Inspection Report Summary
The most recent inspection on April 7, 2021 found no deficiencies and the facility was in compliance with all regulations surveyed. Prior inspections showed a pattern of deficiencies primarily related to care plan revisions, pressure ulcer prevention and treatment, medication management, infection control, and timely notification of physicians and families. Complaint investigations substantiated issues with abuse reporting, supervision, and failure to prevent pressure ulcers in some cases, though many complaints were found unsubstantiated. Enforcement actions included denial of payment for new admissions at times, and termination of provider agreement was recommended if compliance was not achieved, but no fines or license suspensions were listed in the available reports. The facility demonstrated improvement over time, with multiple revisit surveys confirming correction of previously cited deficiencies.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
40.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
568% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
49 residents
Based on a January 2021 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 7, 2021
Visit Reason
A revisit survey was conducted on 04/07/21 to verify correction of all previous deficiencies cited on 01/27/21.
Findings
All deficiencies have been corrected as of the compliance date of 03/05/21, and no noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 13
Jan 27, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to achieve substantial compliance with federal Medicare/Medicaid requirements.
Findings
The plan details corrective actions for multiple deficiencies including required postings, advanced directives, discharge notices, care plan timing and revisions, pressure ulcer treatment, accident hazard supervision, catheter care, drug regimen review, medication monitoring, psychotropic drug use, medication storage, food service temperature, and infection prevention and control. The facility commits to ongoing audits, staff education, and monitoring until compliance is attained by 03/05/2021.
Severity Breakdown
C: 1
D: 9
E: 1
G: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Required postings not properly displayed | C |
| Request/Refuse/Discontinue Treatment; Formulate Advanced Directive issues | D |
| Notice requirements before transfer/discharge not met | D |
| Care plan timing and revision deficiencies | D |
| Treatment/services to prevent/heal pressure ulcers inadequate | G |
| Free of accidents hazards supervision/devices issues | D |
| Bowel/bladder incontinence, catheter, UTI care deficiencies | D |
| Drug regimen review deficiencies | D |
| Free from unnecessary drugs deficiencies | D |
| Free from unnecessary psychotropic drugs/PRN deficiencies | D |
| Label/store drugs and biologicals deficiencies | D |
| Nutritive value/appearance, palatable/preferred temperature issues | D |
| Infection prevention and control deficiencies | E |
Report Facts
Deficiency completion date: Mar 5, 2021
Resident number: 100
Resident number: 49
Resident number: 47
Resident number: 39
Resident number: 34
Resident number: 22
Resident number: 48
Resident number: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Haneke | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added Plan of Correction | |
| Lori Mouak | Modified Plan of Correction | |
| DON | Director of Nursing | Named in multiple findings related to education, audits, and monitoring of care plans, medication, infection control, and fall management |
| Wound Nurse | Provided orientation on wound monitoring |
Inspection Report
Routine
Census: 49
Deficiencies: 13
Jan 27, 2021
Visit Reason
Routine health resurvey inspection of Medicalodges Great Bend to assess compliance with federal regulations including resident rights, care plans, infection control, medication management, and safety.
Findings
The facility was found deficient in multiple areas including failure to post required complaint hotline information, incomplete advance directive documentation, failure to notify ombudsman of resident hospital transfers, incomplete care plan updates, inadequate pressure ulcer prevention and treatment, fall prevention interventions, urinary catheter care, medication regimen review and monitoring, labeling and storage of insulin, meal assistance timing, and infection control practices related to COVID-19 precautions.
Severity Breakdown
SS=C: 1
SS=D: 9
SS=E: 1
SS=G: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to post the required Kansas Department for Aging and Disability Services complaint hotline telephone number. | SS=C |
| Failed to provide advance directive signed by physician for one resident. | SS=D |
| Failed to notify the ombudsman when a resident transferred to the hospital and remained hospitalized. | SS=D |
| Failed to update care plans timely to include hospice services and pressure ulcer prevention interventions. | SS=D |
| Failed to implement interventions to prevent worsening and development of pressure ulcers for two residents. | SS=G |
| Failed to implement fall prevention interventions including a three day bladder assessment for one resident. | SS=D |
| Failed to provide appropriate catheter care and prevent urinary tract infections for one resident. | SS=D |
| Failed to ensure consultant pharmacist irregularities were reported and acted upon, including blood sugar monitoring parameters and quarterly DISCUS assessments. | SS=D |
| Failed to obtain physician orders for blood sugar parameters for a resident receiving insulin. | SS=D |
| Failed to complete quarterly DISCUS assessments for a resident on antipsychotic medication. | SS=D |
| Failed to label opened insulin pens with opened date and dispose of expired insulin pens. | SS=D |
| Failed to provide meal assistance in a timely manner resulting in food becoming unpalatable for one resident. | SS=D |
| Failed to follow proper infection control procedures for a newly admitted resident in COVID-19 isolation, including improper use and removal of isolation gown, mask, and goggles, and lack of signage on isolation room door. | SS=E |
Report Facts
Resident census: 49
Pressure ulcer size: 4
Pressure ulcer size: 3
Pressure ulcer size: 0.5
Pressure ulcer size: 1
Pressure ulcer size: 0.4
Pressure ulcer size: 1.8
Meal temperature: 80
Blood sugar: 47
Blood sugar: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Verified outdated insulin pen and failure to label insulin pens |
| LN I | Licensed Nurse | Administered insulin per sliding scale and described insulin administration practices |
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including advance directive, ombudsman notification, care plan updates, pressure ulcer interventions, catheter care, medication monitoring, and infection control |
| CNA P | Certified Nursing Assistant | Assisted resident and verified lack of advance directive knowledge |
| Administrative Nurse E | Administrative Nurse | Verified infection control procedures and isolation practices |
| LN L | Licensed Nurse | Verified pressure ulcer dressing and skin assessments |
| CNA N | Certified Nursing Assistant | Described resident care and toileting schedule |
| Physician GG | Physician | Commented on pressure ulcer prevention interventions |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 14, 2020
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/25/2020.
Findings
All deficiencies have been corrected as of the compliance date of 09/24/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 2
Sep 24, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to identified deficiencies related to care plan timing and revision, and treatment/services to prevent or heal pressure ulcers.
Findings
The facility acknowledged deficiencies in care plan updates and wound care interventions, and outlined corrective actions including staff in-service training, care plan audits, and monitoring by the Director of Nursing and MDS Coordinator to ensure compliance and substantial compliance by 09/24/2020.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Care Plan Timing and Revision - Resident #3's care plan was not timely reviewed and updated to meet care needs. | D |
| Treatment/Services to Prevent/Heal Pressure Ulcer - Resident #3's care plan lacked appropriate interventions for pressure ulcer treatment. | D |
Report Facts
Complete Date: Sep 24, 2020
In-service training date: Aug 27, 2020
Intervention update date: Aug 25, 2020
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Aug 25, 2020
Visit Reason
The inspection was conducted as a result of complaint investigations #150972, #154140, and #154505.
Findings
The facility failed to revise Resident 3's care plan for pressure ulcers after the resident developed three pressure ulcers on her heels and failed to provide appropriate treatment and interventions to prevent pressure ulcers, placing the resident at risk for delayed wound healing.
Complaint Details
The visit was complaint-related involving investigations #150972, #154140, and #154505. The facility failed to revise care plans and provide timely treatment for pressure ulcers identified on Resident 3.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to revise Resident 3's care plan for pressure ulcers after wounds developed on her heels. | SS=D |
| Failed to provide treatment and services to prevent and heal pressure ulcers for Resident 3. | SS=D |
Report Facts
Resident census: 53
Pressure ulcer measurements: 3
Wound measurements: 3
Wound measurements: 4
Wound measurements: 4.7
Braden Scale score: 14
Bactrim DS antibiotic treatment: 10
Pixie dust application start: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Performed wound care and provided statements regarding treatment and protocols for Resident 3's pressure ulcers. |
| Certified Nurse Aide M | Certified Nurse Aide | Provided information about the use of heel protectors for Resident 3. |
| Administrative Nurse D | Administrative Nurse | Verified staff did not seek timely treatment and lacked guidance for wound care and communication with dietician. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 29, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 04/29/2020 to assess compliance with COVID-19 preparation practices.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 29, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 24, 2019
Visit Reason
A revisit survey was conducted on 7/24/19 to verify correction of all previous deficiencies cited on 6/3/19.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 6/28/19, and no noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 15
Jun 3, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection, outlining corrective actions to achieve substantial compliance with federal Medicare/Medicaid requirements.
Findings
The plan details multiple corrective actions including staff education, audits, monitoring, and care plan updates related to physician notification, risk management, wound care, medication management, infection control, and staffing levels. The facility aims to achieve and maintain compliance by 06/28/2019.
Severity Breakdown
D: 7
E: 1
F: 4
G: 2
J: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to notify physician and legal representative of significant change in resident condition | D |
| Inadequate risk management reporting and investigations | D |
| Care plans not updated to meet resident needs | D |
| Care plans not coordinated with direct care staff recommendations | E |
| Failure to follow hypoglycemic protocol and required notifications | J |
| Inadequate wound monitoring and skin condition assessments | G |
| Care plan updates to prevent injury not implemented | D |
| Lack of appropriate diagnosis for catheter use | D |
| Failure to follow weight loss policy and documentation | G |
| Staffing levels not adequate for resident well-being | F |
| Psychotropic medication orders lacking required stop dates | D |
| Medications requiring monitoring not properly managed | D |
| Psychotropic medication orders lacking appropriate diagnosis | D |
| Failure to maintain compliance with quality systems and clinical excellence | F |
| Infection control practices not consistently followed | F |
Report Facts
Plan of Correction completion date: Jun 28, 2019
In-service training date: Jun 14, 2019
Investigation completion date: May 30, 2019
Physician notification dates: May 22, 2019
Audit dates: May 30, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenda Downing | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 14
Jun 3, 2019
Visit Reason
The inspection was a Health Resurvey and Extended Health Resurvey with complaint investigations.
Findings
The facility failed to notify physicians of critical changes, failed to report and investigate a resident's critically low blood sugar, failed to develop and revise comprehensive care plans, failed to provide adequate nutritional support and pressure ulcer prevention, failed to ensure appropriate use of medications including antipsychotics, failed to maintain a safe environment, and failed to provide sufficient nursing staff.
Complaint Details
The visit included complaint investigations related to failure to notify physicians of critical changes, failure to report and investigate a resident's critically low blood sugar, and other care concerns.
Severity Breakdown
SS=D: 7
SS=E: 1
SS=G: 2
SS=F: 3
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to notify physician for a resident with critically low blood sugars and treatment changes. | SS=D |
| Failed to report to the state agency inappropriate care for a resident with critically low blood sugars. | SS=D |
| Failed to investigate inappropriate care for a resident with critically low blood sugars. | SS=D |
| Failed to develop a comprehensive care plan for a resident with diabetes mellitus. | SS=D |
| Failed to revise care plans for residents with hypoglycemia and pressure ulcers. | SS=E |
| Failed to provide necessary treatment and services to promote healing and prevent pressure ulcers. | SS=D |
| Failed to ensure the resident environment remained free of accident hazards, resulting in skin tears. | SS=D |
| Failed to provide appropriate diagnosis for the use of a Foley catheter. | SS=D |
| Failed to adequately monitor weights and nutritional intake to prevent significant weight loss. | SS=G |
| Failed to provide sufficient nursing staff to maintain residents' well-being. | SS=F |
| Consultant pharmacist failed to report irregularities in drug regimen for residents. | SS=D |
| Failed to ensure appropriate diagnosis and rationale for use of antipsychotic and PRN antianxiety medications. | SS=D |
| Failed to provide effective administration and oversight to maintain residents' well-being. | SS=F |
| Failed to provide a safe, sanitary, and comfortable environment to prevent infection and disease transmission. | SS=F |
Report Facts
Resident census: 51
Blood glucose levels: 29
Blood glucose levels: 42
Blood glucose levels: 211
Weight loss: 11.6
Weight loss percentage: 7.1
Skin wound size: 6
Skin wound size: 2
Skin tear size: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Licensed Nurse | Named in medication error and failure to notify physician for low blood sugar |
| Administrative Nurse D | Administrative Nurse | Verified failures in notification, assessment, and care plan revisions |
| Nurse I | Nurse | Provided information about glucose gel availability |
| Nurse G | Nurse | Observed changing wound dressing |
| Nurse Aide R | Nurse Aide | Provided information about resident care and wound |
| Nurse Aide Q | Nurse Aide | Provided information about resident care and wound |
| Nurse Aide M | Nurse Aide | Observed applying barrier cream and discussed resident wound care |
| Nurse Aide O | Nurse Aide | Discussed resident refusal of geri sleeves |
| Dietary staff BB | Dietary Staff | Provided information about resident appetite and snack monitoring |
| Dietary Consultant II | Dietary Consultant | Provided information about resident weight monitoring |
| Consultant Nurse HH | Consultant Nurse | Provided information about glucometer cleaning training |
| Medication Aide S | Medication Aide | Observed not disinfecting glucometer after use |
| Nurse Aide P | Nurse Aide | Verified staffing irregularities affected resident care |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 10, 2019
Visit Reason
A revisit survey was conducted on 1/10/2019 for all previous deficiencies cited on 12/19/18.
Findings
All deficiencies have been corrected as of the compliance date of 1/9/2019 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Dec 19, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety. Deficiencies were cited that resulted in enforcement remedies including denial of payment for new admissions.
Severity Breakdown
immediate jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F600, "J", CFR 483.12(a)(1) and F610, "L", CFR 483.12 (c)(2)-(4) | immediate jeopardy |
Report Facts
Denial of payment effective date: Jan 10, 2019
Provider agreement termination date: Jun 19, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alisha Craft | Administrator | Facility administrator named in the report |
| Caryl Gill | Complaint Coordinator | Signed the report as Complaint Coordinator |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 3
Dec 19, 2018
Visit Reason
Partial extended survey conducted due to complaint investigation #136269 regarding allegations of abuse at the facility.
Findings
The facility failed to provide a safe environment free from abuse when a Medication Aide grabbed a resident's wrist causing bruising. The incident was not reported immediately, and the staff member continued working. The facility also failed to implement policies to protect residents and prevent abuse, and failed to ensure timely reporting of the incident. Additionally, the facility did not ensure certified nurse aides received required annual in-service training hours.
Complaint Details
Complaint investigation #136269 regarding abuse of Resident #1 by Medication Aide M who grabbed the resident's wrist causing bruising. Nurse G witnessed the incident but delayed reporting until the next day. Medication Aide M continued working the shift. The facility failed to immediately send the staff member home and notify administration. The resident had multiple bruises and abrasions documented. The facility terminated the alleged perpetrator and conducted staff in-service after the incident.
Severity Breakdown
G: 1
F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to provide a safe environment free from abuse when Medication Aide M grabbed Resident #1's wrist causing bruising. | G |
| Facility failed to investigate, prevent further abuse, and report the incident timely after Medication Aide M grabbed Resident #1's wrist causing bruising. | F |
| Facility failed to ensure certified nurse aides received the required minimum 12 hours of in-service training per year. | F |
Report Facts
Resident census: 45
Bruise size: 8
Bruise size: 4
Bruise size: 2.5
Bruise size: 2
Bruise size: 1
Bruise size: 0.8
Abrasion size: 3
Abrasion size: 2.2
Number of CNAs lacking required in-service hours: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide M | Medication Aide | Named in abuse finding for grabbing resident's wrist causing bruising. |
| Nurse G | Nurse | Witnessed abuse incident and delayed reporting to supervisor. |
| Administrative Nurse D | Administrative Nurse | Directed charting of resident behaviors and reported abuse incident to administration. |
| Administrative Staff A | Administrator or Administrative Staff | Informed about incident late and confirmed Medication Aide M was not immediately sent home. |
Inspection Report
Follow-Up
Deficiencies: 4
Oct 10, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Cherry Village were corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-202 (c), 26-41-204 (d), 26-41-205 (d)(1-2), and 26-41-205 (g)(3) were corrected as of the revisit date 10/10/2018.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 26-41-202 (c) |
| Deficiency related to regulation 26-41-204 (d) |
| Deficiency related to regulation 26-41-205 (d)(1-2) |
| Deficiency related to regulation 26-41-205 (g)(3) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Complaint Investigation
Census: 4
Deficiencies: 4
Sep 13, 2018
Visit Reason
The inspection was a resurvey with a complaint (#132729) at the assisted living facility Cherry Village conducted on 9/13/2018.
Findings
The facility failed to develop initial negotiated service agreements at admission for 2 of 4 residents, failed to include the name of the licensed nurse responsible for health care services in the agreements for all 4 residents, failed to administer medications according to medical provider orders for 1 resident, and failed to ensure over-the-counter medications were labeled with the resident's full name.
Complaint Details
The visit was triggered by complaint #132729. The findings included failures related to negotiated service agreements, medication administration, and labeling of over-the-counter medications.
Severity Breakdown
E: 1
F: 2
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure designated staff developed an initial negotiated service agreement at admission for 2 residents (#913 and #914). | E |
| Failed to ensure the negotiated service agreement contained the name of the licensed nurse responsible for implementation and supervision of the health care service plan for 4 residents (#913, #914, #915, #916). | F |
| Failed to ensure 1 resident (#913) received medications according to medical provider's written orders and standards of practice. | D |
| Failed to ensure over-the-counter medications were labeled with the resident's full name. | F |
Report Facts
Census: 4
Residents in sample: 3
Residents with initial negotiated service agreement deficiency: 2
Residents lacking licensed nurse name in service agreement: 4
Residents with medication administration deficiency: 1
Medication errors: 2
Over-the-counter medication bottles observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff B | Reported negotiated service agreements were not signed or printed; did not realize stock medications could not be used for multiple residents; interviewed regarding deficiencies. | |
| Licensed Nursing Staff D | Confirmed medication administration errors related to insulin for resident #913. | |
| Certified Staff A | Observed with medication cart and reported use of stock acetaminophen bottles. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 2, 2018
Visit Reason
A complaint survey was conducted on 5/2/18 for complaint #129032.
Findings
The allegations made in the complaint were not substantiated and no noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint #129032 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 2, 2018
Visit Reason
A complaint survey was conducted on 5/2/18 for complaint #129032.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint #129032 was investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 21, 2018
Visit Reason
An off-site survey was conducted to address a previously cited deficiency from February 21, 2018.
Findings
The deficiency cited on February 21, 2018 was corrected as of the compliance date of March 14, 2018.
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 14, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to the improper use of mechanical lifts by Certified Nursing Aides, outlining corrective actions including staff education, skills demonstration, and ongoing monitoring by administrative nurses.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Improper use of mechanical lifts by Certified Nursing Aides | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Pamla Lewis | Administrator | Submitted the Plan of Correction |
| Jennifer Reed | Added the Plan of Correction | |
| Caryl Gill | Modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Feb 21, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective March 14, 2018.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Feb 21, 2018
Visit Reason
The inspection was conducted as a result of complaint investigations #124022, #124747, #125030, and #126391.
Findings
The facility failed to ensure adequate supervision and staff assistance as care planned, and did not follow the manufacturer's recommendations for the use of a sit to stand assistive device, which caused a resident to fall during a transfer.
Complaint Details
The findings represent the results of complaint investigations #124022, #124747, #125030, and #126391. The facility failed to prevent a fall of Resident #6 during a sit to stand lift transfer due to inadequate staff assistance and supervision.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and staff assistance as care planned, and to follow manufacturer's recommendations for use of a sit to stand assistive device, resulting in a resident fall during transfer. | SS=D |
Report Facts
Resident census: 54
Sample size: 6
Residents reviewed for accidents: 4
Date of resident fall: Jan 19, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide M | Present during the resident fall and assisted the resident after the fall. | |
| Administrative Nurse D | Administrative Nurse | Recommended that all lift transfers be completed with 2 staff members. |
| Nurse G | Nurse | Stated the resident required 2 staff assistance with a sit to stand lift. |
| Nurse Aide N | Nurse Aide | Stated 2 staff assistance were needed to transfer the resident with the sit to stand lift. |
| Administrative Staff A | Administrative Staff | Recommended 2 staff assistance with all sit to stand lift transfers and preferred 2 staff members despite manufacturer recommendations. |
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 6, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a complaint revisit inspection conducted at Cherry Village.
Findings
All deficiencies identified in the complaint revisit inspection have been corrected, and no new noncompliance was found as of the correction date.
Complaint Details
This Plan of Correction relates to a complaint revisit inspection conducted on 2017-11-06.
Deficiencies (1)
| Description |
|---|
| All deficiencies have been corrected, and no new noncompliance was found. |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 6, 2017
Visit Reason
A revisit survey was conducted on 11/6/17 to verify correction of all previous deficiencies cited on 9/19/17.
Findings
All previously cited deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 6, 2017
Visit Reason
A revisit survey was conducted on 11/6/17 to verify correction of all previous deficiencies cited on 9/19/17.
Findings
All previously cited deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 6, 2017
Visit Reason
A revisit survey was conducted on 11/6/17 to verify correction of all previous deficiencies cited on 9/19/17.
Findings
All previously cited deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Sep 19, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a revisit complaint inspection conducted at Cherry Village on 09/19/2017.
Findings
The plan addresses deficiencies related to notification and documentation of nonsuspicious bruising on residents, including corrective actions such as physician and family notification, implementation of a communication tool for skin issues, and daily follow-up by the Director of Nursing.
Complaint Details
This plan of correction is related to a revisit complaint inspection conducted on 09/19/2017 at Cherry Village.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify physicians and families within 48 hours of nonsuspicious bruising on two residents. | D |
| Failure to promptly notify physician for a resident with bruising. | D |
Report Facts
Days for physician notification: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Lacey Hunter | Modified the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 2
Sep 19, 2017
Visit Reason
The inspection was conducted as a Non-compliance Revisit and Complaint investigation related to failure to notify physicians of changes in residents' conditions and failure to provide timely and effective interventions to prevent skin impairment.
Findings
The facility failed to notify physicians of new bruises and skin impairments for two residents, Resident #1 and Resident #2, placing them at risk for further skin injury. Documentation and communication regarding bruises were inadequate, and interventions to prevent skin impairment were not consistently implemented.
Complaint Details
The visit was a complaint investigation triggered by allegations of failure to notify physicians of changes in residents' conditions and inadequate skin impairment care. The complaint was substantiated based on findings.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify the physician of a new area of skin impairment for 2 of 3 sampled residents, including multiple bruises on Resident #1's arms and a large bruise on Resident #2's right arm. | SS=D |
| Failure to assess and provide timely and effective interventions to prevent skin impairment for Resident #1, who acquired large bruises to the right arm. | SS=D |
Report Facts
Census: 47
Bruise measurement: 14
Bruise measurement: 10
Bruise measurement: 8.7
Bruise measurement: 7
Bruise measurement: 6
Bruise measurement: 4
Medication dosage: 4
Medication duration: 6
Medication duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Nurse | Measured bruises on Resident #1's arms and acknowledged failure to notify physician and document assessments |
| Administrative Nurse B | Administrative Nurse | Conducted resident interview and verified lack of physician notification regarding bruises |
| Administrative Staff A | Administrative Staff | Verified failure to document assessments and notify physician, and noted ineffective wound assessment process |
| Nurse Aide D | Nurse Aide | Identified bruising on Resident #1 during bath assistance and reported resident's explanation |
Inspection Report
Re-Inspection
Deficiencies: 1
Sep 19, 2017
Visit Reason
This document reports on a revisit conducted on September 19, 2017, following an abbreviated survey on August 9, 2017, to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The revisit found the most serious deficiency to be a 'D' level deficiency, indicating actual harm or above. As a result, a denial of payment for new Medicare and Medicaid admissions was imposed effective August 29, 2017, and termination of the provider agreement was recommended if substantial compliance is not achieved by February 9, 2017.
Complaint Details
The denial of payment action was based on deficiencies found on the complaint survey conducted on August 29, 2017.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency indicating actual harm or above. | D |
Report Facts
Denial of payment effective date: Aug 29, 2017
Termination recommendation date: Feb 9, 2017
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to complaint coordination and instructions for Informal Dispute Resolution |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 9, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in the Cherry Village complaint inspection dated 08/09/2017.
Findings
The plan addresses skin integrity issues for one affected resident who has since been discharged, outlines preventive measures for other residents at risk, and describes staff in-service training and quality assurance follow-up procedures to ensure physician notification and treatment orders are implemented.
Complaint Details
This Plan of Correction is related to the Cherry Village complaint investigation dated 08/09/2017.
Deficiencies (1)
| Description |
|---|
| Skin integrity breach and related care deficiencies for one resident. |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Aug 9, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#119015) regarding the facility's failure to provide timely and effective interventions to prevent skin breakdown in a resident.
Findings
The facility failed to assess and provide timely interventions for Resident #1 who developed large blisters and open wounds on the thighs within days of admission. Treatment was delayed by several days, and the wounds progressed to large ulcerations, placing the resident at risk for infection.
Complaint Details
Complaint investigation #119015 focused on the facility's failure to provide adequate care to prevent skin breakdown in Resident #1, who developed large blisters and wounds shortly after admission.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assess and provide timely and effective interventions to prevent skin breakdown for Resident #1, resulting in large blisters and open wounds. | SS=G |
Report Facts
Resident census: 62
Braden Scale score: 15
Wound measurements: 15
Wound measurements: 8
Wound measurements: 0.2
Wound measurements: 4
Wound measurements: 2
Wound measurements: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse G | Observed wounds on resident's thighs on 8/2/17. | |
| Administrative Staff A | Reported resident admitted with scars and rash; noted development of blisters. | |
| Physical Therapist H | Evaluated wounds and stated wounds were new since admission. | |
| Nurse J | Hospital nurse who described wounds upon admission to hospital. | |
| Nurse Aide F | Reported notifying nurse immediately when blister popped. | |
| Nurse E | Provided care observations and sent resident to emergency room. | |
| Nurse C | Wound nurse | Assessed resident's skin on 7/20/17 and noted delayed treatment. |
| Nurse D | Verified lack of interventions upon admission and described wound care. | |
| Administrative Nurse B | Verified staff should have notified physician about wounds. | |
| Physician L | Physician | Stated catheter tubing should not lie on compromised skin. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 9, 2017
Visit Reason
An Abbreviated survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to deficiencies cited in this survey and a prior noncompliance history from an April 27, 2017 survey, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.
Severity Breakdown
Level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies constituting a level of actual harm that is not immediate jeopardy were found. | Level of actual harm |
Report Facts
Denial of payment effective date: Aug 29, 2017
Noncompliance follow-up deadline: Feb 9, 2018
Civil Money Penalty minimum amount: 5000
Timeframe for hearing request: 60
Timeframe for IDR request: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the instructions contained in the letter |
Inspection Report
Follow-Up
Deficiencies: 7
Jul 3, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected and to confirm the date such corrective action was accomplished.
Findings
All previously cited deficiencies listed on the CMS-2567 were corrected as of 05/26/2017, with no uncorrected deficiencies remaining at the time of this revisit.
Deficiencies (7)
| Description |
|---|
| Deficiency with regulation 483.20(g)-(j) |
| Deficiency with regulation 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) |
| Deficiency with regulation 483.24, 483.25(k)(l) |
| Deficiency with regulation 483.25(b)(1) |
| Deficiency with regulation 483.30(c)(1)(2) |
| Deficiency with regulation 483.80(a)(1)(2)(4)(e)(f) |
| Deficiency with regulation 483.35(d)(7) |
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Apr 27, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at Cherry Village, addressing deficiencies identified in the facility's care practices.
Findings
The plan outlines corrective actions for multiple deficiencies related to skin care, pain management, wound care, physician visits, wound dressing techniques, and nurse aide training. It includes weekly and monthly monitoring, staff in-service training, and involvement of wound care specialists to ensure sustained compliance.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Cherry Village.
Severity Breakdown
D: 5
J: 1
E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Skin nurse and MDS nurse to meet weekly to communicate skin changes and keep care plans accurate. | D |
| MDS nurse to compare residents' skin condition and skin care services with individual care plans for accuracy. | D |
| Resident affected by deficient practice transferred to hospital and passed away; nurses to be in-serviced on pain management and documentation. | D |
| Resident admitted with skin integrity issues; wound care specialist consulted; system additions for wound care on Medicare Part A stays. | J |
| MDS nurse to monitor 30 day limit for first physician visit post admission and notify physician office. | D |
| Nurse B to be instructed on clean and sterile wound dressing technique; all nurses to be in-serviced on this practice. | D |
| Eight nurse aides to complete 12 in-service hours within 30 days; grid to track in-service completion. | E |
Report Facts
In-service hours required: 12
Timeframe for monitoring: 6
Timeframe for weekly review: 6
Date of wound care specialist additional visit: May 15, 2017
Date of in-service training: Apr 26, 2017
Date of in-service training: Apr 21, 2017
Date of in-service training: Feb 20, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 27, 2017
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety related to pressure ulcers (F314). Enforcement remedies including denial of payment for new admissions were imposed.
Severity Breakdown
Level of actual harm or above: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314 related to pressure ulcers, constituting immediate jeopardy to resident health or safety. | Level of actual harm or above |
Report Facts
Denial of payment effective date: May 22, 2017
Provider agreement termination date: Oct 27, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to complaint coordination and instructions for informal dispute resolution |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 7
Apr 27, 2017
Visit Reason
Complaint Investigation #114603 and a partial extended survey were conducted to assess compliance with regulatory requirements related to resident care, skin integrity, pain management, infection control, and staff education.
Findings
The facility failed to accurately assess residents' risk for pressure ulcers, revise care plans timely, provide adequate pain management, prevent and treat pressure ulcers, ensure timely physician visits, maintain infection control during wound care, and provide required nurse aide education hours. Resident #1 developed multiple pressure ulcers and was not seen by a physician within 30 days of admission. Resident #2 had facility-acquired pressure ulcers and wounds with inadequate care and infection control.
Complaint Details
Complaint Investigation #114603 was conducted, focusing on allegations related to pressure ulcer care, pain management, infection control, and staff education deficiencies.
Severity Breakdown
SS=D: 5
SS=J: 1
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to accurately assess Resident #2's risk for pressure ulcers, placing the resident at risk for inappropriate care and increased risk for pressure ulcers. | SS=D |
| Failed to revise and update care plans for Residents #1 and #2, resulting in inadequate direction for wound care and skin integrity management. | SS=D |
| Failed to provide adequate pain management for Resident #1, including failure to administer pain medication when pain was reported and failure to monitor elevated pulse. | SS=D |
| Failed to provide necessary treatment and services to prevent and heal pressure ulcers for Residents #1 and #2, resulting in multiple facility-acquired pressure ulcers and wounds. | SS=J |
| Resident #1's physician failed to see the resident within 30 days of admission to the facility. | SS=D |
| Failed to provide a safe, sanitary, and comfortable environment to prevent infection transmission during wound care for Residents #2 and #3, including improper handling of dressings and gloves. | SS=D |
| Failed to provide the required 12 hours of annual in-service education for 8 of 27 Certified Nurse Aides employed at the facility. | SS=E |
Report Facts
Census: 36
Pressure ulcers developed: 15
Days until physician visit: 39
Nurse Aides lacking required education hours: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Performed wound care and dressing changes; noted wounds healed and reopened; did not re-cleanse wounds after incontinent brief was pulled up | |
| Administrative Nurse A | Provided statements regarding wound care, pain management, physician visits, and infection control deficiencies | |
| Nurse Aide C | Assisted with wound dressing changes and incontinent brief handling during wound care | |
| Medical Staff G | Physician who admitted Resident #1 to hospital and commented on wound care and skin condition | |
| Hospital Staff I | Consulted on Resident #1's wounds during hospital admission |
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 23, 2017
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The revisit report indicates that the previously cited deficiency with regulation number 26-43-206(d) was corrected and completed as of 02/17/2017. No other deficiencies or findings are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency previously cited under regulation 26-43-206(d) has been corrected. |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 21, 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 have been corrected.
Findings
All previously cited deficiencies were corrected as of 02/17/2017, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiency correction completion date: Feb 17, 2017
Inspection Report
Plan of Correction
Deficiencies: 8
Feb 17, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.
Findings
The Plan of Correction outlines specific corrective actions for multiple deficiencies including hospice resident rights, grievance resolution, bathing preferences, toileting plans, transfer rail safety, food sanitation, environmental cleanliness, and quality assurance program implementation.
Severity Breakdown
D: 4
E: 1
F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Residents' hospice status and appeal rights not properly managed. | D |
| Failure to promptly resolve resident grievances. | D |
| Inadequate bathing alternatives and documentation for residents. | D |
| Lack of accurate toileting plans and voiding diaries for incontinent residents. | D |
| Unsafe transfer rail placement and lack of safety assessments. | E |
| Improper storage of prepared and served food under sanitary conditions. | F |
| Facility environment not sanitary enough to prevent disease transmission. | F |
| Quality Assurance Committee not fully organized or implementing new protocols. | F |
Report Facts
Residents reviewed for bathing deficiency: 39
Date for compliance: Feb 17, 2017
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 9
Jan 19, 2017
Visit Reason
Health resurvey inspection to evaluate compliance with federal nursing facility regulations and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare non-coverage notices, unresolved resident grievance regarding missing personal property, failure to provide scheduled bathing, inadequate assessment and intervention for urinary incontinence, unsafe transfer rail posing entrapment risk, unsecured hazardous chemicals accessible to residents, unsanitary kitchen conditions, improper infection control practices, and failure to maintain an effective Quality Assessment and Assurance (QAA) committee.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=F: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide required Medicare non-coverage liability notices to residents #3, #30, and #38 at the end of Medicare Part A services. | SS=D |
| Failed to resolve grievance regarding missing personal property (pajama bottoms) for Resident #39. | SS=D |
| Failed to provide scheduled bathing for Resident #57, who required extensive assistance. | SS=D |
| Failed to thoroughly assess and provide interventions to prevent increased urinary incontinence for Resident #52. | SS=D |
| Failed to adequately assess a transfer rail with unsafe gaps for Resident #9, posing risk of entrapment and injury. | SS=E |
| Failed to properly store hazardous chemicals in whirlpool room, accessible to 7 cognitively impaired, independently mobile residents. | SS=E |
| Failed to store, prepare, and serve food under sanitary conditions in the facility kitchen, including dirty vents, soiled microwave plate, broken spatulas, and damaged counters. | SS=F |
| Failed to provide sanitary environment and proper infection control in resident rooms, including failure to change gloves between tasks and use of non-disinfectant on floors. | SS=F |
| Failed to maintain an effective Quality Assessment and Assurance (QAA) committee that met quarterly and implemented plans of action to correct quality deficiencies. | SS=F |
Report Facts
Residents reviewed for liability notices: 5
Residents with missing personal property grievance: 1
Residents reviewed for ADL bathing: 3
Residents reviewed for urinary incontinence: 1
Residents reviewed for accident hazards: 3
Residents in facility: 39
Months QAA committee failed to meet quarterly: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Staff J | Observed improper glove use and cleaning practices in resident room. | |
| Administrative Nurse A | Verified multiple deficiencies including QAA committee failures and hazardous chemical storage. | |
| Dietary Manager K | Verified unsanitary kitchen conditions. | |
| Social Service Staff F | Verified failure to provide Medicare liability notices and grievance process failures. |
Inspection Report
Re-Inspection
Deficiencies: 1
Jan 19, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found 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 credible allegation of compliance and evidence of correction effective February 17, 2016.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Date of substantial compliance effective: February 17, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction |
Inspection Report
Renewal
Census: 11
Deficiencies: 1
Jan 11, 2017
Visit Reason
The inspection was conducted as an Assisted Living/Residential Healthcare Licensure Resurvey to assess compliance with food preparation and sanitation regulations.
Findings
The facility failed to store, prepare, and serve food under sanitary conditions in the kitchen, as evidenced by lint blowing from vents, soiled microwave plate, broken spatulas, and deteriorating food prep counter caulking.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to store, prepare, and serve food under sanitary conditions, including lint blowing from vents, soiled microwave plate, broken spatulas, and damaged food prep counter. | SS=F |
Report Facts
Resident census: 11
Lint length: 0.5
Gap size: 0.25
Cleaning frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager K | Verified findings related to kitchen sanitation |
Inspection Report
Life Safety
Deficiencies: 1
Oct 6, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found at "F" level with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jan 6, 2017
Recommended termination date: Apr 6, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and survey results |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 3
Jan 5, 2016
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of failure to notify a resident's physician after an elopement and injury, failure to individualize a care plan for elopement risk, and failure to provide adequate supervision to prevent elopement.
Findings
The facility failed to notify Resident #1's physician after the resident left the facility unattended and sustained injuries. The care plan for the resident was not individualized to address elopement risk. The facility also failed to provide adequate supervision, allowing the resident to leave the secured unit and the facility unattended, resulting in injury. The courtyard door was unlocked without continuous alarm, and the activity room door was left unlocked, facilitating the resident's elopement.
Complaint Details
The complaint investigation #95401 and 92986 focused on Resident #1 who eloped from the facility, sustained injuries, and whose physician was not promptly notified. The investigation found failures in notification, care planning, and supervision.
Severity Breakdown
Level D: 2
Level J: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify Resident #1's physician after the resident left the facility unattended and sustained injuries. | Level D |
| Failure to individualize Resident #1's care plan for elopement risk, resulting in inadequate interventions. | Level D |
| Failure to provide adequate supervision and secure environment to prevent Resident #1 from leaving the facility unattended, resulting in injury and immediate jeopardy. | Level J |
Report Facts
Census: 38
Elopement risk residents: 7
Special care unit census: 18
Time resident outside: 6
Distance crossed: 75
Temperature: 20
Blood pressure: 170
Blood pressure: 92
Pulse: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Reported resident wandering more than usual, notified physician by fax about elopement and injuries, and returned resident to secured unit | |
| Nurse D | Found resident outside after elopement and assisted resident back to facility | |
| Nurse Aide A | Performed bed checks, noted unlocked courtyard door and disabled alarms | |
| Administrative Staff F | Reviewed video footage of resident elopement and verified unlocked doors | |
| Administrative Nurse E | Verified resident was elopement risk and care plan was not individualized |
Inspection Report
Re-Inspection
Deficiencies: 3
Nov 5, 2015
Visit Reason
This report documents a revisit inspection to verify that previously identified deficiencies have been corrected at the facility.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency identified under regulation 28-39-158(a) corrected |
| Deficiency identified under regulation 28-39-162 corrected |
| Deficiency identified under regulation 26-43-202(c) corrected |
Report Facts
Deficiencies corrected: 3
Inspection Report
Follow-Up
Deficiencies: 0
Nov 5, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date of 11/05/2015.
Report Facts
Deficiencies corrected: 11
Inspection Report
Re-Inspection
Deficiencies: 1
Nov 5, 2015
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey and confirms the dates when corrective actions were completed.
Findings
The report indicates that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 11/05/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited |
Report Facts
Date of revisit: Nov 5, 2015
Follow-up survey completion date: Oct 7, 2015
Inspection Report
Plan of Correction
Deficiencies: 10
Oct 22, 2015
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 dietary protocol for weight loss, dignity in care during dining, preventive maintenance, fall prevention, ADL care routines, catheter care, infection control, and staff training. Quality assurance measures and monitoring plans are described for each deficiency.
Severity Breakdown
D: 7
E: 2
F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Dietary protocol for weight loss not properly followed for residents 14 and 17. | D |
| Lack of respect for resident dignity during dining room assistance. | E |
| Preventive maintenance plan not adequately implemented affecting residents with recliners and lift chairs. | E |
| Fall prevention plan not initially implemented for resident 47. | D |
| Inconsistent completion of daily ADL care routines for residents 33, 14, and 19. | D |
| Catheter tubing and bag care not properly maintained for resident 1; voiding study planned for resident 19. | D |
| Fall interventions for residents 33 and 47 not fully integrated into EMR safety portion of admission plan of care. | D |
| Nutritional decline risk not fully addressed for resident 15 after admission and hospice placement. | D |
| Storage, preparation, serving, and sanitation practices require improvement. | F |
| Infection control practices and prevention of spread of infection need enhancement. | F |
Report Facts
Residents referenced: 10
Compliance target: 90
BIMS score: 5
Lessons per month: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 3
Oct 22, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to dietary manager certification, environmental maintenance including carpet replacement and ceiling repairs, and timely completion of negotiated service agreements for new admissions.
Severity Breakdown
F: 2
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Dietary manager not yet certified; currently enrolled in certification classes and supervised by dietician. | F |
| Need to sign contract with licensed contractor for carpet replacement and ceiling repairs in utility room. | F |
| New admissions must have negotiated service agreements signed upon admission within 24 hours. | D |
Report Facts
Complete Date: Nov 5, 2015
Lessons per month: 2
Days per week: 7
Hours: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 10
Oct 7, 2015
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation involving multiple complaint numbers.
Findings
The facility was found deficient in multiple areas including failure to notify responsible parties of significant weight loss for residents, failure to maintain dignity and respect during care, inadequate housekeeping and maintenance, incomplete care plans for fall prevention, failure to provide necessary ADL assistance, improper catheter care, inadequate fall supervision, failure to maintain nutritional status, unsanitary food preparation practices, and inadequate infection control.
Complaint Details
The visit was triggered by multiple complaints resulting in a Health Resurvey and Complaint Investigation.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to notify dietician, physician, and responsible party of significant weight loss for 3 residents (#14, #15, #17). | SS=D |
| Failed to promote dignity and respect; staff performed procedures in dining room and failed to provide butter or margarine for dinner rolls. | SS=E |
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on one hall. | SS=E |
| Failed to complete an initial care plan for falls for Resident #47 who had a history of falls and was high risk. | SS=D |
| Failed to provide necessary ADL assistance including oral care and meal assistance for Residents #33, #14, and #19. | SS=D |
| Failed to provide appropriate catheter care and prevent urinary tract infections for Resident #1 and failed to provide proper peri care and bowel/bladder assessment for Resident #19. | SS=D |
| Failed to ensure resident environment was free of accident hazards and provide adequate supervision to prevent falls for Residents #33 and #47. | SS=D |
| Failed to maintain nutritional status and involve dietician for Resident #15 with 8.3% weight loss in 15 days. | SS=D |
| Failed to prepare, distribute, and serve food under sanitary conditions; staff failed to change gloves between tasks during food preparation. | SS=F |
| Failed to maintain infection control; staff used vinegar instead of disinfectant to clean resident's bathroom and placed soiled rag in housekeeping tote. | SS=F |
Report Facts
Weight loss: 12
Weight loss: 16
Weight loss: 11
Fall risk score: 80
Resident census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Verified missed notifications of weight loss and fall interventions; stated staff should assist Resident #33 when shaky; reviewed weight loss reports. |
| Dietary Staff Q | Dietary Staff | Unaware of residents' weight loss; did not document dietary notes. |
| Registered Dietician T | Registered Dietician | Came weekly; stated no nutritional assessment documentation means no resident visit. |
| Nurse Aide B | Nurse Aide | Observed not assisting Resident #33 during meal when hand shaking. |
| Nurse Aide C | Nurse Aide | Observed not assisting Resident #33 during meal when hand shaking; verified oral care not provided. |
| Nurse Aide G | Nurse Aide | Observed resident getting shaky at meal time; failed to supervise Resident #33 in bathroom after fall. |
| Licensed Nurse D | Licensed Nurse | Administered medication to Resident #33; stated resident stops shaking when encouraged to relax; stated resident should not be left alone in bathroom. |
| Housekeeping Staff H | Housekeeping Staff | Used vinegar and water instead of disinfectant to clean resident's bathroom; placed soiled rag in housekeeping tote. |
| Housekeeping Supervisor I | Housekeeping Supervisor | Verified use of vinegar for cleaning; stated vinegar kills bacteria. |
| Maintenance Coordinator R | Maintenance Coordinator | Verified maintenance deficiencies in resident rooms and hall. |
Inspection Report
Plan of Correction
Census: 16
Deficiencies: 3
Oct 7, 2015
Visit Reason
This inspection was an Assisted Living/Residential Healthcare Licensure resurvey to assess compliance with regulatory requirements.
Findings
The facility failed to employ a full-time qualified dietary manager, failed to maintain a sanitary and comfortable physical environment, and failed to ensure the development of initial negotiated service agreements at admission for some residents.
Severity Breakdown
SS=F: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to employ a full-time qualified dietary manager for residents receiving meals from the facility kitchen. | SS=F |
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for residents. | SS=F |
| Failed to ensure the development of an initial negotiated service agreement at admission for 2 of 3 sampled residents. | SS=D |
Report Facts
Census: 16
Sample size: 3
Days late for negotiated service agreement completion: 37
Days late for negotiated service agreement completion: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff Q | Dietary Staff | Not certified as dietary manager and overseeing meal preparation |
| Administrative Staff J | Administrative Staff | Verified dietary staff certification status and negotiated service agreement delays |
| Maintenance Coordinator R | Maintenance Coordinator | Verified environmental deficiencies during tour |
Inspection Report
Re-Inspection
Deficiencies: 1
Oct 7, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be '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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter and referenced as contact for questions regarding the survey. |
Inspection Report
Follow-Up
Deficiencies: 1
Aug 6, 2015
Visit Reason
This is a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-07-30.
Findings
The report documents that the previously cited deficiency with ID prefix F0323 related to regulation 483.25(h) was corrected as of 2015-08-06.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID prefix F0323 related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jul 30, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person and complaint coordinator in the report. |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Jul 30, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#89728) regarding inadequate supervision and accident hazards at the facility.
Findings
The facility failed to provide adequate supervision to Resident #1, who had severe cognitive impairment and increased behaviors, by sending him/her alone on public transportation to a doctor's appointment. Additionally, the facility failed to provide adequate supervision to four unsampled residents in the special care unit dining room, leaving them unattended.
Complaint Details
The complaint investigation #89728 found substantiated deficiencies related to inadequate supervision resulting in potential accident hazards for residents, including one resident sent alone on public transportation despite severe cognitive impairment and behavioral issues.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to Resident #1 during transportation to a physician's appointment. | SS=D |
| Failure to provide adequate supervision to four unsampled residents in the special care unit dining room. | SS=D |
Report Facts
Census: 38
Sampled residents reviewed: 3
Unsampled residents without supervision: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified resident went alone on mini bus without staff supervision. | |
| Administrative Nurse D | Verified resident had a doctor's appointment and commented on safety concerns about leaving residents unattended. | |
| Administrative Staff E | Spoke with resident's DPOA about supervision needs for doctor's appointment. | |
| Nurse Aide B | Verified loading resident onto mini bus and questioned nurse about lack of staff supervision. | |
| Nurse C | Verified residents in special care unit require family or staff supervision during transportation. | |
| Nurse Aide F | Left residents unattended in dining room due to workload. | |
| Nurse Aide G | Assisted in removing residents from dining room. |
Inspection Report
Life Safety
Deficiencies: 1
Jul 8, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Oct 8, 2015
Provider agreement termination date: Jan 8, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Joe Ewert | Commissioner | Commissioner of KDADS, copied on the letter. |
Inspection Report
Follow-Up
Deficiencies: 1
Mar 12, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report confirms that the deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of 03/12/2015. No other deficiencies are listed.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 25, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Cherry Village.
Findings
The facility was found to have employed individuals who had been found guilty of abuse, neglect, or mistreatment of residents. The plan includes staff in-service on abuse, neglect, and mistreatment policies and monthly review of resident falls by the Quality Assurance committee.
Complaint Details
This Plan of Correction is related to a complaint investigation at Cherry Village, as indicated by the reference to 'Complaint Revised' and the event ID.
Deficiencies (1)
| Description |
|---|
| Facility shall not employ individuals who have been found guilty of abuse, neglect, or mistreatment of residents by a court of law. |
Report Facts
Complete Date: Mar 12, 2015
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Feb 10, 2015
Visit Reason
The inspection was conducted based on complaints #83512, #81943, and #82488 regarding failure to investigate and report incidents involving residents found on the floor and injuries.
Findings
The facility failed to investigate and report to the state agency an unwitnessed incident where Resident #1 was found unresponsive on the floor and a fall with injury for Resident #3. Both incidents were not reported as required by facility policy and state law.
Complaint Details
The visit was complaint-related, triggered by complaints #83512, #81943, and #82488. The facility failed to investigate and report incidents involving Resident #1 and Resident #3 as required.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to investigate and report an unwitnessed incident when Resident #1 was found on the floor unresponsive. | SS=D |
| Failure to investigate and report a fall with injury for Resident #3. | SS=D |
Report Facts
Census skilled facility: 34
Census assisted living: 18
Sample size: 9
Bruise size: 7.5
Bruise size: 4
Abrasion size: 1
Abrasion size: 1
Skin tear width: 1
BIMS score: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified staff alerted him/her about Resident #1 found on the floor | |
| Nurse Aide B | Found Resident #1 lying in hallway and assisted in transferring resident to bed | |
| Nurse G | Verified Resident #3 rolled out of bed and staff performed neurological checks | |
| Administrative Nurse E | Verified Resident #3's fall and that the facility did not report the fall to the state agency | |
| Administrative Staff F | Verified facility had not completed investigation or reported Resident #1's incident |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Feb 10, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and letter. |
Inspection Report
Plan of Correction
Deficiencies: 3
Sep 9, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The facility identified deficiencies related to providing ongoing activity programs to meet residents' interests and well-being, developing comprehensive care plans including activity programs, and maintaining a Quality Assessment and Assurance committee.
Severity Breakdown
D: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide an ongoing program of activities to meet the interests, physical, mental and psychosocial well-being of each resident. | D |
| Failure to develop a comprehensive care plan to include an ongoing activity program for the resident(s). | D |
| Failure to maintain a Quality Assessment and Assurance committee per required regulation. | F |
Report Facts
Deficiencies cited: 3
Inspection Report
Follow-Up
Deficiencies: 3
Sep 9, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.15(f)(1), 483.20(d), 483.20(k)(1), and 483.75(o)(1) have been corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.15(f)(1) |
| Deficiency related to regulations 483.20(d) and 483.20(k)(1) |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Aug 21, 2014
Visit Reason
The inspection was conducted as a Non-compliance Revisit and Complaint investigation #77206 to assess compliance with regulatory requirements related to resident activities and care planning.
Findings
The facility failed to provide an ongoing activity program designed to meet the interests and physical, mental, and psychosocial well-being of residents in the Special Care Unit. Additionally, the facility failed to develop comprehensive care plans including individualized activity programs for sampled residents. The Quality Assessment and Assurance Committee failed to identify and implement corrective plans for these deficiencies.
Complaint Details
The visit was a complaint investigation #77206 and a non-compliance revisit.
Severity Breakdown
SS=D: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide an activity program designed to meet the interests and well-being of 3 of 4 sampled residents in the Special Care Unit (#4, #26, #47). | SS=D |
| Failed to develop comprehensive care plans including measurable objectives and timetables for activities for 3 of 4 sampled residents in the Special Care Unit (#4, #26, #47). | SS=D |
| Failed to maintain an effective Quality Assessment and Assurance program to identify and correct deficiencies related to individualized activity programs for 3 residents in the Special Care Unit (#4, #26, #47). | SS=F |
Report Facts
Resident census: 33
Residents in Special Care Unit: 18
Sampled residents: 4
Activity attendance: 0
Activity attendance: 5
Inspection Report
Follow-Up
Deficiencies: 1
Aug 21, 2014
Visit Reason
This revisit report documents the follow-up inspection to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency with ID prefix S0490 related to regulation 28-39-153(f) was corrected by 07/31/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID prefix S0490 related to regulation 28-39-153(f) |
Report Facts
Deficiency correction date: Jul 31, 2014
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 21, 2014
Visit Reason
The visit was a first revisit conducted on August 21, 2014, following a July 2, 2014 Health survey to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The revisit found the most serious deficiency in the facility to be an "F" level deficiency, indicating the facility was not in substantial compliance. Enforcement remedies including denial of payment for new Medicare/Medicaid admissions and recommendation for termination of the provider agreement were imposed.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an "F" level deficiency. | F |
Report Facts
Effective date of denial of payment: Oct 2, 2014
Recommended termination date: Jan 2, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Wheeler | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions in the letter |
| Joe Ewert | Commissioner of Survey, Certification and Credentialing Commission | Recipient of Informal Dispute Resolution requests |
Inspection Report
Follow-Up
Deficiencies: 18
Aug 21, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from an earlier survey had been corrected by the facility.
Findings
The report shows that all previously identified deficiencies were corrected by the facility as of 07/31/2014, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (18)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.15(g)(1) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(g)-(j) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.35(i)(3) |
| Deficiency related to regulation 483.55(b) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.75(e)(8) |
Report Facts
Deficiencies corrected: 18
Inspection Report
Plan of Correction
Deficiencies: 17
Jul 31, 2014
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 of Correction outlines multiple corrective actions including staff in-service training, reassignment of responsible personnel, environmental repairs, and enhanced monitoring by the Quality Assurance Committee to address various deficiencies.
Deficiencies (17)
| Description |
|---|
| Failure to properly notify physicians and families of changes in resident condition |
| Failure to treat residents with dignity and respect |
| Inadequate activity programming meeting resident needs |
| Lack of medically related social services |
| Insufficient environmental and maintenance program |
| Non-completion and inaccuracy of comprehensive assessments |
| Inadequate care-plan interventions and revisions |
| Failure to provide care/services to maintain resident well-being |
| Inadequate treatment and prevention of pressure sores |
| Unsafe resident environment and accident hazards |
| Failure to follow up on pharmacist recommendations |
| Environmental issues in kitchen requiring repair |
| Need for repair or replacement of garbage dumpster |
| Resident denture issues not resolved |
| Infection control and prevention deficiencies |
| Insufficient nursing staff in-service hours on special resident needs |
| Inadequate Quality Assurance Committee oversight |
Report Facts
Deficiency completion date: Jul 31, 2014
Annual nursing in-service hours: 12
QA Committee members: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 31, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection.
Findings
The plan outlines corrective actions to expand the environmental and maintenance program to include both inside and outside residence areas, identify affected residents, seek bids for building repairs, and submit monthly environmental observation checklists to the Quality Assurance Committee.
Deficiencies (1)
| Description |
|---|
| Environmental and maintenance program deficiencies related to inside and outside residence areas. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Added and modified the Plan of Correction. |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 31, 2014
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.
Findings
The report confirms that the previously identified deficiency with regulation number 28-39-162 was corrected as of 07/31/2014. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 28-39-162 |
Report Facts
Deficiency correction date: Jul 31, 2014
Inspection Report
Enforcement
Deficiencies: 1
Jul 2, 2014
Visit Reason
A health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at an 'F' level, indicating substandard quality of care. Enforcement remedies including denial of payment for new Medicare admissions were imposed effective October 2, 2014, with potential termination recommended if substantial compliance is not achieved within six months.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F253 'F', CFR 01-483.15(h)(2) related to substandard quality of care | F |
Report Facts
Months until recommended termination: 6
Denial of payment effective date: Oct 2, 2014
Civil Money Penalty threshold: 5000
IDR submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Lewis | Administrator | Named as facility administrator in relation to the survey and deficiencies. |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter. |
| Joe Ewert | Commissioner | Commissioner of Kansas Department for Aging and Disability Services, mentioned in relation to the survey and enforcement. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 19
Jul 2, 2014
Visit Reason
The inspection was conducted as a Health Resurvey, Extended Health Resurvey, and Complaint Investigation #74690 and #76167.
Findings
The facility failed to notify physicians of significant changes in residents' conditions, failed to provide dignity and respect, failed to provide adequate activity programs, failed to provide medically related social services, failed to maintain a sanitary environment, failed to complete comprehensive assessments and care plans, failed to provide necessary care and services to maintain residents' well-being, failed to provide oral care assistance, failed to prevent pressure ulcers, failed to ensure safety from accidents, failed to monitor medications properly, failed to prepare and serve food under sanitary conditions, failed to dispose of garbage properly, failed to provide routine dental care, failed to maintain an infection control program, and failed to provide required nurse aide in-service training.
Complaint Details
Complaint Investigation #74690 and #76167 triggered the visit.
Severity Breakdown
SS=E: 5
SS=D: 8
SS=F: 2
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to notify physicians of significant changes in residents' conditions including blood pressure and blood sugar abnormalities. | SS=E |
| Failed to promote dignity and respect for residents, including entering rooms without knocking and inappropriate staff comments. | SS=D |
| Failed to provide an ongoing activity program designed to meet residents' interests and well-being. | SS=D |
| Failed to provide medically related social services to meet residents' needs, including dental care. | SS=E |
| Failed to maintain a sanitary, orderly, and comfortable environment inside and outside the facility. | SS=F |
| Failed to conduct comprehensive assessments accurately and complete care area assessments (CAAs) for residents. | SS=D |
| Failed to develop, review, and revise comprehensive care plans to meet residents' needs including activities and dietary needs. | SS=D |
| Failed to provide necessary care and services to maintain or improve residents' physical, mental, and psychosocial well-being. | SS=E |
| Failed to provide set-up assistance for oral care to maintain resident's current level of function. | SS=D |
| Failed to provide necessary services to maintain good oral hygiene for a resident with poor dentition. | SS=D |
| Failed to implement effective interventions to prevent development of pressure ulcers. | SS=D |
| Failed to ensure resident environment is free of accident hazards and provide adequate supervision and assistance devices to prevent accidents. | SS=D |
| Failed to ensure drug regimen was free from unnecessary drugs including failure to hold blood pressure medication as ordered and failure to follow pharmacist recommendations for antipsychotic medication. | SS=D |
| Failed to prepare and serve food under sanitary conditions including kitchen ceiling leaks and rusty equipment. | SS=E |
| Failed to dispose of garbage and refuse properly including rusted dumpster with holes. | SS=D |
| Failed to provide or obtain routine and emergency dental services to meet residents' needs including failure to address denture problems. | SS=D |
| Failed to establish and maintain an infection control program to provide a safe, sanitary, and comfortable environment and prevent disease transmission including improper cleaning of glucometers and contaminated cleaning supplies. | SS=E |
| Failed to complete required nurse aide in-service training of at least 12 hours per year. | SS=E |
| Failed to maintain a quality assessment and assurance committee with required members and effective corrective plans. | SS=F |
Report Facts
Census: 32
Blood pressure readings outside parameters: 18
Blood sugar readings: 19
Pressure ulcers: 3
Nurse aide inservice hours: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Named in multiple findings including failure to notify physicians, failure to update care plans, and medication monitoring |
| Nurse C | Nurse | Named in findings related to blood pressure monitoring and resident reassessment |
| Nurse D | Nurse | Named in findings related to blood pressure monitoring and glucometer cleaning |
| Nurse Aide G | Nurse Aide | Named in findings related to resident transfer and pressure pad alarm use |
| Nurse Aide E | Nurse Aide | Named in findings related to resident transfer and oral care |
| Nurse Aide K | Nurse Aide | Named in findings related to oral care assistance |
| Housekeeping Staff Q | Housekeeping Staff | Named in findings related to cleaning practices and infection control |
| Activity Staff I | Activity Staff | Named in findings related to lack of activity programming |
| Activity Staff J | Activity Staff | Named in findings related to lack of activity programming |
| Administrative Staff O | Administrator | Named in findings related to environmental conditions and quality assurance committee |
| Administrative Staff S | Administrator | Named in findings related to environmental conditions and quality assurance committee |
| Nurse B | Nurse | Named in findings related to blood pressure monitoring and resident assessment |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 21
Jun 24, 2014
Visit Reason
The inspection was conducted as an Assisted Living/Residential Healthcare Licensure resurvey and complaint investigation #75742.
Findings
The facility failed to provide and maintain a sanitary, orderly, and comfortable interior environment for the 16 residents. Multiple physical environment deficiencies were observed including structural damage, unsanitary conditions, and maintenance issues both outside and inside the facility.
Complaint Details
The inspection included a complaint investigation #75742 and was substantiated by observations and verification from Administrative Staff O and Administrative Staff S.
Deficiencies (21)
| Description |
|---|
| Two holes approximately 2 foot x 2 foot at the edge of the concrete half circle drive with pipes showing. |
| Concrete porch on the front of the building had an approximate 6 foot crack and buckled, making it uneven. |
| Patio chairs at the front of the building had rusted areas at the bottom of the legs. |
| Two air conditioner unit covers for room air conditioner units not in place. |
| Soffit above the double doors to the chapel had an approximate 4 inch x 8 inch hole and an approximate 6 inch x 8 inch section peeling away. |
| Frame boards above the double doors to the chapel had no paint and gray weathered appearance. |
| Double doors to the chapel had chipped white paint all across the outside. |
| Two attic access doors ajar on the porch outside of the main dining room. |
| Patio chairs and table on porch outside of the main dining room covered with a brown substance and one chair with three approximate 6 inch tears in the seat. |
| Barbecue grill on the porch outside of the main dining room had a spatula and tongs visibly soiled with a brownish black substance. |
| Barbecue grill on the porch outside of the main dining room had dried grass sticking out of the holes by the handle and a large bird nest completely filled the grill area. |
| Wooden bench outside of the special care unit door had white paint chipped off across the entire bench and two nail heads sticking up on the edge of seat about an inch where a board had broken off. |
| Floor next to the refrigerator had an approximate 2 foot x 3 foot section of tile missing and the floor was blackish/brown in color. |
| Eight segments of the brown flooring were separating with approximate 1/2 inch black colored cracks between the segments. |
| Chapel ceiling with an approximate 3 foot x 6 foot section of drywall cut away with rafters showing above the double doors. |
| South wall of chapel had an approximate 20 foot section of drywall removed and white plastic showing. |
| Several small trash cans and a 32 gallon trash can had water from ceiling leaks on both sides of the double doors. |
| An approximate 9 foot x 20 foot half moon section of carpet cut out with the base floor showing at the double doors. |
| Southwest ceiling had an approximate 3 foot x 6 foot section of drywall cut away with a brown colored stain approximately 8 inches wide running from the removed section to the floor with a 32 gallon trash can in place. |
| An approximate 6 foot x 10 foot half moon section of carpet cut out with the base floor showing at the southwest corner. |
| An approximate 20 foot section of brownish substance where the wall and ceiling meet above the double door. |
Report Facts
Resident census: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff O | Verified observations of environmental deficiencies | |
| Administrative Staff S | Verified observations of environmental deficiencies |
Inspection Report
Life Safety
Deficiencies: 1
May 7, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level 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 payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Aug 7, 2014
Effective date for provider agreement termination: Nov 7, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Lewis | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Follow-Up
Deficiencies: 1
Apr 28, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiency identified under regulation 483.25(c) with ID prefix F0314 was corrected on 2014-03-21. No other deficiencies are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(c) previously cited and corrected. |
Report Facts
Deficiency correction date: Mar 21, 2014
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Mar 5, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#72867) regarding the facility's failure to prevent the development of pressure ulcers in a resident.
Findings
The facility failed to prevent the development of pressure ulcers on both heels of Resident #1, who was admitted with an immobilizer on the left lower leg and assessed as high risk for pressure ulcers. The care plan lacked interventions such as repositioning schedules or heel protectors, and the ulcers developed despite the resident's high risk status.
Complaint Details
Complaint investigation #72867 found the facility failed to prevent pressure ulcers in Resident #1, who was admitted with an immobilizer and high risk for ulcers. The facility lacked appropriate care plans and interventions to prevent skin breakdown.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent development of pressure ulcers on both heels of Resident #1. | SS=G |
Report Facts
Census: 66
Braden Scale score: 12
Pressure ulcer size: 8
Pressure ulcer size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Assessed resident's left heel pressure ulcer and notified physician. | |
| Nurse Aide B | Reported resident required extensive assistance and that heels were not floated or protected before ulcers developed. | |
| Nurse D | Stated facility admitted resident with immobilizer and no care plan for heel protection. | |
| Nurse E | Stated resident was high risk and preferred to be on back; no care plan for heel protection. | |
| Nurse Aide C | Reported resident required total assistance and heels were not floated or protected before ulcers developed. | |
| Therapy Staff F | Reported resident wore gripper socks and heel protectors were applied only after ulcers developed. | |
| Physician G | Physician | Stated resident was high risk and facility should have provided daily assessments and heel protection. |
Inspection Report
Follow-Up
Deficiencies: 2
Sep 19, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report shows that the previously cited deficiencies identified by regulation numbers 483.13(b), 483.13(c)(1)(i), and 483.13(c)(1)(ii)-(iii), (c)(2)-(4) were corrected as of 08/30/2013.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.13(b), 483.13(c)(1)(i) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
Report Facts
Deficiency correction date: Aug 30, 2013
Inspection Report
Plan of Correction
Deficiencies: 2
Aug 22, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Cherry Village.
Findings
The plan addresses deficiencies related to verbal abuse and failure to report and investigate injuries of unknown origin, with corrective actions including staff inservice training and monitoring by facility leadership.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Cherry Village 082213 Complaint.
Deficiencies (2)
| Description |
|---|
| The facility will ensure residents are free of verbal abuse. |
| The facility will report and investigate all injuries of unknown origin. |
Report Facts
Corrective action completion date: Aug 29, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Aug 21, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#68185) regarding allegations of verbal abuse and failure to investigate abuse incidents at the facility.
Findings
The facility failed to ensure one resident was free from verbal abuse by a staff member and failed to investigate and report allegations of abuse and injuries of unknown origin for two residents. The facility allowed the alleged perpetrator to continue working during the investigation.
Complaint Details
The complaint investigation (#68185) was triggered by reports of verbal abuse by Nurse Aide Staff E towards Resident #1 and failure of the facility to investigate and protect residents from abuse. The facility also failed to report and investigate a skin tear and bruise of unknown origin on Resident #5.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1 was free from verbal abuse by Nurse Aide Staff E. | SS=E |
| Failure to investigate and report verbal abuse and injuries of unknown origin for two residents (Resident #1 and Resident #5). | SS=E |
Report Facts
Census: 37
Sampled residents: 5
Residents sampled for abuse issues: 4
Skin tear length: 3.5
Nurse Aide Staff E work schedule: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide Staff E | Certified Nurse Aide | Named in verbal abuse findings and investigation. |
| Administrative Nurse C | Verified lack of investigation and failure to protect residents from verbal abuse. | |
| Administrative Staff D | Verified suspension of Nurse Aide Staff E and lack of reporting to state agency. | |
| Nurse B | Received verbal abuse report from Resident #1 and reported to Director of Nursing. | |
| Nurse A | Received report from Resident #2 about verbal abuse and reported to Director of Nursing. |
Inspection Report
Follow-Up
Deficiencies: 9
Jul 24, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers and prefix codes were corrected by 07/15/2013 as verified during the revisit.
Deficiencies (9)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.13(c) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.75 |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 10
Jul 9, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a regulatory inspection.
Findings
The plan addresses multiple deficiencies including employment of individuals without background checks, updating resident care plans, ensuring safety in resident living areas, maintaining proper dishwashing temperatures, infection control practices related to oxygen cannulas, administrative staffing, and dietary management certification.
Deficiencies (10)
| Description |
|---|
| Facility shall not employ individuals who have been found guilty of abuse, neglect, or mistreatment of residents by a court of law; background checks required before working with residents. |
| Background checks shall be submitted upon hire and prior to direct care staff caring for residents. |
| Resident #42 plan of care has been updated; medical record RN to perform monthly record reviews to identify missed needs. |
| Resident #18 plan of care reviewed and updated with latest behavior; medical record RN to assure completeness of plans of care. |
| Facility shall assure resident living areas are as free of accident hazards as possible; staff in-serviced on elopement policy and housekeeping carts. |
| Water temperature and PPM in kitchen sink tested at least 3 times daily; dishwashing temperature not to fall below 120 degrees; protocol for disposable use if temperature falls below standard. |
| Oxygen cannulas to be kept in plastic bags when not in use; staff instructed to monitor residents' behavior during oxygen use. |
| Additional administrative staff added to increase compliance with resident well-being and regulatory requirements. |
| Facility will expand membership in QA committee to include multiple disciplines to improve compliance oversight. |
| Current dietary manager enrolled in certification course and supervised by dietician until certification is obtained. |
Report Facts
Completion dates: Jul 9, 2013
Dishwashing temperature: 120
Water temperature checks: 3
Compliance measurement: 90
Compliance measurement: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 8
Jun 27, 2013
Visit Reason
The inspection was conducted as a Non-Compliance Revisit and Complaint Investigation triggered by allegations of potential abuse and neglect, and other regulatory compliance concerns.
Findings
The facility failed to thoroughly investigate allegations of potential abuse and neglect for a cognitively impaired resident who left a locked special care unit unattended. The facility also failed to conduct criminal background checks for new hires, develop and revise comprehensive care plans for residents with nutritional and behavioral concerns, provide adequate supervision and a safe environment free of hazards, maintain proper infection control practices, and effectively manage resources to ensure resident well-being.
Complaint Details
The complaint investigation focused on allegations that Resident #18, a cognitively impaired resident, left the locked special care unit unattended without staff knowledge or supervision. The investigation found failures in supervision, investigation, and care planning related to this incident.
Severity Breakdown
SS=D: 6
SS=E: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate allegations of potential abuse and neglect for Resident #18 who left the locked special care unit unattended. | SS=D |
| Failed to conduct criminal background checks for 1 of 3 newly hired staff members. | SS=D |
| Failed to develop a comprehensive care plan for Resident #42 with nutritional concerns. | SS=D |
| Failed to review and revise the plan of care for Resident #18 who exhibited wandering and anxiety behaviors. | SS=D |
| Failed to provide adequate supervision and a safe environment free of accident hazards for Resident #18 and 11 cognitively impaired residents. | SS=D |
| Failed to maintain infection control by not properly storing oxygen nasal cannulas for residents #2 and #23. | SS=D |
| Failed to effectively administer the facility to maintain the highest practicable well-being of residents, including failure to investigate incidents, conduct background checks, develop and revise care plans, provide supervision, maintain water temperatures, and implement infection control. | SS=E |
| Failed to maintain an effective Quality Assessment and Assurance Committee that identifies and corrects quality deficiencies in a timely manner. | SS=F |
Report Facts
Resident census: 32
Sample size: 8
New hires reviewed: 3
Non-injury falls: 1
Weight: 123.8
Weight: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide B | Nurse Aide | Verified resident left the special care unit and was found in the hallway |
| Nurse C | Nurse | Reported resident exited the special care unit and was redirected |
| Administrative Nurse E | Administrative Nurse | Verified resident left the special care unit and staff redirected resident |
| Administrative Staff D | Administrative Staff | Reported on investigation of resident leaving locked unit and door locking issues |
| Nurse F | Nurse | Reported locksmith repaired door locking mechanism |
| Administrative Nurse E | Administrative Nurse | Verified oxygen nasal cannula infection control issues |
| Nurse G | Nurse | Verified lack of nutritional care plan for resident #42 |
| Auxiliary Staff I | Auxiliary Staff | Verified chemicals on housekeeping cart were left unattended |
| Administrative Staff B | Administrative Staff | Verified failure to complete criminal background check for new hire |
Inspection Report
Follow-Up
Deficiencies: 17
Jun 27, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously cited in the facility's prior survey had been corrected.
Findings
The revisit report documents that all previously cited deficiencies were corrected by the facility as of 06/07/2013, with no uncorrected deficiencies remaining.
Deficiencies (17)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(5)-(10), 483.10(b)(1) |
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.10(e), 483.75(l)(4) |
| Deficiency related to regulation 483.10(g)(1) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.25(n) |
| Deficiency related to regulation 483.30(a) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.70(f) |
| Deficiency related to regulation 483.75(e)(8) |
| Deficiency related to regulation 483.75(m)(2) |
Report Facts
Deficiencies corrected: 17
Inspection Report
Original Licensing
Deficiencies: 0
May 8, 2013
Visit Reason
The licensure survey was conducted to assess compliance for initial licensing of the facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 24
May 8, 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 of Correction outlines corrective actions for multiple deficiencies affecting residents, including notification of Medicare letters, condition change interventions, confidentiality breaches, safety precautions, care plan updates, infection control, staffing, and emergency procedures. The facility commits to completing corrective actions by specified dates and monitoring compliance through QA oversight.
Deficiencies (24)
| Description |
|---|
| Failure to send CMS approved letters to affected residents. |
| Failure to notify physician and family timely of condition changes. |
| Breach of confidentiality by releasing confidential information to survey team. |
| Missing survey results and failure to maintain survey notebook. |
| Lack of safety precautions for cognitively impaired residents. |
| Failure to complete background checks prior to direct care staff providing resident care. |
| Failure to ensure dignity and privacy for affected residents. |
| Lack of preventative maintenance plan for resident safety. |
| Inadequate care plans and interventions for residents with unique needs. |
| Failure to document fluid intake and monitor unique care needs. |
| Inadequate skin assessments and documentation for residents with pressure ulcers. |
| Inadequate incontinence assessment and care. |
| Hazards in living areas and failure to maintain safety alarms. |
| Nutritional risks not adequately identified or addressed. |
| Failure to monitor medication regimens and lab work. |
| Failure to provide current influenza and pneumococcal vaccine information. |
| Insufficient professional nursing staff. |
| Failure to implement effective infection control policies regarding linens and laundry. |
| Failure to maintain a compliant call system for resident assistance. |
| Insufficient administrative staff to ensure compliance with resident well-being. |
| Failure to ensure nursing staff and nurse aides attend required in-service trainings. |
| Failure to train all employees on emergency procedures and conduct unannounced drills. |
| Lack of expanded QA committee membership to oversee compliance. |
| Dietary manager not fully certified and under supervision. |
Report Facts
Deficiency completion dates: 2013
Staffing increase: 3
In-service trainings: 12
Compliance targets: 90
Compliance targets: 100
Inspection Report
Census: 34
Deficiencies: 20
May 8, 2013
Visit Reason
The inspection was a Health Resurvey and Extended Health Resurvey, including a Complaint Investigation #65058.
Findings
The facility had multiple deficiencies including failure to provide proper notification of Medicare rights, failure to notify physicians of significant changes, failure to maintain resident privacy, failure to post survey results accessibly, failure to investigate and report abuse and neglect, failure to conduct criminal background checks timely, failure to provide dignity and respect, inadequate housekeeping and maintenance, failure to develop and revise care plans, failure to monitor nutritional status and medication side effects, failure to provide infection control, failure to maintain functional call light systems, insufficient nursing staff, inadequate nurse aide training, and failure to train staff in emergency procedures.
Complaint Details
Complaint Investigation #65058 was included in the survey and several deficiencies relate to complaint allegations including failure to investigate and report abuse, failure to notify physicians of changes, and failure to maintain resident dignity and privacy.
Severity Breakdown
SS=D: 10
SS=E: 5
SS=F: 5
SS=D: 1
Deficiencies (20)
| Description | Severity |
|---|---|
| Failure to provide Medicare residents with proper notification and opportunity to appeal discontinuation of services. | SS=D |
| Failure to notify physician of significant changes in residents' conditions including bleeding and weight loss. | SS=D |
| Failure to maintain resident privacy and confidentiality, including exposure of residents and improper handling of confidential survey documents. | SS=E |
| Failure to post survey results accessibly to residents and visitors. | SS=E |
| Failure to investigate and report incidents of possible abuse and neglect, including unwitnessed falls and resident found in unlocked housekeeping closet with hazardous chemicals. | SS=E |
| Failure to conduct timely criminal background checks for newly hired staff. | SS=D |
| Failure to provide dignity and respect to residents, including exposure in public areas and inadequate clothing coverage. | SS=E |
| Failure to maintain sanitary and safe environment including urine odors, stains, damaged walls, carpets, and missing caulking. | SS=E |
| Failure to develop and revise comprehensive care plans for residents with pressure ulcers, nutritional concerns, and after accidents. | SS=D |
| Failure to monitor nutritional status and provide nutritional supplements as ordered. | SS=D |
| Failure to monitor and follow up on medication side effects and lab monitoring for residents on high risk medications including blood pressure meds and antipsychotics. | SS=D |
| Failure to provide influenza and pneumococcal vaccine education to residents or their representatives. | SS=D |
| Failure to provide sufficient nursing staff to meet residents' needs and provide required services. | SS=F |
| Failure of pharmacist consultant to identify and report drug irregularities to physician and director of nursing. | SS=D |
| Failure to maintain infection control practices including proper handling of linens, care of residents with MRSA and C-diff, and maintenance of suction equipment. | SS=F |
| Failure to maintain functional resident call light systems for multiple residents. | SS=E |
| Failure to manage resources effectively to maintain residents' highest practicable well-being, including multiple deficient practices across care areas. | SS=F |
| Failure to provide required nurse aide in-service education of at least 12 hours per year. | SS=F |
| Failure to train all employees in emergency procedures upon hire and periodically thereafter. | SS=D |
| Failure of Quality Assessment and Assurance Committee to identify and correct multiple quality deficiencies. | SS=D |
Report Facts
Census: 34
Fall Risk Assessment Score: 29
Fall Risk Assessment Score: 20
Weight Loss Percentage: 7.35
Blood Pressure Reading: 148
Blood Pressure Reading: 118
Lipid Panel Interval: 13
Nurse Aide Inservice Hours: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Administrative Nurse | Verified multiple care plan and medication monitoring deficiencies |
| Nurse D | Nurse | Verified medication orders and call light system deficiencies |
| Nurse E | Nurse | Verified blood pressure monitoring deficiencies |
| Nurse F | Nurse | Witnessed resident found in housekeeping closet and verified lack of investigation |
| Administrative Staff B | Administrator | Unaware of housekeeping closet door issues and call light problems |
| Ancillary Staff A | Housekeeping Staff | Demonstrated housekeeping closet door could be pushed open easily |
| Ancillary Staff Q | Housekeeping Staff | Transported soiled linens improperly in clear plastic bags |
| Nurse G | Nurse | Unable to locate suction catheter and verified suction machine not covered |
| Nurse Aide P | Nurse Aide | Found resident in housekeeping closet and verified door was not locked |
| Nurse Aide T | Nurse Aide | Observed resident wandering and later found in housekeeping closet |
Inspection Report
Plan of Correction
Deficiencies: 15
May 11, 2012
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 for multiple deficiencies affecting residents, including weight loss policy compliance, dignity and respect, dental care, medication monitoring, food service, communication systems, and care planning. The facility commits to monitoring compliance through Quality Assurance committee activities and resident/family interviews.
Severity Breakdown
D: 9
E: 5
Deficiencies (15)
| Description | Severity |
|---|---|
| Weight loss policy and procedure compliance | F157-D |
| Resident dignity and respect of individuality | F241-E |
| Dental needs assessment and follow-up | F250-D |
| Call system equipment repair and testing | F258-E |
| Vision assessments accuracy and reassessment | F278-D |
| Comprehensive plan of care timeliness and individuality | F279-D |
| Family and resident notification of care plan meetings | F280-D |
| Weight loss policy application | F325-D |
| Lab work to indicate need for medications and medication review | F329-D |
| Nutritious and palatable food served at proper temperatures | F364-D |
| Food procurement and sanitary food service conditions | F371-E |
| Dental assessment and development of dental policy | F412-D |
| Monthly drug regimen review by pharmacist | F428-D |
| Working communication system assured by monthly testing | F463-E |
| Safe family-type environment monitored by Q.A. committee | F520-E |
Report Facts
Residents affected: 11
Residents affected: 7
Residents affected: 34
Residents deceased: 2
Resident readmissions: 3
Plan of correction completion date: May 11, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Follow-Up
Deficiencies: 15
May 11, 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 05/11/2012.
Deficiencies (15)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.15(g)(1) |
| Deficiency related to regulation 483.15(h)(7) |
| Deficiency related to regulation 483.20(g)-(j) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(d)(1)-(2) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.55(b) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.70(f) |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 15
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 15
Apr 11, 2012
Visit Reason
The inspection was conducted as a Health Resurvey and investigation of complaint #52209 at Cherry Village.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant weight loss for residents, failure to promote dignity and respect, inadequate provision of medically-related social services, failure to maintain comfortable sound levels, inaccurate resident assessments, incomplete care plans, inadequate monitoring of nutritional status and medications, unsanitary food preparation, failure to provide dental services, malfunctioning resident call system, and ineffective quality assurance program.
Complaint Details
The visit was complaint-related, investigating complaint #52209.
Severity Breakdown
SS=E: 5
SS=D: 9
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to notify physician of significant weight loss for residents #38 and #40. | SS=D |
| Failure to promote care that maintains or enhances resident dignity and respect. | SS=E |
| Failure to provide medically-related social services to attain or maintain highest practicable well-being for resident #28. | SS=D |
| Failure to maintain comfortable sound levels; call lights and alarms excessively loud and disruptive. | SS=E |
| Failure to accurately assess vision status of residents #9, #11, and #20. | SS=D |
| Failure to develop comprehensive care plan for resident #10. | SS=D |
| Failure to involve resident or representative in care planning and revise care plan for residents #38 and #40 regarding significant weight loss. | SS=D |
| Failure to maintain nutritional status and monitor significant weight loss for residents #38 and #40. | SS=D |
| Resident #37's drug regimen included thyroid and cholesterol medications without adequate lab monitoring. | SS=D |
| Failure to provide food that is palatable and at proper temperature for residents requiring extensive assistance (#12, #36, and one unsampled resident). | SS=D |
| Failure to prepare, distribute, and serve food under sanitary conditions; dietary staff observed without hairnets and improper storage of frozen food products. | SS=E |
| Failure to provide or obtain routine and emergency dental services for resident #28 with poor dentition and tooth pain. | SS=D |
| Consultant pharmacist failed to report drug regimen irregularities to physician or director of nursing for resident #37. | SS=D |
| Resident call system malfunctioned in 7 of 11 sampled resident rooms and bathrooms, impairing residents' ability to call for assistance. | SS=E |
| Failure to maintain an effective quality assessment and assurance program to identify and correct quality deficiencies. | SS=E |
Report Facts
Resident census: 34
Weight loss: 21.6
Weight loss: 22
Call lights not working: 7
Residents sampled for unnecessary medications: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Verified failure to notify physician of weight loss and confirmed call light issues. | |
| Nurse B | Verified inaccurate vision assessments. | |
| Nurse G | Verified resident's poor dental condition and pain management. | |
| Nurse H | Verified lack of lab monitoring for medications and pharmacy oversight. | |
| Dietary Manager P | Observed without hairnet and verified food storage practices. | |
| Dietary Cook W | Observed without proper hairnet. | |
| Dietary Aide A | Observed without hairnet. | |
| Administrative Staff H | Verified QA program deficiencies and dental service issues. |
Inspection Report
Plan of Correction
Deficiencies: 1
N005001 POC NTIS11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to sanitary storage of prepared and served food, with corrective actions including staff education, monitoring, and monthly reporting to the Quality Assurance committee.
Deficiencies (1)
| Description |
|---|
| Facility will ensure to store prepared and served food under sanitary conditions. |
Report Facts
Facility compliance date: Feb 17, 2017
Inspection Report
Plan of Correction
Deficiencies: 3
N005001 POC QU3U11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 12/19/2018.
Findings
The plan addresses deficiencies related to resident assessment with injury noted, abuse prevention and reporting, staff education on abuse policies, and staff performance reviews including required in-service education hours.
Deficiencies (3)
| Description |
|---|
| Resident assessment completed with injury noted; resident care plan reviewed and updated; follow-up by social services planned. |
| Interviews conducted with residents regarding abuse; staff educated on Abuse, Neglect, and Exploitation Policy; additional training assigned. |
| Staff performance reviews and required 12 hr/year in-service education completed and verified; ongoing monitoring planned. |
Report Facts
Date of resident assessment: Dec 12, 2018
Date of resident care plan update: Dec 17, 2018
Frequency of resident interviews: 3
Training completion deadline: Jan 1, 2018
In-service education hours: 12
Inspection Report
Plan of Correction
Deficiencies: 1
N005001 POC 1J9V11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Cherry Village.
Findings
The plan addresses deficient practices related to skin care and prevention of pressure ulcers, including reviewing assessment and care plan practices, assigning weekly skin checks to an RN, and mandatory staff in-service training.
Complaint Details
This Plan of Correction is related to a complaint investigation at Cherry Village.
Deficiencies (1)
| Description |
|---|
| Deficient practice related to skin care and prevention of pressure ulcers. |
Inspection Report
Plan of Correction
Deficiencies: 3
N005001 POC 54M811
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Cherry Village.
Findings
The plan addresses deficiencies related to notification of physicians in elopement situations, expanded care plans for residents with wandering behavior, and security measures including locking doors and alarm systems to prevent elopement.
Complaint Details
This Plan of Correction is related to a complaint investigation at Cherry Village, referenced as Complaint 01052016.
Severity Breakdown
D: 2
J: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Nurses (LPN & RN) have been inserviced on notification of physicians by phone in an elopement situation where immediate direct care or treatment intervention may be needed. | D |
| Residents care plan has been expanded to include history of wandering behavior and visual monitoring every 30 minutes. | D |
| Courtyard door to activity room was locked immediately; bolt lock placed on door exiting special care unit sitting room to patio; continuous alarm placed on this door that must be manually reset by staff if activated. | J |
Report Facts
Complete Date: Jan 28, 2016
Complete Date: Jan 9, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Plan of Correction
Deficiencies: 1
N005001 POC 91GD11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Cherry Village.
Findings
The plan addresses deficiencies related to resident assessments for ability to transport without immediate staff presence, particularly for residents with low BIMS scores, and outlines weekly reviews by the Quality Assurance committee to ensure resident safety during appointments.
Complaint Details
This Plan of Correction is related to a complaint investigation at Cherry Village.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents will be assessed by nursing staff as to ability to transport without immediate staff presence, especially those with low BIMS scores. | D |
Report Facts
Complete Date: Aug 6, 2015
Complete Date: Aug 26, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamla Lewis Irinastrakhova | Submitted the Plan of Correction to KDADS | |
| Shirley Boltz | Contact person for Plan of Correction assistance |
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