Inspection Reports for Meridian Rehabilitation & Health Care Center
1555 N. MERIDIAN STREET, WICHITA, KS, 67203-1998
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 30, 2019, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed recurring deficiencies related to resident care, including enteral feeding tube management, nursing staffing and leadership, medication labeling, and cleanliness of feeding equipment. Complaint investigations over the years identified issues with resident dignity, pressure ulcer prevention and treatment, fall prevention, medication errors, infection control, and staffing adequacy, with some substantiated complaints leading to enforcement actions such as denial of payment for new admissions. Enforcement remedies were noted in earlier years, particularly related to pressure ulcers and widespread deficiencies at an "F" level, but no fines or license suspensions were listed in the available reports. The facility appears to have made improvements over time, correcting previously cited deficiencies and achieving compliance in the most recent surveys.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
41 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
583% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
89 residents
Based on a November 2019 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 30, 2019
Visit Reason
A revisit survey was conducted on 12/30/19 to verify correction of all previous deficiencies cited on 11/07/19.
Findings
All deficiencies have been corrected as of the compliance date of 12/16/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Nov 21, 2019
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey that exited on 2019-11-21 at Meridian Rehabilitation & Health Care Center, outlining corrective actions to assure compliance with regulations.
Findings
The facility addressed multiple deficiencies including care for residents with enteral feeding tubes, nursing coverage and leadership by the Director of Nursing, proper labeling of insulin pens, and cleanliness of feeding pump poles. Corrective actions include staff education, auditing schedules and care practices, and ongoing QA committee review to ensure substantial compliance.
Deficiencies (4)
Standard of care for resident #1 enteral feeding tube was deficient.
Nursing coverage and leadership by the Director of Nursing was inadequate.
Insulin pens were not properly labeled with open or discard dates.
Feeding pump poles were not clean and lacked a cleaning schedule.
Report Facts
Audit frequency: 2
Audit frequency: 3
Audit duration: 8
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 4
Date: Nov 7, 2019
Visit Reason
The inspection was a Non-Compliance Revisit to assess correction of previously cited deficiencies related to tube feeding management, staffing, medication labeling, and infection control.
Findings
The facility failed to ensure proper care for a resident's enteral feeding tube, adequate licensed nurse staffing, proper labeling of insulin pens, and maintenance of cleanliness of tube feeding pumps and poles, posing risks to resident safety and infection control.
Deficiencies (4)
Failed to ensure standard of care for resident's gastric feeding tube, including failure to replace leaking feeding tube plug before dialysis.
Failed to ensure adequate licensed nurse staffing; Director of Nursing worked floor as charge nurse in a facility with census over 60.
Failed to properly label two insulin pens with an 'open date' or 'discard by' date.
Failed to develop a cleaning schedule and provide ongoing monitoring of cleanliness of tube feeding pumps and poles, leading to dried, spilled feeding formula on equipment and floor.
Report Facts
Facility census: 89
Feeding tube flush volume: 200
Fluid restriction: 1500
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Director of Nursing | Named in findings related to staffing and feeding tube care |
| Licensed Nurse J | Licensed Nurse | Performed feeding tube care and dressing changes for resident R1 |
| Certified Nurse Aide B | Certified Nurse Aide | Reported resident resistance to care and feeding tube issues |
| Licensed Nurse G | Licensed Nurse | Reported on insulin labeling and feeding pump cleanliness |
| Administrative Staff A | Administrative Staff | Commented on staffing challenges and feeding pump cleanliness |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 22, 2019
Visit Reason
A revisit survey was conducted on 8/21/19-8/22/19 for all previous deficiencies cited on 6/26/19.
Findings
All deficiencies have been corrected as of the compliance date of 7/31/19 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 14
Date: Jul 12, 2019
Visit Reason
The inspection was conducted as a result of multiple complaint investigations regarding resident care, dignity, pressure ulcers, falls, medication errors, infection control, and facility environment.
Complaint Details
The inspection was triggered by multiple complaint investigations (#KS00142800, #KS00142584, #KS00142427, #KS00142364, #KS00142247, #KS00142302, #KS00141854, #KS00141739, #KS00141273, and #KS00137377).
Findings
The facility failed to treat residents with respect and dignity, failed to provide adequate care to prevent and treat pressure ulcers, failed to provide adequate supervision and fall prevention, failed to prevent significant medication errors, failed to employ qualified dietary staff and follow nutritional guidelines, failed to maintain sanitary conditions, and failed to manage resident pain appropriately.
Deficiencies (14)
Failed to treat residents with respect and dignity during incontinence care and grooming.
Failed to provide necessary services to maintain good nutrition, grooming, and hygiene for dependent residents.
Failed to provide care to prevent and promote healing of pressure ulcers including timely repositioning and incontinence care.
Failed to provide adequate supervision and assistive devices to prevent accidents and falls.
Failed to care for resident's catheter to prevent infection following bowel incontinence.
Failed to manage pain for a resident during transfer and incontinence care, ignoring verbal and non-verbal pain indicators.
Failed to have sufficient nursing staff with appropriate competencies and skill sets to provide nursing services to assure resident safety.
Failed to ensure residents were free of significant medication errors including administering 8 times the ordered dose of Clonidine and administering insulin to a non-diabetic resident.
Failed to employ a full time registered dietitian or certified dietary manager with appropriate competencies and skill sets.
Failed to follow menus prepared by the registered dietitian to ensure residents received foods meeting nutritional needs.
Failed to serve food that was palatable and at a safe and appetizing temperature to residents on the 400 hallway.
Failed to store food in refrigerators and freezers in accordance with professional food safety standards.
Failed to provide a safe, sanitary environment including failure to bag soiled laundry, store clean linens properly, and change gloves during incontinence care to prevent cross contamination.
Failed to provide a sanitary, comfortable environment in the 400 hallway dining room with heavily stained chairs and a fish tank with murky, malodorous water.
Report Facts
Deficiencies cited: 14
Resident census: 84
Medication error dose: 8
Blood sugar reading: 59
Food temperature: 122.9
Food temperature: 130.4
Pressure ulcer size: 8.3
Pressure ulcer size: 7.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse I | Licensed Nurse | Administered 8 times the ordered dose of Clonidine to resident #2. |
| Administrative Nurse B | Administrative Nurse | Provided expectations on care and staffing, confirmed medication error and pain management issues. |
| Direct Care Staff E | Direct Care Staff | Involved in transfer and incontinence care of resident #1, left resident suspended in lift despite pain complaints. |
| Direct Care Staff J | Direct Care Staff | Reported staffing shortages and assisted with resident care. |
| Dietary Manager L | Dietary Manager | Reported on food service issues and staffing. |
| Mid-Level Practitioner H | Physician Extender | Ordered Clonidine for resident #2 and commented on pain management and transfer safety. |
| Licensed Nurse K | Licensed Nurse | Intervened during resident #1's transfer due to pain complaints. |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Jul 12, 2019
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 serious deficiencies at a level of actual harm but not immediate jeopardy, including deficiencies related to pressure ulcers and other care standards, resulting in enforcement remedies including denial of payment for new Medicare and Medicaid admissions.
Deficiencies (4)
Deficiency F686 related to Pressure Ulcers
Deficiency F689
Deficiency F697
Deficiency F760
Report Facts
Denial of payment effective date: Aug 3, 2019
Potential termination date: Jan 12, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Contact person for questions regarding the survey and enforcement |
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Jul 12, 2019
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation & Health Care Center in response to deficiencies identified during a survey that exited on July 12, 2019.
Findings
The Plan of Correction outlines multiple deficiencies related to resident privacy, dignity, assistance with activities of daily living, pressure ulcer prevention, fall prevention, catheter care, pain management, staffing, nursing competencies, medication administration, dietary services, food safety, infection control, and environmental cleanliness. The facility describes systemic changes, staff education, monitoring, and audit plans to achieve substantial compliance by July 31, 2019.
Deficiencies (13)
Resident privacy and dignity not adequately maintained during peri-care and clothing changes.
Residents not consistently provided necessary services for bathing, grooming, repositioning, and assistance with eating.
Care to prevent pressure ulcer development and promote healing not consistently provided.
Fall prevention measures and post-accident procedures not adequately implemented.
Catheter care not consistently preventing infection following bowel incontinence.
Pain assessment and management not consistently provided.
Insufficient nursing staff and nursing competencies to provide care according to plan.
Medication administration errors and improper procedures for receiving medication orders.
Dietary manager education and oversight insufficient; food storage, temperature, and menu adherence issues.
Food served not always palatable or at safe and appetizing temperatures.
Food storage in refrigerators and freezers not consistently meeting professional standards.
Infection control practices, including linen handling and hand hygiene, not consistently followed.
Sanitary environment in dining room not consistently maintained.
Report Facts
Audit frequency: 5
Audit frequency: 3
Substantial compliance deadline: Jul 31, 2019
Date of survey exit: Jul 12, 2019
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 29, 2019
Visit Reason
An off-site survey was conducted to address a deficiency cited on 2019-01-14.
Findings
The deficiency cited on 2019-01-14 was placed into compliance effective 2019-01-21.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 14, 2019
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 effective January 21, 2019.
Deficiencies (1)
Most serious deficiency found was a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
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
Date: Jan 14, 2019
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey conducted at Meridian Rehabilitation & Health Care Center on 2019-01-14.
Findings
The facility had a deficiency related to the development and treatment of a left heel pressure ulcer in Resident #2, with failures in documentation and reporting. The facility implemented corrective actions including staff education, facility-wide skin assessments, and ongoing monitoring through QAPI meetings and wound rounds.
Deficiencies (1)
Failure to properly document and report a left heel pressure ulcer for Resident #2.
Report Facts
Date of survey exit: Jan 14, 2019
Plan of Correction completion date: Jan 21, 2019
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 1
Date: Jan 14, 2019
Visit Reason
The inspection was conducted as a result of complaint investigations KS00136842, KS00136742, KS00136772, KS00136777, and KS00135368.
Complaint Details
The inspection findings represent the results of multiple complaint investigations identified by case numbers KS00136842, KS00136742, KS00136772, KS00136777, and KS00135368.
Findings
The facility failed to monitor and document a left heel pressure ulcer for cognitively impaired resident #2, who was at risk for pressure ulcer development. Staff were unaware of the untreated pressure ulcer approximately 1.5 cm by 1.5 cm on the resident's left heel, which was covered with eschar.
Deficiencies (1)
Failure to monitor and document a left heel pressure ulcer for resident #2.
Report Facts
Census: 76
Residents reviewed for pressure ulcers: 3
Pressure ulcer size: 1.5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 8, 2018
Visit Reason
An offsite revisit survey was conducted on 11/08/2018 for all previous deficiencies cited on 09/20/2018.
Findings
All deficiencies have been corrected as of the compliance date of 10/19/2018, 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: 1
Date: Sep 20, 2018
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 an "E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective 10/19/2018.
Deficiencies (1)
Most serious deficiencies found to be an "E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Contact person for questions concerning the information in the letter. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Sep 20, 2018
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey conducted on September 20, 2018, at Meridian Rehabilitation & Health Care Center, outlining corrective actions and interventions to assure compliance with regulations.
Findings
The facility addressed multiple deficiencies related to resident privacy, transfer/discharge notifications, care plan development and updates, behavior management, and infection control practices, with systemic changes and monitoring plans to ensure substantial compliance by October 19, 2018.
Deficiencies (6)
Resident privacy during intimate moments not adequately protected
Failure to properly communicate transfer/discharge notices to the State Long-Term Care Ombudsman
Baseline care plans not developed or individualized for new admissions
Care plans not updated to account for all areas of care including antidepressants or antipsychotic medications
Inadequate communication and documentation of resident behaviors with physicians
Improper disinfection of glucose meters
Report Facts
Deficiencies cited: 6
Substantial compliance date: Oct 19, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Administrator | Submitted the Plan of Correction |
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 6
Date: Sep 20, 2018
Visit Reason
A recertification survey was conducted including complaint investigations related to resident rights and other compliance issues.
Complaint Details
Complaints investigated in conjunction with the recertification survey included complaint numbers KS00133289, KS00132697, KS00132579, KS00132010, KS00131245, KS00128905, KS00126408, KS00123517, KS00122975, KS00121741, and facility reported incident KS00133433.
Findings
The facility was found not in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to honor resident rights regarding consensual sexual activity, failure to notify the Ombudsman of resident transfers, incomplete baseline and comprehensive care plans, failure to provide appropriate behavioral health services, and inadequate infection control practices related to disinfecting glucose meters.
Deficiencies (6)
Failure to honor residents' rights and support consensual sexual activity choices for two residents.
Failure to send notice of discharge to the Office of the State Long-Term Care Ombudsman for one resident.
Failure to develop an accurate baseline care plan including urinary catheter and hospice services for one resident.
Failure to develop and implement comprehensive, person-centered care plans for two residents, including medication and behavioral health needs.
Failure to provide appropriate behavioral health services and notify physician of increased behaviors for one resident.
Failure to implement infection control policies and procedures for disinfecting multi-use blood glucose meters properly.
Report Facts
Sample Size: 18
Supplemental Sample: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Defined one-on-one monitoring and provided facility policy information. | |
| Psychiatric Nurse Practitioner | Evaluated resident R13 and provided statements on resident consent and behaviors. | |
| Medical Director | Provided statements regarding resident consent and sexual behaviors. | |
| Assistant Director of Nursing | Confirmed lack of discharge documentation and Ombudsman notification. | |
| Minimum Data Set Coordinator | Explained care plan development process and responsibilities. | |
| Registered Nurse 33 | Observed disinfecting glucose meter with alcohol pad. | |
| Licensed Practical Nurse 59 | Described use of alcohol wipes and Sani-wipes for glucose meter cleaning. | |
| Registered Nurse 53 | Described use of Sani-wipe for glucose meter cleaning. | |
| Registered Nurse 63 | Described use of Sani-wipe and uncertainty about required wet time. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 11, 2018
Visit Reason
A complaint survey was conducted on 06/8 & 06/11/2018 for complaint #KS00130222.
Complaint Details
Complaint #KS00130222 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 11, 2018
Visit Reason
A complaint survey was conducted on 06/8 and 06/11/2018 for complaint #KS00130222.
Complaint Details
Complaint #KS00130222 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 11, 2018
Visit Reason
A complaint survey was conducted on 06/08/2018 and 06/11/2018 for complaint #KS00130222.
Complaint Details
Complaint #KS00130222 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2018
Visit Reason
A complaint survey was conducted on 2018-04-05 and 2018-04-09 for complaints #KS00128201, #KS00120881, and #KS127419.
Complaint Details
The allegations made in the complaints were not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2018
Visit Reason
A complaint survey was conducted on 2018-04-05 and 2018-04-09 for complaints #KS00128201, #KS00120881, and #KS127419.
Complaint Details
The allegations made in the complaints were not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 6, 2018
Visit Reason
An off-site survey was conducted to review deficiencies cited on February 27, 2018.
Findings
The deficiencies cited in the prior survey were corrected as of the compliance date of March 16, 2018.
Report Facts
Compliance date: Mar 16, 2018
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 5, 2018
Visit Reason
A complaint survey was conducted on 4/5/18 and 4/9/18 for complaints #KS00128201, #KS00120881, and #KS127419.
Complaint Details
The complaints investigated were not substantiated.
Findings
The allegations made in the complaints were not substantiated and no noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 27, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective March 16, 2018.
Deficiencies (1)
Most serious deficiency was an "E" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to survey findings and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Feb 27, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #125501 and #126601.
Complaint Details
The visit was triggered by complaint investigations #125501 and #126601.
Findings
The facility failed to maintain a comfortable temperature in the therapy room for residents receiving therapy services and failed to provide routine monitoring and treatment of skin conditions for three sampled residents, resulting in inadequate care and documentation.
Deficiencies (2)
Failed to maintain the therapy room at a comfortable temperature for residents receiving therapy services.
Failed to ensure routine monitoring of skin conditions to promote healing or identify need for further medical intervention for 3 sampled residents.
Report Facts
Facility census: 92
Residents receiving therapy: 44
Temperature readings: 51
Temperature readings: 60.1
Temperature readings: 55
Temperature readings: 64.1
Temperature readings: 48
Temperature readings: 38
Maintenance log entries: 8
Skin tear measurement: 3
Bruise size: 4
Bruise size: 4
Ulcer size: 4.9
Ulcer size: 2.7
Ulcer size: 0.8
Ulcer size: 1
Ulcer size: 5
Ulcer size: 1.5
Ulcer size: 0.7
Ulcer size: 0.8
Ulcer size: 0.5
Ulcer size: 0.5
Ulcer size: 4
Ulcer size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Therapy staff F | Reported therapy room thermostat temperature and assisted resident #4. | |
| Therapy staff G | Reported therapy room was too cold while working with resident #5. | |
| Therapy staff A | Reported therapy room had been cold most of the winter and heating unit issues. | |
| Licensed nurse B | Confirmed therapy room temperature issues. | |
| Therapy staff C | Reported heater not working and working with residents in hallway. | |
| Maintenance staff D | Reported thermostat issues and maintenance of HVAC unit #7. | |
| Licensed nurse H | Reported changing dressings for resident #1 and knowledge of skin tear treatment. | |
| Licensed nurse J | Reported changing dressings for resident #1 and knowledge of skin tear treatment. | |
| Direct care staff K | Reported resident #1 had bandage and non-skid socks. | |
| Direct care staff L | Reported resident #1 performed own cares and wore non-skid socks. | |
| Licensed nurse M | Unaware of treatment for resident #1's feet. | |
| Direct care staff N | Reported resident #2 wore protective sleeves and no current skin issues known. | |
| Direct care staff O | Reported resident #2 had bruising from hospital stay. | |
| Licensed nurse P | Reported changing bandage on resident #2 and knowledge of bruising. | |
| Direct care staff Q | Reported resident #3 had diabetic sore scheduled for surgical removal. | |
| Licensed nurse R | Reported resident #3's toe ulcers and wound clinic referral. | |
| Licensed nurse S | Physician | Discussed resident #3's ulcers related to diabetes. |
| Administrative nurse E | Reviewed weekly skin check documentation and confirmed deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 27, 2018
Visit Reason
This Plan of Correction document responds to deficiencies identified during a complaint survey conducted on February 27, 2018, at Meridian Rehabilitation and Health Care Center.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as Meridian complaint 02272018.
Findings
The facility addressed deficiencies related to maintaining appropriate therapy room temperature and proper documentation of treatment orders and skin assessments. Corrective actions include education, audits, and preventative maintenance scheduling to ensure compliance.
Deficiencies (2)
Therapy room temperature maintained at a comfortable level; HVAC system functioning properly.
Treatment orders audited to ensure attachment to TAR; skin assessments updated to reflect skin alterations.
Report Facts
Date of compliance: Mar 16, 2018
Skin assessments audit frequency: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Caryl Gill | Modified the Plan of Correction document |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 4, 2018
Visit Reason
An off-site survey was conducted to verify correction of deficiencies cited on November 22, 2017.
Findings
The deficiencies cited in the prior inspection were corrected as of the compliance date of December 8, 2017.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 22, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective December 8, 2017.
Deficiencies (1)
Most serious deficiency found was an "E" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 22, 2017
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey exiting on November 22, 2017, related to a revised complaint investigation at Meridian Rehabilitation and Health Care Center.
Complaint Details
This Plan of Correction follows a revised complaint investigation survey conducted on November 22, 2017.
Findings
The facility implemented corrective actions to address issues including unwanted sexual advances and inappropriate contact among residents on the special care unit, with staff receiving dementia training and increased monitoring. The facility asserts substantial compliance with regulations as of December 8, 2017.
Deficiencies (2)
Interventions to decrease unwanted sexual advances and protect residents on the special care unit from inappropriate contact.
Provision of sufficient staffing to monitor residents on the special care unit to prevent roaming and inappropriate touching.
Report Facts
Date of survey exit: Nov 22, 2017
Plan of Correction completion date: Dec 8, 2017
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Date: Nov 22, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#KS00122834) regarding allegations of abuse, neglect, and exploitation at the facility.
Complaint Details
The complaint investigation focused on allegations of abuse, neglect, exploitation, and mistreatment involving inappropriate sexual contact and failure to protect residents. The facility's investigations into incidents involving residents #1, #2, and #3 found the incidents unsubstantiated as abuse due to cognitive impairments, but the facility failed to prevent recurrence and adequately supervise residents.
Findings
The facility failed to protect residents in the special care unit from unwanted inappropriate personal contact, including sexual advances and kissing between cognitively impaired residents. Additionally, the facility failed to provide sufficient staffing to monitor residents and prevent inappropriate behaviors and wandering into opposite gender rooms.
Deficiencies (2)
Failed to protect residents in the special care unit from unwanted inappropriate personal contact from residents #2 and #3.
Failed to provide sufficient nursing staff to monitor 19 residents in the special care unit to prevent roaming into opposite gender rooms and inappropriate touching.
Report Facts
Facility census: 86
Special care unit residents: 19
BIMS score: 11
BIMS score: 3
Staffing: 3
Residents per staff: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff D | Observed and reported inappropriate contact between residents #2 and #3 | |
| Administrative nurse B | Provided statements about staffing and education of dementia unit staff | |
| Direct care staff C | Reported on staff education and monitoring failures related to resident #2 and #1 | |
| Direct care staff F | Reported insufficient staffing on special care unit | |
| Direct care staff G | Assisted resident #5 out of a room during observation |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 19, 2017
Visit Reason
A revisit survey was conducted on 10/17/17, 10/18/17, and 10/19/17 for all previous deficiencies cited on 9/12/17.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 12, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers, indicating avoidable pressure ulcers and inadequate care and services to prevent worsening of existing pressure ulcers.
Report Facts
Denial of payment effective date: Oct 3, 2017
Compliance deadline: Mar 12, 2018
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to instructions for dispute resolution and contact for questions |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 12, 2017
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey exiting on September 12, 2017, for Meridian Rehabilitation and Health Care Center. It outlines corrective actions taken to address specific deficiencies and ensure compliance with regulations.
Findings
The facility identified deficiencies related to catheter dignity bag placement, pressure ulcer risk assessment and prevention, fall root cause analysis, and nutritional interventions for residents. Corrective actions include staff education, audits, and ongoing monitoring to ensure compliance and resident safety.
Deficiencies (4)
Resident #1 catheter is in a dignity bag; all residents with foley catheters potentially affected.
Resident #2 skin risk assessment updated with interventions to prevent or heal pressure ulcers; all residents at risk potentially affected.
Root Cause Analysis completed for Resident #1 falls; all residents who have had falls potentially affected.
Resident #2 has had nutritional interventions implemented to address inadequate nutrition and/or weight loss; all residents with inadequate nutrition or weight loss potentially affected.
Report Facts
Audit frequency: 5
Audit frequency: 3
Audit frequency: 5
Audit frequency: 3
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Devon Hiebert | Administrator | Submitted Plan of Correction to KDADS |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 4
Date: Sep 12, 2017
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint numbers related to the facility's care and compliance.
Complaint Details
The inspection findings represent the results of complaint investigations #119979, #119989, #120169, #119270, and #120235.
Findings
The facility was found deficient in maintaining resident dignity by failing to keep a catheter drainage bag in a dignity bag, failing to reassess and intervene for pressure ulcer risk after a significant change in condition leading to pressure ulcers, failing to thoroughly investigate a resident fall and implement appropriate interventions, and failing to develop nutritional interventions for a resident at risk for inadequate nutrition and weight loss.
Deficiencies (4)
Failed to maintain catheter drainage bag in a dignity bag for resident #1.
Failed to reassess pressure ulcer risk and develop interventions after significant change for resident #2, resulting in pressure ulcers.
Failed to complete thorough fall investigation and implement appropriate interventions for resident #1.
Failed to develop nutritional interventions for resident #2 at risk for inadequate nutrition and weight loss.
Report Facts
Resident census: 84
Weight loss: 6
Fall risk score: 39
Pressure ulcer measurements: 2
Pressure ulcer measurements: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse D | Licensed Nurse | Noted wound appearance and applied ointment for pressure ulcer |
| Administrative nurse B | Administrative Nurse | Interviewed regarding catheter dignity bag and fall investigation process |
| Licensed nurse J | Licensed Nurse | Cared for resident with pressure ulcers and discussed interventions |
| Licensed nurse L | Licensed Nurse | Assisted with repositioning and care of resident with pressure ulcers |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 31, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, July 31, 2017.
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Jul 31, 2017
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 shows that all previously cited deficiencies identified by regulation numbers 26-40-303 and 26-40-305 were corrected as of the revisit date 07/31/2017.
Deficiencies (3)
Deficiency related to regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c)
Deficiency related to regulation 26-40-305 (3)
Deficiency related to regulation 26-40-305 (i)(1)(2)(3)
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Jul 31, 2017
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation & Health Care Center outlining corrective actions taken in response to deficiencies identified during a re-survey inspection.
Findings
The facility addressed multiple deficiencies including resident rights to bathing preferences, accommodation of individual needs, significant change assessments, fluid restrictions, blood glucose monitoring, vaccine administration, dietary food preparation, medication storage, infection control, emergency call button accessibility, electrical safety, and maintenance of whirlpool tubs and hot water tanks.
Deficiencies (13)
Residents' right to choose bathing schedule was not properly documented or followed.
Reasonable accommodations for residents' needs regarding wheelchair placement were not ensured.
Significant change in status assessments were not consistently completed.
Fluid restriction orders were not properly communicated or followed.
Physician notification for abnormal blood glucose readings was not consistently done.
Pneumococcal vaccine administration and refusal documentation were incomplete.
Dietary staff did not follow proper puree food preparation procedures.
Thickened liquids and other food items were not properly labeled and dated.
Medication storage was not properly labeled, dated, or monitored, and refrigerator temperatures were not adequately logged.
Infection control procedures for cleaning C-diff rooms were not properly followed.
Emergency call buttons or pull cords were not accessible in whirlpool tubs and common bathrooms.
Hydrocollator was not plugged into a GFCI outlet as required.
Two whirlpool tubs were not operable and hot water tank piping showed signs of corrosion or leaks.
Report Facts
Audit frequency: 3
Audit frequency: 3
Audit frequency: 4
Audit frequency: 3
Audit frequency: 3
Audit frequency: 3
Audit frequency: 3
Audit frequency: 3
Audit frequency: 3
Education completion date: Jul 21, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Administrative Nurse GG | Administrative Nurse | Educated on Monthly QA Infection Control Report |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 3, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level 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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction effective July 31, 2017.
Deficiencies (1)
Most serious deficiencies found were 'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to the survey findings and compliance decision. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 10
Date: Jul 3, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving multiple complaint numbers.
Complaint Details
The visit was complaint-related as it included a complaint investigation with multiple complaint numbers (#111548, #110101, #109989, #106277, #105700, #104154, #101434, #99217).
Findings
The facility was found deficient in multiple areas including failure to follow resident bathing preferences, failure to accommodate resident needs regarding wheelchair placement, failure to complete significant change assessments timely, failure to monitor and follow fluid restrictions for dialysis residents, failure to notify physicians of abnormal blood sugar levels, failure to ensure influenza and pneumococcal immunizations, failure to prepare pureed foods according to dietician recipes, failure to store and distribute food and medications under sanitary conditions, failure to maintain proper infection control practices including cleaning and disinfecting protocols.
Deficiencies (10)
Failed to follow resident bathing preferences for resident #12.
Failed to make reasonable accommodations for resident #12 regarding placement of resident #58's wheelchair blocking hand sink.
Failed to complete significant change in status MDS within 14 days for resident #12.
Failed to implement fluid restriction and monitor fluids for resident #60 on dialysis.
Failed to notify physician of blood sugars above parameters for resident #11.
Failed to ensure residents received influenza and pneumococcal immunizations or education about them.
Failed to prepare pureed foods according to dietician approved recipe, specifically pureed turkey.
Failed to store and distribute food under sanitary conditions including expired and undated food items.
Failed to monitor medication refrigerator temperatures, medication expiration dates, and disposal of unused medications.
Failed to maintain an effective infection prevention and control program including lack of infection trending and failure to follow disinfectant wet times and proper cleaning techniques.
Report Facts
Residents in sample: 28
Fluid restriction: 960
Blood sugar readings: 456
Blood sugar readings: 467
Blood sugar readings: 396
Facility census: 75
Pureed diet residents: 12
Health shakes: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Administrative Nurse | Reported expectations for staff regarding bathing preferences, fluid restrictions, immunizations, infection control, and medication monitoring. |
| Licensed nurse C | Licensed Nurse | Reported resident #118 diagnosed with C-Diff and described infection control procedures. |
| Dietary staff N | Dietary Staff | Prepared pureed foods incorrectly and was directed to re-puree turkey without bread. |
| Dietary staff M | Dietary Staff | Reported knowledge of expired and undated food items. |
| Licensed nurse G | Licensed Nurse | Reported failure to notify physician of abnormal blood sugars. |
| Consulting pharmacist Q | Consulting Pharmacist | Reviewed medication regimen but failed to identify irregularities related to blood sugar notifications. |
| Housekeeping staff HH | Housekeeping Staff | Failed to follow disinfectant wet times and used incorrect disinfectants for C-Diff. |
| Housekeeping staff KK | Housekeeping Staff | Failed to follow disinfectant wet times and proper cleaning protocols. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 15, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were found to be corrected as of 05/05/2017, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Date corrections completed: May 5, 2017
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 15, 2017
Visit Reason
This revisit report documents the follow-up inspection to verify that previously reported deficiencies have been corrected and the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency with ID Prefix S0740 and Regulation 28-39-160 was corrected as of 05/05/2017. No other deficiencies or corrections are listed.
Deficiencies (1)
Deficiency with ID Prefix S0740, Regulation 28-39-160
Report Facts
Correction completion date: May 5, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Apr 19, 2017
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at F225 (Restraints) and F323, with substandard quality of care determined at F225 and actual harm at F323. The facility was cited for deficiencies that require correction and will not be given an opportunity to correct before enforcement remedies are imposed.
Deficiencies (2)
Noncompliance at F225 related to the use of physical restraints, placing residents at risk for urinary incontinence, skin breakdown, accidents, increased agitation, and social isolation.
Deficiency at F323 at a level of actual harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: May 12, 2017
Timeframe for substantial compliance: 6
Fine amount threshold: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Contact person for questions regarding the letter and informal dispute resolution |
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Apr 19, 2017
Visit Reason
This Plan of Correction document addresses the corrective actions taken by Meridian Rehabilitation and Health Care Center following deficiencies identified during a survey exiting on April 19, 2017.
Findings
The facility implemented multiple corrective actions including updating care plans, providing staff education on resident privacy, restraint policies, abuse prevention, grooming and hygiene, activity programming, communication methods, fall prevention, infection control, and admission procedures. Ongoing monitoring and re-education are planned to ensure compliance and resident safety.
Deficiencies (13)
Personal Privacy/Confidentiality of Records
Care plans for residents updated to address wandering and supervision
Assessment and care plan updates related to transfer/mobility/restraint status
Education on restraint policy and prevention of improper restraints
Education on Abuse Prevention and Prohibition policy
Education on protecting resident dignity and grooming/hygiene
Review and update of activity programs to meet individual resident needs
Communication assistance for residents with communication challenges
Audit and update of care plans to ensure compliance with resident needs and preferences
Education on fall prevention interventions and occurrence reporting
Education on staff responsibility to provide appropriate supervision and care
Education on infection control related to incontinent episodes
Physician order audits and admission criteria compliance for unit placement
Report Facts
Date of survey exit: Apr 19, 2017
Plan of Correction completion date: May 5, 2017
Frequency of QA meetings: 5
Frequency of observation rounds: 4
Frequency of staff interviews: 2
Frequency of activity observations: 4
Frequency of communication card observations: 3
Frequency of incontinent care observations: 2
Care plan reviews: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Derousseau | Administrator | Submitted the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 9
Date: Apr 19, 2017
Visit Reason
The inspection was a partial extended survey for complaint investigations related to resident privacy, physical restraints, abuse, falls, infection control, and staffing at Meridian Rehabilitation and Health Care Center.
Complaint Details
The complaint investigation was triggered by allegations of resident privacy violations, improper use of restraints, resident-to-resident abuse, inadequate fall prevention, insufficient activities, lack of medically related social services, inadequate care planning, insufficient staffing, and infection control deficiencies.
Findings
The facility failed to ensure resident privacy in the memory care unit due to lack of supervision allowing residents to wander into others' rooms, failed to ensure residents were free from inappropriate physical restraints, failed to provide structured activities, failed to thoroughly investigate and report a resident-to-resident altercation, failed to provide medically related social services for residents with limited English proficiency, failed to maintain accurate and specific care plans especially related to fall prevention, failed to prevent falls resulting in serious injury, failed to provide adequate staffing to supervise residents and provide care, and failed to maintain proper infection control practices including cleaning and changing soiled clothing and linens.
Deficiencies (9)
Failed to ensure privacy for residents in the memory care unit by lack of supervision allowing residents #5 and #20 to wander into other resident rooms.
Failed to ensure residents #3 and #4 were free from inappropriate physical restraints and assessed for restraint use.
Failed to provide structured activities to residents of the memory care unit per the activity schedule.
Failed to provide adequate supervision to prevent falls for resident #4 who sustained serious injury including subdural hematoma and hospitalization.
Failed to provide medically related social services to residents #2 and #5 with limited English proficiency to ensure communication needs were met.
Failed to develop and implement accurate and specific care plans for resident #6 related to preferences and fall prevention.
Failed to identify causal factors and provide adequate supervision and interventions to prevent falls for residents #1, #2, and #4.
Failed to provide sufficient nursing staff with appropriate competencies and skills to provide care, supervision, privacy, and activities in the memory care unit.
Failed to maintain infection control including proper cleaning of urine spills, changing soiled socks and clothing, cleaning chairs after residents with incontinence, and changing bedding after residents with soiled briefs.
Report Facts
Residents in memory care unit: 17
Residents census: 84
Number of lacerations: 4
Staples to head: 5
Subdural hematoma size: 2
Falls: 11
Falls: 8
Falls: 5
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 20, 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 have been corrected.
Findings
The report indicates that all previously cited deficiencies have been corrected as of the revisit date, with corrections completed and documented for each identified regulation.
Deficiencies (2)
Deficiency related to regulation 483.40(d)
Deficiency related to regulations 483.10(c)(2)(i-ii,iv,v), (3), 483.21(b)(2)
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 20, 2016
Visit Reason
This Plan of Correction document responds to deficiencies identified in a prior complaint-related survey conducted at Meridian Rehabilitation and Health Care Center, addressing corrective actions to assure compliance with regulations.
Complaint Details
This Plan of Correction follows a complaint investigation survey conducted on December 20, 2016, related to resident behavioral issues and care plan deficiencies.
Findings
The facility implemented interventions to address escalating resident behaviors, including updating care plans, enhancing social services involvement, and conducting staff in-services on behavior identification and documentation. The multidisciplinary team will monitor and revise care plans as needed, with ongoing review through facility quality assurance meetings.
Deficiencies (2)
Failure to provide medically related social services involvement to develop plans to address, manage, and prevent escalating behaviors.
Failure to provide individualized resident care plans updated with interventions to manage resident behaviors.
Report Facts
Date of survey exit: Dec 20, 2016
Plan of Correction completion date: Dec 20, 2016
Plan of Correction submission date: Dec 21, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Wyckoff | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 8, 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 effective December 20, 2016.
Deficiencies (1)
Most serious deficiency found was a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person and signer of the report letter. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Date: Dec 8, 2016
Visit Reason
The inspection was conducted as a complaint survey (#109036) to investigate allegations of abuse and failure to provide medically related social services for a resident exhibiting escalating sexually inappropriate behaviors.
Complaint Details
The complaint survey #109036 focused on abuse allegations involving resident #1 exhibiting escalating sexually inappropriate behaviors toward resident #2. The facility failed to involve social services or update care plans adequately to address these behaviors prior to and during the investigation period.
Findings
The facility failed to ensure that one of two residents reviewed for abuse had medically related social service involvement to develop a plan to manage and prevent escalating sexual behaviors. Additionally, the facility failed to develop individualized care plans with interventions to prevent behaviors and protect residents in the Memory Care Unit when behaviors occurred.
Deficiencies (2)
Failure to provide medically related social service involvement to manage and prevent escalating sexual behaviors in a resident.
Failure to ensure individualized care plans with interventions to prevent behaviors and protect residents in the Memory Care Unit.
Report Facts
Facility census: 84
Memory Care Unit residents: 17
Resident BIMS score: 2
Dates of documented behaviors: 10
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 4, 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 at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
Deficiencies cited at 'F' level with no harm but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Feb 4, 2017
Provider agreement termination date: May 4, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned as responsible for licensure certification and enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 18, 2016
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as of the revisit date.
Findings
The report shows that the previously identified deficiency with ID prefix F0441 related to regulation 483.65 was corrected by 01/18/2016. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Deficiency with ID prefix F0441 related to regulation 483.65
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 5, 2016
Visit Reason
This Plan of Correction document addresses the corrective actions taken by Meridian Rehabilitation and Health Care Center following findings from a survey conducted on January 5, 2016.
Findings
The facility implemented interventions to ensure proper hand hygiene practices to reduce infection risk, assessed residents for infection symptoms, and established ongoing monitoring and staff in-service training on infection control.
Deficiencies (1)
Failure to ensure staff uses proper hand hygiene practices to reduce the risk of infection and cross contamination for all residents.
Report Facts
Date of survey exit: Jan 5, 2016
Plan of Correction completion date: Jan 18, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Wyckoff | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Date: Jan 5, 2016
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint cases (#5347, #4904, #4909, #4844, #4875, #4796, and #4814).
Complaint Details
The findings represent the results of complaint investigations for cases #5347, #4904, #4909, #4844, #4875, #4796, and #4814.
Findings
The facility failed to ensure proper hand hygiene practices by direct care staff during incontinent care, placing 45 incontinent residents at risk for cross contamination and infection spread.
Deficiencies (1)
Facility failed to ensure three of five direct care staff washed their hands after each direct resident contact during incontinent care for residents #2, #3, and #4.
Report Facts
Facility census: 85
Incontinent residents: 45
Direct care staff observed: 5
Direct care staff non-compliant: 3
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 31, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 7, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 8, 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 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 which was accepted, resulting in a finding of substantial compliance effective November 7, 2015.
Deficiencies (1)
Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter regarding enforcement and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 10
Date: Oct 8, 2015
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation #79684 at Meridian Rehabilitation and Health Care Center.
Complaint Details
The inspection included complaint investigation #79684.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and respect during dining, failure to honor resident bathing preferences, failure to complete significant change assessments timely, failure to develop and revise comprehensive care plans, inadequate nursing staffing during dining, unsafe storage of chemicals accessible to residents, unsanitary food handling practices, and medication administration errors.
Deficiencies (10)
Failure to promote dignity and respect during dining in the secured dementia unit.
Failure to honor resident choices regarding bathing for 2 of 3 residents.
Failure to complete a significant change in status MDS within 14 days of decline for resident #40.
Failure to develop comprehensive care plans for bathing and dialysis for residents #123 and #85.
Failure to revise care plan to include pressure ulcer care and repositioning for resident #35.
Failure to provide necessary care and services to resident #85 including monitoring shunt post dialysis, vital signs, and dietary/fluid restrictions.
Failure to provide adequate nursing staffing during dining in the secured dementia unit.
Failure to ensure hazardous chemicals were locked and inaccessible to cognitively impaired residents.
Failure to serve food under sanitary conditions; use of pans with peeling non-stick coating and improper handling of dishware.
Failure to ensure residents #33 and #120 received medications as ordered, including failure to notify physician when Oxycodone was unavailable and failure to administer Mirtazapine as ordered.
Report Facts
Residents in secured dementia unit: 19
Residents sampled: 21
Pressure ulcer size: 2.5
Pressure ulcer size: 1.5
Fluid restriction: 32
Dialysis days: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse Z | Licensed Nurse | Named in dining observation and assistance to resident #26. |
| Direct care staff X | Direct Care Staff | Named in dining observation and resident assistance. |
| Direct care staff Y | Direct Care Staff | Named in dining observation and resident assistance. |
| Administrative nurse I | Administrative Nurse | Interviewed regarding dignity, bathing choices, and dining supervision. |
| Administrative nurse J | Administrative Nurse | Interviewed regarding bathing choices, MDS assessments, and medication administration. |
| Licensed nurse G | Licensed Nurse | Interviewed regarding resident care, bathing, and medication administration. |
| Direct care staff P | Direct Care Staff | Interviewed regarding dialysis care and resident transfers. |
| Licensed nurse V | Licensed Nurse | Interviewed regarding dialysis shunt care and assessments. |
| Direct care staff L | Direct Care Staff | Interviewed regarding dialysis care and dietary restrictions. |
| Licensed nurse H | Licensed Nurse | Interviewed regarding medication administration and bathing schedules. |
| Direct care staff AA | Direct Care Staff | Interviewed regarding dining supervision. |
| Licensed nurse K | Licensed Nurse | Observed dressing changes and resident repositioning. |
| Direct care staff D | Direct Care Staff | Observed assisting resident repositioning and dressing changes. |
| Certified dietary staff A | Dietary Staff | Interviewed regarding food handling and pan condition. |
| Dietary staff B | Dietary Staff | Observed handling plates with oven mitts touching food surfaces. |
| Licensed nursing staff U | Licensed Nurse | Interviewed regarding medication administration procedures. |
| Licensed nursing staff W | Licensed Nurse | Interviewed regarding dialysis vital signs and shunt assessments. |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Oct 7, 2015
Visit Reason
This Plan of Correction document outlines the facility's corrective actions and interventions in response to deficiencies identified during the survey exiting on October 7, 2015, aiming to achieve substantial compliance upon resurvey.
Findings
The facility addressed multiple deficiencies including promoting resident dignity during dining, honoring resident bathing preferences, completing significant change MDS assessments timely, developing comprehensive care plans, pressure ulcer prevention and treatment, ensuring resident safety by securing hazardous chemical rooms, providing adequate nursing staff during dining in the dementia unit, maintaining sanitary food service conditions, and ensuring necessary pharmacy services for residents.
Deficiencies (10)
Failure to promote an environment that maintains and enhances each resident's dignity during dining.
Failure to honor resident choices regarding bathing.
Failure to complete a significant change MDS within 14 days of qualifying changes in a resident's condition.
Failure to develop care plans which address the needs of residents.
Failure to revise resident care plans as necessary to include pressure ulcer prevention and treatment.
Failure to reposition all residents as necessary to prevent the development or worsening of pressure ulcers.
Failure to ensure the resident environment remains as free of accident hazards as possible.
Failure to provide adequate nursing staff during dining in the Courtyard Unit (dementia unit).
Failure to properly handle dishware and prepare food in pans free of debris; failure to serve food under sanitary conditions.
Failure to ensure the necessary pharmacy services for all residents.
Report Facts
Date of survey exit: Oct 7, 2015
Plan of Correction completion date: Nov 7, 2015
Significant change MDS completion timeframe: 14
Pain monitoring period for resident #33: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Wyckoff | Administrator | Administrator involved in monitoring compliance and conducting in-services |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jul 21, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.20(d), 483.20(k)(1), 483.25(d), and 483.25(h) were corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 22, 2015
Visit Reason
The visit consisted of an Abbreviated survey conducted on June 22, 2015, and a Life Safety Code survey conducted on June 30, 2015, to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The surveys found the most serious deficiencies to be 'F' level for the Life Safety Code survey and 'D' level for the Abbreviated survey. The facility submitted a plan of correction for the Abbreviated survey deficiencies, which was accepted, resulting in a finding of substantial compliance based on the credible allegation of compliance and plan of correction.
Deficiencies (2)
Deficiencies cited during the Life Safety Code survey
Deficiencies cited during the Abbreviated survey
Report Facts
Date of Abbreviated survey: Jun 22, 2015
Date of Life Safety Code survey: Jun 30, 2015
Effective date for plan of correction: Jul 21, 2015
Denial of payments effective date: Sep 22, 2015
Provider agreement termination date: Dec 22, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Wyckoff | Administrator | Named as facility administrator in the report |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution for Life Safety Code Survey |
| Irina Strakhova | Enforcement Coordinator | Signed the report and provided contact information for questions |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 22, 2015
Visit Reason
An Abbreviated survey was conducted on June 22, 2015, and a Life Safety Code survey on June 30, 2015, to determine compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The surveys found the most serious deficiencies to be 'F' level for the Life Safety Code survey and 'D' level for the Abbreviated survey. The facility submitted a plan of correction for the Abbreviated survey deficiencies, which was accepted, resulting in a finding of substantial compliance based on the credible allegation of compliance.
Deficiencies (2)
Deficiencies cited during the Life Safety Code survey
Deficiencies cited during the Abbreviated survey
Report Facts
Effective date for denial of payments: Sep 22, 2015
Provider agreement termination date: Dec 22, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter and contact for questions concerning instructions in the letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution for Life Safety Code Survey |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 4
Date: Jun 22, 2015
Visit Reason
The inspection was conducted based on complaint investigations #87866 and #87957 to evaluate allegations of abuse, neglect, and failure to report injuries, as well as to assess care planning and fall prevention measures.
Complaint Details
The inspection was triggered by complaints #87866 and #87957 regarding failure to report injuries, inadequate care planning, and fall prevention.
Findings
The facility failed to report an injury of unknown origin immediately, did not develop comprehensive care plans for toileting and skin care for residents #1, #2, and #3, and failed to implement effective toileting programs and bladder management. Additionally, the facility did not thoroughly investigate falls or implement effective fall prevention interventions for resident #1.
Deficiencies (4)
Failure to report an injury of unknown origin immediately for resident #1.
Failure to develop comprehensive care plans related to toileting and skin care for residents #1, #2, and #3.
Failure to provide appropriate treatment and services to prevent urinary tract infections and restore bladder function for residents #1, #2, and #3.
Failure to ensure the resident environment is free of accident hazards and to provide adequate supervision to prevent falls for resident #1.
Report Facts
Facility census: 80
Fall incidents: 7
Bruising measurement: 9.5
Urinary incontinence occurrences: 39
Urinary incontinence occurrences: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Administrative Nurse | Reported injury of unknown origin late and confirmed failure to report immediately; involved in fall investigations |
| Administrative nursing staff B | Administrative Nursing Staff | Completed comprehensive care plans and provided interviews about care planning |
| Direct care staff C | Provided care and interviews regarding residents' toileting and fall risk | |
| Licensed nursing staff D | Licensed Nursing Staff | Provided interviews regarding fall risk and care planning |
| Direct care staff F | Provided care and interviews regarding toileting assistance | |
| Licensed nursing staff G | Licensed Nursing Staff | Provided interview regarding resident's bruising prior to hospitalization |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jun 22, 2015
Visit Reason
This Plan of Correction document addresses the findings from a survey exiting on June 22, 2015, related to complaint deficiencies at Meridian Rehabilitation and Health Care Center.
Findings
The facility identified deficiencies related to resident injury reporting, toileting and skin care needs, voiding monitoring, and fall management. Corrective actions and ongoing monitoring plans were outlined to ensure compliance by July 21, 2015.
Deficiencies (4)
Resident #1 incident resulting in injury was investigated and reported to the State Agency.
Assessment and care plan updates for toileting needs of residents #2 and #3, and audits of all residents' care plans for toileting and skin care.
72 hour voiding monitor and toileting program initiation for residents #2 and #3; audits of incontinent residents' care plans.
Root Cause Analysis and interventions for all falls; therapy referrals and medication reviews for residents with repeat falls.
Report Facts
Date of survey exit: Jun 22, 2015
Date of compliance: Jul 21, 2015
Audit frequency: 10
Medication review timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Wyckoff | Administrator | Administrator submitting the Plan of Correction and responsible for monitoring compliance |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Sep 16, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies were corrected by the revisit date of 09/16/2014, with no uncorrected deficiencies remaining.
Deficiencies (7)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.30(a)
Deficiency related to regulation 483.30(b)
Deficiency related to regulation 483.30(e)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
A first revisit was conducted on August 18, 2014, for the June 20, 2014 health survey to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective September 16, 2014.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator in the report |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
The revisit was conducted on August 18, 2014, as a result of the June 20, 2014 Health survey to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The revisit found the most serious deficiencies in the facility to be widespread 'F' level deficiencies, indicating the facility was not in substantial compliance. Enforcement remedies including denial of payment for new admissions and recommendation for termination of provider agreement were imposed.
Deficiencies (1)
Most serious deficiencies found at 'F' level, widespread
Report Facts
Effective date of denial of payment: Sep 20, 2014
Recommended termination date: Dec 20, 2014
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter Mungai | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator for the Survey, Certification and Credentialing Commission |
| Joe Ewert | Commissioner of Survey, Certification and Credentialing Commission | Named as Commissioner responsible for receiving IDR requests |
| Sherriann Pater | Branch Manager Associate Regional Administrator | Authorized the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 13
Date: Aug 18, 2014
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 08/15/2014, indicating compliance with the required standards.
Deficiencies (13)
Deficiency related to regulation 483.10(c)(2)-(5)
Deficiency related to regulation 483.10(c)(6)
Deficiency related to regulation 483.10(f)(2)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.15(e)(2)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(b)(1)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Report Facts
Deficiencies corrected: 13
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
This revisit report documents the follow-up inspection to verify correction of previously cited deficiencies at Meridian Rehabilitation and Health Care Center.
Findings
The report confirms that the previously reported deficiency identified by regulation 26-40-305 (c)(1)(2) with ID prefix S1354 was corrected as of 08/15/2014.
Deficiencies (1)
Deficiency identified under regulation 26-40-305 (c)(1)(2) corrected
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 7
Date: Aug 18, 2014
Visit Reason
The inspection was conducted as a non-compliance revisit and complaint investigation related to allegations of abuse, neglect, and other regulatory concerns at Meridian Rehabilitation and Health Care Center.
Complaint Details
The visit was a complaint investigation #77169 and a non-compliance revisit. The facility failed to report an injury of unknown origin immediately for one of three incidents reviewed.
Findings
The facility failed to immediately report an injury of unknown origin, failed to complete a timely voiding diary for a resident, failed to maintain adequate staffing levels, failed to have a registered nurse on duty for 8 consecutive hours on one day, failed to properly post daily nursing staffing information, failed to label opened medication vials with discard dates, and failed to implement effective quality assurance plans to correct identified deficiencies.
Deficiencies (7)
Failed to immediately report an injury of unknown origin to the administrator and State agency.
Failed to complete a voiding diary in a timely manner to assess resident's voiding pattern after bladder assessment.
Failed to maintain adequate staffing to meet residents' needs including toileting, call light response, personal care, and restorative services.
Failed to have a registered nurse on duty for 8 consecutive hours on 8/3/14.
Failed to post daily nursing staffing information including total and actual hours worked by nursing staff categories.
Failed to properly label opened insulin and Tuberculin vials with opened or discard dates in medication room refrigerators.
Failed to develop and implement effective quality assurance plans to correct previously identified deficiencies.
Report Facts
Census: 74
Deficiencies cited: 7
Registered nurse hours missing: 8
Medication vial discard days - Novolog: 28
Medication vial discard days - Tuberculin: 30
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Aug 18, 2014
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation and Health Care Center in response to deficiencies identified during a survey exit on 08/18/2014.
Findings
The Plan of Correction addresses multiple deficiencies including investigation and reporting of abuse allegations, prevention of urinary tract infections, sufficient nursing staff coverage, RN staffing requirements, posting of nurse staffing information, proper labeling and storage of drugs and biologicals, and quality assurance committee meetings. The facility outlines corrective actions, monitoring plans, and completion dates to ensure compliance.
Deficiencies (7)
Failure to properly investigate and report allegations of abuse, including injuries of unknown origin.
Failure to prevent urinary tract infections and restore bladder function through appropriate voiding patterns and toileting programs.
Insufficient 24-hour nursing staff per care plans.
Failure to maintain RN coverage for 8 consecutive hours 7 days per week as required.
Failure to post nurse staffing information daily.
Failure to properly label and store drugs and biologicals, including opened vials without discard dates.
Failure to conduct and document quarterly quality assurance committee meetings and plans.
Report Facts
Deficiencies cited: 8
Completion date: Sep 16, 2014
Incident report date: Jul 28, 2014
Survey exit date: Aug 18, 2014
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 6, 2014
Visit Reason
A Life Safety Code survey was conducted on August 6, 2014, by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Calendar days for plan of correction submission: 10
Year effective for denial of payments: 2014
Year effective for provider agreement termination: 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter Mungai | Administrator | Named as facility administrator in the report |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Joe Ewert | Commissioner | Mentioned in correspondence copy |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jun 20, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at an "F" level, resulting in enforcement remedies including denial of payment for new Medicare admissions effective September 20, 2014, until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Most serious deficiencies found at an "F" level
Report Facts
Months until recommended termination: 6
Denial of payment effective date: Sep 20, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter Mungai | Administrator | Named as facility administrator in the report header. |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter. |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 18
Date: Jun 20, 2014
Visit Reason
The inspection was a health resurvey and investigation of multiple complaints, including concerns about facility management of personal funds, staffing, resident rights, and care quality.
Complaint Details
The inspection included investigation of complaints #KS00068786, KS00067209, KS00066548, KS00064655, KS00075599, KS00071403.
Findings
The facility was found deficient in multiple areas including failure to notify residents about personal funds nearing Medicaid limits, delayed conveyance of funds upon resident death, inadequate response to staffing concerns, failure to investigate and report abuse allegations, failure to honor resident bathing preferences, failure to notify residents of roommate changes, inadequate maintenance, incomplete resident assessments and care plans, failure to revise care plans after falls, inadequate nail care, failure to provide appropriate urinary incontinence treatment, failure to monitor medications with black box warnings, insufficient nursing staff, failure to post accurate nurse staffing data, and failure to maintain sanitary food service practices.
Deficiencies (18)
Failed to notify a resident receiving Medicaid when personal funds balance reached $200 less than SSI limit.
Failed to convey resident funds within 30 days after death for 3 residents.
Failed to respond and resolve repeated concerns of insufficient nursing staff.
Failed to immediately report, investigate, and submit results of resident-to-resident abuse incident.
Failed to offer and honor resident's choice for bathing due to non-functioning bathtubs.
Failed to notify resident prior to roommate change.
Failed to ensure proper preventative maintenance in resident rooms and hallways.
Failed to complete individualized Care Area Assessments (CAAs) for multiple residents.
Failed to develop comprehensive care plan related to nail care for a resident.
Failed to revise care plans for residents after falls to include appropriate interventions.
Failed to provide necessary services to maintain good grooming and personal hygiene (nail care).
Failed to provide appropriate treatment and services to restore bladder function and implement toileting program.
Failed to ensure resident's drug regimen was free from unnecessary drugs by not monitoring black box warnings for serious adverse effects.
Failed to ensure sufficient nursing staff to meet residents' needs.
Failed to post daily nursing staffing information including census and total hours worked.
Failed to serve food under sanitary conditions by not restraining or covering hair while serving food.
Failed to ensure pharmacist reported drug irregularities related to black box warnings to physician and director of nursing.
Failed to properly label insulin pens and remove them from use within 28 days of opening.
Report Facts
Facility census: 79
Resident sample size: 22
Residents reviewed for personal funds: 5
Residents reviewed for conveyance of funds upon death: 3
Days late for insulin pen discard: 39
Insulin pen discard timeframe: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Administrative Staff | Responsible for sending notifications about resident funds nearing Medicaid limits and handling funds after death |
| Staff A | Administrative Nursing Staff | Interviewed regarding staffing, care plans, CAAs, and medication monitoring |
| Staff H | Administrative Nursing Staff | Interviewed regarding CAAs and care plan development |
| Staff L | Licensed Nurse | Interviewed regarding medication monitoring and resident care |
| Staff G | Licensed Nursing Staff | Reported inadequate staffing and supervision |
| Staff K | Licensed Nursing Staff | Reported staffing concerns and resident care issues |
| Staff N | Direct Care Staff | Observed serving food without hair restraint and reported resident care issues |
| Staff V | Direct Care Staff | Observed serving food without hair restraint |
| Staff R | Activities Staff | Provided nail care and reported lack of documentation |
| Consultant DD | Consultant Pharmacist | Reviewed medications monthly but did not check care plans for black box warnings |
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Jun 20, 2014
Visit Reason
This Plan of Correction document addresses the corrective actions taken by Meridian Rehabilitation and Health Care Center following deficiencies identified during a survey that exited on June 20, 2014.
Findings
The facility submitted a detailed Plan of Correction outlining interventions and monitoring plans for multiple deficiencies related to personal funds management, grievance resolution, care planning, medication management, staffing, housekeeping, and facility maintenance. The facility asserts substantial compliance and ongoing monitoring to ensure correction of cited deficiencies.
Deficiencies (19)
Facility management of personal funds
Conveyance of personal funds upon death
Right to prompt efforts to resolve grievances
Investigate/report allegations/individuals
Self-determination - Right to make choices
Right to notice before room/roommate change
Housekeeping and Maintenance
Comprehensive Assessments
Develop comprehensive care plans
Right to participate in planning care revisions
ADL care provided for dependent residents
No catheter, prevent UTI, restore bladder
Drug regimen is free from unnecessary drugs
Sufficient 24 hour nursing staff per care plans
Posted nurse staffing information
Food procure, store/prepare/serve - Sanitary
Drug regimen review, report irregular, act on
Drug records, label, store drugs, and biologicals
Heating Ventilation, and AC
Report Facts
Completion date: Jul 20, 2014
Audit frequency: 100
Audit frequency: 5
Audit frequency: 6
Audit frequency: 4
Audit frequency: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter Mungai | Administrator | Named as responsible for monitoring and corrective actions |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Document modification | |
| DON | Director of Nursing | Involved in monitoring and staff education |
| Business Office Manager | Responsible for auditing resident accounts | |
| Maintenance Director | Responsible for monitoring maintenance and ventilation | |
| Dietary Manager | Responsible for monitoring food service sanitary conditions | |
| MDS Coordinator | Involved in care plan and assessment monitoring | |
| Regional Nurse | Assists Administrator with grievance resolution | |
| Regional Director | Assists Administrator with grievance resolution | |
| Social Services Director | Inserviced on room/roommate change policy | |
| Staff Development Coordinator | Reeducated on nurse staffing posting |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 12, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, April 12, 2013.
Report Facts
Deficiencies corrected: 12
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 12
Date: Mar 14, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation covering multiple complaint investigation numbers.
Complaint Details
The inspection included complaint investigations #62931, 62917, 63383 and 58483.
Findings
The facility was found deficient in multiple areas including failure to provide written notification of payment status changes, failure to develop comprehensive care plans, failure to provide appropriate treatment and services to maintain or improve residents' conditions, failure to prevent falls, medication errors, failure to monitor and document medication effectiveness, failure to maintain sanitary food storage and serving conditions, failure to provide routine dental services, and failure to properly manage drug records and expired medications.
Deficiencies (12)
Failed to have evidence of written notification of the resident and/or the resident's representative of a change in payment status for 1 of 3 sampled residents receiving skilled services (#86).
Failed to ensure the development of a comprehensive care plan for 2 sampled residents (#110 and #80).
Failed to develop a care plan to address services to maintain or improve the contracture of the resident's left hand (#80).
Failed to ensure 1 of 3 sampled residents (#87) received bathing on a regular basis.
Failed to provide timely services to maintain good personal hygiene for one sampled resident (#75).
Failed to provide services to increase range of motion and/or to prevent further decrease in range of motion for one resident (#80) with a limited range of motion.
Failed to implement interventions identified to provide additional supervision and assistance devices to prevent falls for 1 of the 5 sampled residents (#87).
Failed to ensure adequate indications for use of all medications administered, failed to monitor for side effects of black box warning medications, failed to monitor for the need and follow-up for effectiveness of all "as needed" medications administered and failed to administer all medications ordered by the physician for 5 sampled residents (#110, #46, #55, #26 and #99).
Failed to ensure that it is free of medication error rates of five percent or greater. Medication pass observation included 3 errors in administration of medications to 1 resident (#110), for an error rate of 11.53%.
Failed to store, and serve food under sanitary conditions and failed to maintain dining tables under sanitary conditions in all three dining rooms. Observed food packaging tears, dried food debris on tables, and improper serving practices.
Failed to obtain dental services from an outside resource to repair the teeth of one sampled resident (#6).
Failed to identify open and expiration dates of medications, then dispose of expired medications for three residents. Expired medications remained available for administration.
Report Facts
Residents sampled for liability notices: 3
Residents sampled for care plans: 27
Residents sampled for activities of daily living: 3
Residents sampled for falls: 5
Residents sampled for unnecessary medications: 10
Medication pass observation count: 26
Medication administration error count: 3
Medication administration error rate: 11.53
Facility census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Documented verbal notification to resident's representative about payment status change. | |
| Licensed Staff Q | Confirmed lack of comprehensive care plan for resident #110. | |
| Licensed Staff J | Described medication follow-up procedures and medication reorder process. | |
| Administrative Staff C | Discussed medication monitoring, physician communication, and fall prevention care plan issues. | |
| Physician R | Physician | Confirmed expectation for staff to notify physician of medications without diagnosis. |
| Consultant S | Consulting Pharmacist | Described expectations for medication diagnosis, monitoring, and black box warning care plans. |
| Licensed Staff L | Acknowledged lack of black box warning care plan and medication administration issues. | |
| Direct Care Staff N | Delayed response to resident's request for personal care. | |
| Direct Care Staff E | Provided incontinent care and assisted resident to dress. | |
| Direct Care Staff F | Provided incontinent care and assisted resident to dress; noted resident needed a shower. | |
| Direct Care Staff G | Reported resident's refusal of care and improvement after hospitalization. | |
| Licensed Staff K | Reported resident's improved compliance with care after hospitalization. | |
| Licensed Staff I | Reported resident's decline and refusal of care prior to hospitalization. | |
| Staff X | Dietary Staff | Observed wiping tables inadequately. |
| Staff Z | Dietary Staff | Confirmed dried food debris and sticky rings on dining tables. |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Mar 14, 2013
Visit Reason
This document is a Plan of Correction submitted by Meridian Health Care and Rehabilitation Center in response to deficiencies identified during a survey conducted on March 14, 2013.
Findings
The Plan of Correction outlines corrective actions taken to address multiple deficiencies including notice of rights, comprehensive care plans, treatment/services to improve ADLs, medication management, fall prevention, food sanitation, dental services, and drug records. The facility asserts substantial compliance will be achieved by April 12, 2013 through staff re-education, audits, and quality assurance monitoring.
Deficiencies (11)
Notice of rights, rules, services, charges not properly issued
Development of comprehensive care plans incomplete or untimely
Treatment/services to improve/maintain ADLs not consistently provided
ADL care provided for dependent residents inadequate
Failure to increase/prevent decrease in range of motion
Free of accident hazards/supervision/devices deficiencies
Unnecessary drugs prescribed or administered
Medication error rates of 5% or more
Food procurement, storage, preparation, and service unsanitary
Routine/emergency dental services not adequately provided
Drug records, labeling, storage, and disposal of expired drugs deficient
Report Facts
Deficiencies cited: 11
Plan of Correction completion date: Apr 12, 2013
Dental appointment date: Apr 1, 2013
Medication in-service date: Apr 10, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Melisa Lang | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Sep 21, 2012
Visit Reason
This is a post-certification revisit to verify that previously identified deficiencies have been corrected as of the revisit date.
Findings
The report documents that multiple deficiencies previously cited under various regulations were corrected by 09/20/2012.
Deficiencies (4)
Deficiency under regulation 483.10(b)(2)
Deficiency under regulation 483.10(b)(11)
Deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency under regulation 483.25
Report Facts
Deficiencies corrected: 4
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 18, 2012
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey and confirms the dates when corrective actions were completed.
Findings
The report shows that previously cited deficiencies identified by regulation numbers 26-40-303 (b)(c) and 26-40-305 (c)(1)(2) were corrected as of 07/18/2012.
Deficiencies (2)
Deficiency related to regulation 26-40-303 (b)(c)
Deficiency related to regulation 26-40-305 (c)(1)(2)
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 18, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all previously cited deficiencies were corrected as of the revisit date, with multiple regulatory items marked as corrected on 07/18/2012.
Report Facts
Correction completion date: Jul 18, 2012
Followup to Survey Completed on: May 25, 2012
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jul 18, 2012
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Meridian Nursing & Rehabilitation Center, detailing regulatory deficiencies identified during a survey completed on July 18, 2012.
Findings
The facility was found deficient in multiple areas including failure to provide residents access to their records within 24 hours, failure to notify residents or their representatives of changes or injuries, failure to investigate and report allegations of abuse or neglect, and failure to provide care and services to attain or maintain the highest practicable well-being of residents.
Deficiencies (4)
Right to access/purchase copies of records not met as evidenced by failure to provide access within 24 hours.
Failure to notify resident, physician, or legal representative of changes such as injury, decline, or room changes.
Failure to investigate and report allegations of abuse, neglect, or mistreatment and to prevent further potential abuse during investigations.
Failure to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jul 18, 2012
Visit Reason
This document serves as the Plan of Correction submitted by Meridian Health Care and Rehabilitation Center in response to deficiencies identified during the survey exiting on July 18, 2012.
Findings
The facility outlines corrective actions and interventions addressing deficiencies related to medical record access, notification of significant changes, investigation and reporting of allegations, and provision of care for residents' highest well-being. Staff re-education and quality assurance measures are emphasized to ensure compliance by July 31, 2012.
Deficiencies (4)
Right to access/purchase copies of medical records
Notification of changes (injury/decline/room etc)
Investigate/report allegations/individuals
Provide care/services for highest well being
Report Facts
Plan of Correction completion date: Jul 31, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staci Wasser | RN, Director of Nursing | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 18
Date: May 25, 2012
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations to assess compliance with regulatory requirements and investigate complaints.
Complaint Details
The inspection included complaint investigations #56526, #56934, and #55949.
Findings
The facility had multiple deficiencies including failure to notify family of significant changes, dignity and respect issues, unresolved resident grievances, unsafe environment conditions, incomplete assessments and care plans, inadequate hydration and nutrition management, improper medication management, unsanitary food preparation, infection control lapses, unsafe equipment, and nonfunctional resident call systems.
Deficiencies (18)
Failure to promptly notify a resident's legal representative or family of declining oral intake.
Failure to communicate with dignity and respect to residents.
Failure to listen and act upon resident council grievances regarding linens, ice water, staffing, call lights, trash removal, and food temperature.
Failure to maintain window screens and cleanliness of dining room cabinets and countertops.
Failure to conduct comprehensive assessments including dehydration risk and significant weight loss.
Failure to complete significant change assessments after severe weight loss and failure to revise care plans accordingly.
Failure to revise care plans to address changes in resident status including weight loss and behavioral issues.
Failure to provide necessary grooming including fingernail care for a dependent resident.
Failure to conduct comprehensive assessments and provide individualized behavioral interventions for residents with dementia and behavioral disturbances.
Failure to maintain a safe environment by preventing resident access to potentially dangerous areas and failure to safely transfer a resident using a mechanical lift.
Failure to maintain safe water temperatures in the main dining room handwashing sink.
Failure to maintain acceptable nutritional status and provide therapeutic diets for residents with nutritional problems.
Failure to provide food substitutions with equivalent nutritive value and failure to maintain food at proper temperatures.
Failure to maintain sanitary conditions in food preparation and serving areas including unclean microwave, improper hair restraints, and improper food handling.
Failure to maintain an effective infection control program including failure to change gloves and wash hands between residents and failure to properly clean shower room and equipment.
Failure to maintain mechanical lifts in safe operating condition.
Failure to maintain functional resident call system in shower room.
Failure of Quality Assessment and Assurance (QAA) program to identify and correct multiple quality deficiencies including weight loss, dehydration risk, broken equipment, glove usage, cleanliness, pressure ulcers, care plan revisions, and resident grievances.
Report Facts
Facility census: 90
Residents in sample: 27
Residents attending resident council: 20
Residents attending resident council: 24
Weight loss: 29
Weight loss percentage: 15.9
Water temperature: 134.6
Water temperature: 133.7
Water temperature: 133.9
Weight loss percentage: 13.8
Weight loss percentage: 9.63
Fluid intake average: 1233
Fluid intake deficit: 267
Residents using Station II shower room: 28
Residents using Station II dining room: 27
Residents using mechanical lifts: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Named in multiple findings including failure to notify family, hydration issues, medication side effect concerns, and QAA program deficiencies. |
| Direct Care staff M | Direct Care Staff | Named in hydration and nutrition findings, dignity issues, and resident behavior observations. |
| Direct Care staff FF | Direct Care Staff | Named in dignity and behavior findings. |
| Licensed nursing staff GG | Licensed Nursing Staff | Named in nutrition and hydration findings. |
| Consultant W | Dietitian/Consultant | Named in nutrition and hydration findings. |
| Maintenance staff T | Maintenance Staff | Named in mechanical lift and water temperature findings. |
| Dietary staff EE | Dietary Staff | Named in nutrition and food preparation findings. |
| Social Service staff KK | Social Service Staff | Named in behavior management findings. |
Inspection Report
Plan of Correction
Deficiencies: 22
Date: May 25, 2012
Visit Reason
This document is a Plan of Correction submitted by Meridian Health Care and Rehabilitation Center in response to deficiencies identified during a survey exiting on May 25, 2012. The plan outlines corrective actions and interventions to assure compliance with regulations.
Findings
The facility identified multiple deficiencies related to notification of changes, dignity and respect, grievance handling, environment cleanliness, comprehensive assessments, care planning, treatment services, accident hazards, nutrition, hydration, drug regimen, infection control, equipment safety, call system functionality, and quality assurance. The facility has implemented staff re-education, audits, interdisciplinary meetings, and ongoing monitoring to address these issues and achieve substantial compliance by June 22, 2012.
Deficiencies (22)
Notification of changes not properly documented for residents with significant weight loss or refusal to eat
Failure to promote dignity and respect of individuality
Failure to listen and act on group grievances in a timely manner
Unsafe, unclean, or uncomfortable environment
Incomplete comprehensive assessments
Incomplete comprehensive assessments after significant change
Failure to revise care plans to reflect resident needs and participation
Inadequate ADL care provided by dependent residents
Inadequate treatment services to prevent or heal pressure sores
Inadequate treatment/services for mental/psychosocial difficulties
Failure to be free of accident hazards and provide supervision/devices
Failure to maintain nutritional status unless unavoidable
Failure to provide sufficient fluid to maintain hydration
Drug regimen not free from unnecessary drugs
Failure to maintain nutritive value, appearance, palatability, and preferred temperature of food
Failure to procure, store, prepare, and serve food under sanitary conditions
Infection control failures including prevention of spread of infection and linens
Essential equipment not in safe operating condition
Resident call system in rooms, toilet, and bath not fully functional
Quality assurance committee not meeting quarterly plans
Door monitoring system alarms not properly set or monitored
Heating, ventilation, and air conditioning issues
Report Facts
Date of survey exit: May 25, 2012
Plan of correction completion date: Jun 22, 2012
Frequency of dietary manager food inventory audits: 4
Frequency of maintenance schedule for lifts: 14
Frequency of documented random competency checks of mechanical lift transfers: Completed by nursing staff and placed in personnel files
Frequency of shower cleaning observations: 2
Frequency of resident behavior monitoring checks: 15
Frequency of department manager rounds: 2
Frequency of grievance reviews: 1
Frequency of resident interviews by department managers: 2
Fluid offered per meal for residents on thickened liquids: 720
Fluid offered between meals for residents on thickened liquids: 240
Frequency of weekly interdisciplinary meetings: 1
Care plan rewrite timeframe: 90
Frequency of QA action plan reviews: 7
Date of staff re-education on various topics: Jun 6, 2012
Date of wound care specialist meeting: Jun 19, 2012
Date of psychiatrist review for resident #104: Jun 1, 2012
Date of contractor ventilation work completion: Jun 4, 2012
Date of call light repair: May 31, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Lang | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Director of Nursing | DON | Responsible for monitoring compliance, staff re-education, and quality assurance |
| Dietary Manager | Responsible for dietary audits, education, and compliance | |
| Administrator | Responsible for ongoing compliance and monitoring | |
| Activity Director | Involved in care planning and behavioral management | |
| Social Services Director | SSD | Responsible for scheduling care plan meetings and resident activities |
| Maintenance Director | Responsible for equipment maintenance and safety | |
| Regional RAC Specialist | Provided re-education on significant change assessments | |
| Regional Staff | Provided re-education on behavior management and SBAR training |
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