Inspection Report Summary
The most recent inspection on August 28, 2025, found no deficiencies and confirmed the facility was in compliance with all regulations. Earlier inspections showed a pattern of deficiencies primarily related to staff reporting and prevention of verbal abuse, documentation and timely completion of assessments, emergency preparedness, and food safety practices. Notably, a substantiated complaint investigation in July 2025 identified verbal abuse by a staff member and delayed reporting of the incident, which the facility addressed through staff education and termination of the involved employee. Prior complaint investigations mostly resulted in substantiated findings related to abuse, medication management, and resident care documentation, but enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with recent inspections showing correction of previously cited deficiencies and no new noncompliance found.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
24 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 28, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 07/02/25.
Findings
All previously cited deficiencies have been corrected as of 08/01/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 2
Jul 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation (KS00195955) regarding an allegation of verbal abuse by a Certified Nurse Aide (CNA) towards a resident.
Findings
The facility failed to ensure Resident 1 was free from verbal abuse and mistreatment by CNA M, who threatened the resident with physical violence. Additionally, the facility failed to report the allegation of abuse within the required timeframe, allowing CNA M to work additional shifts before termination. Staff education was inconsistently provided following the incident.
Complaint Details
The complaint investigation involved an allegation that on 06/08/2025 at approximately 01:30 AM, CNA M verbally threatened Resident 1 with physical violence. The incident was witnessed by CNA O. The allegation was not reported to the nurse or administration until 06/11/2025, three days later. CNA M was terminated following the investigation. The facility's failure to timely report the abuse allowed CNA M to work three additional shifts.
Severity Breakdown
SS = D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure Resident 1 remained free from verbal abuse and mistreatment by CNA M. | SS = D |
| Facility failed to report an allegation of abuse within the required timeframe, allowing CNA M to work additional shifts. | SS = D |
Report Facts
Census: 24
Resident reviewed for abuse: 4
BIMS score: 7
BIMS score: 99
Incident date: Jun 8, 2025
Incident report delay: 3
Shifts worked by CNA M after incident: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in verbal abuse finding and terminated due to investigation results. |
| CNA O | Certified Nurse Aide | Witnessed the verbal abuse incident and provided a witness statement. |
| Administrative Staff A | Initiated investigation, reported termination of CNA M, and provided information on staff education. | |
| Administrative Nurse D | Notified of the incident and participated in investigation and staff education. | |
| CNA N | Certified Nurse Aide | Interviewed about reporting inappropriate staff behavior and confirmed education was provided. |
| CMA R | Certified Medication Aide | Interviewed about reporting inappropriate staff behavior and confirmed education was provided. |
| Maintenance U | Interviewed about reporting inappropriate staff behavior and confirmed education was provided. | |
| Dietary BB | Interviewed about reporting inappropriate staff behavior and reported no education was provided. | |
| Dietary CC | Interviewed about reporting inappropriate staff behavior and reported no education was provided. | |
| Laundry W | Interviewed about reporting inappropriate staff behavior and reported no education was provided. |
Inspection Report
Plan of Correction
Deficiencies: 9
Jun 11, 2025
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 taken related to psychosocial needs and abuse recognition and reporting.
Findings
The plan details corrective actions including weekly psychosocial visits, suspension and termination of a CNA pending investigation, staff education on abuse recognition and reporting, resident interviews, emergency QAPI meetings, and law enforcement notification.
Deficiencies (9)
| Description |
|---|
| R1 care plan was updated to have weekly SSD visits x 4 weeks for psychosocial needs. |
| CNA M was suspended pending investigation and then terminated. |
| CNA O received individual education on recognizing abuse and timely reporting. |
| Clinical staff received ANE education. |
| All staff received ANE education by 7/22/25. |
| Resident interviews conducted. |
| Emergency QAPI conducted with Medical Director, DON, and ED. |
| Law Enforcement notified - case #25ED1140. |
| ED or designee will monitor through leadership rounding and clinical excellence. |
Report Facts
Date of CNA suspension: Jun 11, 2025
Date of CNA termination: Jun 13, 2025
Date of staff education: Jun 11, 2025
Date all staff education completed: Jul 22, 2025
Number of weekly SSD visits: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nursing Assistant | Suspended and terminated pending investigation |
| CNA O | Certified Nursing Assistant | Received individual education on abuse recognition and reporting |
| ANGELA DREILING | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
May 13, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-04-29.
Findings
All deficiencies have been corrected as of the compliance date of 2025-05-12, 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: 0
Apr 29, 2025
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey conducted on 04/29/2025.
Findings
The plan of correction addresses the deficiencies identified during the licensure resurvey of the facility on 04/29/2025.
Report Facts
Inspection date: Apr 29, 2025
Plan of correction completion date: May 13, 2025
Inspection Report
Renewal
Census: 4
Deficiencies: 1
Apr 29, 2025
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance with staff qualifications and employee record requirements.
Findings
The facility failed to obtain timely supporting documentation for evidence of certification and criminal background checks for newly hired staff, as required by state regulations. The Administrator/Licensed Nurse confirmed missing and late documentation for several employees.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain supporting documentation for evidence of certification at the time of hire and evidence of criminal background checks for facility staff. | SS=F |
Report Facts
Census: 4
Staff sample size: 5
Resident sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator/ Licensed Nurse A | Administrator/ Licensed Nurse | Named in findings for failure to obtain required documentation |
| Certified Nurse Aide C | Employee with late registry check | |
| Certified Nurse Aide D | Employee with late registry check | |
| Dietary Staff E | Employee with late criminal background check |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 22, 2025
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 11/20/24.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 12/19/24, 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: 7
Nov 20, 2024
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 compliance with federal Medicare/Medicaid requirements.
Findings
The plan addresses multiple deficiencies including proper issuance of Beneficiary Protection Notification forms, completion of significant change MDS assessments, skin condition assessments, pain assessments, medication monitoring, kitchen sanitation, and accurate reporting of staffing hours. The facility outlines education, monitoring, and auditing processes to maintain compliance.
Severity Breakdown
D: 5
J: 1
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure correct and complete Beneficiary Protection Notification forms were issued. | D |
| Failure to complete significant change MDS assessments for residents with status changes. | D |
| Failure to complete weekly skin condition assessments for residents. | D |
| Failure to complete pain assessments and update care plans appropriately. | J |
| Failure to monitor medications that were not given. | D |
| Kitchen sanitation issues including unclean surfaces, undated opened products, and improper utensil handling. | D |
| Failure to report staffing hours accurately. | F |
Report Facts
Deficiency completion dates: Dec 19, 2024
Resident identifiers: 74
Resident identifiers: 16
Resident identifiers: 11
Resident identifiers: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caroline Garvey | Manager of Clinical Operations for Pharmerica | Educated Consultant Pharmacist on auditing medications not given |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 7
Nov 20, 2024
Visit Reason
An extended recertification survey and complaint investigation were conducted due to concerns including pain management and compliance with Medicaid/Medicare coverage requirements.
Findings
The facility was found not in substantial compliance with multiple deficiencies including failure to manage pain effectively for Resident 74, failure to complete significant change assessments for residents 11 and 19, failure to issue accurate Medicaid notices for Resident 16, failure to complete weekly skin assessments for Resident 19, failure to administer heart medication for Resident 16, unsanitary food storage and preparation practices, and failure to submit accurate staffing data to Payroll Based Journal.
Complaint Details
The complaint investigation focused on Resident 74's pain management, which was found to be inadequate and led to immediate jeopardy. The facility failed to respond appropriately to pain complaints, communicate effectively with providers, and manage the resident's pain, contributing to distress and potential complications.
Severity Breakdown
Level J: 1
Level D: 5
Level F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure staff identified, updated providers and responded appropriately to complaints of Resident 74's pain, leading to immediate jeopardy. | Level J |
| Failure to issue accurate and complete Beneficiary Protection Notification forms to Resident 16. | Level D |
| Failure to identify significant change and complete assessments for Residents 11 and 19. | Level D |
| Failure to complete weekly skin assessments for Resident 19 with a skin tear. | Level D |
| Failure to ensure consultant pharmacist identified lack of administration of heart medication for Resident 16. | Level D |
| Failure to store, prepare, and serve food in a sanitary manner, including unlabeled and expired food items and unsanitary kitchen conditions. | Level D |
| Failure to submit complete and accurate staffing information to Payroll Based Journal, including missing licensed nurse coverage hours. | Level F |
Report Facts
Resident census: 22
Deficiency count: 7
Days medication not administered: 70
PBJ missing RN coverage days: 4
Resident sample size: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Named in relation to pain management failure and Medicaid notice deficiencies | |
| Administrative Nurse B | Named in relation to pain management failure and documentation restrictions | |
| Certified Nurse Aide M | CNA | Reported on Resident 74's pain complaints and Resident 19's decline |
| Licensed Nurse H | LN | Interviewed regarding Resident 19's decline and medication administration |
| Dietary Manager C | Named in relation to food safety and kitchen sanitation deficiencies | |
| Consultant Staff T | Participated in immediate jeopardy notification | |
| Consulting Staff Pharmacist U | Interviewed regarding medication administration irregularities | |
| Licensed Nurse I | LN | Named in relation to skin assessment deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 14, 2023
Visit Reason
An offsite revisit survey was conducted on 11/14/23 to verify correction of all previous deficiencies cited on 10/25/23.
Findings
All deficiencies cited in the previous inspection have been corrected as of 11/14/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Renewal
Census: 5
Deficiencies: 3
Oct 25, 2023
Visit Reason
Licensure resurvey conducted to assess compliance with regulatory requirements for the facility.
Findings
The facility failed to conduct required annual functional capacity screenings and negotiated service agreement reviews for sampled residents. Additionally, the facility did not perform quarterly reviews of the emergency management plan with residents and staff, and the plan lacked procedures for natural gas leak emergencies.
Severity Breakdown
SS=E: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to conduct functional capacity screening at least once every 365 days for 2 of 3 sampled residents. | SS=E |
| Failure to review and revise negotiated service agreements at least once every 365 days for 2 sampled residents. | SS=E |
| Failure to perform quarterly review of the emergency management plan with residents and staff and lack of procedures for natural gas leak emergencies. | SS=F |
Report Facts
Residents present: 5
Sampled residents: 3
Employee records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN B | Licensed Nurse | Interviewed regarding functional capacity screenings and medication administration |
| Administrator/LN A | Administrator / Licensed Nurse | Responsible for ensuring compliance with screenings, service agreements, and emergency preparedness |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 25, 2023
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey conducted at the facility on 10/25/23.
Findings
The plan of correction addresses citations identified during the licensure resurvey conducted on 10/25/23 at the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 7, 2023
Visit Reason
An offsite revisit survey was conducted on 03/07/2023 for all previous deficiencies cited on 01/19/2023.
Findings
All deficiencies have been corrected as of the compliance date of 02/23/2023, 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
Jan 19, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated 01/19/2023.
Findings
The plan addresses deficiencies related to nebulizer equipment maintenance and staff education on BIPA posting and RN coverage, with corrective actions and monitoring plans described to achieve substantial compliance by 02/22/2023.
Severity Breakdown
D: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Nebulizer mask for resident 10 was changed out on 01/20/23; all residents with nebulizer orders had equipment changed; staff educated on rinsing, drying, and storage of nebulizer masks. | D |
| Staff education provided on 01/30/23 regarding BIPA posting including RN coverage; monitoring to ensure 8 hours of RN coverage during Clinical Excellence; ongoing recruitment and retention of RNs. | F |
Report Facts
Complete Date for Plan of Correction: Feb 23, 2023
Staff education date: Jan 30, 2023
Nebulizer mask change date: Jan 20, 2023
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 2
Jan 19, 2023
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to respiratory care and staffing compliance at Medicalodges Kinsley.
Findings
The facility failed to ensure necessary respiratory care for a resident requiring inhalation treatments, including improper cleaning and storage of nebulizer equipment, and lacked a respiratory care policy. Additionally, the facility failed to provide required registered nurse coverage for at least 8 hours a day, seven days a week, for five of the six months reviewed.
Complaint Details
The visit was triggered by complaints identified as #KS00176439 and #KS00176011, involving respiratory care and staffing issues.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure necessary respiratory care and services for a resident requiring inhalation respiratory treatments, including improper cleaning and storage of nebulizer equipment. | SS=D |
| Failure to use the services of a registered nurse for at least 8 hours a day, seven days a week, for five of the six months reviewed. | SS=F |
Report Facts
Census: 20
Sample size: 12
MDS BIMS score: 2
Medication dosage: 0.5
Medication dosage: 2.5
Medication volume: 3
Medication frequency: 4
Months reviewed: 6
Days without RN coverage: 5
Dates of staffing review: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CMA) R | Provided inhalation treatment to Resident R10 and reported on nebulizer cleaning procedures | |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding nebulizer cleaning procedures and RN staffing coverage |
Inspection Report
Re-Inspection
Deficiencies: 2
Oct 12, 2022
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey, verifying that corrective actions were completed as of the revisit date.
Findings
The report confirms that previously identified deficiencies related to regulations 26-41-104(d) and 26-41-207(b)(5-6)(c) were corrected and completed by 10/12/2022.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-104(d) |
| Deficiency related to regulation 26-41-207(b)(5-6)(c) |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 25, 2022
Visit Reason
The document is a plan of correction submitted in response to the findings of the licensure resurvey conducted on 08/25/22 at the facility.
Findings
The plan of correction addresses the citations identified during the licensure resurvey of the facility on 08/25/22. No specific deficiencies or severity levels are detailed in this document.
Report Facts
Inspection date: Aug 25, 2022
Plan of Correction completion date: Sep 12, 2022
Inspection Report
Renewal
Census: 3
Deficiencies: 2
Aug 25, 2022
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance with state regulations for the facility.
Findings
The facility failed to ensure disaster and emergency preparedness by not performing quarterly reviews of the emergency management plan with staff and residents, and not conducting an annual emergency drill including evacuation. Additionally, the facility did not comply with tuberculosis (TB) guidelines, as several employees lacked timely TB testing and questionnaires upon hire.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure quarterly review of the emergency management plan with staff and residents and failure to conduct an annual emergency drill including evacuation. | SS=E |
| Failure to comply with tuberculosis guidelines; employees lacked timely TB testing and questionnaires upon hire. | SS=E |
Report Facts
Resident census: 3
Employee records reviewed: 5
Weeks delay in TB testing: 6
Weeks delay in TB testing: 7
Weeks delay in TB testing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator LN A | Administrator/Licensed Nurse | Named in findings related to failure to ensure emergency preparedness reviews and TB compliance |
| CNA C | Certified Nurse Aide | Employee with delayed TB testing and questionnaire |
| Facility Staff D | Employee with delayed TB testing and questionnaire | |
| Facility Staff E | Employee with delayed TB testing and questionnaire |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 1, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/02/21.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 09/10/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 3
Aug 2, 2021
Visit Reason
The inspection was conducted as a complaint investigation (KS00164373) focusing on the facility's management and accounting of residents' personal funds.
Findings
The facility failed to provide quarterly resident funds statements to one resident and/or their durable power of attorney (DPOA), failed to notify a resident and/or DPOA when funds reached within $200 of the SSI resource limit, and failed to convey remaining resident funds within 30 days of death for two residents.
Complaint Details
The complaint investigation KS00164373 focused on accounting and records of personal funds, specifically regarding quarterly statements, notification of SSI resource limit balances, and conveyance of funds upon resident death.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide quarterly resident funds statements to one of five residents reviewed. | SS=D |
| Failed to notify resident and/or DPOA when resident funds account balance reached within $200 of the SSI resource limit. | SS=D |
| Failed to convey remaining resident funds within 30 days of death for two residents. | SS=D |
Report Facts
Census: 23
Residents sampled: 5
Residents with managed funds: 10
Account balances for Resident 3: 3720.86
Account balances for Resident 3: 3106.72
Days since death for Resident 4: 255
Days since death for Resident 5: 48
Resident 4 funds balance: 176.34
Resident 5 funds balance: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Staff B | Confirmed failures to provide quarterly statements, notify SSI limit balances, and convey funds after resident deaths. |
Inspection Report
Plan of Correction
Deficiencies: 2
Aug 2, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 08/02/2021.
Findings
The plan addresses deficiencies related to providing quarterly resident funds statements and notification requirements when resident funds approach the SSI resource limit, including conveyance of remaining funds after discharge. The facility outlines corrective actions including education, audits, and ongoing monitoring to achieve substantial compliance by 09/10/2021.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide quarterly resident funds statements to resident and/or durable power of attorneys for April, May, and June. | D |
| Failure to notify resident and/or durable power of attorney when resident funds account balance reached within $200 of the SSI resource limit and failure to convey remaining funds after discharge. | D |
Report Facts
SSI resource limit: 2000
Notification threshold: 200
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 2, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2021-05-12.
Findings
All previously cited deficiencies have been corrected as of the compliance date 2021-06-01, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Jun 1, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to identified deficiencies, outlining corrective actions to achieve substantial compliance with federal Medicare/Medicaid requirements.
Findings
The plan addresses deficiencies related to food procurement, storage, preparation, and sanitary practices, as well as abuse, neglect, and exploitation training for staff. The facility has implemented staff education, weekly audits, and ongoing monitoring to ensure compliance.
Deficiencies (2)
| Description |
|---|
| Food Procurement, Store/Prepare/Serve - Sanitary practices including proper food storage, labeling, and hair restraints |
| Abuse, Neglect, and Exploitation Training including immediate reporting and protection of residents |
Report Facts
Complete Date for Plan of Correction: Jun 1, 2021
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 2
May 12, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #157445 to assess compliance with food safety and abuse, neglect, and exploitation training requirements.
Findings
The facility failed to ensure dietary staff wore hairnets and properly date food items after opening, posing a risk to all residents. Additionally, the facility did not ensure all staff received annual Abuse, Neglect, and Exploitation (ANE) training as required.
Complaint Details
The visit was triggered by a complaint investigation #157445. The complaint was substantiated as deficiencies were found related to food safety and staff training.
Severity Breakdown
SS=F: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Dietary staff failed to wear hairnets and food items were not properly dated after opening. | SS=F |
| Facility staff failed to receive annual Abuse, Neglect, and Exploitation training. | SS=D |
Report Facts
Census: 21
Number of chocolate shakes: 24
Number of boiled eggs: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff H | Dietary Staff | Observed not wearing hairnet properly in kitchen |
| Dietary Manager I | Dietary Manager | Interviewed regarding expectations for food dating and hairnet use |
| Certified Nurse Aide D | Certified Nurse Aide | Lacked evidence of annual Abuse, Neglect, and Exploitation training |
| Administrative Nurse A | Administrative Nurse | Interviewed about staff training monitoring |
| Administrative Staff B | Administrative Staff | Monitored staff trainings and interviewed about training compliance |
Inspection Report
Follow-Up
Deficiencies: 2
Dec 16, 2020
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-104(d) and 26-41-207(b)(5-6)(c) were corrected as of 12/16/2020.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-104(d) |
| Deficiency related to regulation 26-41-207(b)(5-6)(c) |
Inspection Report
Renewal
Census: 3
Deficiencies: 2
Nov 23, 2020
Visit Reason
The inspection was a licensure resurvey conducted on 11/18/2020, 11/19/2020, and 11/23/2020 to assess compliance with regulatory requirements for the Residential Health Care Facility.
Findings
The facility failed to ensure quarterly reviews of the emergency management plan with employees and residents, and failed to comply with tuberculosis guidelines by not completing TB questionnaires for all residents since 07/31/19.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure quarterly reviews of the facility's emergency management plan with employees and residents. | SS=F |
| Failure to comply with tuberculosis guidelines by not completing TB questionnaires for all residents since 07/31/19. | SS=F |
Report Facts
Census: 3
Employees participating in disaster plan review: 41
Residents sampled: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 19, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Kansas Department for Aging and Disability Services (KDADS).
Findings
The facility was found to be in compliance with Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 25, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 6/25/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 15, 2019
Visit Reason
An offsite revisit survey was conducted on 10/15/19 for all previous deficiencies cited on 08/27/19 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 09/27/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 9
Aug 27, 2019
Visit Reason
Health resurvey inspection conducted to evaluate compliance with regulatory requirements and previous deficiencies.
Findings
The facility failed to inform and provide resident R16 the opportunity to make decisions regarding alternative treatment options, failed to ensure quarterly care plan meetings for R16 and/or the resident's representative, failed to have a system for residents to file grievances anonymously, failed to follow care plans for oxygen tubing changes for residents R2 and R10 and to utilize R16's communication book, failed to provide an environment free from accident hazards by leaving chemicals accessible to residents, failed to ensure RN coverage for at least 8 consecutive hours a day on certain dates, failed to prepare pureed diets according to recipes, and failed to properly date food items stored in the refrigerator.
Severity Breakdown
SS=D: 5
SS=E: 1
SS=F: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to inform and provide R16 the opportunity to make decisions regarding the alternative treatment option of a suprapubic catheter. | SS=D |
| Failed to ensure quarterly care plan meetings for R16 and/or the resident's representative. | SS=D |
| Failed to have a system in place for residents to file grievances anonymously. | SS=F |
| Failed to follow care plan to date and/or change oxygen tubing for residents R2 and R10. | SS=D |
| Failed to utilize R16's communication book as per care plan. | SS=D |
| Failed to provide an environment free from accident hazards by leaving chemicals in an unlocked cabinet accessible to residents. | SS=E |
| Failed to utilize the services of a registered nurse for at least eight consecutive hours a day, seven days a week on specified dates. | SS=F |
| Failed to prepare pureed diets by methods that conserved nutritive value and did not follow recipes. | SS=D |
| Failed to properly store food items in refrigerator by not ensuring dessert items were dated. | SS=F |
Report Facts
Residents in census: 27
Residents in sample: 12
Dates without RN coverage for 8 consecutive hours: 4
Pureed pasta shells servings: 2
Bread slices for pureed bread: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide G | CNA | Mentioned in relation to communication with R16 and oxygen tubing care |
| Licensed Nurse C | LN | Mentioned in relation to care plan knowledge, oxygen tubing changes, and communication with R16 |
| Social Service Designee H | SSD | Mentioned in relation to communication with R16 and grievance reporting |
| Administrative Nurse B | Administrative Nurse | Mentioned in relation to communication with R16, oxygen tubing care, and grievance system |
| Environmental Services Manager D | ESM | Mentioned in relation to chemical storage and removal |
| Dietary Manager E | Dietary Manager | Mentioned in relation to pureed diet preparation and food storage |
| Certified Medication Aide J | CMA | Mentioned in relation to communication tools for R16 |
| Certified Nurse Aide I | CNA | Mentioned in relation to communication tools for R16 |
| Administrator A | Administrator | Mentioned in relation to grievance system and RN coverage |
Inspection Report
Plan of Correction
Deficiencies: 9
Aug 27, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on 2019-08-27.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including resident rights, care plan meetings, safety concerns, outdated oxygen tubing, chemical storage, staffing coverage, and dietary food handling and storage.
Severity Breakdown
D: 5
E: 1
F: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure residents' rights including informed consent and opportunity to refuse treatment. | D |
| Failure to ensure quarterly care plans were completed for all residents. | D |
| Failure to ensure residents feel safe and have unresolved issues addressed. | F |
| Outdated oxygen tubing not changed as required. | D |
| Chemicals and wipes left out improperly. | E |
| Outdated oxygen tubing not changed as required (repeat). | D |
| Insufficient RN coverage; education provided on RN coverage requirements. | F |
| Inappropriate processing of pureed food in dietary. | D |
| Undated desserts found in refrigerator; dietary staff educated on proper dating and storage. | F |
Report Facts
Deficiencies cited: 9
Audit frequency: 3
Audit duration: 4
RN coverage hours: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alisha Craft | Administrator | Administrator responsible for ensuring substantial compliance and submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 17, 2018
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 17, 2018
Visit Reason
The inspection was conducted as a health survey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 4, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each correction documented by regulation number and completion date.
Report Facts
Deficiencies corrected: 11
Inspection Report
Re-Inspection
Census: 3
Deficiencies: 11
Mar 1, 2018
Visit Reason
The inspection was a resurvey conducted on 2/28/18 and 3/1/18 to evaluate compliance with previously cited deficiencies.
Findings
The facility was found deficient in multiple areas including failure to post required notices accessible to residents, incomplete and untimely functional capacity screenings, incomplete negotiated service agreements, medication administration errors, lack of quarterly emergency preparedness reviews, and failure to comply with tuberculosis testing requirements for residents and staff.
Severity Breakdown
F: 4
E: 2
D: 5
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to post notice of availability of Residential health care policies and procedures in a place readily accessible to residents. | F |
| Failed to post names, addresses, and telephone numbers of Kansas Department on Aging and Long-Term Care Ombudsman in an accessible area. | F |
| Failed to complete functional capacity screening on or before admission for 1 of 3 residents and failed to have licensed nurse or social worker conduct screening for 1 of 3 residents. | E |
| Failed to complete functional capacity screening at least every 365 days for 1 of 3 residents. | D |
| Failed to develop a written negotiated service agreement including required elements for 1 of 3 residents. | D |
| Failed to develop an initial negotiated service agreement at admission for 1 of 3 residents. | D |
| Failed to review and revise negotiated service agreement at least every 365 days for 1 of 3 residents. | D |
| Failed to obtain signatures of all parties involved in the negotiated service agreement for 1 of 3 residents. | D |
| Failed to administer medications according to medical care provider orders and professional standards for 2 of 3 residents. | E |
| Failed to conduct quarterly reviews of the facility's emergency management plan with employees and residents. | F |
| Failed to comply with tuberculosis guidelines by not administering 2-step TB skin tests upon admission and annual TB questionnaires for residents and new employees. | F |
Report Facts
Residents: 3
Deficiencies cited: 11
Days late for functional capacity screening: 7
Days late for medication discontinuation: 8
Days late for negotiated service agreement: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff C | Confirmed lack of posting for Residential health care policies and emergency preparedness education | |
| Administrative nursing staff A | Reported on functional capacity screening and medication administration issues | |
| Administrative nursing staff B | Reported on tuberculosis testing records absence |
Inspection Report
Follow-Up
Deficiencies: 2
Nov 3, 2016
Visit Reason
The visit was a post-certification revisit to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report indicates that all previously cited deficiencies identified by regulation numbers 483.13(b) and 483.13(c)(1)(i)-(iv) were corrected as of 10/17/2016.
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
Date correction completed: Oct 17, 2016
Inspection Report
Follow-Up
Deficiencies: 0
Nov 3, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were corrected as of 10/17/2016, with corrective actions completed for each identified regulation.
Report Facts
Deficiencies corrected: 10
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 2
Oct 5, 2016
Visit Reason
Partial extended survey conducted for investigation of complaint KS00106192 regarding alleged abuse of resident #1.
Findings
The facility failed to ensure resident #1 was free from physical and verbal abuse by Direct Care Staff C, who was witnessed abusing the resident and making derogatory statements. The facility also failed to immediately report the abuse, conduct a thorough investigation, protect all residents during the investigation, and submit investigation results timely. The alleged perpetrator continued to provide care to other residents for up to two months.
Complaint Details
Investigation of complaint KS00106192 involving allegations of physical and verbal abuse of resident #1 by Direct Care Staff C. Abuse was witnessed by another staff member and reported to nursing and administrative staff who failed to take appropriate action or report to the State survey agency. The alleged perpetrator continued working and providing care to other residents for up to two months, placing all residents in immediate jeopardy.
Severity Breakdown
G: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure resident #1 was free from physical and verbal abuse by staff. | G |
| Failure to immediately report, investigate, protect residents, and submit results regarding abuse allegations. | F |
Report Facts
Census: 22
Residents selected for sample: 3
Brief Interview for Mental Status score: 9
Brief Interview for Mental Status score: 12
Time period: 2
Date of immediate jeopardy abatement: Sep 29, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff C | Direct Care Staff | Alleged perpetrator of physical and verbal abuse toward resident #1. |
| Direct Care Staff B | Direct Care Staff | Witnessed abuse of resident #1 and reported it to nursing and administrative staff. |
| Administrative Staff A | Administrator | Failed to report abuse allegation to State agency and allowed alleged perpetrator to continue working. |
| Administrative Nurse E | Former Director of Nursing | Failed to take action on abuse allegations reported by staff. |
| Licensed Nurse D | Charge Nurse | Was informed of abuse incident by staff but did not ensure appropriate action. |
| Direct Care Staff F | Direct Care Staff | Reported concerns about Staff C's rough and impatient behavior to former Director of Nursing. |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Oct 5, 2016
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 and that conditions constituted immediate jeopardy to resident health or safety from July 31, 2016 through September 29, 2016. The facility was determined to have substandard quality of care.
Severity Breakdown
immediate jeopardy: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Noncompliance with F223, "J" CFR 483.13(b) | immediate jeopardy |
| Noncompliance with F225, "L" CFR 483.13(c)(1)(ii)-(iii) | immediate jeopardy |
Report Facts
Denial of payment effective date: Oct 19, 2016
Recommended provider agreement termination date: Mar 28, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to the survey findings and enforcement actions |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 29, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during an annual survey and complaint investigation related to allegations of abuse and rough handling by staff.
Findings
The facility addressed allegations of abuse and rough handling by staff, including resignation of involved employees, counseling and education of the administrator, resident interviews showing no further allegations, skin assessments with no injuries, and implementation of ongoing monitoring and reporting protocols.
Complaint Details
Complaint investigation related to allegations of abuse and rough handling by staff; interviews and assessments found no further allegations or injuries; employee involved resigned; administrator counseled and educated on abuse reporting.
Deficiencies (1)
| Description |
|---|
| Failure to properly report and investigate allegations of abuse including rough handling by staff |
Report Facts
Plan of Correction submission date: Oct 17, 2016
Resident follow-up duration: 4
Interview monitoring duration: 3
Monthly interviews duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ALISHA CRAFT | Administrator | Administrator was counseled and further educated on reporting of abuse; submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 11
Sep 28, 2016
Visit Reason
This document is a Plan of Correction submitted in response to an annual survey inspection, addressing deficiencies cited during the survey.
Findings
The plan outlines corrective actions for multiple deficiencies including bed hold policies, significant change assessments, care plan updates, fall management, medication regimen reviews, immunization documentation, nurse staffing postings, refrigerator temperature monitoring, pharmacy recommendations follow-up, infection control program implementation, and quality assurance performance improvement.
Severity Breakdown
D: 4
G: 1
E: 3
C: 1
F: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Bed hold policy not properly signed upon admission and transfers | D |
| Significant change assessments not consistently completed | D |
| Care plans not updated appropriately related to toileting needs and bowel/bladder assessments | D |
| Fall assessments and care plan updates incomplete | G |
| Medication regimen review and audits for unnecessary medications incomplete | E |
| Pneumococcal vaccination documentation incomplete | D |
| Posted nurse staffing information incomplete or inaccurate | C |
| Refrigerator temperature issues and improper administration of snacks | E |
| Pharmacy recommendations not consistently followed up | E |
| Infection control program not fully implemented prior to September 2016 | F |
| Quality assurance performance improvement plans not fully implemented | F |
Report Facts
Deficiencies cited: 11
Audit frequency: 3
Audit frequency: 2
Education dates: Oct 4, 2016
Education dates: Oct 13, 2016
Education dates: Oct 11, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alisha Craft | Administrator | Submitted the plan of correction and involved in monitoring and audits |
| ML Kinsley | Linked to Deficiency Report | |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Enforcement
Deficiencies: 0
Sep 28, 2016
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, resulting in denial of payment for new Medicare and Medicaid admissions effective October 19, 2016, with no opportunity to correct deficiencies before remedies are imposed.
Report Facts
Denial of payment effective date: Oct 19, 2016
Compliance deadline: Mar 28, 2017
Civil Money Penalty threshold: 5000
Hearing request deadline: 60
IDR request deadline: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the enforcement action and instructions in the letter |
Inspection Report
Annual Inspection
Census: 24
Deficiencies: 8
Sep 28, 2016
Visit Reason
The inspection was a health resurvey and complaint investigation including review of bed hold policy, significant change assessments, care planning, fall prevention, medication monitoring, infection control, and other compliance areas.
Findings
The facility failed to inform a resident's responsible party about the bed hold policy, complete significant change MDS assessments timely, revise care plans for toileting and fall prevention, conduct root cause analysis for falls, monitor and manage unnecessary medications including psychotropics and insulin, maintain infection control program with proper infection trending, post nurse staffing data, and maintain safe food storage and serving temperatures.
Severity Breakdown
SS=D: 3
SS=G: 1
SS=E: 3
SS=C: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to inform resident's responsible party about bed hold policy at transfer to hospital. | SS=D |
| Failed to complete significant change MDS within 14 days after decline in ADLs and bowel incontinence. | SS=D |
| Failed to revise resident's care plan to include specific toileting needs to prevent falls. | SS=D |
| Failed to complete root cause analysis and implement interventions to prevent further falls; resident had 27 falls including one with laceration requiring sutures. | SS=G |
| Failed to ensure residents did not receive unnecessary medications by not monitoring for specific targeted behaviors and blood sugars, failure to complete gradual dose reduction, and duplication of therapy. | SS=E |
| Failed to maintain infection control program including trending infections, pathogens, antibiotic use and data analysis. | SS=F |
| Failed to post daily nurse staffing information including licensed staff and resident census. | SS=C |
| Failed to store potentially hazardous foods at safe temperatures below 41°F and failed to serve potentially hazardous foods at safe temperature. | SS=E |
Report Facts
Resident census: 24
Falls: 27
Laceration sutures: 6
Temperature: 52
Temperature: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | MDS Coordinator / Administrative Nurse | Failed to complete significant change MDS and revise care plan for resident #16 |
| Physician H | Physician | Provided clinical opinions on resident discharge and medication monitoring |
| Consultant Pharmacist S | Consultant Pharmacist | Recommended gradual dose reductions and medication monitoring |
| Direct Care Staff C | Reported resident behaviors and toileting practices | |
| Direct Care Staff E | Reported resident behaviors and toileting practices | |
| Licensed Nurse F | Licensed Nurse | Reported resident behaviors and medication monitoring |
| Administrative Staff B | Administrative Nurse | Discussed infection control program and medication monitoring |
| Administrative Staff A | Administrator | Discussed QAA committee and nurse staffing posting |
| Dietary Manager L | Dietary Manager | Reported on refrigerator temperature and food safety |
| Direct Care Staff M | Observed serving unsafe temperature food to resident |
Inspection Report
Life Safety
Deficiencies: 1
Apr 20, 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 deficiency to be at '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 deficiency found to be '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: Jul 20, 2016
Provider agreement termination date: Oct 20, 2016
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 certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 1
May 15, 2015
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at Medicalodges Kinsley.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 05/15/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited and corrected. |
Inspection Report
Follow-Up
Deficiencies: 0
May 15, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, May 15, 2015.
Report Facts
Deficiencies corrected: 11
Inspection Report
Plan of Correction
Deficiencies: 9
May 1, 2015
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Kinsley in response to deficiencies identified in a prior survey (Event ID OHO711). It outlines corrective actions to address cited deficiencies and achieve substantial compliance.
Findings
The Plan of Correction details multiple corrective actions including audits, education, monitoring, and environmental safety improvements to address deficiencies related to resident assessments, catheter care, medication use, food storage, laundry equipment, and facility safety.
Deficiencies (9)
| Description |
|---|
| Quality Assurance efforts to maintain substantial compliance with Requirements of Participation |
| Significant change completed and submitted on resident #5; review of residents with recent declines |
| Residents #25 and #21 no longer reside; corrections to assessments for residents #32 and #3 |
| Clarification of catheter order and care plan for resident #39; audit of catheter care plans |
| Securing hazardous items and locking doors to assisted living and soiled utility areas |
| Care plan indicators and interventions for anti-anxiety medication use for resident #31 |
| Proper labeling, dating, storing, temperature taking, and sanitary conditions of food in refrigerators |
| Washing machines not dispensing proper chemicals taken out of service; new machine quoted |
| Cleaning of trough and industrial washing machines; daily cleaning log created |
Report Facts
Completion date for substantial compliance: May 15, 2015
Date of significant change submission: May 1, 2015
Education dates: Apr 27, 2015
Education dates: May 1, 2015
Education dates: Apr 17, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alisha Craft | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 16, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective May 15, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| F level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy | F |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 1
Apr 16, 2015
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to employ a full-time dietary supervisor who had successfully completed a certified dietary manager's training/education course, as the current dietary manager was still enrolled in the certification course and not yet certified.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to employ a full-time dietary supervisor who successfully completed a certified dietary manager's training/education course. | F |
Report Facts
Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff O | Dietary Manager | Named as the dietary manager who was enrolled but not yet certified in the dietary manager certification course. |
| Administrative Staff A | Confirmed Dietary Staff O lacked certification but was enrolled in the course. |
Inspection Report
Life Safety
Deficiencies: 1
Sep 16, 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 'D' level deficiencies, isolated, with no harm but 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
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found during the Life Safety Code survey | D |
Report Facts
Denial of payments effective date: Dec 16, 2014
Provider agreement termination date: Mar 16, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carie Perez | 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 |
| Joe Ewert | Commissioner | Mentioned in report distribution |
Inspection Report
Re-Inspection
Deficiencies: 1
Jan 20, 2014
Visit Reason
This revisit report documents the correction of deficiencies previously reported during a prior survey conducted on 12/23/2013.
Findings
The report confirms that the previously cited deficiency with ID prefix S0835 and regulation number 28-39-161 was corrected as of 01/20/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency previously cited under regulation 28-39-161 with ID prefix S0835 |
Report Facts
Deficiencies corrected: 1
Inspection Report
Follow-Up
Deficiencies: 0
Jan 20, 2014
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 numbers were corrected as of the revisit date, January 20, 2014.
Report Facts
Deficiency corrections: 8
Inspection Report
Re-Inspection
Deficiencies: 4
Dec 31, 2013
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey, verifying that corrective actions were completed by the facility.
Findings
The report confirms that all previously identified deficiencies related to specific regulations were corrected as of 12/31/2013.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 26-41-205 (a) (1) |
| Deficiency related to regulation 26-41-205 (h) |
| Deficiency related to regulation 26-41-206 (d) |
| Deficiency related to regulation 26-41-207 (a) (b) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 11
Dec 24, 2013
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Kinsley in response to deficiencies cited in a prior inspection report (2567). It outlines corrective actions to address identified issues and maintain compliance with Federal Medicare and State Medicaid requirements.
Findings
The Plan of Correction details multiple corrective actions including cleaning and maintenance of facility areas, staff in-service education on procedures such as pain assessment and sharps disposal, monitoring of resident assessments and care plans, and ongoing quality assurance oversight to prevent recurrence of deficiencies.
Deficiencies (11)
| Description |
|---|
| Ceiling vents and light fixtures on 300 hall were thoroughly cleaned; linoleum flooring repair scheduled; shower room wall repair planned; housekeeping staff in-serviced on deep cleaning procedures. |
| Full comprehensive assessments for residents #2 and #29 to be completed using MDS/CAA process; audits of assessments to ensure compliance. |
| Pain assessment completed for resident #10; staff educated on PRN pain medication administration and documentation. |
| Metal hardware on 200 hall wall repaired; routine environmental rounds to monitor prevention of deficient practices. |
| Hazardous chemicals secured; staff educated on proper storage; patient care areas monitored through environmental rounds. |
| Resident #18 fall risk assessment reviewed; staff educated on fall prevention care planning; monitoring of compliance by DON. |
| Resident #31 blood sugar notification procedures improved; staff educated on physician notification and documentation. |
| Ice machine vents and kitchen air circulation vent cleaned; monthly cleaning and defrost schedules established. |
| Pharmacist consultant to monitor medication orders and report irregularities monthly. |
| Sharps disposal education provided; compliance monitored through direct observation. |
| Laundry personnel trained on wash water temperature monitoring; compliance monitored through temperature logs. |
Report Facts
Dates of in-service education: Dec 23, 2013
Dates of repairs and cleaning: Dec 31, 2013
Dates of monitoring and audits: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carie Perez | Administrator | Administrator involved in environmental rounds and monitoring compliance |
| Director of Nursing | DON | Oversight of assessments, pain management, fall prevention, and quality assurance monitoring |
| MDS Coordinator | Responsible for auditing comprehensive assessments | |
| Dietary Manager | Monitors cleaning schedule of kitchen equipment | |
| Pharmacist Consultant | Monitors medication orders and reports irregularities | |
| Maintenance/Housekeeping Supervisor | Conducts environmental rounds and monitors compliance |
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 9
Dec 23, 2013
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with regulatory requirements including housekeeping, comprehensive assessments, care and services, accident hazards, drug regimen, food sanitation, infection control, and medication review.
Findings
The facility was found deficient in multiple areas including failure to maintain sanitary conditions, incomplete comprehensive assessments, inadequate pain assessment and management, unsafe environment hazards, failure to prevent falls, improper medication monitoring, failure to report medication irregularities, improper disposal of sharps, and failure to maintain food storage sanitation.
Severity Breakdown
SS=E: 2
SS=D: 5
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior including unclean ceiling vents, dead insects in light fixtures, damaged flooring, and unrepaired shower room wall. | SS=E |
| Failed to complete comprehensive assessments (CAAs) timely and adequately for multiple residents regarding ADLs, psychosocial well-being, pain, psychotropic drug use, falls, and urinary incontinence. | SS=D |
| Failed to provide necessary care and services to attain or maintain highest practicable well-being when nursing staff failed to assess a resident's complaint of pain prior to administering as needed pain medication. | SS=D |
| Failed to ensure resident environment free of accident hazards including unsecured metal hardware and accessible hazardous chemicals. | SS=E |
| Failed to develop and implement appropriate fall prevention strategies after multiple falls for a resident at high risk for falls. | SS=D |
| Failed to ensure drug regimen free from unnecessary drugs by inadequate monitoring of blood sugar levels and failure to notify physician, and failure to include black box warning for antipsychotic medication on care plan. | SS=D |
| Failed to store food under sanitary conditions including dust on air circulation vents, frost inside chest freezer, and uncovered mixer stored upright. | SS=F |
| Failed to ensure pharmacist reported medication irregularities to director of nursing and physician related to inadequate monitoring of medications. | SS=D |
| Failed to provide a safe, sanitary environment to prevent infection by improper disposal of sharp equipment in non-designated trash containers. | SS=D |
Report Facts
Residents sampled: 11
Residents sampled for medication review: 5
Fall risk score: 21
Blood sugar readings above 350 mg/dl: 5
Residents census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Housekeeping/Maintenance/Laundry Staff | Denied awareness of damaged wall and torn linoleum; confirmed dust and dead insects in light fixtures |
| Licensed Nursing Staff C | Licensed Nurse | Acknowledged failure to complete MDS/CAA process and inadequate pain assessment |
| Direct Care Staff O | Direct Care Staff | Administered as needed Tylenol without reporting pain complaint to nurse |
| Administrative Nurse B | Administrative Nurse | Confirmed failure to complete MDS/CAA and pain assessment processes |
| Consultant M | Consultant Pharmacist | Failed to report medication irregularities related to blood sugar monitoring and black box warnings |
| Licensed Nursing Staff D | Licensed Nurse | Improper disposal of lancet and sharps in regular trash |
Inspection Report
Re-Inspection
Census: 5
Deficiencies: 4
Dec 23, 2013
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with state regulations for a residential health care facility.
Findings
The facility failed to complete a required assessment before a resident began self-administration of medications, failed to securely store medications accessible only to the resident and authorized staff, failed to maintain sanitary food storage and preparation conditions, and failed to ensure proper laundering and handling of linens by not monitoring laundry water temperatures daily.
Severity Breakdown
SS=D: 2
SS=F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to complete an assessment for self-administration of medications before a resident initially began self-administration. | SS=D |
| Failed to store medications in a place accessible only to the resident, licensed nurses, and medication aides. | SS=D |
| Failed to store food in a sanitary manner as required by federal, state, and local laws. | SS=F |
| Failed to ensure laundering and handling of soiled linens met professional health care standards by not monitoring laundry water temperatures daily. | SS=F |
Report Facts
Census: 5
Sample size: 3
Rings of frost: 4
Inspection Report
Follow-Up
Deficiencies: 9
Oct 5, 2012
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
The report shows that all previously identified deficiencies were corrected by the revisit date of 10/05/2012, with corrections documented for multiple regulatory requirements.
Deficiencies (9)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(5) - (10), 483.10(b)(1) |
| Deficiency related to regulation 483.10(g)(1) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.70(c)(2) |
Report Facts
Deficiencies corrected: 9
Inspection Report
Census: 6
Deficiencies: 3
Sep 7, 2012
Visit Reason
The visit was a licensure survey conducted to assess compliance with regulatory requirements for an adult day care facility.
Findings
The facility was found deficient in developing a written negotiated service agreement reflecting residents' service needs, ensuring accessibility of the most recent survey report to residents and visitors, and maintaining sanitary food preparation conditions, specifically failing to clean the kitchen exhaust hood adequately.
Severity Breakdown
SS=D: 1
SS=C: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to develop a written negotiated service agreement based on resident #2's service needs, specifically lacking medication management services description. | SS=D |
| Failure to ensure residents and visitors had accessibility to the most recent survey report, as it was placed out of reach for wheelchair users. | SS=C |
| Failure to store, prepare, and distribute food under sanitary conditions due to inadequate cleaning of the kitchen exhaust hood over food preparation and dish storage areas. | SS=F |
Report Facts
Census: 6
Sampled residents for review: 3
Inspection Report
Plan of Correction
Deficiencies: 9
Sep 7, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report (2567) for Med Kinsley 090712 ALF State and Federal surveys.
Findings
The Plan of Correction outlines specific corrective actions to address multiple deficiencies including medication management, accessibility of survey results, cleanliness and maintenance of equipment and facility areas, and compliance with pharmacy review protocols. Responsibilities for ongoing compliance are assigned to various staff members including the Director of Nursing, Environmental Services Supervisor, and Facility Administrator.
Severity Breakdown
C: 3
E: 5
F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Inaccuracy in the Negotiated Service Agreement for residents needing medication management. | C |
| Survey Results Book not accessible to wheelchair-bound residents and visitors. | C |
| Exhaust hood and venting system not properly cleaned. | F |
| Medicare/Medicaid benefits posting incomplete. | C |
| Dirt and grime buildup at baseboards and maintenance issues with laundry equipment. | E |
| Housekeeping carts not secured and hazardous chemicals not properly stored. | E |
| Black box warning medications not properly care planned or monitored. | E |
| Air conditioning equipment not maintaining proper medication storage temperatures. | E |
| Malfunctioning laundry equipment and corroded hose connectors. | E |
Report Facts
Completion Date: Sep 7, 2012
Completion Date: Oct 5, 2012
Completion Date: Sep 10, 2012
Completion Date: Sep 13, 2012
Completion Date: Sep 17, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Velder | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 4
N024001 POC NE8U11
Visit Reason
This document is a Plan of Correction submitted by Medicalodges, Kinsley in response to deficiencies cited in a prior survey (Deficiency Report 2567). It outlines corrective actions to address issues identified by surveyors.
Findings
The Plan of Correction details specific actions including assessment of resident #1 for medication self-administration, securing medications with a lock, cleaning and maintenance schedules for equipment, and staff training on laundry water temperature monitoring to prevent recurrence of cited deficiencies.
Severity Breakdown
D: 2
F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Resident #1 was assessed by a licensed nurse for self-administration of medications with documentation placed in medical record. | D |
| A lock was placed to the top dresser drawer of resident #1 to provide a secure storage area for medications and ensure restricted access by others. | D |
| Ice machine vents, air circulation vent, and mixer were cleaned. The chest freezer was defrosted and cleaned. | F |
| Laundry personnel received in-service education and training on checking daily wash water temperatures, notification of supervisor if not within limits, and documentation on temperature log per chemical supplier recommendations. | F |
Report Facts
Complete Date: Jan 20, 2014
Complete Date: Dec 31, 2013
Complete Date: Dec 27, 2013
Complete Date: Dec 23, 2013
Complete Date: Dec 31, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carie Perez | Administrator | Submitted the Plan of Correction to KDADS |
Loading inspection reports...
