Inspection Report Summary
The most recent inspection on July 19, 2016, found that all previously cited deficiencies had been corrected. Earlier inspections showed multiple deficiencies related mainly to environmental cleanliness, food sanitation, medication management—particularly monitoring black box warnings—and resident safety, including supervision to prevent elopement. Complaint investigations substantiated issues with resident supervision and medication practices, though fines or enforcement actions were not listed in the available reports. The facility submitted plans of correction addressing these areas, and follow-up visits confirmed many corrections over time. The inspection history indicates improvement in compliance, especially in environmental and safety concerns, by the time of the most recent revisit.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
81 residents
Based on a June 2016 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Jul 19, 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 identified by regulation numbers 483.15(h)(6), 483.20(g)-(j), 483.25(l), 483.35(i), 483.60(c), and 483.70(c)(2) were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 81
Deficiencies: 6
Jun 20, 2016
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously identified deficiencies.
Findings
The facility failed to maintain comfortable temperature levels in resident rooms and common areas, failed to complete accurate resident assessments, failed to monitor and document black box warnings for medications, failed to maintain sanitary food preparation conditions, failed to maintain essential equipment in safe operating condition, and failed to ensure pharmacist review identified care plan omissions.
Severity Breakdown
SS=E: 2
SS=D: 3
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain comfortable temperature levels in 5 resident rooms, a common TV room, and a men's bathing room with temperatures below the required range of 71-81°F. | SS=E |
| Failed to complete accurate comprehensive assessments for 2 of 9 sampled residents related to activities of daily living (ADLs). | SS=D |
| Failed to ensure resident's drug regimen was free from unnecessary drugs; specifically, failed to include black box warning for Lamictal in the care plan. | SS=D |
| Failed to store, prepare, and serve food under sanitary conditions, including dusty fan blowing on clean dishes, expired food item, unclean cabinet surfaces, missing trash can lids, and ineffective sanitizer buckets. | SS=F |
| Failed to ensure pharmacist review identified and reported irregularities related to black box warnings for medications. | SS=D |
| Failed to maintain essential mechanical and patient care equipment in safe operating condition, including 2 resident bathtubs out of order, nonfunctional beauty shop exhaust vent, and a nonworking, grimy kitchen oven. | SS=E |
Report Facts
Resident census: 81
Resident sample size: 9
Residents reviewed for unnecessary medications: 5
Resident rooms with temperature issues: 5
Sanitizer buckets without proper sanitizer: 2
Resident bathtubs out of order: 2
Resident sample with inaccurate assessments: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Maintenance Staff | Set temperature controls and reported bathtub seal leak |
| Staff F | Administrative Nursing Staff | Reviewed medication black box warnings and coded resident assessments |
| Staff C | Dietary Staff | Responsible for checking food expiration dates and sanitizer buckets |
| Staff I | Dietary Staff | Checked sanitizer buckets and reported issues with sanitizer levels |
| Staff H | Dietary Staff | Reported kitchen oven not working |
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 20, 2016
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 deficiency to be an 'F' level deficiency, 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 deficiency found was an 'F' level deficiency, 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 | Licensure Certification & Enforcement Manager | Named as contact and signatory related to the survey findings and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 6
Jun 16, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection report dated 06/20/2016.
Findings
The Plan of Correction outlines specific corrective actions for multiple deficiencies including room temperature adjustments, accurate MDS coding, monitoring of medications with black box warnings, sanitation improvements in dietary areas, and maintenance repairs.
Severity Breakdown
E: 3
D: 3
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Room temperatures adjusted to acceptable levels and periodic checks instituted. | E |
| Quarterly MDS corrections to reflect accurate resident ambulation and assistance needs; additional ADL coding training provided. | D |
| Monitoring and documentation of black box warnings for Lamictal on EMAR and physician orders with audits. | D |
| Cleaning and sanitation improvements in dishwashing and dietary areas including disposal of corn syrup and replacement of trash cans. | F |
| Pharmacist consultant to review medication regimens monthly including black box warnings. | D |
| Facility to repair floor drain, replace exhaust fan in beauty shop, and conduct periodic equipment checks. | E |
Report Facts
Deficiency completion dates: Jul 19, 2016
Quarterly MDS date: Jun 16, 2016
Inspection Report
Follow-Up
Deficiencies: 1
Apr 14, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective action was accomplished.
Findings
The revisit report indicates that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected and completed as of 04/14/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID Prefix F0323 related to regulation 483.25(h) |
Inspection Report
Life Safety
Deficiencies: 1
Mar 22, 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 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 not constituting immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jun 22, 2016
Provider agreement termination date: Sep 22, 2016
IDR request 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 for Informal Dispute Resolution process and enforcement actions. |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Mar 16, 2016
Visit Reason
The inspection was conducted as an investigation of complaints #97875 and #98169 regarding resident safety and supervision.
Findings
The facility failed to ensure that one of five residents sampled for elopement did not leave the facility without staff knowledge. The resident, who had moderate cognitive impairment and a high risk for elopement, left the facility after 7:30 P.M. and was missing until staff and police found him approximately 11 hours later about 0.1 mile from the facility with minor injury.
Complaint Details
The investigation was triggered by complaints #97875 and #98169. The resident eloped from the facility without staff knowledge, was missing for approximately 11 hours, and was found with a minor injury. The resident had a history of schizophrenia, moderate cognitive impairment, and was assessed as high risk for elopement.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure resident environment remained free of accident hazards and provide adequate supervision to prevent elopement of a high-risk resident. | SS=D |
Report Facts
Census: 83
Resident elopement risk score: 15
Resident elopement risk score: 18
Resident elopement risk score: 15
Elapsed time resident missing: 11.75
Temperature low point: 42
Safety check interval: 30
Visual check interval: 15
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 16, 2016
Visit Reason
This plan of correction document addresses deficiencies identified in a complaint investigation related to resident safety and elopement risk.
Findings
The facility implemented corrective actions including moving resident #1 closer to the nurse's station, initiating 15-minute observation checks, updating care plans for residents at risk of elopement, educating staff on missing resident policies, and installing cameras at exits.
Complaint Details
This plan of correction is linked to a complaint investigation identified as ML Paola complaint dated 03/16/2016.
Deficiencies (1)
| Description |
|---|
| Resident #1 was at risk of elopement and required closer observation and individualized interventions. |
Report Facts
Observation check interval: 15
Completion date for camera installation: Mar 28, 2016
Substantial compliance date: Apr 14, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for plan of correction assistance. | |
| Nanci Rowlett | Business Office Manager | Submitted the plan of correction to KDADS. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Mar 16, 2016
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 of correction.
Severity Breakdown
D level: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be a D level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D level |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 17, 2016
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified related to Resident #1's care, specifically regarding observation and elopement risk management following a complaint investigation.
Findings
Resident #1 was under 1 to 1 observation until hospitalization screening, then sent to a psychiatric facility. Upon return, the resident was placed on 15-minute visual checks with an elopement assessment completed. The care plan was updated, staff educated, and alerts sent to staff regarding elopement risk.
Complaint Details
This Plan of Correction is linked to a complaint investigation (ML Paola complaint 02122016) involving Resident #1's observation and elopement risk management.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to adequately monitor Resident #1 for elopement risk and update care plan accordingly. | D |
Report Facts
Observation frequency: 15
Plan of Correction completion date: Mar 13, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Unknown | Contact person for Plan of Correction assistance |
| Nanci Rowlett | Business Office Manager | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Feb 12, 2016
Visit Reason
The inspection was conducted as a result of complaint investigations #96687 and #93170 regarding resident safety and supervision.
Findings
The facility failed to ensure that one resident with schizophrenia and psychosis eloped from the facility without staff knowledge, despite documented risks and behavioral changes. The resident was found off premises and returned with police assistance. The facility did not prevent the elopement, violating safety and supervision requirements.
Complaint Details
The complaint investigations #96687 and #93170 found that the resident eloped from the facility on 1-30-16 at 12:15 p.m. The resident had increased hallucinations, delusions, manic behavior, and medication refusal prior to elopement. The resident was placed on safety checks upon return and qualified for hospitalization but no bed was available immediately. The facility failed to prevent the elopement despite risk assessments indicating no elopement risk.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that one of four sampled residents did not leave the facility without staff knowledge. |
Report Facts
Census: 82
Sample size: 4
BIMS score: 15
Elopement time: 1215
Observation interval: 15
Date of resident readmission: Jan 21, 2016
Inspection Report
Follow-Up
Deficiencies: 3
Apr 11, 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
The report documents that corrections were completed for deficiencies identified under regulations 483.15(h)(2), 483.35(i), and 483.70(h) as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.70(h) |
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 12, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date of substantial compliance: Apr 11, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darin Cizerle | Administrator | Facility administrator named in the report |
| Irina Strakhova | Enforcement Coordinator | Author of the report |
| Janice VanGotten | Regional Manager | Copied on the report |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 3
Mar 12, 2015
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation #75812 to assess housekeeping, maintenance, food sanitation, and environmental conditions at the facility.
Findings
The facility failed to maintain sanitary housekeeping and maintenance services in resident hallways, failed to store, prepare, and serve food under sanitary conditions in the dietary department, and failed to maintain a safe, functional, sanitary, and comfortable environment in the kitchen and front exterior of the building.
Complaint Details
The visit was triggered by a complaint investigation #75812. The findings represent deficiencies identified during this complaint-related resurvey.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services to maintain a sanitary interior on 2 of 2 resident hallways, including dirty carpets, dusty debris, stained walls, and damaged doors. | SS=F |
| Failed to store, prepare, and serve food under sanitary conditions, including dirty storage racks, contaminated condiment tubs, unclean refrigerators, baking pans with buildup, dirty cutting boards, dusty ice machine vent, and inadequate cleaning documentation. | SS=F |
| Failed to provide a safe, functional, sanitary, and comfortable environment in the kitchen and front exterior of the facility, including accumulation of grime and dirt on kitchen floors, dirty front entrance door and grounds with cigarette butts and debris. | SS=F |
Report Facts
Census: 87
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported on housekeeping and maintenance issues and cleaning responsibilities | |
| Housekeeping staff E | Reported on housekeeping issues and cleaning responsibilities | |
| License nursing staff F | Advised uncertainty about cleaning responsibilities for oxygen concentrators and CPAP machines | |
| Resident #80 | Reported dirty CPAP and oxygen machine | |
| Administrative nursing staff B | Advised on cleaning schedules and documentation for resident equipment | |
| Housekeeping staff E | Stated dietary staff needed to clean dietary department | |
| Dietary staff D | Reported on kitchen cleaning responsibilities and conditions | |
| Maintenance staff H | Reported on exterior grounds cleaning and resident participation in cigarette butt cleanup |
Inspection Report
Life Safety
Deficiencies: 1
Jun 17, 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 deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Denial of payments effective date: Sep 17, 2014
Provider agreement termination date: Dec 17, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Niels Nielsen | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Follow-Up
Deficiencies: 1
Dec 26, 2013
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 confirms that the deficiency identified under regulation 483.60(b), (d), (e) with ID prefix F0431 was corrected as of 12/26/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.60(b), (d), (e) previously cited and corrected. |
Report Facts
Deficiency correction date: Dec 26, 2013
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 3
Nov 26, 2013
Visit Reason
The inspection was conducted as a health resurvey and complaint investigations #69598, 70548, and 70640.
Findings
The facility failed to monitor medication expiration dates, administer medications according to standards of practice, and maintain accurate reconciliation of discontinued medications to be returned to the pharmacy.
Complaint Details
The visit included complaint investigations #69598, 70548, and 70640. The deficiencies were substantiated as evidenced by observations and interviews.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to monitor expiration dates on medications, including expired Simethicone and Vitamin E found on medication carts. | SS=E |
| Failed to administer medications in accordance with standards of practice, including setting up medications ahead of administration time. | SS=E |
| Failed to maintain accurate reconciliation and documentation of discontinued medications to be returned to the pharmacy. | SS=E |
Report Facts
Census: 86
Expired medication quantities: 6
Expired medication quantities: 3
Discontinued medications count: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Reported on medication aide checks and medication administration policies. | |
| Direct care staff B | Reported on medication setup practices and filling out medication return papers. | |
| Direct care staff C | Reported on missed expiration date monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 26, 2013
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited during a survey completed on November 26, 2013, related to medication storage and handling.
Findings
The facility was found deficient in medication storage and destruction practices, including improper handling of discontinued medications and expired medications. The plan outlines corrective actions including staff education, routine inspections, and ongoing monitoring to ensure compliance.
Severity Breakdown
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to properly fill out the 'Drug Returned to Pharmacy Log' and timely removal of discontinued medications from medication carts. | — |
| Issues related to storing and destruction of medications, including expired medications not being properly removed. | E |
Report Facts
Deficiency cited date: Nov 26, 2013
Plan of Correction completion date: Dec 26, 2013
Inspection Report
Follow-Up
Deficiencies: 4
Sep 2, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously cited deficiencies identified by regulation numbers 483.15(h)(2), 483.25(h), 483.25(l), and 483.60(c) were corrected as of 09/02/2012.
Deficiencies (4)
| Description |
|---|
| 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 483.60(c) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 4
Aug 3, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with housekeeping, maintenance, accident hazards, and medication regimen requirements, including monitoring of medications with black box warnings.
Findings
The facility failed to maintain a sanitary and comfortable environment, with multiple housekeeping and maintenance deficiencies noted. The facility also failed to provide an environment free of accident hazards. Additionally, the facility failed to identify, monitor, and act on adverse consequences related to medications with black box warnings for multiple residents, and lacked policies and procedures to address these issues.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services to maintain a sanitary and comfortable interior. | SS=E |
| Failed to provide an environment free of accident hazards on 2 of 2 halls. | SS=E |
| Failed to ensure residents' drug regimens were free from unnecessary drugs and failed to monitor adverse consequences of medications with black box warnings. | SS=E |
| Failed to act on pharmacy recommendations regarding monitoring adverse side effects for residents receiving medications with black box warnings. | SS=E |
Report Facts
Census: 83
Deficiencies cited: 4
Medication sample size: 8
Residents with medication monitoring failures: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| maintenance staff B | Acknowledged housekeeping and maintenance concerns during environmental tour | |
| housekeeping staff C | Acknowledged housekeeping and maintenance concerns during environmental tour | |
| housekeeping staff D | Reported new mops and cleaning practices | |
| licensed nursing staff H | Reported on black box warnings and side effects of medications | |
| direct care staff I | Reported black box warnings listed on MAR and care plans | |
| administrative nursing staff A | Reported lack of policy for black box warnings and changes to care plans | |
| administrative nursing staff E | Confirmed black box warnings not on care plans and pharmacy consultant involvement | |
| licensed nursing consultant G | Reported corporation had not implemented changes and plan was on hold | |
| consultant pharmacist staff F | Recommended adding specific black box warnings to care plans | |
| licensed nursing staff J | Verified physician order for lab testing and lack of lab results | |
| licensed nursing staff K | Explained lab testing was delayed and rescheduled |
Inspection Report
Plan of Correction
Deficiencies: 4
Aug 3, 2012
Visit Reason
This Plan of Correction document addresses deficiencies cited during the survey completed on August 3, 2012, outlining corrective actions the facility will implement to ensure compliance with regulations.
Findings
The facility identified multiple deficiencies related to housekeeping and maintenance services, resident environment safety, and medication management, particularly regarding monitoring and administration of antipsychotic drugs and black box warning medications. The plan details specific corrective actions, including cleaning schedules, repairs, staff education, and ongoing audits.
Severity Breakdown
E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. | E |
| Failure to ensure the resident environment remains as free of accident hazards as possible and provide adequate supervision and assistance devices to prevent accidents. | E |
| Failure to ensure residents who have not used antipsychotic drugs are given these drugs only when necessary and that residents using antipsychotic drugs receive gradual dose reductions and behavioral interventions unless contraindicated. | E |
| Failure to ensure the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist, with irregularities reported and acted upon. | E |
Report Facts
Date of survey: Aug 3, 2012
Plan of Correction completion date: Sep 2, 2012
Scheduled QA/SEP committee meeting: Aug 29, 2012
Bid award deadline: Sep 13, 2012
Sample residents reviewed: 7
Inspection Report
Plan of Correction
Deficiencies: 3
N061002 POC EK4B11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of the facility.
Findings
The plan addresses multiple environmental and cleanliness deficiencies including cleaning and repairing rooms, bathrooms, kitchen equipment, and facility grounds. Specific corrective actions and timelines for achieving substantial compliance by 04/11/2015 are detailed.
Deficiencies (3)
| Description |
|---|
| Environmental cleanliness issues including floor and corners of rooms, window sills, CPAP machine, shelves, bathroom grout and walls, carpeted walls, bathroom floors, toilets, sinks, unlabeled hair brush, damaged walls and doors, and light switches. |
| Food storage and kitchen cleanliness issues including cleaning and rust removal of storage racks, cleaning condiment containers, covering salad dressing containers, cleaning refrigerator handles and shelves, cleaning cookie sheets and muffin pans, repairing pan storage rack, replacing cutting boards, cleaning kitchen equipment and surfaces, and discarding toaster. |
| Kitchen floor cleaning, debris removal from facility grounds, cleaning brick wall on front of building, and establishing cleaning schedules and periodic audits. |
Report Facts
Complete Date: Apr 11, 2015
QA Committee Date: Mar 19, 2015
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