Inspection Reports for Paramount Community Living and Rehab Inc
200 SW 14TH STREET, KS, 67114
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 26, 2018, found the facility in compliance with all regulations and no deficiencies. Prior inspections in 2018 had cited deficiencies related to resident care plans, medication administration, activity programming, and food service, but these issues were corrected by the October revisit. Earlier complaint investigations included a substantiated case in 2015 involving improper use of transfer bars that resulted in a resident’s death, along with other care and safety concerns such as notification failures and abuse investigations in 2012. Enforcement actions included denial of payment for new admissions in 2017 due to actual harm-level deficiencies, but no license suspensions or fines were listed in the available reports. The inspection history shows improvement over time, with the facility addressing prior deficiencies and achieving compliance in its most recent survey.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
15.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
160% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
94 residents
Based on a September 2018 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 26, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-09-13.
Findings
All deficiencies have been corrected as of the compliance date of 2018-10-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Sep 13, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in the Asbury Park facility inspection report dated 09/13/2018.
Findings
The Plan of Correction outlines corrective actions to address deficiencies related to resident care plans, medication administration, activity programming, meal choices, medication storage and destruction, and staff education. Monitoring and compliance measures are described with projected completion dates mostly by 10/19/2018.
Deficiencies (8)
| Description |
|---|
| Resident care plans will include goals for admission and desired outcomes including resident preferences and potential for future discharge. |
| Care plans for residents with dementia will have specific identification of problems, goals, approaches, and target dates designed to meet resident preferences and needs. |
| Staff administering medications educated on policies and procedures to ensure medication error rate is below 5%. |
| Medication storage and destruction procedures education provided to staff; open medications dated and discarded appropriately. |
| Residents in Green House units will have needs assessments and activity calendars developed and monitored. |
| Residents will have meal choices according to preferences and cultural beliefs with posted menus and revised meal choice policy. |
| Green House staff trained on food handling and nutritional services will monitor food quality. |
| Special food needs snacks will be available and labeled; education provided to staff and residents. |
Report Facts
Medication error rate target: 5
Projected completion date: Oct 19, 2018
Education completion date: Sep 19, 2018
Medication labeling policy dissemination date: Sep 25, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Williams | CEO/NHA | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 13, 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 accepted, and the facility was found to be in substantial compliance effective 2018-10-19.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact and signatory related to enforcement and plan of correction acceptance. |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 8
Sep 13, 2018
Visit Reason
A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of Kansas Department for Aging and Disability Services (KDADS) to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with multiple regulatory requirements including failure to develop individualized comprehensive care plans for residents, inadequate activities programming, medication administration errors, expired medications not removed, inconsistent menu posting, poor food quality, and failure to provide sugar free snacks for diabetic residents.
Severity Breakdown
SS=E: 1
SS=D: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to develop individualized person-centered comprehensive care plans for 18 of 21 sampled residents. | SS=E |
| Failed to provide ongoing activities to meet interests and support psychosocial well-being for 4 of 19 sampled residents. | SS=D |
| Failed to develop person-centered comprehensive care plans for dementia care for 3 sampled residents. | SS=D |
| Medication error rate of 23% due to failure to follow accepted standards related to crushing and combining multiple medications for administration via feeding tube for one resident. | SS=D |
| Failed to destroy expired medications and document open dates on multi-use medication bottles in medication rooms and carts. | SS=D |
| Failed to post daily dining menus consistently for one unit, Green House 0405. | SS=D |
| Failed to provide palatable food; residents reported limp fries, bland food, and undercooked items. | SS=D |
| Failed to provide sugar free snacks for two diabetic residents who identified this as a preference. | SS=D |
Report Facts
Survey Census: 94
Sample Size: 37
Medication Error Rate: 23
Residents with deficient care plans: 18
Residents without adequate activities: 4
Residents with dementia care plan deficiencies: 3
Residents reporting food quality issues: 7
Diabetic residents without sugar free snacks: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chief Nursing Officer | Confirmed lack of individualized care plans and use of 'Profile History Report' as care plan | |
| Director of Nursing 2 | Director of Nursing | Confirmed responsibility for medication expiration checks and lack of policy on open dates; confirmed sugar free snacks should be available |
| Licensed Practical Nurse 6 | LPN | Confirmed diabetic residents and lack of sugar free snacks |
| Certified Medication Aide 9 | CMA | Reported no activities done on first shift and rotation of activity responsibilities |
| Certified Medication Aide 14 | CMA | Responsible for cooking and posting menus; admitted menus not consistently posted |
| Certified Nurse Aide 15 | CNA | Explained limitations in cooking French fries due to lack of deep fryer |
| Licensed Practical Nurse 7 | LPN | Observed expired medications on medication cart |
Inspection Report
Follow-Up
Deficiencies: 6
Jul 14, 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 had been corrected.
Findings
All previously cited deficiencies were corrected as of 06/28/2017, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (6)
| Description |
|---|
| Deficiency with regulation 483.10(a)(1) |
| Deficiency with regulations 483.24, 483.25(k)(l) |
| Deficiency with regulations 483.25(d)(1)(2)(n)(1)-(3) |
| Deficiency with regulations 483.35(a)(1)-(4) |
| Deficiency with regulations 483.60(i)(1)-(3) |
| Deficiency with regulation 483.90(i)(5) |
Report Facts
Date corrections completed: Jun 28, 2017
Follow-up survey completion date: Jun 12, 2017
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 14, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report indicates that the previously cited deficiency with regulation number 26-40-303 (2)(a)(i)(ii)(iii) was corrected as of 06/28/2017. No other deficiencies or findings are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-303 (2)(a)(i)(ii)(iii) |
Report Facts
Deficiency correction date: Jun 28, 2017
Inspection Report
Plan of Correction
Deficiencies: 7
Jun 28, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction outlines corrective actions including staff counseling, education on resident dignity and dialysis care policies, improvements in resident supervision and safety, cleaning and maintenance of facility units, and upgrades to door alarm systems to address the cited deficiencies.
Severity Breakdown
D: 2
G: 1
E: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Unit 1 nursing staff scheduled to work nights were counseled on resident dignity and properly following Plan of Care. | D |
| Nurses working with residents receiving dialysis services were counseled on properly following physician orders. | D |
| Unit 1 nursing staff were counseled to follow all residents' Plan of Care and rounds were to be ensured. | G |
| Evening and night shifts in Unit 2 were counseled on organizing responsibilities and using chain of command for support. | E |
| Observations and concerns for Units 2, 4, and 6 were addressed by cleaning, sanitizing, repairing, and replacing items as needed. | E |
| Permanent removal of courtyard furniture in Unit 2 and education on maintenance and care of courtyard furniture. | E |
| Installation and upgrade of door alarms to paging systems in all seven units to monitor entrances and exits. | E |
Report Facts
Complete Date: Jun 28, 2017
Units: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Williams | Administrator | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 12, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a previous inspection report for Asbury ALF dated 06/12/2017.
Findings
No deficiencies were cited in the referenced inspection report, so no corrective actions were required.
Report Facts
Plan of Correction completion date: Jun 12, 2017
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Jun 12, 2017
Visit Reason
The inspection was conducted as a Licensure Resurvey and Complaint Investigation involving multiple complaint numbers (#97650, #113377, #97880, and #100553).
Findings
The facility failed to provide a functioning electrical monitoring alarm system on exit doors for 7 of 7 units, including front doors, kitchen/dining room doors, and french doors, which did not alert staff when opened by residents who should not leave unaccompanied.
Complaint Details
The visit included a complaint investigation as indicated by the referenced complaint numbers and the nature of the findings related to door monitoring system failures.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide an electrical monitoring system on each door that exits the nursing facility to alert staff when residents opened exit doors in 7 of 7 units. | SS=E |
Report Facts
Census: 92
Units with door alarm failures: 7
Residents in affected units: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff Y | Stated the front door never had an alarm system, only a keypad | |
| Licensed nursing staff R | Reported exit door was not locked during the day and did not notify staff when open | |
| Administrative staff Z | Informed of lack of door alarms and advised doors to outside must alarm | |
| Administrative maintenance staff I | Verified doors did not alarm and ordered door alarms | |
| Administrative maintenance staff S | Confirmed alarm on unit #7 activated with a key by house supervisor or maintenance man |
Inspection Report
Enforcement
Deficiencies: 0
Jun 12, 2017
Visit Reason
A Health survey was conducted on June 12, 2017, by the Kansas Department for Aging and Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, resulting in denial of payment for new Medicare and Medicaid admissions effective July 2, 2017, with no opportunity to correct deficiencies before remedies are imposed.
Report Facts
Denial of payment effective date: Jul 2, 2017
Termination recommendation date: Dec 12, 2017
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the enforcement action |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 12, 2017
Visit Reason
The licensure survey was conducted to assess compliance with regulatory requirements for the facility.
Findings
The survey resulted in a finding of no deficiency citations for the facility.
Inspection Report
Life Safety
Deficiencies: 1
Nov 22, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: 2017
Effective date for provider agreement termination: 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and survey results |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Plan of Correction
Deficiencies: 7
Dec 3, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions for multiple deficiencies including resident fund authorization, cleanliness of the beauty shop and elevator, heating system adjustments, updated nursing policies on resident status changes, urinary continence, fall management, and dietary food safety and storage.
Severity Breakdown
D: 4
E: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Lack of signed authorization for resident funds. | D |
| Cleanliness issues in the beauty shop and elevator area. | E |
| Inadequate heating in Nelson Hall. | E |
| Outdated policy on resident status changes and care plans. | E |
| Urinary continence and incontinence policy not updated or followed. | D |
| Fall management program and interventions not properly implemented. | D |
| Dietary food safety issues including expired food and shelving problems. | E |
Report Facts
Date of corrective action completion: Dec 3, 2015
Resident number referenced: 80
Number of nursing units: 8
Duration of QA log monitoring: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Williams | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| VP of Support Services | Monitors heating system and cleanliness corrective actions. | |
| VP of Nursing Services | VPNS | Monitors nursing policy updates and compliance. |
| Nursing Services Director | NSD | Monitors nursing policy updates and compliance. |
| VP of Nutritional Services | Monitors dietary food safety corrective actions. |
Inspection Report
Follow-Up
Deficiencies: 7
Dec 3, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report documents that all previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, December 3, 2015.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 483.10(c)(2)-(5) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.15(h)(6) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.35(i) |
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Census: 97
Deficiencies: 7
Nov 5, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to obtain written authorization for managing resident funds, inadequate housekeeping and maintenance services, failure to maintain comfortable temperature levels, incomplete care plans for residents with behaviors, catheter care deficiencies, failure to prevent repeated falls, and unsanitary food storage conditions.
Severity Breakdown
SS=E: 4
SS=D: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to obtain written authorization prior to managing funds for one resident. | SS=E |
| Facility failed to provide effective housekeeping and maintenance services for 43 residents in beauty shop and common living areas. | SS=E |
| Facility failed to provide comfortable temperature levels for 43 residents on two nursing units. | SS=E |
| Facility failed to review and revise care plans for 5 residents including behavior interventions, catheter care, fall prevention, and side rail use. | SS=D |
| Facility failed to provide appropriate treatment and services to prevent urinary tract infections and urethral trauma for a resident with an indwelling catheter. | SS=D |
| Facility failed to ensure timely interventions to prevent repeated falls for two residents at risk for falls. | SS=E |
| Facility failed to store food under sanitary conditions in 5 kitchens and 1 kitchenette, including outdated food items and unsanitary shelving. | — |
Report Facts
Census: 97
Residents with managed funds: 23
Residents in affected nursing units: 43
Sampled residents: 23
Deficiency count: 6
Outdated food items: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Staff | Verified facility failed to obtain written authorization for managing resident funds |
| Staff B | Maintenance Staff | Confirmed housekeeping deficiencies and temperature control issues |
| Staff L | Direct Care Staff | Provided information on resident behaviors and fall circumstances |
| Staff G | Licensed Nursing Staff | Discussed catheter care and fall interventions |
| Staff C | Administrative Nursing Staff | Explained care plan review responsibilities and fall intervention challenges |
| Staff A | Licensed Administrative Staff | Stated responsibility for care plan updates and catheter care requirements |
Inspection Report
Renewal
Deficiencies: 0
Nov 5, 2015
Visit Reason
The Health Licensure Resurvey was conducted as a renewal inspection of the facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 1
Nov 5, 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 '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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter. |
Inspection Report
Life Safety
Deficiencies: 1
Jul 24, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Life Safety Code deficiencies at 'F' level, widespread, with no harm but potential for more than minimal harm. | F |
Report Facts
Denial of payments effective date: Oct 24, 2015
Provider agreement termination date: Jan 24, 2016
Plan of Correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Joe Ewert | Commissioner | Commissioner of KDADS, copied on the letter. |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 19, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report documents that deficiencies identified in prior surveys related to regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) were corrected as of the revisit date.
Report Facts
Correction completion date: Jun 19, 2015
Previous survey date: May 20, 2015
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
May 20, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#86456) regarding the facility's failure to review and revise care plans and ensure safety related to the use of positioning devices (transfer bars) for residents.
Findings
The facility failed to review and revise care plans to include the use of transfer bars for two residents, resulting in inconsistent care. Additionally, the facility failed to ensure residents remained free of accidents related to improperly fitted transfer bars, lacked proper assessments and policies for siderail/transfer bar use, and did not consistently complete safety assessments.
Complaint Details
Complaint investigation #86456 focused on care plan revisions and accident prevention related to transfer bars for residents #1 and #3.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to review and revise the plan of care to include the use of positioning devices (transfer bars) for 2 of 4 residents sampled. | SS=D |
| Failure to ensure residents remained free of accidents related to improper fitting of positioning devices (transfer bars) on beds for 2 of 4 residents sampled. | SS=D |
Report Facts
Resident census: 48
Residents sampled: 4
Measurement of gap between transfer bar and mattress: 5.5
Safe maximum gap measurement: 4.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff A | Confirmed continued use of transfer bar after assessment indicated it was not indicated; confirmed lack of measurement of gap; confirmed system problems with siderail/transfer bar assessments | |
| Licensed Nursing Staff C | Reported side rail/transfer bar assessments are done on admission and with condition changes; stated lack of training and difficulty interpreting assessments; reported inconsistent completion of assessments | |
| Direct Care Staff D | Reported resident's use of side rail and mobility assistance needs; described resident's condition and fall risk | |
| Direct Care Staff E | Reported resident's dependency on staff for mobility and transfers; stated resident did not use transfer bar independently |
Inspection Report
Plan of Correction
Deficiencies: 1
May 20, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at the facility.
Findings
The plan addresses deficiencies related to the improper use of side rails and transfer bars, including removal of hazardous equipment and revision of care plans. The facility outlines corrective actions, staff education, and ongoing monitoring to prevent recurrence.
Complaint Details
This plan of correction is in response to a complaint investigation linked to the Asbury Park 052015 Complaint. The complaint involved issues with resident safety related to side rails and transfer bars, including the death of Resident #1 on 5/07/15.
Severity Breakdown
D: 2
Deficiencies (1)
| Description | Severity |
|---|---|
| Improper use of side rails and transfer bars leading to resident harm, including the death of Resident #1. | D |
Report Facts
Deficiency tags: 2
Dates of corrective actions: May 7, 2015
Dates of corrective actions: May 20, 2015
Dates of corrective actions: May 26, 2015
Completion date: Jun 19, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 20, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'D' level that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 27, 2014
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
All previously cited deficiencies identified by regulation numbers 483.25, 483.35, and 483.65 were corrected as of the revisit date 08/27/2014.
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Aug 7, 2014
Visit Reason
This document is a Plan of Correction submitted by Asbury Park in response to deficiencies identified in a prior inspection report.
Findings
The plan outlines corrective actions for multiple deficiencies including communication with dialysis centers, therapy program follow-up, catheter care, nutritional intake monitoring, bowel movement documentation, kitchen sanitation, and cleaning of glucometers and soiled linen handling.
Severity Breakdown
D: 5
E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Communication with dialysis center regarding resident care information was deficient. | D |
| Lack of Functional Maintenance Program for residents discharged from Rehab Therapy. | D |
| Inappropriate catheter care by staff. | D |
| Failure to offer health shakes to residents consuming less than 25% of meals. | D |
| Inadequate documentation and monitoring of bowel movements for residents. | D |
| Poor kitchen sanitation including air circulation and cleaning of equipment. | E |
| Inadequate cleaning and disinfecting of glucometers and improper handling of soiled linens. | E |
Report Facts
Date: Aug 27, 2014
Date: Aug 7, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Law | Assistant Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Original Licensing
Deficiencies: 0
Jul 31, 2014
Visit Reason
The licensure survey was conducted to assess compliance for the facility's licensing requirements.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Census: 101
Deficiencies: 7
Jul 29, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements related to resident care, treatment, infection control, and facility sanitation.
Findings
The facility was found deficient in multiple areas including failure to ensure communication with dialysis center for a resident, lack of restorative program for a resident post-therapy, inadequate catheter care leading to risk of urinary tract infections, failure to provide nutritional supplements when needed, inadequate monitoring of bowel movements related to medication use, unsanitary conditions in the dietary department, and inadequate infection control practices including improper cleaning of glucometers and handling of soiled linens.
Severity Breakdown
SS=D: 4
SS=E: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure communication between the facility and dialysis center for one resident receiving dialysis services. | SS=D |
| Failed to provide a restorative program to maintain walking ability for one resident post-therapy. | SS=D |
| Failed to provide necessary catheter care to prevent urinary tract infections and urethral trauma for one resident with an indwelling urinary catheter. | SS=D |
| Failed to provide nutritional supplements when less than 25% of the meal was consumed by a dependent resident. | SS=D |
| Failed to adequately monitor bowel movements and administer medications as needed for two residents, resulting in prolonged periods without bowel movements. | SS=E |
| Failed to maintain a clean and sanitary dietary department, including dirty pans and grease buildup on equipment. | SS=E |
| Failed to adequately clean glucometers between resident uses and improperly handled soiled linens, risking infection spread. | SS=E |
Report Facts
Resident census: 101
Residents sampled: 18
Residents served meals from main kitchen: 53
Days without bowel movement: 8
Weight measurements: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff EE | Licensed nursing staff | Reported no paperwork sent with resident to dialysis center and confirmed failure to clean glucometer between uses |
| Staff C | Administrative nursing staff | Reported expectation of communication with dialysis center and responsibility for restorative program oversight |
| Staff V | Direct care staff | Assisted resident with walking and personal hygiene, reported resident's mobility status |
| Staff N | Direct care staff | Reported resident's bowel movement charting and assisted with toileting and personal care |
| Staff L | Licensed nursing staff | Reported expectations for bowel movement monitoring and glucometer cleaning |
| Staff G | Administrative nursing staff | Reported expectations for glucometer cleaning and dialysis communication |
| Staff HH | Direct care staff | Observed using glucometer without cleaning between residents |
| Staff R | Housekeeping staff | Observed transporting unbagged soiled linens |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 29, 2014
Visit Reason
The inspection 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 'E' level deficiencies, 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 accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter regarding acceptance of plan of correction and enforcement decision |
Inspection Report
Follow-Up
Deficiencies: 8
Mar 12, 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 shows that all previously cited deficiencies were corrected by 02/28/2014, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| 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 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(i) |
Report Facts
Deficiencies corrected: 8
Inspection Report
Follow-Up
Deficiencies: 8
Mar 12, 2014
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers and prefix codes were corrected by 02/28/2014.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| 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 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(i) |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 8
Feb 28, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Asbury Park facility.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies related to resident care, including notification of changes, skin integrity, pressure ulcer management, transfer techniques, and nutritional replacements. It details systemic changes, staff education, and monitoring processes to ensure compliance and prevent recurrence.
Severity Breakdown
D: 6
G: 1
E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to appropriately notify physician and family of resident changes and maintain documentation. | D |
| Inadequate reporting and handling of abuse, neglect, and exploitation (ANE) incidents. | D |
| Insufficient care plan updates and monitoring for bruising and open skin areas. | D |
| Inadequate care plan and monitoring for pressure sores, including coordination with hospice. | D |
| Lack of review and implementation of Skin Integrity Report Sheets and notification logs. | D |
| Failure to consistently reposition residents at risk for pressure ulcers and provide staff education. | G |
| Improper use of mechanical lifts and gait belts by direct care staff, requiring retraining. | E |
| Failure to offer nutritional replacements to residents consuming less than 50% of meals and document accordingly. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Nancy Law | Assistant Administrator | Submitted the Plan of Correction |
| Mary Jane Kennedy | Modified the Plan of Correction | |
| Irina Strakhova | Added the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 7
Jan 31, 2014
Visit Reason
Complaint investigations for complaints #72182, #70964, #70048, and #69656 were conducted to assess compliance with resident care and safety regulations.
Findings
The facility failed to notify physicians and family members of significant resident changes, failed to investigate injuries of unknown origin, failed to develop and implement comprehensive care plans addressing skin integrity and fall risks, failed to provide adequate supervision and safe transfer techniques, and failed to maintain nutritional status for residents at risk.
Complaint Details
The inspection was triggered by multiple complaints (#72182, #70964, #70048, and #69656) alleging failures in resident care including notification, investigation, care planning, supervision, and nutrition.
Severity Breakdown
SS=D: 5
SS=G: 1
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to notify physician and family of resident's pressure ulcers and repeated skin tears. | SS=D |
| Failed to investigate and report a large bruise of unknown origin to the State. | SS=D |
| Failed to develop and implement care plans addressing fragile skin, bruising, and use of mechanical lifts. | SS=D |
| Failed to revise care plans to address pressure sores and increased supervision to decrease falls. | SS=D |
| Failed to provide necessary care and services to prevent pressure ulcers from developing or worsening. | SS=G |
| Failed to ensure resident environment was free of accident hazards and provide adequate supervision and assistance devices to prevent accidents. | SS=E |
| Failed to maintain nutritional status by not consistently providing planned nutritional supplements. | SS=D |
Report Facts
Resident census: 98
Skin tears documented: 10
Bruise size: 7
Bruise size: 9
Pressure ulcer open areas: 5
Pressure ulcer stage II sizes: 0.5
Pressure ulcer stage II sizes: 0.6
Pressure ulcer stage II size: 1.1
Pressure ulcer stage III size: 0.8
Resident weight: 156.2
Resident weight: 151.2
Resident weight: 153.4
Resident weight: 153.8
Resident weight: 150.2
Meals eaten 50% or less: 66
Meals without health shake offered: 47
Falls: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Provided statements regarding notification, supervision, wound care, and transfer safety | |
| Administrative staff C | Provided statements regarding investigation of bruise and notification policies | |
| Administrative Nurse B | Confirmed expectations for family notification and supervision | |
| Licensed nurse A | Provided statements about wound care and resident condition | |
| Licensed nurse H | Provided statements about wound care and resident condition | |
| Therapy staff R | Provided statements about transfer assessments and safety | |
| Direct care staff F | Provided statements about resident skin tears and care | |
| Direct care staff I | Provided statements about resident skin tears and care | |
| Direct care staff K | Observed assisting resident with mechanical lift | |
| Direct care staff L | Observed assisting resident with mechanical lift |
Inspection Report
Life Safety
Deficiencies: 1
Jan 14, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Denial of payments effective date: Apr 14, 2014
Provider agreement termination date: Jul 14, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Williams | Administrator | Facility administrator named 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. |
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 19, 2013
Visit Reason
The health survey was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 19, 2013
Visit Reason
The licensure survey was conducted to assess compliance with regulatory requirements for the facility.
Findings
The survey resulted in findings of no deficiency citations, indicating full compliance with licensure standards.
Inspection Report
Follow-Up
Deficiencies: 1
Jun 21, 2012
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as noted on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of 06/21/2012.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
Report Facts
Deficiency correction date: Jun 21, 2012
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
May 23, 2012
Visit Reason
The inspection was conducted as an Abbreviated Survey and Complaint Investigations triggered by allegations of resident abuse.
Findings
The facility failed to conduct a thorough investigation of an allegation of resident abuse, failed to ensure staff immediately notified the administrator or designee of the abuse allegation, and failed to protect the 29 residents residing on the Sunflower neighborhood.
Complaint Details
The complaint investigations #57002, #57190, and #56953 involved allegations of employee to resident abuse on May 6, 2012, specifically involving resident #5. Multiple staff interviews and observations revealed staff D acted inappropriately by attempting to force the resident into a sit-to-stand lift despite the resident's refusal and agitation. Licensed nursing staff E intervened but failed to immediately report the incident to administration. Administrative nursing staff confirmed delays in notification and failure to remove the alleged perpetrator from the unit.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to conduct a thorough investigation of an allegation of resident abuse, failure to ensure staff immediately notified the administrator or designee of an allegation of abuse, and failure to protect residents on the Sunflower neighborhood. | SS=E |
Report Facts
Facility census: 98
Residents on Sunflower neighborhood: 29
Witness statements: 5
Additional staff present: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Direct care staff | Alleged perpetrator who attempted to force resident #5 into sit-to-stand lift despite refusal |
| Licensed nursing staff E | Licensed nurse | Intervened during incident, told Staff D to stop, reported incident to administration the next day |
| Direct care staff C | Direct care staff | Witnessed incident and reported Staff D's behavior |
| Direct care staff F | Direct care staff | Witnessed incident and reported Staff D's behavior |
| Direct care staff G | Direct care staff | Witnessed incident and reported Staff D's behavior to charge nurse |
| Direct care staff H | Direct care staff | Witnessed incident and reported Staff D's behavior |
| Licensed nursing staff J | Licensed nurse | Received report from Staff E about incident, confirmed Staff D was insubordinate |
| Administrative nursing staff I | Administrator | Confirmed delayed notification of incident and failure to remove Staff D from unit |
| Administrative nursing staff K | Administrator | Reported staff should have notified administration and removed alleged perpetrator |
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 1
N040002 POC IW4011
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation regarding an allegation of abuse, neglect, or exploitation (ANE) involving Resident #5 at Asbury Park.
Findings
The deficiency involved an allegation of ANE that was self-reported by the facility prior to the survey. The investigation included interviews with staff, residents, and families. Systemic changes and enhanced staff education were planned to prevent recurrence.
Complaint Details
The visit was complaint-related, triggered by an allegation of abuse, neglect, or exploitation (ANE) involving Resident #5. The allegation was self-reported by the facility prior to the survey. Additional staff interviews were conducted during the investigation.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Allegation of abuse, neglect, or exploitation (ANE) involving Resident #5, with investigation and corrective actions planned. | E |
Report Facts
Residents on Sunflower Unit: 29
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