Inspection Report Summary
The most recent inspection on December 22, 2015, found that all previously cited deficiencies had been corrected. Prior inspections showed a pattern of deficiencies related mainly to resident care, including fall prevention, care planning especially for residents receiving dialysis, catheter and infection control, and dietary issues such as meal preparation. Complaint investigations substantiated failures in supervision and alarm use to prevent falls, and enforcement actions included a denial of payment for new Medicare admissions in 2014 due to a "G" level deficiency. Fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with follow-up inspections confirming correction of earlier deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
23 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
283% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
63 residents
Based on a December 2015 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 7
Dec 22, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously reported deficiencies listed with their regulation numbers were corrected as of the revisit date, December 22, 2015.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(5)-(10), 483.10(b)(1) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.35(d)(1)-(2) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 7
Inspection Report
Enforcement
Deficiencies: 1
Dec 9, 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 deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 22, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter. |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 9
Dec 9, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #94136 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to post state agency complaint information, failure to thoroughly investigate and report a resident fall with injury, failure to develop and implement comprehensive care plans especially for residents receiving dialysis, failure to provide adequate care and monitoring for residents with fluid restrictions, failure to provide appropriate catheter care and prevent urinary tract infections, failure to provide meals with correct nutritive value for residents on pureed diets, and failure to maintain infection control including improper storage of oxygen equipment and use of inappropriate disinfectants.
Complaint Details
The complaint investigation included allegations related to failure to post abuse reporting information, failure to investigate and report a fall with injury, and inadequate care and infection control practices.
Severity Breakdown
SS=C: 1
SS=D: 5
SS=F: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to post state agency information to report abuse, neglect and misappropriation in accessible locations for residents and families. | SS=C |
| Failed to thoroughly investigate and report a fall with injury to the state agency for a resident (#71). | SS=D |
| Failed to develop a comprehensive care plan for a resident (#29) receiving dialysis, including care of dialysis access site and fluid restrictions. | SS=D |
| Failed to ensure provision and monitoring of sufficient fluid intake to maintain adequate hydration for a resident (#29) with physician ordered fluid restriction. | SS=D |
| Failed to ensure proper catheter care and personal hygiene to prevent urinary tract infections for residents (#35, #45). | SS=D |
| Failed to provide the correct nutritive value of a meal by leaving out the bread component for a resident (#34) on a pureed diet. | SS=D |
| Failed to properly store oxygen equipment to prevent potential spread of infection for residents receiving oxygen therapy. | SS=F |
| Failed to use approved disinfectants to clean resident rooms, using vinegar solution instead, which is not effective against human pathogens. | SS=F |
| Failed to follow policy and procedure for catheter care, including improper use of wipes, failure to prevent catheter bag from touching floor, and failure to prevent contamination during care for residents (#35, #45). | SS=F |
Report Facts
Census: 63
Sample size: 15
Fall incident: 1
Dialysis frequency: 3
Fluid restriction: 500
Catheter care frequency: 2
Cleaning frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Administrative Nurse | Verified fall incident was not reported and lack of care plan for dialysis resident |
| Nurse G | Stated aides provide catheter care twice per shift and should follow policy | |
| Nurse M | Dialysis center Nurse | Verified dialysis treatment details and fluid restrictions for resident #29 |
| Nurse Aide H | Observed providing catheter care with improper technique | |
| Nurse Aide N | Observed handling wipes improperly and catheter bag touching floor | |
| Housekeeping Staff D | Used vinegar solution to clean resident rooms instead of approved disinfectants | |
| Dietary Staff Q | Prepared pureed foods without bread component | |
| Dietary Staff P | Verified pureed foods did not contain bread and resident did not receive bread |
Inspection Report
Life Safety
Deficiencies: 1
Sep 10, 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 with potential for more than minimal harm that is not immediate jeopardy. An acceptable plan of correction was required to address these deficiencies.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Dec 10, 2015
Provider agreement termination date: Mar 10, 2016
IDR request 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. |
Inspection Report
Follow-Up
Deficiencies: 3
Oct 22, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies at Park Lane Nursing Home.
Findings
The report documents that deficiencies previously cited under regulations 483.10(b)(4), 483.20(b)(2)(ii), and 483.25(a)(2) were corrected as of 10/10/2014.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 483.10(b)(4) |
| Deficiency under regulation 483.20(b)(2)(ii) |
| Deficiency under regulation 483.25(a)(2) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Oct 1, 2014
Visit Reason
This document is a Plan of Correction submitted by Park Lane Nursing Home in response to deficiencies cited in a prior inspection.
Findings
The plan addresses deficiencies related to CPR certification for licensed nursing staff, comprehensive assessments for residents with significant changes, and implementation of restorative therapy programs for residents.
Severity Breakdown
E: 1
D: 1
G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Licensed nursing staff lacked current CPR certification documentation. | E |
| Significant change comprehensive assessments were not completed for affected residents. | D |
| Residents were not consistently placed on restorative therapy programs after discharge from therapy services. | G |
Report Facts
Complete Date: Oct 15, 2014
Complete Date: Oct 10, 2014
Complete Date: Oct 2, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Nicole Turner | Administrator | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Sep 23, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be a "G" level. As a result, enforcement remedies including denial of payment for new Medicare admissions effective December 23, 2014, were imposed until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found at the facility | G |
Report Facts
Denial of payment effective date: Dec 23, 2014
Termination recommendation date: Mar 23, 2015
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Turner | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
| Joe Ewert | Commissioner | Recipient of Informal Dispute Resolution requests |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 3
Sep 23, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation #78831 to assess compliance with regulatory requirements related to resident rights, comprehensive assessments after significant change, and treatment/services to maintain or improve activities of daily living (ADLs).
Findings
The facility failed to ensure all licensed staff had current CPR certification for residents requesting full code status, failed to conduct comprehensive assessments within 14 days after significant changes in physical condition for two residents, and failed to provide restorative services to prevent significant decline in ADL function for two residents after discharge from therapy services.
Complaint Details
The inspection included a complaint investigation #78831.
Severity Breakdown
Level E: 1
Level D: 1
Level G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to have licensed staff with current Cardiopulmonary Resuscitation (CPR) certification available for 18 residents requesting full code status. | Level E |
| Facility failed to conduct a comprehensive assessment within 14 days after determining a significant change in the physical condition of 2 sampled residents (#60 and #62). | Level D |
| Facility failed to provide restorative services to prevent significant decline of ADL function for 2 sampled residents (#60 and #62) who were not assessed/evaluated for a nursing restorative program after discharge from therapy services. | Level G |
Report Facts
Resident census: 60
Sample size: 18
Licensed nurses employed: 23
Licensed staff without current CPR certification: 8
Residents requesting CPR if needed: 18
Residents reviewed for rehabilitation: 3
Inspection Report
Life Safety
Deficiencies: 1
Apr 8, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. | E |
Report Facts
Effective date for denial of payments: Jul 8, 2014
Effective date for provider agreement termination: Oct 8, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Turner | Administrator | Named as facility administrator |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 1
Feb 20, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) was corrected as of 02/20/2014. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(h) corrected |
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 18, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Park Lane Nursing Home.
Findings
Deficiencies involved failure to update and follow care plans properly, specifically related to alarm checks and fall prevention. The facility developed a care plan protocol, educated nursing staff, and implemented two-hour rounds to ensure alarms are in place and functioning.
Complaint Details
The plan of correction addresses deficiencies cited in a complaint investigation at Park Lane Nursing Home.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to update and follow care plans correctly, including ensuring alarms are in place and working. | D |
Report Facts
Complete Date for corrective actions: Feb 20, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Turner | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Feb 10, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#KS00072196) regarding the facility's failure to ensure adequate supervision and use of assistive devices to prevent accidents for residents.
Findings
The facility failed to ensure two of three sampled residents received adequate supervision and use of alarms as care planned to prevent falls. Resident #1 experienced multiple falls resulting in fractures, with staff failing to use alarms as required. Resident #2 also fell due to staff failing to properly use alarms, including failure to plug in a floor alarm.
Complaint Details
The complaint investigation #KS00072196 found substantiated failures related to fall prevention and alarm use for residents #1 and #2.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure resident #1 had alarms in place as care planned, resulting in falls and fractures. | SS=D |
| Failure to ensure resident #2 had alarms in place as care planned, including failure to plug in the alarm, resulting in a fall. | SS=D |
Report Facts
Resident census: 59
Falls for resident #1: 2
Fall risk assessment score for resident #1: 11
Fall risk assessment score for resident #1: 14
Falls for resident #2: 6
Fall risk assessment score for resident #2: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Licensed Nurse | Verified staff initiated use of alarms for residents and checked alarms frequently. |
| Nurse B | Administrative Nurse | Confirmed staff failed to place alarm as care planned for resident #1 and failed to plug in alarm for resident #2. |
| Physician H | Physician | Provided medical opinion on resident #1's fall risk and use of alarms. |
| Direct Care Staff F | Witnessed and reported failure to place alarm on resident #1 during transfer. | |
| Direct Care Staff G | Reported checking alarms for resident #2 frequently. |
Inspection Report
Follow-Up
Deficiencies: 10
Sep 13, 2013
Visit Reason
This visit was a post-certification revisit to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with corrections documented for multiple regulatory requirements.
Deficiencies (10)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(5) - (10), 483.10(b)(1) |
| Deficiency related to regulation 483.10(q)(1) |
| Deficiency related to regulation 483.20(q) - (i) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(k) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 10
Inspection Report
Follow-Up
Deficiencies: 1
Sep 13, 2013
Visit Reason
This revisit inspection was conducted to verify that previously cited deficiencies have been corrected by the facility.
Findings
The report confirms that the deficiency identified as S1364 under regulation 26-40-305 (3) was corrected as of 09/13/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency identified as S1364 under regulation 26-40-305 (3) |
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 10
Sep 13, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection, outlining corrective actions to address each deficiency.
Findings
The plan details corrective actions for multiple deficiencies including posting of Ombudsman hotline information, updating MDS assessments and care plans, securing oxygen tanks to walkers, monitoring B12 levels, dietary staff training, medication management, laundry procedures, and electrical safety compliance.
Deficiencies (10)
| Description |
|---|
| Ombudsman hotline poster not posted on both sides of the facility |
| Most recent statement of deficiencies not posted on both sides of the facility |
| Inaccurate MDS assessments for residents #17 and #47 |
| Care plans not current for residents #52, #32, and #61 |
| Oxygen tank not secured to walker for resident #52 |
| B12 levels not checked for resident #47 and others receiving B12 injections |
| Dietary staff not trained on hand washing, glove use, and food storage |
| Expired vial of TB discarded without proper dating education |
| Improper transportation and cleaning of linens |
| Hydrocollator receptacle not equipped with GFCI |
Report Facts
Correction completion date: Sep 13, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jan Scoggins | Ombudsman | Ordered new Ombudsman hotline posters and brochures |
| Nicolet Turner | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 10
Aug 20, 2013
Visit Reason
The inspection was a health resurvey to assess compliance with federal regulations and to verify correction of previously cited deficiencies.
Findings
The facility was found deficient in multiple areas including failure to inform residents of their rights and complaint procedures, failure to maintain and display survey results, inaccurate resident assessments, incomplete care plans, improper respiratory equipment care, failure to monitor medication effectiveness, unsanitary food handling and storage, expired medications not disposed, and inadequate infection control practices.
Severity Breakdown
SS=C: 1
SS=D: 5
SS=E: 2
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to inform residents of their right to contact the ombudsman or state agency and failure to display complaint hotline information. | SS=C |
| Failure to maintain and prominently display the latest state survey results for residents and visitors. | SS=D |
| Failure to provide accurate resident assessments for cognitive status and mobility devices. | SS=D |
| Failure to develop comprehensive individualized care plans addressing bathing needs and medication behaviors. | SS=D |
| Failure to ensure proper care and services related to respiratory equipment; oxygen tank unsecured on walker basket. | SS=D |
| Failure to monitor effectiveness of Vitamin B-12 injections for over 2 years for a cognitively impaired resident. | SS=F |
| Failure to prepare and store food in a sanitary manner including uncovered and undated foods and improper glove use. | SS=D |
| Failure to dispose of expired medications (Tubersol test vials) in medication rooms. | SS=E |
| Failure to monitor and report irregularities in drug regimen related to Vitamin B-12 monitoring by pharmacy consultant. | SS=D |
| Failure to properly clean resident rooms and handle laundry to prevent infection spread, including improper glove use and uncovered laundry. | SS=E |
Report Facts
Census: 61
Vitamin B-12 monitoring interval: 2
Expired medication count: 2
Vitamin B-12 injection order date: 2013
Survey completion date: 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Licensed Nursing Staff | Acknowledged lack of Vitamin B-12 monitoring and inaccurate resident assessment |
| Staff D | Administrative Nursing Staff | Acknowledged responsibility for lab orders and monitoring, and noted survey results not prominently displayed |
| Staff J | Licensed Nursing Staff | Expected Vitamin B-12 levels to be checked annually and acknowledged resident required cueing |
| Staff F | Administrative Nursing Staff | Completed inaccurate MDS assessments and acknowledged errors |
| Staff LL | Direct Care Staff | Observed handling laundry uncovered and placing clean clothing protectors uncovered |
| Staff X | Laundry Worker | Transported uncovered soiled laundry |
| Staff AA | Housekeeping Staff | Stated cleaning should proceed from cleanest to dirtiest area |
| Staff Z | Housekeeping Staff | Failed to change gloves after cleaning toilet before cleaning resident's personal area |
| Consultant Pharmacist JJ | Consultant Pharmacist | Acknowledged lack of monitoring for Vitamin B-12 injections and expected 6 month lab checks |
| Staff E | Administrative Licensed Staff | Reported pharmacist advised use of expired Tubersol test vials due to shortage |
Inspection Report
Follow-Up
Deficiencies: 10
May 29, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the prior survey were corrected.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Deficiencies (10)
| Description |
|---|
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(g)-(j) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 10
Inspection Report
Plan of Correction
Deficiencies: 10
May 8, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior deficiency report, outlining corrective actions to address identified deficiencies.
Findings
The plan details corrective actions including education, audits, care plan updates, policy revisions, and monitoring related to comprehensive assessments, medication management, infection control, safety devices, and food handling.
Severity Breakdown
D: 8
E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Comprehensive assessments and nursing care plans completion timeliness | D |
| Assessment accuracy and coordination, including oral/dental status | D |
| Provision of care/services for highest well-being including neurological assessments after unwitnessed falls | D |
| Treatment/services to improve or maintain activities of daily living | D |
| Free of accident hazards, supervision, and devices including side rail assessments | D |
| Drug regimen free from unnecessary drugs, including monitoring psychotropic and hypnotic medications | D |
| Food procurement, storage, preparation, and serving sanitary practices | E |
| Drug regimen review, reporting irregularities, and acting on findings | D |
| Drug records, labeling, and storage of drugs and biologicals | D |
| Infection control, prevention of spread, and handling of linens | E |
Report Facts
Date of corrective actions completion: May 29, 2012
Date of initial corrective action: May 8, 2012
Date of staff education: May 4, 2012
Resident numbers referenced: 40
Resident numbers referenced: 18
Resident numbers referenced: 12
Resident numbers referenced: 42
Resident numbers referenced: 59
Resident numbers referenced: 14
Resident numbers referenced: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicolet Turner | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 8
Apr 30, 2012
Visit Reason
The inspection was a health resurvey visit to assess compliance with federal regulations for nursing homes.
Findings
The facility failed to complete timely and accurate comprehensive assessments and care plans for residents, failed to provide necessary care including neurological checks after falls and appropriate eating assistance, failed to ensure a safe environment free of accident hazards, failed to maintain drug regimens free from unnecessary medications, failed to serve food under sanitary conditions, and failed to maintain an effective infection control program.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to complete comprehensive assessments and individualized nursing care plans in a timely manner for residents #40 and #14. | SS=D |
| Failed to accurately complete MDS assessments reflecting residents' status for residents #18 and #24. | SS=D |
| Failed to provide necessary care and services including neurological checks after unwitnessed falls for resident #40. | SS=D |
| Failed to provide appropriate treatment to maintain/improve eating ability for resident #40. | SS=D |
| Failed to ensure resident environment free of accident hazards due to unsafe side rails posing entrapment risk for resident #12. | SS=D |
| Failed to maintain drug regimen free from unnecessary drugs for residents #42, #59, and #14 due to inadequate monitoring and excessive duration without gradual dose reduction or risk benefit statement. | SS=D |
| Failed to label drugs properly; an open multi-dose vial of Novolog insulin lacked date opened and discard date. | SS=D |
| Failed to maintain an infection control program and failed to prevent spread of infection including improper food handling, linen transport, and hand hygiene. | SS=E |
Report Facts
Residents sampled for review: 12
Residents census: 49
Medication doses: 10
Medication doses: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Licensed Nurse | Confirmed MDS, CAAs and care plan completion timelines and acknowledged inaccurate assessments. |
| Licensed nursing staff E | Licensed Nursing Staff | Reported resident #40 as high fall risk, confirmed failure to perform neurological checks after falls, and reported monitoring failures for residents #42 and #12. |
| Direct Care Staff O | Direct Care Staff | Reported resident #40 wandered and did not notice obstacles. |
| Administrative Nursing Staff A | Administrative Nursing Staff | Confirmed failure to assess neurological checks after unwitnessed falls and infection control program deficiencies. |
| Consultant Staff R | Consultant Pharmacist | Acknowledged failure to request gradual dose reduction and inadequate monitoring for resident #42 and #14. |
| Licensed Nursing Staff X | Licensed Nursing Staff | Managed infection control program and confirmed lack of infection tracking and antibiotic use monitoring. |
Inspection Report
Plan of Correction
Census: 120
Deficiencies: 7
N086001 POC JDT911
Visit Reason
This document is a Plan of Correction submitted by Park Lane Nursing Home addressing deficiencies cited in a prior inspection report.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including posting new posters, updating care plans for residents with falls and dialysis needs, catheter and perineal care, dietary staff training on puree meals, and housekeeping procedures related to oxygen and nebulizer equipment. Monthly monitoring and staff education are planned to ensure compliance.
Severity Breakdown
C: 1
D: 5
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to post required posters and ensure residents access service hallways. | C |
| Inadequate fall interventions and investigation for residents with cognitive impairment. | D |
| Incomplete care plans for residents receiving dialysis including access site care and fluid restriction. | D |
| Failure to monitor and record fluid intake for residents on fluid restriction. | D |
| Inadequate catheter and perineal care and improper storage of catheter bags. | D |
| Deficient dietary practices related to preparation of puree meals. | D |
| Improper housekeeping procedures for oxygen and nebulizer equipment and use of vinegar without disinfectant. | F |
Report Facts
Census: 120
Date of Compliance: Dec 22, 2015
Inservice Dates: Dec 15, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicolet Turner | Administrator | Administrator who submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Person who added and modified the Plan of Correction |
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