporting.
F226-F Employees accused of abuse will be suspended immediately pending investigation outcomes.
F250-D Support and follow-up visits will be provided to residents involved in abuse allegations to ensure psychosocial well-being.
F280-D Staff are responsible for communicating interventions and updating care plans following incidents such as falls or abuse.
F496-F The facility will verify nurse aide competency through registry verification prior to employment, including contacting multiple states if needed.
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Apr 26, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be immediate jeopardy related to deficiencies F223, F225, and F226. Enforcement remedies including a $7,000 civil monetary penalty, denial of payment for new admissions, and potential termination of provider agreement were imposed.
Deficiencies (3)
Deficiency F223, K, CFR 483.12(a)(1) was cited with immediate jeopardy conditions.
Deficiency F225, L, CFR 483.12(a)(3)(4)(c)(1)-(4) was cited with immediate jeopardy conditions.
Deficiency F226, F, CFR 483.12(b)(1)(2) was cited with substandard quality of care.
Report Facts
Civil Monetary Penalty: 7000
Denial of Payment Effective Date: Jun 1, 2017
Termination Effective Date: Oct 26, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Brown | Administrator | Named as facility administrator in the report. |
| Caryl Gill | RN, BSN, Complaint coordinator | Named as complaint coordinator and contact for questions. |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 7
Date: Apr 26, 2017
Visit Reason
Complaint investigation triggered by allegations of staff-to-resident abuse and resident-to-resident altercation.
Complaint Details
The complaint investigation involved multiple allegations of staff-to-resident abuse including physical abuse and confidentiality breaches, failure to report and investigate abuse allegations timely, failure to protect residents from abuse, and failure to revise care plans after resident-to-resident altercations. The investigation confirmed credible witness statements supporting abuse allegations and identified systemic failures placing residents in immediate jeopardy.
Findings
The facility failed to protect residents from abuse by staff, failed to report incidents timely, failed to provide social services after abuse incidents, failed to revise care plans after resident-to-resident altercations, and failed to verify nurse aide registry prior to employment. Multiple residents were abused by staff, and the facility allowed alleged perpetrators to continue working before suspension.
Deficiencies (7)
The facility failed to protect resident #1's confidentiality when staff text-messaged details of alleged mistreatment including the resident's name.
The facility failed to provide an environment free from abuse when staff G and H abused resident #1 by restraining, pinching nose, and forcing medication, and staff H abused residents #4, #5, and #6 by hair pulling, verbal abuse, and pushing causing pain.
The facility failed to report and investigate allegations of abuse timely, allowing alleged perpetrators to continue working and placing all residents in immediate jeopardy.
The facility failed to provide social service support to resident #1 following staff-to-resident abuse to ensure psychosocial well-being.
The facility failed to revise the care plan for resident #2 following a resident-to-resident altercation on 1/3/17 to prevent future occurrences.
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse and to investigate allegations, including protection of residents during investigations.
The facility failed to document verification of nurse aide registry prior to employment for 4 nurse aides, potentially affecting all residents.
Report Facts
Facility census: 42
Residents sampled for abuse: 6
BIMS score: 9
BIMS score: 8
BIMS score: 4
BIMS score: 3
BIMS score: 12
BIMS score: 15
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff G | Nurse aide | Named in abuse findings involving resident #1. |
| Direct care staff H | Nurse aide | Named in multiple abuse findings involving residents #1, #4, #5, #6 and confidentiality breach. |
| Direct care staff D | Nurse aide | Witnessed abuse incident and texted details. |
| Administrative nurse K | Administrator/Nurse | Directed text communication, received abuse reports, and managed investigation. |
| Licensed nurse F | Nurse | Reported verbal and physical abuse by staff H and left notes for administration. |
| Direct care staff C | Nurse aide | Reported verbal and physical abuse by staff H and witnessed mistreatment. |
| Administrative staff S | Administrator | Confirmed policy gaps and registry verification issues. |
| Social service staff U | Social worker | Did not provide social services after abuse incident. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 11, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated in the plan of correction.
Findings
The report confirms that all previously reported deficiencies identified by regulation numbers 483.24 and 483.25(k)(l) and 483.25(d)(1)(2)(n)(1)-(3) have been corrected as of the revisit date.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 12, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be F523, an 'E' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
Deficiency F523 was cited as an 'E' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person and author of the report letter. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 12, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Meade District Hospital LTCU.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation at Meade District Hospital LTCU.
Findings
The facility identified deficiencies related to quality of life and safety, specifically regarding nursing assessments following resident elopement and ensuring the environment is free from accident hazards with adequate supervision and device use.
Deficiencies (2)
F309: The facility will ensure a complete nursing assessment is done following an elopement, including vital signs, skin, mobility, and injury symptom assessments, with follow-ups at 1 and 4 hours. An incident report will document weather and elopement duration, and a monitoring camera will be installed.
F323: The facility will ensure the resident environment remains free from accident hazards and residents receive adequate supervision and devices to prevent accidents. New policies require visual checks when door alarms activate without apparent reason, and monthly drills will train staff on alarm response and equipment monitoring.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Date: Jan 1, 2017
Visit Reason
Complaint investigation KS0010330 was conducted due to concerns about the facility's failure to provide necessary care and supervision to residents, including a failure to conduct a thorough nursing assessment after an elopement and inadequate supervision to prevent accidents.
Complaint Details
The investigation was triggered by a complaint (KS0010330) regarding failure to provide necessary care and supervision to residents, including inadequate response to an elopement and failure to maintain functional door alarms and supervision to prevent resident exit and accidents.
Findings
The facility failed to provide one resident with a thorough nursing assessment following an elopement in cold weather and failed to provide adequate supervision and assistive devices to eight cognitively impaired and independently mobile residents to prevent accidents related to malfunctioning door alarms and unsecured exit doors.
Deficiencies (2)
F309: The facility failed to provide resident #1 with a thorough nursing assessment following an elopement in 33.8 degree weather to maintain the resident's highest practicable physical well-being.
F323: The facility failed to provide 8 cognitively impaired and independently mobile residents with adequate supervision and assistive devices to prevent accidents when exit door alarms malfunctioned, an unalarmed door led to an enclosed courtyard, and staff silenced alarms without checking the door.
Report Facts
Resident census: 41
Residents selected for sample: 3
Cognitively impaired and independently mobile residents: 8
Temperature at time of elopement: 33.8
Wind chill at time of elopement: 25.3
Months door alarm malfunctioned: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff E | Reported resident elopement and described resident's clothing and return | |
| Direct Care Staff F | Reported observation of resident walking outside without coat or shoes | |
| Direct Care Staff C | Reported seeing resident outside and silencing door alarm without checking door | |
| Administrative Nurse B | Administrative Nurse | Confirmed failure to complete thorough nursing assessment after elopement |
| Maintenance/Housekeeping Staff G | Reported door alarm malfunction and lack of alarm on courtyard door | |
| Maintenance Staff H | Confirmed door alarm malfunction and lack of alarm on courtyard door | |
| Administrative Staff A | Administrative Staff | Reported staff should not reset door alarms without checking doors |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 23, 2015
Visit Reason
This document is a Plan of Correction submitted by Meade District Hospital LTCU to address deficiencies identified in a prior inspection.
Findings
The plan addresses deficiencies related to skin assessments and pharmaceutical services, including medication administration procedures and documentation.
Deficiencies (2)
F314-D: Residents will have skin assessments at admission, return, weekly, and PRN by licensed staff. Non-blanchable areas trigger a SDTI-PRU tool and referral to a wound specialist for staging and interventions.
F425-D: Pharmaceutical services will ensure accuracy in acquiring, dispensing, and administering medications within one hour of prescribed times. Documentation is required for missed doses and follow-up attempts must be made.
Report Facts
Plan of Correction completion date: Nov 23, 2015
Inspection Report
Follow-Up
Deficiencies: 2
Date: Nov 23, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that deficiencies related to regulations 483.25(c) and 483.60(a),(b) were corrected as of the revisit date.
Deficiencies (2)
Regulation 483.25(c) deficiency was corrected by 11/23/2015.
Regulation 483.60(a),(b) deficiency was corrected by 11/23/2015.
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 2
Date: Nov 2, 2015
Visit Reason
This inspection was a health resurvey to verify compliance with previously cited deficiencies related to pressure ulcer prevention and pharmaceutical services.
Findings
The facility failed to provide necessary services to prevent one resident from developing a stage 2 pressure ulcer and failed to ensure medications were administered as ordered to another resident.
Deficiencies (2)
F314: The facility failed to prevent resident #48 from developing a stage 2 pressure ulcer despite risk assessments and care plans.
F425: The facility failed to ensure resident #39 received Megace as ordered due to staff not waking the resident for medication administration.
Report Facts
Facility census: 45
Residents in sample: 9
Weight loss: 14.6
Weight loss: 8.8
Pressure ulcer wound size: 0.5
Medication doses missed: 18
Medication doses missed: 2
Medication doses missed: 2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 2, 2015
Visit Reason
The visit was a Health survey conducted 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 constituted no actual harm but had 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 based on the credible allegation of compliance.
Deficiencies (1)
The survey cited isolated 'D' level deficiencies indicating no actual harm but potential for more than minimal harm without immediate jeopardy.
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 18, 2015
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 deficiency 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 possible termination of provider agreement were outlined.
Deficiencies (1)
The facility was found to have 'F' level deficiencies that are widespread with no harm but with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payment: Nov 18, 2015
Effective date for termination: Feb 18, 2016
Days to request Informal Dispute Resolution: 10
Days to request fair hearing: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 13, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of 08/29/2014, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiencies corrected: 15
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 1, 2014
Visit Reason
A Health recertification survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency at a 'G' level, isolated, with no actual harm but potential for more than minimal harm that is not immediate jeopardy. Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were outlined.
Deficiencies (1)
The facility was cited with a 'G' level deficiency, isolated, indicating no actual harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Civil Money Penalty minimum amount: 5000
Effective date for denial of payment: Nov 1, 2014
Effective date for termination: Feb 1, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Brown | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator for the survey |
| Joe Ewert | Commissioner of Survey, Certification and Credentialing Commission | Named as Commissioner overseeing the survey |
Inspection Report
Plan of Correction
Capacity: 45
Deficiencies: 14
Date: Jul 25, 2014
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 maintenance of call lights, housekeeping, admission assessments, MDS accuracy, care plan development and updates, skin care and assessments, fall prevention, medication management including black box warnings, dietary staffing and food quality, and sanitary food handling.
Deficiencies (14)
F246-D Call lights will be maintained and placed within resident reach. Maintenance will perform monthly and weekly inspections to ensure all devices are functional and in place.
F253-E Housekeeping services will maintain a sanitary, orderly, and comfortable interior. Nightstands in disrepair will be removed and housekeeping staff will be trained on routine cleaning.
F273-D Admission assessments will be completed within 14 days of admission. MDS coordinator will ensure timely completion and conduct monthly audits.
F278-D MDS errors, including a missed mark on resident #42, will be corrected and submitted to CMS. Accuracy checks will be implemented prior to MDS completion.
F279-D Comprehensive care plans will be developed within 21 days of admission and reviewed regularly to include all resident needs and services.
F280-D Care plans will be reviewed and revised to maintain or improve residents' well-being, with weekly monitoring by MDS coordinator or nursing staff.
F309-D Skin care assessments will be conducted weekly, including on bath days if residents refuse baths. Staff will be trained on skin assessment and documentation.
F314-D Skin assessments will prevent pressure ulcers. Bath aides will report refusals and professional nurses will conduct assessments with proper documentation and reporting.
F323-G Fall prevention committee will meet promptly after falls to review interventions and update care plans. Residents will be categorized by fall risk level.
F329-D Black box warnings will be included on all care plans. Resident #23's care plan will be updated, and nursing staff will monitor medication changes.
F362-E Dietary staffing will be maintained through ongoing recruitment and staff training to assist with timely food service.
F364-F Meals will be palatable with attention to texture, flavor, and variety. Dietary staff will follow standardized recipes and solicit resident input.
F371-E Food will be stored, prepared, distributed, and served under sanitary conditions. Staff and volunteers will be trained on hygiene and glove use.
F428-D Consultant pharmacist will review drug regimens monthly for black box warnings and report irregularities to the attending physician and director of nursing.
Report Facts
Potential residents affected: 45
Completion dates: Aug 29, 2014
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 14
Date: Jul 23, 2014
Visit Reason
Health resurvey inspection to evaluate compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility had multiple deficiencies including failure to maintain accessible call lights, inadequate housekeeping and maintenance, incomplete comprehensive assessments, inaccurate assessments, failure to develop comprehensive care plans, failure to monitor skin issues, inadequate treatment of pressure ulcers, insufficient supervision to prevent falls, inadequate dietary staffing, poor food quality, unsanitary food handling, failure to monitor medications with black box warnings, and failure to report drug irregularities.
Deficiencies (14)
F246: Facility failed to maintain accessible call lights in shared bathrooms for residents #9 and #47.
F253: Facility failed to maintain resident nightstands in good condition and maintain clean surfaces in 1 of 3 halls.
F273: Facility failed to conduct a comprehensive assessment within 14 calendar days of admission for resident #49.
F278: Facility failed to ensure resident #42's admission MDS assessment accurately reflected nutritional status.
F279: Facility failed to develop comprehensive care plans with measurable objectives for residents #20, #8, and #28 related to pressure ulcers, urinary catheter care, and skin breakdown.
F280: Facility failed to revise nursing care plan for resident #29 after multiple falls to prevent future falls.
F309: Facility failed to monitor and document bruises on resident #49's arms with weekly skin assessments.
F314: Facility failed to provide necessary treatment and services to promote healing and prevent infection of pressure ulcers for resident #20, including weekly wound assessments and documentation.
F323: Facility failed to provide adequate supervision and fall prevention interventions for resident #29 and failed to secure hazardous chemicals from cognitively impaired residents.
F329: Facility failed to ensure resident #23's care plan included black box warning information and monitoring interventions for Coumadin and Effexor medications.
F362: Facility failed to provide adequate dietary support staff to serve meals in a timely manner in the main dining room.
F364: Facility failed to provide meals that were palatable and of good quality for resident #14 and others, including tough meat and overcooked potatoes.
F371: Facility failed to ensure dietary staff wore hair nets properly, washed hands, and changed gloves appropriately to prevent food contamination.
F428: Facility failed to ensure consultant pharmacist identified drug irregularities related to black box warnings and reported them to the director of nursing and attending physician for resident #23.
Report Facts
Resident census: 43
Deficiency count: 13
Staff serving dinner: 2
Volunteers serving dinner: 3
Weight gain: 6
Pressure ulcer size: 2
Pressure ulcer size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Administrative Nurse | Named in multiple interviews related to care plan and fall prevention deficiencies |
| Licensed nurse E | Licensed Nurse | Named in interviews related to skin assessments and fall prevention |
| Dietary staff S | Dietary Staff | Named in observations and interviews related to food service and hygiene |
| Consultant Z | Consultant Pharmacist | Named in interview related to medication review and black box warnings |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 28, 2013
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 an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited with an 'F' level deficiency that was widespread, indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Brown | Administrator | Named as facility administrator in the report. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Joe Ewert | Commissioner of Survey, Certification and Credentialing Commission | Copied on the letter. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 7, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously cited deficiencies under regulations 483.35(d)(1)-(2), 483.35(i), 483.35(i)(3), and 483.65 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Apr 18, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions for deficiencies related to food preparation and nutrition, food procurement and sanitation, garbage disposal, and infection control programs. The facility commits to staff retraining, policy revisions, ongoing monitoring, and reporting to the Quality Assurance committee.
Deficiencies (4)
F364-E: The facility will ensure food is prepared to conserve nutritive value, flavor, and appearance, and served at proper temperature. Staff will be retrained on recipes and measurements for pureed foods with ongoing compliance monitoring.
F371-E: The facility will procure food from approved sources and maintain sanitary conditions in storage, preparation, and serving. Staff will be retrained on handwashing, glove use, and sanitation with ongoing monitoring and policy review.
F372-C: The facility will properly dispose of garbage and refuse by increasing dumpster availability and pickup frequency. Maintenance staff will monitor waste and report as needed.
F441-F: The facility will maintain an Infection Control Program with interdepartmental monitoring, infection tracking, investigations, prevention interventions, and staff education. Monthly reporting to QA committee and nursing staff will occur.
Report Facts
Plan of Correction completion dates: Completion dates range from 2013-04-18 to 2013-05-08 as stated for each corrective action.
Dumpster pickup frequency: 4
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 5
Date: Apr 10, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements related to food service, sanitation, infection control, and waste disposal at the facility.
Complaint Details
The inspection included a complaint investigation identified as #KS00064959. The complaint involved concerns about food service, sanitation, and infection control practices. The findings substantiated failures in these areas.
Findings
The facility failed to provide full portions of pureed meat to residents, maintain sanitary food handling and storage practices, properly dispose of garbage, and implement effective infection control procedures including proper cleaning and laundry handling. These deficiencies affected multiple residents and posed risks for infection and nutritional inadequacies.
Deficiencies (5)
F 364: The facility failed to ensure 7 residents with physician orders for pureed meat received full meat portions and nutrients at lunch, with leftover pureed meat not served.
F 371: The facility failed to store and serve food under sanitary conditions, including staff touching eating surfaces with contaminated hands and improper glove use, affecting multiple residents.
F 371: The facility failed to store food under sanitary conditions, including unsealed opened bags of prunes and coconut without opened dates.
F 372: The facility failed to properly dispose of garbage and refuse, with overflowing dumpsters and lids left open.
F 441: The facility failed to use chemicals for cleaning resident rooms and shower chairs according to manufacturer instructions, failed to prevent cross contamination of clean laundry during transport, and did not monitor infection control trends.
Report Facts
Resident census: 42
Residents on pureed meat diet: 7
Dining areas: 2
Dumpster lids open: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Staff | Named in findings related to improper food preparation and sanitary violations |
| Staff B | Dietary Staff | Interviewed regarding food preparation and sanitary practices |
| Consultant J | Consultant Dietitian | Interviewed regarding dietary practices and awareness |
| Staff F | Housekeeping Staff | Observed cleaning resident rooms and handling laundry |
| Staff G | Housekeeping Staff | Interviewed and observed regarding cleaning and laundry transport |
| Staff I | Direct Care Staff | Observed cleaning shower chair |
| Nurse H | Licensed Nurse | Interviewed regarding infection control monitoring and infection logs |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 3, 2012
Visit Reason
This document is a Plan of Correction related to a previous inspection or regulatory finding for the facility identified as ASPEN with State ID H060101.
Findings
No deficiencies or findings are listed in this Plan of Correction document. It serves as a corrective action response to prior inspection results.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: H060101 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified as State ID H060101.
Findings
No deficiency records or details are provided in this Plan of Correction document.
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