Inspection Reports for
Paramount Community Living and Rehab Inc
200 SW 14TH STREET, NEWTON, KS, 67114
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
12.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
103% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
91% occupied
Based on a March 2024 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 6
Date: Mar 28, 2024
Visit Reason
Annual inspection survey of Paramount Community Living and Rehab Inc to assess compliance with regulatory requirements and resident care standards.
Findings
The facility failed to ensure resident dignity, develop comprehensive care plans reflecting resident preferences, monitor fluid restrictions, maintain infection control practices, and revise care plans after significant events. Multiple residents experienced lapses in care including improper catheter care, lack of dignity in feeding and personal care, and inadequate infection prevention.
Deficiencies (6)
F 0550: The facility failed to honor residents' rights to dignity and self-determination, including failure to dress R37 in preferred support hose, failure to knock before entering R60's room during care, standing over R31 while feeding, and failure to use dignity bags for catheter collection for R78.
F 0584: The facility failed to provide unstained, clean towels and washcloths to residents in one house, compromising comfort and hygiene.
F 0656: The facility failed to develop comprehensive, person-centered care plans for four residents, omitting preferences for support hose, fluid restriction, activity preferences, and facial shaving.
F 0657: The facility failed to revise care plans timely to include new pressure ulcers and falls with fractures, and failed to assess effectiveness of off-loading devices for pressure ulcer prevention and healing.
F 0692: The facility failed to monitor and document physician-ordered fluid restriction for resident R35, lacked a policy on fluid restrictions, and staff were unaware of monitoring requirements.
F 0880: The facility failed to implement infection prevention and control practices including improper storage of oxygen tubing and cannulas for R9, failure to maintain hand hygiene and glove changes during catheter and perineal care for R60 and R78, and improper catheter care for R242.
Report Facts
Residents in census: 92
Residents sampled: 22
Fluid restriction: 2000
Fluid intake day shift: 1200
Fluid intake evening shift: 600
Fluid intake night shift: 180
Inspection Report
Routine
Census: 92
Deficiencies: 14
Date: Mar 28, 2024
Visit Reason
Routine inspection of Paramount Community Living and Rehab Inc to assess compliance with healthcare facility regulations including resident care, safety, and infection control.
Findings
The facility failed to ensure resident dignity, complete accurate assessments and care plans, provide appropriate activities, maintain infection control, monitor fluid restrictions, and ensure proper medication administration. Multiple deficiencies were noted in resident care, pressure ulcer management, restorative services, catheter care, food safety, and infection prevention.
Deficiencies (14)
F 0550: The facility failed to honor residents' rights to dignity and self-determination, including failure to provide support hose, respect privacy during care, and use dignity bags for catheter bags.
F 0584: The facility failed to provide unstained, clean towels and washcloths to residents in one house.
F 0636: The facility failed to complete accurate Minimum Data Set (MDS) assessments and Care Area Assessments (CAA) for residents, resulting in incomplete care planning.
F 0656: The facility failed to develop comprehensive, person-centered care plans reflecting resident preferences for support hose, fluid restriction, activities, and facial shaving.
F 0657: The facility failed to revise care plans to include a resident's fall with fractured toe and pressure ulcer care.
F 0677: The facility failed to provide appropriate facial shaving care for a dependent resident.
F 0679: The facility failed to provide meaningful activities to residents, resulting in limited participation and lack of structured programs.
F 0686: The facility failed to provide effective heel off-loading interventions for a resident with a deep tissue injury, resulting in worsening pressure ulcer.
F 0688: The facility failed to provide range of motion (ROM) services for a resident, resulting in decreased mobility and hand contractures.
F 0690: The facility failed to utilize an anchoring device for a resident's urinary catheter tubing and failed to keep catheter tubing off the floor for another resident, risking injury and infection.
F 0692: The facility failed to monitor a resident's physician-ordered fluid restriction, resulting in lack of fluid intake monitoring and documentation.
F 0757: The facility failed to monitor vital signs weekly and failed to hold hypertensive medications when blood pressure was below physician-ordered parameters. The facility also failed to monitor bowel movements for a resident at risk for constipation.
F 0812: The facility failed to prepare and serve food under sanitary conditions, including unclean kitchen equipment, undated opened food, and poor storage practices, risking foodborne illness.
F 0880: The facility failed to ensure infection control techniques including proper storage of oxygen tubing and cannulas, proper catheter care with glove changes, and prevention of cross-contamination during incontinent care.
Report Facts
Resident census: 92
Residents reviewed: 22
Days without bowel movement: 10
Blood pressure readings outside parameters: 14
Deep tissue injury size: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple interviews regarding care expectations and deficiencies |
| Certified Medication Aide M | Certified Medication Aide | Observed and interviewed regarding resident care and activities |
| Certified Nurse Aide UU | Certified Nurse Aide | Observed providing care with infection control lapses |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding pressure ulcer care and catheter care |
| Administrative Nurse E | Administrative Nurse | Interviewed regarding pressure ulcer care and fluid restriction monitoring |
Inspection Report
Routine
Census: 87
Deficiencies: 9
Date: May 9, 2022
Visit Reason
Routine inspection of nursing home facility to assess compliance with regulatory requirements including resident care, medication management, staffing, and infection control.
Findings
The facility failed to provide resident food choices, develop comprehensive care plans for oxygen and restorative care, maintain respiratory equipment properly, provide timely pain medication, post accurate nurse staffing information, complete baseline assessments for antipsychotic side effects, limit psychotropic PRN medication duration, and implement effective antibiotic stewardship.
Deficiencies (9)
F 0561: The facility failed to provide food choices for a resident related to food preferences, including failure to offer alternate meals when disliked items were served.
F 0656: The facility failed to develop comprehensive care plans for residents requiring oxygen maintenance and restorative care, including lack of instructions for oxygen equipment maintenance.
F 0688: The facility failed to provide restorative services to maintain or prevent decline in range of motion for a resident with a contracture.
F 0695: The facility failed to maintain respiratory equipment in a sanitary manner, including failure to change oxygen tubing timely, label and store tubing and nebulizer kits properly, increasing infection risk.
F 0697: The facility failed to provide timely pain management for a resident, resulting in four missed scheduled doses of narcotic medication and increased pain level.
F 0732: The facility failed to post accurate and identifiable daily nurse staffing information for a unit for five consecutive days.
F 0756: The facility and consulting pharmacist failed to complete baseline and periodic assessments for extrapyramidal side effects of antipsychotic medications for a resident.
F 0758: The facility failed to limit as needed psychotropic medication orders to 14 days without physician reevaluation and failed to ensure specified duration for PRN orders for three residents.
F 0881: The facility failed to implement an effective antibiotic stewardship program, including failure to track and trend infections and causative organisms and compile antibiotic use data for prescribers.
Report Facts
Resident census: 87
Residents sampled: 23
Missed scheduled narcotic doses: 4
Days without updated nurse staffing posted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| TT | Certified Medication Aide | Reported staff did not check resident food dislikes and failed to offer alternate meals |
| MM | Certified Nurse Aide | Reported frequent complaints about food and sometimes cooked alternate meals |
| G | Licensed Nurse | Reported nursing staff were universal workers and lacked knowledge of food preparation and oxygen equipment maintenance |
| E | Administrative Nurse | Reported expectations for staff to offer food alternatives and maintain oxygen equipment |
| SS | Certified Medication Aide | Confirmed resident had oxygen order but lacked instruction on tubing/humidifier changes |
| RR | Certified Medication Aide | Reported oxygen tubing, humidifier bottle, and nebulizer kit should be changed weekly and dated |
| I | Licensed Nurse | Reported resident R63 ran out of pain medication due to delayed reorder |
| D | Administrative Nurse | Confirmed incomplete antibiotic stewardship data and failure to track infections |
| LL | Licensed Nurse | Confirmed failure to complete baseline assessment for antipsychotic side effects |
| Pharmacist II | Consultant Pharmacist | Confirmed expectation for baseline and periodic assessment of antipsychotic side effects |
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 3
Date: Feb 16, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with Medicare/Medicaid regulations and evaluate the facility's care practices.
Findings
The facility failed to notify a resident in advance of Medicare Part A service termination, did not adequately evaluate and intervene to prevent falls for a resident, and failed to maintain oxygen humidifier and tubing for a resident requiring respiratory care.
Deficiencies (3)
F 0582: The facility failed to provide Resident 5 written notification of Medicare Part A skilled nursing services ending prior to the coverage termination date as required by CMS regulations.
F 0689: The facility failed to identify causal factors and implement appropriate interventions to prevent Resident 45 from falling despite multiple falls and documented risks.
F 0695: The facility failed to ensure Resident 45's oxygen humidifier and tubing were properly maintained, with cracked humidifier container and no liquid present.
Report Facts
Residents present: 92
Falls: 6
Oxygen flow rate: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 26, 2019
Visit Reason
This document is a plan of correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses self-reported deficient practices related to medication administration that did not have an adverse effect on residents. Nursing staff were counseled and scheduled for in-service training on medication administration and error reporting.
Deficiencies (2)
F755-D: The self-reported deficient practice did not adversely affect the resident involved. Nurses were counseled and an in-service was scheduled to address the deficient practice.
F760-D: The self-reported deficient practice did not adversely affect the resident involved. Nurses were counseled and an in-service was scheduled to address the deficient practice.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Norman Forbes | V.P. Nursing Services | Submitted the plan of correction |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Date: Apr 1, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#KS00134591) regarding medication errors at the facility.
Complaint Details
The complaint investigation found substantiated medication errors involving two residents. The facility failed to follow physician orders for medication administration, resulting in incorrect dosing.
Findings
The facility failed to accurately follow physician's orders for medication administration for two residents. Resident #1 received Lamictal twice daily instead of once daily on multiple days, and Resident #2 was administered an extra dose of extended-release morphine.
Deficiencies (2)
F755 Pharmacy Services: The facility failed to ensure Resident #1 received Lamictal once daily as ordered, instead administering it twice daily on four consecutive days.
F760 Residents are Free of Significant Med Errors: The facility failed to keep Resident #2 free of significant medication errors by administering an extra dose of extended-release morphine.
Report Facts
Resident census: 96
Medication error days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff G | Discovered medication error with Resident #1's Lamictal dosing and involved in notification and investigation. | |
| Licensed nursing staff C | Administered extra dose of extended-release morphine to Resident #2 and failed to respond to interview requests. | |
| Administrative nursing staff A | Provided incident log and explained medication error procedures. | |
| Administrative nursing staff B | Received medication discrepancy and teachable moment forms and assessed corrective actions. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 7, 2019
Visit Reason
A revisit survey was conducted on 1/7-8/2019 for all previous deficiencies cited on SU0E11 to verify correction of prior deficiencies.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 11/21/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 12, 2018
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified in a prior complaint investigation at the facility.
Findings
The plan addresses deficiencies related to personalized care planning, fall prevention, toileting protocols, and staff accountability. Multiple corrective actions including staff education, policy revisions, and monitoring by nursing leadership are outlined with completion dates.
Deficiencies (1)
F689-G: Detailed personalized care plan is developed to include toileting schedule and resident assistance and ambulation needs. Nursing staff are held accountable and monitored by VP of Nursing.
Report Facts
Plan of Correction completion dates: Nov 12, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Williams | CEO/NHA | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lacey Hunter | Added Plan of Correction entry | |
| Caryl Gill | Modified Plan of Correction entry |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 1
Date: Nov 7, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#KS00134172) regarding a resident fall incident.
Complaint Details
The complaint investigation found the facility failed to supervise a resident who fell while on the toilet unattended, resulting in injury. The staff member responsible was coached and subsequently terminated. The facility acknowledged the deficient practice and initiated corrective actions.
Findings
The facility failed to ensure adequate supervision for one resident during toileting, resulting in a fall and a fractured nose. The investigation found that staff left the resident unattended on the toilet, contrary to facility policy.
Deficiencies (1)
F 689: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent a resident fall during toileting. The resident fell unassisted from the toilet and sustained a fractured nose.
Report Facts
Resident census: 94
Residents reviewed for accidents: 4
Fall Risk Assessment score: 40
BIMS score: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 7, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Based on 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.
Report Facts
Denial of Payment Effective Date: Nov 24, 2018
Termination Recommendation Date: May 7, 2019
Civil Money Penalty Threshold: 10483
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Contact person for questions regarding the letter and instructions for informal dispute resolution. |
| Benton Williams | CMS Regional Office | Contact for questions regarding the matter by phone at (816) 426-6336. |
| Brad Fischer | Commissioner | Recipient of written requests for informal dispute resolution. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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
Annual Inspection
Census: 94
Deficiencies: 8
Date: 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, inadequate activity programs, medication errors, expired medications, inconsistent menu posting, poor food quality, and failure to provide sugar free snacks for diabetic residents.
Deficiencies (8)
F656: The facility failed to develop individualized person-centered comprehensive care plans for 18 of 21 sampled residents that included measurable objectives and interventions based on assessments.
F679: The facility failed to provide ongoing activities to meet the interests and psychosocial well-being of four residents, with no comprehensive care plans for activities and inconsistent activity scheduling.
F744: The facility failed to develop person-centered comprehensive care plans for dementia care for three sampled residents, lacking measurable objectives and interventions.
F759: The facility failed to follow accepted medication administration standards by crushing and combining multiple medications for administration via feeding tube, resulting in a medication error rate of 23%.
F761: The facility failed to destroy expired medications in two medication rooms and failed to document open dates on multi-use medication bottles.
F803: The facility failed to consistently post daily dining menus for residents in one unit, leaving residents unaware of meal options and alternatives.
F804: The facility failed to provide palatable food during one meal observed, with residents reporting limp fries, bland food, and improperly cooked items.
F806: The facility failed to provide sugar free snacks for two diabetic residents despite their preferences and dietary needs.
Report Facts
Survey Census: 94
Sample Size: 37
Medication error rate: 23
Number of residents with deficient care plans: 18
Number of residents without adequate activities: 4
Number of residents reporting poor food quality: 7
Number of diabetic residents lacking sugar free snacks: 2
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 13, 2018
Visit Reason
The visit 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 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 2018-10-19.
Deficiencies (1)
The facility had an 'E' level deficiency pattern that constitutes no actual harm but has potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Sep 13, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior 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 staff training. The facility describes monitoring and compliance measures with projected completion dates mostly by 10/19/2018.
Deficiencies (8)
F656-E: Resident care plans will include goals for admission and desired outcomes including resident preferences and potential for future discharge. Care plans are monitored and updated by nursing staff.
F679-D: Needs assessments will be conducted for residents in the Green House to determine interests and update care plans accordingly. Activity calendars will be developed and monitored.
F744-D: Care plans for residents with dementia will have specific identification of problems, goals, and approaches addressing medical, physical, mental, and psychosocial needs.
F759-D: Staff administering medications have been educated on policies to maintain medication error rates below 5%, including standards for crushing and combining medications for feeding tubes.
F761-D: Staff educated on medication storage and destruction procedures; all open medications will be dated and discarded per policy. Monitoring conducted monthly.
F803-D: Residents in each Green House can make daily meal choices; menus will be posted and updated daily with staff oversight. A campus-wide meal choice policy will be distributed.
F804-D: Green House staff receive training on safe food handling and preparation, including competency checks and ongoing nutritional services support.
F806-D: Snacks will be readily available and labeled for residents with special dietary needs, including diabetes. Staff and residents will be educated on snack availability.
Report Facts
Medication error rate goal: 5
Projected completion date: Oct 19, 2018
Education completion date: Sep 19, 2018
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 14, 2017
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The report confirms that the previously identified deficiency related to regulation 26-40-303 (2)(a)(i)(ii)(iii) was corrected as of 06/28/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 26-40-303 (2)(a)(i)(ii)(iii) deficiency was corrected by 06/28/2017.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 14, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies listed with their regulation numbers were corrected by 06/28/2017 as confirmed during this revisit.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 14, 2017
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency under regulation 26-40-303 (2)(a)(i)(ii)(iii) was corrected as of 06/28/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 26-40-303 (2)(a)(i)(ii)(iii) deficiency was corrected by 06/28/2017.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 14, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
All previously reported deficiencies listed on the CMS-2567 were corrected as of 06/28/2017, with no uncorrected deficiencies noted at the time of this revisit.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: 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 safety monitoring, kitchen cleanliness, courtyard maintenance, and door alarm system upgrades.
Deficiencies (7)
F241-D: Unit 1 nursing staff scheduled for night shifts were counseled on resident dignity and properly following the Plan of Care. Education on Resident Dignity policy was scheduled for all nursing staff.
F309-D: Nurses working with residents receiving dialysis were counseled on following physician orders. Education on Resident Dialysis Care policy was scheduled for all nursing staff.
F323-G: Unit 1 nursing staff were counseled to follow residents' Plan of Care. The facility purchased radio frequency monitors to improve supervision of at-risk residents.
F353-E: Unit 2 evening and night shift staff were counseled on organizing responsibilities and using the chain of command for support. Staffing model alignment with the Green House model was confirmed.
F371-E: Observations and concerns in Units 2, 4, and 6 were addressed by cleaning, sanitizing, repairing, and replacing equipment. Kitchen cleaning schedules were updated and staff educated.
F465-E: Courtyard furniture in Unit 2 was permanently removed. Staff were educated on maintenance requests and preventive maintenance checklists were updated for courtyard inspections.
S1174-E: Door alarms on entrance/exit doors were upgraded to a paging system in all seven units. Staff were counseled to complete work orders if alarms malfunction.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Date: 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).
Complaint Details
The visit included a complaint investigation as indicated by the referenced complaint numbers. The findings confirmed the complaint regarding lack of door alarms.
Findings
The facility failed to provide a functioning electrical door monitoring system on all exit doors accessible to residents across 7 units. Multiple doors, including front doors, kitchen/dining room doors, and french doors, lacked alarms to alert staff when opened by residents.
Deficiencies (1)
26-40-303 (2)(a)(i)(ii)(iii) P E - Door monitoring system. The facility failed to provide an electrical monitoring system on each exit door to alert staff when residents opened doors in 7 units. Multiple doors including front, kitchen, dining room, and french doors did not alarm as required.
Report Facts
Resident census: 92
Units affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff Y | Stated the front door never had an alarm system, only a keypad. | |
| Administrative staff Z | Informed of the lack of door alarms and advised any door to the outside must alarm. | |
| Licensed nursing staff R | Stated the exit door was not locked during the day and did not notify staff when open. | |
| Administrative maintenance staff I | Verified the doors did not alarm and had ordered door alarms. | |
| Administrative maintenance staff S | Confirmed the alarm on unit #7 activated with a key by the house supervisor or maintenance man. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 12, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior inspection report.
Findings
No deficiencies were cited in the related inspection report.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jun 12, 2017
Visit Reason
The licensure survey was conducted to assess compliance for facility licensing.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 0
Date: Jun 12, 2017
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy. Based on 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 effective July 2, 2017.
Report Facts
Denial of payment effective date: Jul 2, 2017
Enforcement compliance deadline: Dec 12, 2017
Civil Money Penalty minimum amount: 5000
Hearing request deadline: 60
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact for questions concerning the instructions contained in the letter |
Inspection Report
Life Safety
Deficiencies: 0
Date: Nov 22, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine 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. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Dec 3, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including resident fund authorizations, cleanliness of the beauty shop and elevator, heating system adjustments, updated nursing policies on care plans, urinary continence, fall management, and dietary food safety and storage.
Deficiencies (7)
F159-D: Administrative staff obtained signed authorization from resident #80 for resident funds. Audits will ensure all residents with funds have authorizations.
F253-E: The Beauty Shop will be cleaned and painted; carpet stains addressed; elevator scrapes covered; housekeeping will maintain cleanliness with QA checklists.
F257-E: Heating system fans turned on to improve comfort in Nelson Hall; policy developed for maintenance staff to adjust heating seasonally.
F280-E: Updated policy on resident status changes and care plans; nurses will be in-serviced and compliance monitored by VP Nursing Services and Nursing Director.
F315-D: Updated urinary continence policy with staff in-service; weekly spot checks to ensure compliance and proper catheter tubing anchoring.
F323-D: Updated fall management program and checklist; nursing staff to complete checklist after falls; compliance monitored and noncompliance disciplined.
F371-E: Dietary shelves lined; expired food disposed and responsible employees disciplined; new labeling and food rotation procedures implemented.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 3, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 97
Deficiencies: 7
Date: Nov 5, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with previously cited deficiencies and overall facility regulatory requirements.
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 plan revisions for residents with behaviors, catheter care deficiencies, failure to prevent repeated falls, and unsanitary food storage conditions.
Deficiencies (7)
483.10(c)(2)-(5) Facility failed to obtain written authorization prior to managing personal funds for 1 resident out of 6 reviewed.
483.15(h)(2) Facility failed to provide effective housekeeping and maintenance services for 43 residents in 2 nursing units, including grime buildup and damaged surfaces in beauty shop and common areas.
483.15(h)(6) Facility failed to provide comfortable temperature levels for 43 residents in 2 nursing units, with temperatures below required range and no individual room temperature control.
483.20(d)(3), 483.10(k)(2) Facility failed to review and revise care plans timely for 5 residents, lacking specific behavior interventions, catheter care instructions, fall prevention updates, and side rail use guidance.
483.25(d) Facility failed to provide appropriate treatment and services to prevent urinary tract infections and urethral trauma for a resident with an indwelling catheter, including failure to keep catheter tubing off the floor and lack of anchoring device.
483.25(h) Facility failed to ensure timely interventions to prevent repeated falls for 2 residents at risk for falls.
483.35(i) Facility failed to store food under sanitary conditions in 5 kitchens and 1 kitchenette, including outdated food items, porous shelving, broken drawers, and unlabeled food containers.
Report Facts
Resident census: 97
Residents with managed funds: 23
Residents with housekeeping deficiencies: 43
Residents in nursing units with temperature issues: 43
Residents sampled for care plan review: 23
Residents with indwelling catheters: 7
Residents reviewed for accidents: 3
Outdated food items found: 11
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 5, 2015
Visit Reason
The Health Licensure Resurvey was conducted to assess compliance and verify correction of previous deficiencies at the facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 5, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be an 'E' level deficiency pattern, indicating no actual harm but potential for more than minimal harm without 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.
Deficiencies (1)
The facility had an 'E' level deficiency pattern indicating no actual harm but potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey findings. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 24, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied 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, and not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended due to failure to achieve substantial compliance.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Report Facts
Enforcement 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 |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 24, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine 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, and not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Oct 24, 2015
Provider agreement termination date: Jan 24, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 19, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-05-20.
Findings
The revisit confirmed that the previously reported deficiencies under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) were corrected as of 2015-06-19.
Deficiencies (2)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date.
Report Facts
Date of Revisit: Jun 19, 2015
Date of Original Survey: May 20, 2015
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 19, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-05-20.
Findings
The revisit confirmed that the previously reported deficiencies under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) were corrected as of 2015-06-19.
Deficiencies (2)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiency corrected by the revisit date.
Regulation 483.25(h): Previously cited deficiency corrected by the revisit date.
Report Facts
Deficiencies corrected: 2
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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, resulting in a finding of substantial compliance.
Deficiencies (1)
The facility had 'D' level deficiencies indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and plan of correction acceptance. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Deficiencies (1)
The facility had 'D' level deficiencies that constitute 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
Complaint Investigation
Census: 48
Deficiencies: 2
Date: 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 resident safety related to the use of positioning devices (transfer bars) in bed for sampled residents.
Complaint Details
The complaint investigation (#86456) substantiated that the facility failed to properly assess, document, and ensure safety related to transfer bars for residents, leading to accidents and inconsistent care.
Findings
The facility failed to review and revise care plans to include the use of transfer bars for two residents, resulting in inconsistent care. The facility also failed to ensure residents remained free of accidents related to improperly fitted transfer bars, including a resident who fell out of bed and sustained an abrasion. Staff lacked training on siderail/transfer bar assessments, and the facility lacked a policy addressing their use.
Deficiencies (2)
F 280: The facility failed to review and revise the plan of care to include the use of positioning devices in bed for 2 of 4 sampled residents related to transfer bars.
F 323: The facility failed to ensure 2 of 4 sampled residents remained free of accidents related to improper fitting of transfer bars on their beds, resulting in a fall and injury.
Report Facts
Resident census: 48
Residents sampled for accidents: 4
Measurement of gap between transfer bar and mattress: 5.5
Safe maximum measurement for gap: 4.75
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 7, 2015
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation regarding deficiencies found at the facility.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Asbury Park 052015 Complaint.
Findings
The facility identified issues related to the use of shepherd hook style transfer bars on beds, which affected residents including one who died. The facility implemented corrective actions including removal of the transfer bars, policy revisions, staff education, and ongoing monitoring to prevent recurrence.
Deficiencies (2)
F280-D: The facility failed to ensure proper use of side rails, resulting in removal of shepherd hook style transfer bars from residents' rooms after a resident death and care plan updates.
F323-D: The facility failed to maintain compliance with policies on side rail use, requiring staff education and monitoring to prevent deficient practices from recurring.
Report Facts
Date of resident death: May 7, 2015
Plan of Correction completion date: Jun 19, 2015
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 27, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date of 08/27/2014.
Inspection Report
Follow-Up
Deficiencies: 7
Date: Aug 27, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-07-29.
Findings
All previously reported deficiencies identified on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Deficiencies (7)
Regulation 483.25 (F0309) deficiency was corrected by 08/27/2014.
Regulation 483.25(a)(2) (F0311) deficiency was corrected by 08/27/2014.
Regulation 483.25(d) (F0315) deficiency was corrected by 08/27/2014.
Regulation 483.25(i) (F0325) deficiency was corrected by 08/27/2014.
Regulation 483.25(l) (F0329) deficiency was corrected by 08/27/2014.
Regulation 483.35(i) (F0371) deficiency was corrected by 08/27/2014.
Regulation 483.65 (F0441) deficiency was corrected by 08/27/2014.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Aug 7, 2014
Visit Reason
This document is a Plan of Correction submitted by Asbury Park facility to address deficiencies identified in a prior inspection.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including communication with dialysis centers, therapy program maintenance, catheter care, nutritional intake monitoring, bowel movement documentation, kitchen sanitation, glucometer cleaning, and soiled linen handling.
Deficiencies (7)
F309-D: Communication forms will be used between licensed nurses and dialysis centers to ensure proper information exchange for residents receiving dialysis.
F311-D: A Functional Maintenance Program has been developed for residents discharged from rehab therapy to ensure continued care.
F315-D: Staff have been re-educated on appropriate catheter care procedures for residents with indwelling catheters.
F325-D: Staff have been re-educated to offer health shakes to residents consuming less than 25% of meals to improve nutrition.
F329-D: Documentation and monitoring of bowel movements will be reviewed daily to ensure interventions for residents with no bowel movement for three days.
F371-E: Kitchen dampers were fixed and cleaning procedures improved to enhance sanitation and air drying in the main and satellite kitchens.
F441-E: Glucometers have been cleaned and disinfected; individual glucometers ordered; staff re-educated on cleaning and soiled linen transport policies.
Inspection Report
Original Licensing
Deficiencies: 0
Date: 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 for the facility.
Inspection Report
Re-Inspection
Census: 101
Deficiencies: 7
Date: Jul 29, 2014
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 ensure communication with dialysis center for one resident, failure to provide a restorative program for one resident, inadequate catheter care for one resident, failure to provide nutritional interventions for one resident, inadequate monitoring of unnecessary medications for two residents, unsanitary conditions in the dietary department, and inadequate infection control practices related to glucometer cleaning and linen handling.
Deficiencies (7)
F309: The facility failed to ensure communication between the facility and the dialysis center to maintain the highest well-being for one resident receiving dialysis.
F311: The facility failed to provide a restorative program to maintain walking ability for one resident discharged from therapy.
F315: The facility failed to provide necessary catheter care to prevent urinary tract infections and urethral trauma for one resident with an indwelling catheter.
F325: The facility failed to ensure one resident received nutritional supplements when consuming less than 25% of meals to maintain acceptable body weight.
F329: The facility failed to adequately monitor bowel movements and use of medications for two residents, resulting in prolonged periods without bowel movements or necessary medication.
F371: The facility failed to maintain a clean and sanitary dietary department, with dirty pans and grease build-up in the main and satellite kitchens.
F441: The facility failed to adequately clean glucometers between resident use and improperly handled soiled linens, risking infection spread.
Report Facts
Resident census: 101
Residents sampled: 18
Residents reviewed for rehabilitation: 3
Residents reviewed for catheter use: 2
Residents reviewed for nutritional status: 4
Residents reviewed for unnecessary medications: 5
Residents served meals from main kitchen: 53
Residents requiring glucometer checks: 33
Days without bowel movement: 8
Days without bowel movement: 3
Weight measurements: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff EE | Licensed Nursing Staff | Named in findings related to dialysis communication and glucometer cleaning |
| Staff C | Administrative Nursing Staff | Named in restorative program and bowel management findings |
| Staff G | Administrative Nursing Staff | Named in dialysis communication and glucometer cleaning findings |
| Staff L | Licensed Nursing Staff | Named in bowel management and glucometer cleaning findings |
| Staff N | Direct Care Staff | Named in bowel management and linen handling findings |
| Staff HH | Direct Care Staff | Named in glucometer cleaning findings |
| Staff R | Housekeeping Staff | Named in linen handling findings |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 12, 2014
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 deficiencies previously cited in the original survey were corrected by 02/28/2014 as documented by the correction completion dates for each regulation cited.
Report Facts
Correction completion date: Feb 28, 2014
Follow-up survey completion date: Jan 31, 2014
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 12, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected by 02/28/2014 as documented in this report.
Report Facts
Deficiencies corrected: 9
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 12, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented in the CMS-2567 and Plan of Correction.
Findings
All previously reported deficiencies were corrected by 02/28/2014 as verified during this revisit. The report confirms completion of corrective actions for multiple regulatory requirements.
Report Facts
Correction completion date: Feb 28, 2014
Follow-up survey completion date: Jan 31, 2014
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 12, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 and Plan of Correction.
Findings
All deficiencies previously reported were corrected by 02/28/2014 as verified during this revisit. The report confirms completion of corrective actions for multiple regulatory requirements.
Report Facts
Correction completion date: Feb 28, 2014
Follow-up survey completion date: Jan 31, 2014
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Feb 28, 2014
Visit Reason
This document is a Plan of Correction submitted by Asbury Park in response to deficiencies cited in a complaint investigation.
Findings
The plan outlines corrective actions for multiple deficiencies related to resident care, including notification of changes, skin integrity, pressure sore management, transfer assistance, and nutritional replacements. The facility describes systemic changes and education measures to prevent recurrence.
Deficiencies (8)
F157-D: Resident #4's physician and family have been notified of changes; a Daily Notification/Change Log has been developed to ensure appropriate notification of all changes.
F225-D: Staff education on Abuse, Neglect, and Exploitation (ANE) and use of a Skin Integrity Report Sheet have been implemented to improve reporting and documentation of skin issues.
F279-D: Care plans for residents with bruising and open areas have been updated; Daily Notification/Change Log will ensure notification and care plan implementation.
F280-D: Care plan updated for pressure sore monitoring; coordination with hospice provider; staff re-education on care plans and documentation updates planned.
F309-D: Review of Skin Integrity Report Sheet and Daily Notification/Change Log at weekly Clinical Risk Management meetings; use of Performance Improvement Plans (PIPs) as appropriate.
F314-G: Staff re-educated on repositioning and pressure ulcer assessments; monitoring of Skin Integrity Report Sheets at weekly Clinical Risk Management meetings.
F323-E: Direct care staff re-trained on mechanical lifts and gait belts; review of Lift/Transfer Policy with therapy staff; direct observation of transfer device use planned.
F325-D: Nutritional Policy updated to offer nutritional replacements to residents consuming less than 50% of meals; staff education and weekly review of CareTracker logs planned.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Nancy Law | Assistant Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 8
Date: Jan 31, 2014
Visit Reason
Complaint investigations for complaints #72182, #70964, #70048, and #69656.
Complaint Details
The inspection was triggered by complaints #72182, #70964, #70048, and #69656.
Findings
The facility failed to notify physicians and family members of significant changes including pressure ulcers and skin tears, failed to investigate injuries of unknown source, failed to develop and implement comprehensive care plans addressing fragile skin and pressure ulcers, failed to revise care plans for pressure sores and fall supervision, failed to provide necessary care to prevent skin tears and pressure ulcers, failed to ensure safe transfers and use of gait belts, failed to provide sufficient supervision for residents with multiple falls, and failed to consistently provide planned nutritional supplements.
Deficiencies (8)
F157: The facility failed to notify the physician and family of residents' significant changes including pressure ulcers and repeated skin tears for 2 of 8 sampled residents.
F225: The facility failed to investigate and report a large bruise of unknown source for 1 of 8 residents and failed to report alleged violations of abuse or neglect.
F279: The facility failed to develop and implement comprehensive care plans addressing fragile skin, bruising, and pressure ulcers for 3 of 8 sampled residents.
F280: The facility failed to revise care plans for 2 residents regarding pressure sores and increased supervision to prevent falls.
F309: The facility failed to assess causal factors for repeated skin tears and failed to develop and implement effective interventions for 1 of 4 sampled residents.
F314: The facility failed to provide consistent assessments and treatment for pressure ulcers, failed to reposition residents as planned, and failed to develop plans addressing increased repositioning needs for 4 residents.
F323: The facility failed to ensure safe use of mechanical lifts, use of gait belts, and sufficient supervision for residents with multiple falls for 4 residents.
F325: The facility failed to consistently provide planned nutritional supplements to 1 of 3 sampled residents at risk for weight loss.
Report Facts
Facility census: 98
Skin tears documented: 10
Weight loss percentage: 2.3
Meals with 50% or less eaten: 66
Meals without health shake offered: 47
Pressure ulcer Stage II sizes (cm): Array
Pressure ulcer Stage III size (cm): 0.8
Skin tear size (cm): Array
BIMS scores: Array
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Provided multiple statements regarding facility policies and failures related to notifications, supervision, and care. | |
| Administrative staff C | Commented on lack of investigation for bruise of unknown source and Director of Nursing change. | |
| Administrative Nurse B | Confirmed expectations for family notification and supervision. | |
| Licensed nurse A | Involved in wound care assessments and transfers. | |
| Licensed nurse H | Provided wound care and observations of pressure ulcers. | |
| Direct care staff F | Recalled resident's fragile skin and care needs. | |
| Direct care staff I | Commented on resident's skin tears and care. | |
| Therapy staff R | Discussed transfer assessments and safety. | |
| 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
Date: Jan 14, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be widespread 'F' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for widespread 'F' level deficiencies indicating noncompliance with Life Safety Code requirements. These deficiencies posed no immediate jeopardy but had potential for more than minimal harm.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Apr 14, 2014
Provider agreement termination date: Jul 14, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter and coordinated survey certification. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 14, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found widespread 'F' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility had widespread 'F' level deficiencies indicating noncompliance with Life Safety Code requirements. These deficiencies posed potential for more than minimal harm but did not constitute immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Apr 14, 2014
Provider agreement termination date: Jul 14, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 19, 2013
Visit Reason
The licensure survey was conducted to assess compliance for renewal of the facility's license.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 19, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection of Asbury Park Assisted Living Facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves solely as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 19, 2013
Visit Reason
The document is a plan of correction related to a health survey of a long term care facility conducted under 42 CFR Part 483, Subpart B.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations for long term care facilities.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 21, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that the previously identified deficiencies under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) were corrected as of the revisit date.
Deficiencies (1)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiencies previously cited were corrected by the revisit date of 06/21/2012.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 21, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the previously reported deficiencies under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) were corrected as of the revisit date.
Deficiencies (1)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiencies previously cited were corrected by the revisit date of 06/21/2012.
Inspection Report
Abbreviated Survey
Census: 98
Deficiencies: 1
Date: May 23, 2012
Visit Reason
The inspection was an abbreviated survey combined with complaint investigations triggered by allegations of resident abuse at the facility.
Complaint Details
The complaint investigations #57002, #57190, and #56953 involved allegations of employee to resident abuse on May 6, 2012, specifically concerning resident #5. Multiple staff interviews and observations revealed staff D acted inappropriately by forcibly attempting to put the resident to bed despite the resident's resistance and agitation. Licensed nursing staff failed to remove the alleged perpetrator or notify administration promptly. The facility did not follow its abuse policy requiring immediate reporting and investigation.
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.
Deficiencies (1)
F 225 - The facility failed to investigate and report allegations of resident abuse, including injuries of unknown source and misappropriation of resident property, and did not ensure immediate notification to the administrator or other officials as required by state law.
Report Facts
Facility census: 98
Residents on Sunflower neighborhood: 29
Witness statements: 5
Additional staff present during incident: 4
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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) at the facility.
Complaint Details
The visit was complaint-related concerning an allegation of abuse, neglect, or exploitation (ANE). The allegation was self-reported by the facility and investigated with staff and resident interviews.
Findings
The deficiency involved an allegation of abuse, neglect, or exploitation specific to one resident, with potential impact on all residents of the Sunflower Unit. The facility self-reported the allegation and conducted additional staff interviews during the investigation.
Deficiencies (1)
F225-E: Allegation of abuse, neglect, or exploitation was self-reported by the facility prior to the survey. Additional staff interviews were conducted to complete the investigation in greater detail.
Report Facts
Residents on Sunflower Unit: 29
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040002 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection or deficiency report for the facility identified as State ID N040002 ASPEN.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040002 POC KSLD11
Visit Reason
This document is a plan of correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the plan of correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040002 POC 2CYG11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Asbury Park ALF.
Findings
No specific findings or deficiencies are detailed in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040002 POC KX5411
Visit Reason
This document is a Plan of Correction related to a prior inspection event for a regulated assisted living facility.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040002 POC NEYQ11
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility Asbury Park.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the plan of correction submission and modification dates.
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