Inspection Reports for
Park Lane Nursing Home
210 E. PARK LANE, SCOTT CITY, KS, 67871
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
133% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
65% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Jun 9, 2025
Visit Reason
The investigation was conducted due to a complaint regarding the facility's failure to provide cardiopulmonary resuscitation (CPR) to Resident 1 (R1), who had a full code status, during a medical emergency.
Complaint Details
The complaint investigation substantiated that the facility did not perform CPR on Resident 1 despite his full code status. Staff delayed response and collectively decided not to initiate CPR, resulting in immediate jeopardy to resident health and safety.
Findings
The facility failed to initiate CPR for R1 despite his full code status, resulting in immediate jeopardy to resident health and safety. Staff assessed R1 as deceased without attempting resuscitation, contrary to facility policy and R1's documented wishes.
Deficiencies (1)
F 0678: The facility failed to provide basic life support, including CPR, to Resident 1 who had a full code status. Staff determined resuscitative measures would do more harm than help and did not initiate CPR, placing residents at immediate jeopardy.
Report Facts
Residents present: 35
Residents with full code status: 5
Residents sampled for code status: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Assessed Resident 1, decided not to initiate CPR, pronounced resident deceased |
| LN H | Licensed Nurse | Oncoming nurse who confirmed full code status and recommended CPR initiation |
| CNA M | Certified Nurse Aide | Discovered Resident 1 unresponsive, called for nurse STAT, unaware of full code status |
| CNA N | Certified Nurse Aide | Assisted in discovering Resident 1 unresponsive, unaware of full code status |
| Administrative Nurse D | CPR Instructor | Provided staff CPR training and stated expectations for CPR initiation on full code residents |
Inspection Report
Routine
Census: 37
Deficiencies: 8
Date: Mar 5, 2025
Visit Reason
Routine inspection of Park Lane Nursing Home to assess compliance with regulatory requirements including resident rights, safety, medication management, and immunization protocols.
Findings
The facility had multiple deficiencies including failure to provide correct Medicare ABN forms, incomplete criminal background checks for employees, failure to notify the Long Term Care Ombudsman of resident discharges, inadequate bed hold policy communication, incomplete fall investigations, lack of smoking assessments, failure to obtain approved indications for antipsychotic medications, and failure to offer recommended pneumococcal vaccinations.
Deficiencies (8)
F 0582: The facility failed to provide Residents R3, R14, and R36 the correct Medicare Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) including estimated costs, placing residents at risk of uninformed decisions.
F 0607: The facility failed to conduct a criminal background check for Maintenance Staff U prior to employment, placing residents at risk for abuse or neglect.
F 0623: The facility failed to notify the Long Term Care Ombudsman of facility-initiated discharges for Residents R8 and R4, risking impaired resident rights.
F 0625: The facility failed to provide Residents R8 and R4 written notification of the bed hold policy upon hospital transfer, risking loss of bed and return to the facility.
F 0689: The facility failed to thoroughly investigate the cause of Resident R1's fall from a wheelchair and failed to complete a smoking assessment for Resident R6, placing residents at risk of injury and fire hazards.
F 0756: The consultant pharmacist failed to obtain approved indications for antipsychotic medications Seroquel for Residents R23, R24 and Zyprexa for Resident R15, risking unnecessary medication use.
F 0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions prior to continuing psychotropic medications for Resident R15, risking unnecessary medication exposure.
F 0883: The facility failed to offer the PCV20 pneumococcal vaccination to Residents R8, R15, R19, R23, and R24 as recommended by CDC guidelines, placing residents at risk of pneumococcal disease.
Report Facts
Residents in census: 37
Sample size: 12
Residents reviewed for unnecessary medication: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Staff U | Employee for whom criminal background check was not completed prior to employment | |
| Administrative Staff A | Verified issues related to ABN forms, background checks, and notification failures | |
| Administrative Nurse E | Verified medication and immunization deficiencies and smoking assessment issues | |
| Certified Medication Aide R | Administered medication to Resident R24 |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 6
Date: May 15, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the quality of care provided to residents at Park Lane Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, inadequate bowel management leading to risk of impaction, failure to prevent and properly treat pressure ulcers, unsafe environment contributing to resident falls, and inappropriate use and monitoring of antipsychotic medications.
Deficiencies (6)
F 0550: The facility failed to provide a dignified dining experience for Resident 8 by not assisting the resident properly during meals, placing the resident at risk for impaired wellbeing.
F 0684: The facility failed to provide interventions for lack of bowel movements for Resident 36, placing the resident at risk for impaction and decline.
F 0686: The facility failed to prevent the development of a Stage 2 pressure ulcer for Resident 38 and failed to implement nutritional consults to promote healing, placing the resident at risk for further breakdown.
F 0689: The facility failed to provide a safe environment and follow care plans for Residents 36 and 38, placing them at risk for further falls and injury.
F 0756: The facility failed to ensure the pharmacist identified and reported inappropriate use of antipsychotic medication for Residents 38 and 39, placing them at risk for adverse medication reactions.
F 0758: The facility failed to provide appropriate indication or documented physician rationale for continued use of antipsychotic medications for Residents 38 and 39, placing them at risk for unnecessary psychotropic medication use and related consequences.
Report Facts
Residents Affected: 46
Sample Residents Reviewed: 12
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified expectations for dignified dining assistance and confirmed pharmacist failures |
| Licensed Nurse H | Licensed Nurse | Provided information on bowel protocol and fall risk for Resident 36 |
| Licensed Nurse I | Licensed Nurse | Observed wound care for Resident 38 |
| Licensed Nurse G | Licensed Nurse | Provided information on wound care and dietician involvement for Resident 38 |
| Certified Nurse Aide M | Certified Nurse Aide | Observed assisting residents and provided statements on resident safety and falls |
| Certified Nurse Aide O | Certified Nurse Aide | Observed assisting Resident 8 during dining and Resident 36 during transfer |
| Certified Nurse Aide N | Certified Nurse Aide | Assisted Resident 38 during transfer |
Inspection Report
Routine
Census: 43
Deficiencies: 4
Date: Oct 5, 2021
Visit Reason
Routine inspection of Park Lane Nursing Home to assess compliance with medication management, staffing qualifications, and quality assurance processes.
Findings
The facility failed to ensure that PRN psychotropic medications for six sampled residents had required stop dates, placing residents at risk for unnecessary medication use. Additionally, the facility did not employ a full-time certified dietary manager and lacked a developed Quality Assurance and Performance Improvement (QAPI) plan.
Deficiencies (4)
F 0756: The facility's consultant pharmacist failed to notify the Director of Nursing, medical director, or physicians that six sampled residents' PRN psychotropic medications lacked required stop dates, risking unnecessary medication use.
F 0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions prior to continuing psychotropic medications, and PRN orders lacked required stop dates for six residents.
F 0801: The facility failed to employ a full-time certified dietary manager for 43 residents, placing residents at risk for inadequate nutrition.
F 0865: The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan, limiting its ability to assure and improve care quality for all residents.
Report Facts
Census: 43
Residents reviewed for unnecessary medications: 6
Residents affected by PRN medication stop date deficiency: 6
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Dec 22, 2015
Visit Reason
This document is a Plan of Correction submitted by Park Lane Nursing Home in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction addresses multiple deficiencies including fall interventions, dialysis care plans, catheter and perineal care, dietary puree meal preparation, and housekeeping procedures related to oxygen and nebulizer equipment. The facility outlines corrective actions, staff education, policy updates, and monitoring plans to ensure compliance.
Deficiencies (7)
F156-C: New posters were ordered from the state complaint staff and will be posted upon arrival. The administrator will monitor monthly to ensure posters remain properly placed.
F225-D: Resident #71's care plan was updated for fall interventions. Unwitnessed falls with significant injury in residents with BIMS score 12 or lower will be investigated and reported if warranted.
F279-D: Resident #29's care plan was updated to reflect dialysis access site care and fluid restriction. A dialysis policy and communication forms were created and staff educated.
F309-D: Resident #29's fluid restriction is monitored daily using a new form. Dialysis policy education was provided to licensed nurses.
F315-D: Residents #35 and #45 will receive catheter and perineal care per facility policy. Staff will be inserviced and observations performed regularly.
F364-D: Dietary staff received mandatory inservice on puree meal preparation. Compliance will be monitored through meal observations.
F441-F: Residents with catheters and oxygen therapy will receive care per updated policies. Housekeeping procedures updated to require approved disinfectant use after vinegar.
Report Facts
Date of Compliance: Dec 22, 2015
Inservice Dates: Dec 9, 2015
Inservice Dates: Dec 15, 2015
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 22, 2015
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 reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 7
Date: Dec 9, 2015
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation #94136 conducted to investigate complaints and assess compliance with regulatory requirements.
Complaint Details
The complaint investigation included allegations of failure to post required information, failure to investigate and report a fall, inadequate care planning and monitoring for dialysis residents, improper catheter care, and infection control deficiencies.
Findings
The facility failed to post required state agency complaint information in accessible locations, failed to thoroughly investigate and report a fall with injury, failed to develop and implement comprehensive care plans for residents receiving dialysis, failed to ensure adequate hydration monitoring, and failed to provide appropriate catheter care and infection control practices. Additionally, the facility failed to provide a resident with the correct nutritive value of a pureed meal and failed to properly store oxygen equipment and use approved disinfectants.
Deficiencies (7)
F156: The facility failed to post state agency information to report abuse, neglect, and misappropriation in accessible locations for residents and families.
F225: The facility failed to thoroughly investigate and report a fall with injury for Resident #71 to the state agency within required timeframes.
F279: The facility failed to develop a comprehensive care plan for Resident #29 directing care of dialysis access site and fluid restrictions.
F309: The facility failed to ensure adequate hydration monitoring and provision of fluid intake per physician orders for Resident #29 receiving dialysis.
F315: The facility failed to provide appropriate catheter care and prevent urinary tract infections for Residents #35 and #45 by improper hygiene practices and catheter bag handling.
F364: The facility failed to provide Resident #34 with the correct nutritive value of a pureed meal by omitting the bread component.
F441: The facility failed to maintain infection control by improper catheter care, failure to store oxygen equipment in protective bags, and use of non-approved disinfectants for resident rooms.
Report Facts
Resident census: 63
Sample size: 15
Dialysis frequency: 3
Fluid restriction: 500
Catheter care frequency: 2
Catheter change frequency: 30
Number of residents receiving oxygen therapy: 24
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 9, 2015
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the plan of correction acceptance. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 10, 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, not constituting immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.
Deficiencies (1)
The facility was cited with 'F' level deficiencies indicating widespread issues with potential for more than minimal harm but no immediate jeopardy.
Report Facts
Effective date for denial of payments: Dec 10, 2015
Provider agreement termination date: Mar 10, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Oct 22, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report documents that previously identified deficiencies 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)
Regulation 483.10(b)(4): Previously cited deficiency was corrected by 10/10/2014.
Regulation 483.20(b)(2)(ii): Previously cited deficiency was corrected by 10/10/2014.
Regulation 483.25(a)(2): Previously cited deficiency was corrected by 10/10/2014.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 3
Date: Sep 23, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation #78831 to assess compliance with regulatory requirements.
Complaint Details
The inspection included a complaint investigation identified as #78831.
Findings
The facility failed to ensure all licensed staff had current CPR certification and failed to conduct comprehensive assessments within 14 days after significant changes in residents' conditions. Additionally, the facility did not provide restorative services to prevent decline in Activities of Daily Living (ADL) for two residents after discharge from therapy services.
Deficiencies (3)
F 155: The facility failed to have licensed staff with current Cardiopulmonary Resuscitation certification available for residents requesting full code status.
F 274: The facility failed to conduct a comprehensive assessment within 14 days after determining a significant change in the physical condition of two sampled residents.
F 311: The facility failed to provide restorative services to prevent significant decline of ADL function for two residents not assessed for a nursing restorative program after discharge from therapy.
Report Facts
Resident census: 60
Licensed nurses employed: 23
Licensed staff without current CPR certification: 8
Residents requesting CPR: 18
Sample size: 18
Residents reviewed for rehabilitation: 3
Residents with failed comprehensive assessment: 2
Inspection Report
Enforcement
Deficiencies: 0
Date: Sep 23, 2014
Visit Reason
The inspection 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 'G' level. As a result, enforcement remedies including denial of payment for new Medicare admissions were imposed effective December 23, 2014, pending substantial compliance.
Report Facts
Denial of payment effective date: Dec 23, 2014
Compliance deadline: Mar 23, 2015
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 8, 2014
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 deficiency to be an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited with an 'E' level deficiency related to Life Safety Code compliance, indicating a pattern of deficiencies with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Jul 8, 2014
Provider agreement termination date: Oct 8, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated survey certification. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 20, 2014
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) was corrected by the revisit date of 02/20/2014.
Deficiencies (1)
Regulation 483.25(h) deficiency was identified and corrected by 02/20/2014.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 18, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Park Lane Nursing Home.
Findings
The facility developed a care plan protocol and educated all nursing staff to address issues with care plans not being updated or followed correctly. Nurse rounds were implemented to ensure alarms are in place and functioning, and falls were reviewed by the medical director and interdisciplinary team.
Deficiencies (1)
F323-D: The facility developed a care plan protocol and educated nursing staff. Nurse rounds were instituted to ensure alarms are in place and working, addressing risks from care plans not being updated or followed.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Date: Feb 10, 2014
Visit Reason
The inspection was conducted as a complaint investigation identified as #KS00072196 regarding resident safety and supervision.
Complaint Details
The complaint investigation #KS00072196 found substantiated failures in supervision and use of assistive devices to prevent falls for residents #1 and #2.
Findings
The facility failed to ensure adequate supervision and use of assistive devices such as alarms for two residents at high risk of falls, resulting in multiple falls and injuries. Staff failed to properly implement care plans and alarm protocols for fall prevention.
Deficiencies (2)
F 323: The facility failed to ensure resident #1 had alarms in place as care planned, resulting in falls with fractures. Staff also failed to update the CNA care plan with alarm use.
F 323: The facility failed to ensure resident #2 had a functioning alarm in place when the resident fell, as staff did not plug in the alarm to the alarm box.
Report Facts
Resident census: 59
Fall risk assessment score: 11
Fall risk assessment score: 14
Fall risk assessment score: 30
Number of falls: 2
Number of falls: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Licensed Nurse | Verified staff initiated alarm use for resident #1 and checked alarms frequently for resident #2. |
| 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 alarm use during hospital stay. |
Inspection Report
Follow-Up
Deficiencies: 10
Date: Sep 13, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Deficiencies (10)
Regulation 483.10(b)(5) - (10), 483.10(b)(1): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.10(g)(1): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.20(g) - (j): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.20(d), 483.20(k)(1): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.25(k): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.25(l): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.35(i): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.60(c): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.60(b), (d), (e): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.65: Previously cited deficiencies were corrected by the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 13, 2013
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies from the survey completed on 2013-08-20.
Findings
The report confirms that the previously reported deficiency with regulation number 26-40-305 (3) and ID prefix S1364 was corrected as of 2013-09-13.
Deficiencies (1)
Regulation 26-40-305 (3) deficiency previously cited was corrected on 2013-09-13.
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Sep 5, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior statement of deficiencies identified during an inspection.
Findings
The Plan of Correction addresses multiple deficiencies including posting of ombudsman hotline information, accuracy of MDS assessments, care plan corrections, medication management, dietary staff training, linen handling, and maintenance of safety equipment. Corrective actions and monitoring plans are outlined for each deficiency.
Deficiencies (11)
F156-C: Ombudsman hotline posters were not posted on both sides of the facility. New posters were ordered and posted, and monitoring will ensure ongoing compliance.
F167-C: The most recent statement of deficiencies was not posted on both sides of the facility. Additional copies were placed and monitoring established.
F278-D: MDS assessments for residents #17 and #47 contained inaccuracies regarding ambulation and decision-making assistance. Quarterly audits and education were planned.
F279-D: Care plans for residents #52, #32, and #61 were not current or accurate. Quarterly monitoring and corrections were scheduled.
F328-D: Resident #52 will be screened by PT for gait stability and a holder secured to the walker for the oxygen tank.
F329-D: Resident #47 will have B12 levels checked annually to ensure safe medication administration.
F371-F: Dietary staff will attend mandatory training on hand washing, glove use, and food storage. Audits will be conducted regularly.
F428-D: Consultant pharmacist will monitor residents' lab levels monthly to correct deficient medication practices.
F431-D: Expired TB vial was discarded and nurses educated on dating opened vials. Monthly audits will be conducted.
F441-E: Laundry and nursing staff will be educated on proper transport of clean and soiled linens using color safe bleach. Audits will ensure compliance.
S1364-D: The hydrocollator receptacle was replaced with a GFCI. Maintenance staff will inspect GFCIs periodically to ensure proper function.
Report Facts
Completion date: Sep 13, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jan Scoggins | Ombudsman | Ordered new Ombudsman hotline posters for the facility. |
| Nicolet Turner | Administrator | Submitted the Plan of Correction. |
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 10
Date: Aug 20, 2013
Visit Reason
The inspection was a health resurvey to evaluate compliance with regulatory requirements and to verify correction of previous 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.
Deficiencies (10)
F156: The facility failed to inform residents on the west unit about their right to contact the ombudsman and state complaint hotline and failed to visibly display this information.
F167: The facility failed to maintain and prominently display the latest state survey results in a location clearly marked for residents and visitors.
F278: The facility failed to provide accurate assessments for residents #17 and #47, including incorrect mobility device use and cognitive status.
F279: The facility failed to develop comprehensive individualized care plans addressing bathing preferences for residents #52 and #61, and medication-related behaviors for resident #32.
F328: The facility failed to ensure proper care and services related to respiratory equipment for resident #52, including unsecured oxygen tanks on a walker.
F329: The facility failed to monitor effectiveness of monthly Vitamin B-12 injections for resident #47 for over two years, lacking laboratory testing orders and monitoring.
F371: The facility failed to prepare and store food in a sanitary manner, including uncovered and undated food items and improper glove use by dietary staff.
F428: The facility's pharmacy consultant failed to identify and report the lack of Vitamin B-12 laboratory monitoring for resident #47 over multiple months.
F431: The facility failed to dispose of expired Tubersol test vials in two medication rooms, using vials beyond the recommended 30-day use period.
F441: The facility failed to properly handle and sanitize resident and facility laundry to prevent cross contamination and failed to clean resident rooms properly, including not changing gloves after cleaning toilets.
Report Facts
Resident census: 61
Vitamin B-12 monitoring gap: 2
Expired Tubersol vials: 2
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 29, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies from the prior survey were corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of the revisit date. The report lists multiple regulatory citations with correction completion dates.
Inspection Report
Plan of Correction
Deficiencies: 10
Date: May 8, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions including education, audits, care plan updates, and policy revisions to address deficiencies in comprehensive assessments, oral/dental care, neurological assessments, assistance with activities of daily living, accident hazards, drug regimen management, food handling, medication storage, and infection control.
Deficiencies (10)
F272 Comprehensive Assessments: Education was provided to the MDS Coordinator on timely completion of assessments and care plans. Monthly monitoring and review of assessments will be conducted.
F278 Assessment Accuracy/Coordination Certified: Resident #18's MDS assessment was corrected for oral/dental status and care plans updated. Ongoing audits and dental appointment tracking will be implemented.
F309 Provide Care/Services For Highest Well Being: Neurological assessments for resident #40 will be completed following new policy for unwitnessed falls including neuro checks.
F311 Treatment/Services To Improve/Maintain ADLS: Staff education and audits will ensure residents needing assistance with eating receive appropriate help.
F323 Free of Accident Hazards/Supervision/Devices: Resident #12's side rails and mattress were replaced and audits will ensure proper fitting and accurate care plans.
F329 Drug Regimen is Free From Unnecessary Drugs: Care plans updated for residents using psychotropic and hypnotic medications with behavior monitoring and sleep assessments.
F371 Food Procure, Store/Prepare/Serve-Sanitary: Staff received in-service on food handling; audits will ensure compliance with policies.
F428 Drug Regimen Review, Report Irregular, Act on: Pharmacy consultant and physician assessed residents; monitoring and reporting of drug irregularities will continue.
F431 Drug Records, Label/Store Drugs & Biologicals: Open multi-dose vial of insulin was destroyed; medication rooms audited and staff trained on storage and labeling policies.
F441 Infection Control, Prevent Spread, Linens: In-services on safe food handling, linen handling, and hand hygiene were conducted; infection control system and audits implemented.
Report Facts
Complete Date: May 8, 2012
Complete Date: May 29, 2012
Date: May 13, 2012
Date: May 4, 2012
Date: May 8, 2012
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 10
Date: Apr 30, 2012
Visit Reason
Annual health resurvey visit to assess compliance with federal regulations for nursing home care.
Findings
The facility failed to complete timely and accurate comprehensive assessments and care plans for residents, failed to provide necessary care and services including neurological checks after falls, failed to maintain a safe environment due to side rail entrapment risks, failed to ensure drug regimens were free from unnecessary medications, failed to serve food and handle linens in a sanitary manner, and failed to maintain an effective infection control program.
Deficiencies (10)
F272: Facility failed to complete comprehensive assessments and individualized care plans within the required 14-day timeframe for residents #40 and #14.
F278: Facility failed to accurately complete Minimum Data Set assessments reflecting residents' status for residents #18 and #24.
F309: Facility failed to provide necessary care including neurological checks after unwitnessed falls for resident #40.
F311: Facility failed to provide appropriate treatment and prompting to maintain or improve resident #40's ability to eat.
F323: Facility failed to ensure resident #12's environment was free of accident hazards due to side rails with entrapment risks and lack of proper monitoring.
F329: Facility failed to ensure residents #42, #59, and #14 had drug regimens free from unnecessary drugs due to inadequate monitoring and lack of gradual dose reduction or risk benefit statements.
F371: Facility failed to serve food in a sanitary manner as staff touched rims of glasses and dessert cups during meal service.
F428: Facility failed to ensure pharmacist reported drug regimen irregularities to physician and director of nursing and that recommendations were acted upon for residents #42, #59, and #14.
F431: Facility failed to label drugs properly; an open multi-dose vial of Novolog insulin lacked date opened and discard date.
F441: Facility failed to maintain an infection control program, failed to serve food and handle linens in a sanitary manner, and failed to wash hands after resident contact.
Report Facts
Resident census: 49
Residents sampled for review: 12
Medication doses: 10
Medication doses: 0.25
Medication doses: 0.5
Entrapment risk space: 144
Entrapment risk gap: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Licensed Nurse | Confirmed timing requirements for assessments and care plans, acknowledged inaccurate assessments for residents #14, #18, #24, and failure to assess neurological checks after falls for resident #40. |
| Direct Care Staff O | Direct Care Staff | Observed assisting resident #40 and reported wandering behavior. |
| Licensed Nursing Staff E | Licensed Nurse | Reported resident #40 as high fall risk, confirmed failure to prompt resident #40 to eat, and reported resident #12's side rail use and monitoring. |
| Consultant Staff R | Consultant Pharmacist | Acknowledged failure to request gradual dose reduction for resident #14 and failure to recommend monitoring for anxiety for resident #42. |
| Administrative Nursing Staff A | Administrative Nurse | Confirmed failure to assess neurological checks after falls and lack of infection control program tracking. |
| Administrative Nursing Staff B | Administrative Nurse | Confirmed lack of awareness of side rail use for resident #12 and failure to monitor side rail safety. |
| Licensed Nursing Staff X | Infection Control Nurse | Reported lack of infection control tracking and lack of culture and sensitivity reports. |
| Direct Care Staff K | Direct Care Staff | Observed touching rims of glasses and dessert cups during meal service. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N086001 POC LVT511
Visit Reason
This document is a Plan of Correction related to a previous inspection event identified as LVT511 for the facility with State ID N086001.
Findings
No deficiency details or findings are included in this Plan of Correction document. It only references the related deficiency report and provides contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N086001 POC OEBX11
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 outlines corrective actions for deficiencies related to CPR certification of licensed nursing staff, comprehensive assessments for residents with significant changes, and implementation of restorative therapy programs for affected residents.
Deficiencies (3)
F155-E: Licensed nursing staff lacked current CPR certification on file, affecting all residents. The facility will ensure all licensed nurses maintain current CPR certification.
F274-D: Significant change comprehensive assessments were not completed for affected residents. The facility will complete assessments and monitor ADL scores weekly.
F311-G: Two residents were not added to the restorative therapy program. The facility will add residents to the program and ensure follow-up after therapy discharge.
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