Inspection Report Summary
The most recent inspection on March 31, 2017, found that previously cited deficiencies related to food storage and sanitation had been corrected. Earlier inspections showed a pattern of deficiencies primarily involving food safety and sanitary conditions in the kitchen, as well as issues with resident care documentation, medication management, and infection control. Complaint investigations substantiated failures in safe transfer procedures, resident dignity, incident reporting, and care plan revisions, with enforcement actions including denial of payment for new admissions at times. Fines or license suspensions were not listed in the available reports. The facility appears to have addressed many prior deficiencies through plans of correction and follow-up visits, indicating some improvement over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
32.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
445% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
31 residents
Based on a March 2017 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 1
Mar 31, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report indicates that the previously cited deficiency with ID Prefix F0371 under regulation 483.60(i)(1)-(3) was corrected and completed as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID Prefix F0371 related to regulation 483.60(i)(1)-(3) |
Inspection Report
Re-Inspection
Deficiencies: 1
Mar 23, 2017
Visit Reason
A first revisit was conducted on March 23, 2017, for a February 14, 2017 Health survey to determine if the facility was in compliance with Federal participation requirements for nursing homes 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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction effective March 31, 2017.
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 |
Report Facts
Denial of Payment for New Admissions (D.DOPNA) effective period: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to enforcement and compliance findings |
Inspection Report
Life Safety
Deficiencies: 1
Mar 23, 2017
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. A plan of correction was required, and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited during the Life Safety Code survey resulting in an 'F' level finding. | F |
Report Facts
Effective date for denial of payments: Jun 23, 2017
Effective date for provider agreement termination: Sep 23, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 23, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with corrective actions completed on 03/23/2017.
Inspection Report
Plan of Correction
Deficiencies: 3
Mar 23, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the Park Villa revisit inspection conducted on March 23, 2017.
Findings
The facility failed to date frozen meat and vegetables in the store room freezer, maintain safe and sanitary storage in refrigerators and freezers, and prepare and serve food under sanitary conditions in the kitchen. The Plan of Correction outlines training and monitoring actions to address these issues.
Deficiencies (3)
| Description |
|---|
| The facility failed to date frozen meat and vegetables in the store room freezer; kitchen freezer refrigerator contained open undated products without date labels. |
| The facility failed to maintain safe and sanitary storage in refrigerator and freezers; food preparation equipment needing cleaning included toasters, food processors, stove and surrounding areas. |
| The facility failed to prepare and serve food under sanitary condition in kitchen in the facility. |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 7
Mar 20, 2017
Visit Reason
The visit was a Non-Compliance Revisit to assess the facility's compliance with food procurement, storage, preparation, and serving sanitary standards.
Findings
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen, including issues with undated opened food packages, food contamination during preparation, and unclean kitchen equipment, placing 31 residents at risk for foodborne illnesses.
Deficiencies (7)
| Description |
|---|
| Numerous packages of opened, undated bags of frozen meat and vegetables in the freezer and refrigerator. |
| Thick layer of ice and tan/brown circular rings and stains inside the storeroom refrigerator. |
| Kitchen freezer contained open boxes of frozen biscuits, cinnamon rolls, and hamburger patties exposed to air. |
| Food processor and other kitchen equipment had grease, grime, and splattered food particles. |
| Dietary staff contaminated bread and buns by handling with gloved hands that touched other food and surfaces without proper sanitation. |
| Food processor containers were rinsed but not washed or sanitized between uses. |
| Opened food packages lacked labels indicating the date the food was opened. |
Report Facts
Resident census: 31
Sample size: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff D | Observed contaminating bread and buns during food preparation and meal service. | |
| Dietary Manager B | Verified opened packages of food in the storeroom freezer lacked date labels. | |
| Dietary Staff C | Verified opened packages of food in refrigerators lacked date labels. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 12
Feb 14, 2017
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation triggered by complaints #111266 and #111073.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of resident condition changes, failure to maintain resident dignity, failure to notify residents of room changes, failure to revise care plans for medication and pressure ulcers, inadequate pain management assessments, improper catheter care, expired medications and food safety violations, and infection control breaches.
Complaint Details
The visit was triggered by complaints #111266 and #111073.
Severity Breakdown
SS=D: 8
SS=G: 2
SS=E: 1
SS=F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to notify the physician for a resident who had a change in condition requiring hospitalization. | SS=D |
| Failure to promote dignity by not assisting a resident to change a soiled shirt. | SS=D |
| Failure to notify residents prior to room or roommate changes. | SS=D |
| Failure to revise care plans for residents regarding use of prn antipsychotic medication and pressure ulcer care. | SS=D |
| Failure to provide adequate pain management and assessments for prn medications. | SS=G |
| Failure to adequately assess and seek physician involvement for a resident with a change in condition resulting in hospitalization. | SS=G |
| Failure to provide necessary services to maintain good personal hygiene for 5 residents. | SS=E |
| Failure to provide care and services to prevent development and worsening of pressure ulcers for 3 residents. | SS=D |
| Failure to provide appropriate catheter care to prevent infection and improper handling of urinary drainage bag. | SS=D |
| Failure to provide adequate assessments before administration of prn pain, antianxiety and antipsychotic medications for 3 residents. | SS=D |
| Failure to ensure medications in emergency kits and insulin vials were not expired or undated. | SS=D |
| Failure to provide a safe, sanitary, and comfortable environment to prevent infection and disease transmission, including improper catheter care and improper laundry and food handling practices. | SS=F |
Report Facts
Resident sample size: 17
Facility census: 34
Expired food items: 44
Expired medications: 4
Undated insulin vials: 3
Days without bathing: 7
Days without bathing: 9
Days without bathing: 10
Days without bathing: 16
Pressure ulcer size: 1.5
Pressure ulcer size: 1
Medication administrations without assessment: 35
Medication administrations without assessment: 38
Medication administrations without assessment: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Nurse | Named in relation to administration of prn Haldol and Baclofen without proper assessment. |
| Administrative Nurse A | Administrative Nurse | Verified lack of documentation and improper catheter care; stated nurses should assess before prn medication administration. |
| Administrative Nurse B | Administrative Nurse | Verified lack of physician notification and improper pressure ulcer care. |
| Medication Aide E | Medication Aide | Administered prn Haldol without assessment; unaware of Black Box Warning. |
| Medication Aide F | Medication Aide | Administered prn Haldol without assessment; unaware of Black Box Warning. |
| Nurse Aide R | Nurse Aide | Failed to follow proper catheter care and infection control procedures. |
| Dietary Staff M | Dietary Staff | Observed not changing gloves between food preparation tasks and serving. |
| Dietary Manager N | Dietary Manager | Verified expired and unlabeled foods in kitchen. |
| Maintenance Staff V | Maintenance Staff | Verified lack of documentation of laundry water temperatures. |
Inspection Report
Enforcement
Deficiencies: 0
Feb 14, 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, resulting in enforcement remedies including denial of payment for new Medicare and Medicaid admissions effective March 7, 2017, with no opportunity to correct deficiencies before remedies are imposed.
Report Facts
Denial of payment effective date: Mar 7, 2017
Timeframe for substantial compliance: 6
Civil Money Penalty minimum amount: 5000
Hearing request deadline: 60
Informal Dispute Resolution request deadline: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the enforcement action and instructions |
Inspection Report
Plan of Correction
Deficiencies: 14
Feb 14, 2017
Visit Reason
This document is a Plan of Correction submitted by Park Villa in response to deficiencies cited during a prior inspection conducted on February 14, 2017.
Findings
The facility was cited for multiple deficiencies including lack of documentation of changing medical status, failure to maintain resident dignity, failure to notify residents of room changes, inadequate medication administration procedures, improper catheter care, facility-acquired pressure ulcers, expired and unlabeled medications, and infection control issues. The Plan of Correction outlines corrective actions such as staff re-education, policy revisions, and monitoring by QA nurse and DON.
Severity Breakdown
D: 8
E: 3
F: 2
G: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Lack of documentation related to changing medical status of Resident #23 | D |
| Resident #18 left with soiled shirt causing dignity issue and failure to document refusals | D |
| Failure to notify Resident #30 of room change and Resident #6 of new roommate | D |
| Failure to identify black box warning for antipsychotic medication for Resident #36 | D |
| Failure to include skin integrity/pressure ulcer management in Resident #35's plan of care | D |
| Decline in health of Resident #23 not properly documented | G |
| Failure to properly document ADLs on 5 of 8 sampled residents | E |
| Facility-acquired pressure ulcers in Residents #35, #9, and #38 | D |
| Improper catheter care and handling of urinary drainage bag for Residents #3 and #9 | D |
| PRN medications given without assessment or reason prior to administration for Residents #36, #12, and #23 | D |
| Expired and unlabeled medications found during survey | E |
| Resident #3 receiving care not following standard precautions; improper handling of linens; neglect in recording water temperatures | F |
| Dietary staff not following proper sanitary conditions and standard precautions | F |
| Failure to properly label medications and monitor expiring medications | D |
Report Facts
Deficiencies cited: 14
BIM score: 13
Sampled residents for ADL documentation: 8
Residents with facility-acquired pressure ulcers: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Scott | Administrator | Submitted Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction | |
| Dietary Manager | Responsible for compliance of dietary sanitary conditions | |
| QA nurse | Responsible for monitoring compliance and documentation | |
| DON | Director of Nursing | Responsible for monitoring compliance and documentation |
| Facilities Pharmacist | Responsible for medication administration procedures and monitoring |
Inspection Report
Plan of Correction
Deficiencies: 12
Feb 9, 2016
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 addresses multiple deficiencies including privacy concerns, resident care issues such as bowel and wound care, dietary and food safety violations, building maintenance, and staff training. The facility outlines corrective actions with completion dates ranging from February 2016 to March 2016.
Severity Breakdown
F: 3
E: 3
D: 6
Deficiencies (12)
| Description | Severity |
|---|---|
| Privacy curtain to shield Director of Nursing's desk and computer monitor. | F |
| Resident #23's clothing protector use and dignity concerns. | E |
| Building maintenance issues including gouges in sheetrock and broken floor tiles. | E |
| Nursing staff digitally removed feces from Resident #35 without physician order. | D |
| Lack of formal review of Resident #6's wheelchair posture and need for comprehensive therapy assessments. | D |
| Two residents had facility acquired pressure ulcers; wound care procedures updated. | D |
| Violation of facility policy on Urinary Catheter Care. | D |
| Provision and monitoring of thickened liquids per physician order. | E |
| Resident #34 received several administrations of PRN anti-psychotic medications without documentation of non-pharmaceutical interventions. | D |
| Meal service protocol revised to improve supervision and food temperature monitoring. | D |
| Improper food storage violating federal, state, and facility policy; dietary staff policies revised. | F |
| Dumpster lids secured and importance of keeping trash containers closed to be discussed. | F |
Report Facts
Deficiencies cited: 12
Completion dates: Feb 17, 2016
Completion dates: Feb 18, 2016
Completion dates: Feb 25, 2016
Completion dates: Feb 26, 2016
Completion dates: Mar 4, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Scott | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 11
Feb 1, 2016
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy, dignity, and respect; inadequate housekeeping and maintenance; failure to provide necessary care and services including proper wheelchair positioning, pressure ulcer prevention and treatment, catheter care, and appropriate thickened liquids; improper medication monitoring; and food safety violations including improper food temperatures and unsanitary food handling.
Severity Breakdown
Level E: 3
Level D: 5
Level F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to provide privacy for resident clinical records in shared office space. | Level E |
| Failure to promote dignity and respect for residents, including inadequate changing of soiled clothing protectors and inappropriate use of incontinent pads in living areas. | Level E |
| Failure to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment, including broken floor tiles, gouged walls, and missing light fixture covers. | Level D |
| Failure to provide necessary care and services for wheelchair positioning and digital removal of stool, resulting in improper positioning and lack of therapy services. | Level D |
| Failure to provide treatment and services to prevent pressure ulcers and to promote healing, including lack of weekly wound assessments and development of pressure ulcers in the facility. | Level D |
| Failure to provide proper catheter care to prevent infection and secure catheter tubing, resulting in risk of urinary tract infection. | Level E |
| Failure to provide correct fluid consistency as ordered for residents requiring thickened liquids, with no standardized procedure for thickening liquids. | Level D |
| Failure to adequately assess and monitor effectiveness of psychotropic medications and failure to use non-pharmacological interventions prior to medication administration. | Level D |
| Failure to maintain food at proper temperatures, resulting in food served at unsafe temperatures. | Level F |
| Failure to store, prepare, distribute and serve food under sanitary conditions, including uncovered and undated food items and improper hair covering by kitchen staff. | Level F |
| Failure to properly dispose of garbage and refuse, including dumpsters without functioning lids. | Level F |
Report Facts
Residents in facility: 28
Residents in sample: 22
Temperature of spaghetti: 87
Temperature of orange juice: 57
Number of broken floor tiles: 5
Number of incontinent pads on chairs: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Verified privacy issues, dignity concerns, catheter care, wheelchair positioning, food temperature issues, and thickened liquid procedures |
| Nurse Aide I | Nurse Aide | Observed providing resident care with poor hygiene practices and improper thickened liquids |
| Dietary Staff C | Dietary Staff | Verified food safety violations and lack of thickener guidelines |
| Maintenance Staff D | Maintenance Staff | Verified dumpsters without functioning lids |
| Nurse E | Nurse | Provided information on resident therapy and medication interventions |
Inspection Report
Follow-Up
Deficiencies: 1
Nov 3, 2015
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiency identified as F0323 related to regulation 483.25(h) was corrected by 10/09/2015. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency identified as F0323 related to regulation 483.25(h) |
Report Facts
Deficiency correction date: Oct 9, 2015
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 24, 2015
Visit Reason
The document is a Plan of Correction responding to deficiencies cited in a complaint investigation at Park Villa, focusing on minimizing accidents and hazards in the long term care environment.
Findings
The plan addresses deficiencies related to resident safety, specifically fall prevention and appropriate use of assistive devices, and outlines staff training and implementation of a proactive assessment system.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as Park Villa 091615 Complaint.
Deficiencies (1)
| Description |
|---|
| Failure to promote a systems approach to minimize accidents and hazards and provide appropriate supervision and assistive devices based on assessed resident needs (F323). |
Report Facts
Complete Date for Plan of Correction: Oct 9, 2015
Incident Date: Sep 24, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 16, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be a 'G' level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective December 16, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be a 'G' level | G |
Report Facts
Denial of Payment for New Admissions Effective Date: Dec 16, 2015
Termination Recommendation Date: Mar 16, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Sep 16, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#90422) regarding the facility's failure to ensure a safe transfer using the sit to stand mechanical lift, which resulted in a fracture for one resident.
Findings
The facility failed to provide adequate supervision and safe transfer procedures for Resident #1, who sustained a significantly displaced fracture of the left humerus caused by being pinched by the mechanical lift during transfer. Documentation showed the resident had severe cognitive impairment and required extensive assistance, and staff failed to reassess the resident's ability to use the mechanical lift safely despite observed difficulties.
Complaint Details
Complaint investigation #90422 focused on the unsafe transfer of Resident #1 using a mechanical lift, which caused a fracture. The investigation found the resident was pinched by the lift jacket during transfer, leading to bruising and a displaced fracture of the humerus.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a safe transfer for the use of the sit to stand mechanical lift, resulting in a fracture for one resident. | SS=G |
Report Facts
Resident census: 33
Medication dosage: 5
Timeframe: 6
Timeframe: 12
Timeframe: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide D | Reported resident did not assist with transfers and noted issues with the easy stand mechanical lift | |
| Nurse Aide C | Observed resident's discomfort and improper weight bearing during transfers with the easy stand mechanical lift | |
| Nurse E | Verified resident had not been re-evaluated for mechanical lift use and noted decline in transfer ability | |
| Nurse Aide A | Noted resident unable to hold on to the easy stand lift due to contracted arms | |
| Administrative Nurse F | Verified staff notification expectations for transfer decline and lack of facility policy for mechanical lift assessment |
Inspection Report
Follow-Up
Deficiencies: 5
Jul 22, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited under regulations 483.10(b)(11), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.25, 483.25(h), and 483.25(l) were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency under regulation 483.10(b)(11) |
| Deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency under regulation 483.25 |
| Deficiency under regulation 483.25(h) |
| Deficiency under regulation 483.25(l) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 5
Jul 8, 2015
Visit Reason
This document is a Plan of Correction submitted in response to a complaint survey conducted at Park Villa, addressing alleged deficiencies identified during the inspection.
Findings
The plan outlines corrective actions including in-service training sessions for licensed staff and other caregivers to address issues related to communication with physicians and families, reporting and investigation of incidents, implementation of physician orders, and resident safety such as fall prevention. The provider maintains that the alleged deficiencies do not jeopardize resident health or safety.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure accurate and timely communications to physicians and families (F157) | D |
| Failure to accurately and timely report incidents of suspected or observed mistreatment, neglect, or abuse and lack of appropriate investigation and reporting (F225) | D |
| Failure to accurately and timely implement Physicians' orders and provide feedback regarding treatment effectiveness (F309) | D |
| Failure to accurately and timely analyze resident safety issues such as falls (F323) | D |
| Failure to accurately and timely implement Physicians' orders and provide feedback regarding treatment effectiveness and lab reports (F329) | D |
Report Facts
Complete Date for F0000: Plan of correction to be reviewed by Quality Assurance Committee on or before July 24, 2015
In-service training dates: Training sessions scheduled on July 8, 2015 and July 9, 2015; Fall committee training by July 22, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Scott | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 24, 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 and was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy | D |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 5
Jun 24, 2015
Visit Reason
The inspection was conducted based on complaint investigations #87599, #87595, and #87314 regarding failure to notify physicians of changes, failure to investigate and report allegations of abuse and neglect, and failure to provide adequate care and services.
Findings
The facility failed to notify the physician of Resident #3's lab results and skin tear, failed to thoroughly investigate and report incidents involving Resident #3 and Resident #4, failed to provide timely assessment and monitoring for Resident #3, failed to maintain a safe environment preventing falls for Residents #1 and #3, and failed to prevent unnecessary medication use for Resident #3.
Complaint Details
The visit was complaint-related involving investigations of failure to notify physicians of changes, failure to investigate and report abuse and neglect, failure to provide adequate care, and failure to prevent unnecessary medication use.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify physician of Resident #3's lab results and newly acquired skin tear. | SS=D |
| Failed to thoroughly investigate and report allegations of abuse and neglect involving Resident #3 and Resident #4. | SS=D |
| Failed to provide timely and thorough assessment and monitor intake and output for Resident #3. | SS=D |
| Failed to provide an environment free of accident hazards for Residents #1 and #3, resulting in falls and injury. | SS=D |
| Failed to prevent unnecessary medication use by administering antibiotics to Resident #3 when UA indicated no UTI. | SS=D |
Report Facts
Resident census: 30
Skin tear size: 4
Medication dosage: 500
Medication duration: 10
BIMS score: 12
BIMS score: 8
BIMS score: 2
Urinary output: 0
Urinary output: 400
Urinary output: 475
Urinary output: 200
Urinary output: 100
Blood pressure: 88
Blood pressure: 44
Skin tear measurement: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Nurse | Verified Resident #3 had a UTI and physician ordered antibiotics; did not notify administration or physician of skin tear |
| Nurse C | Nurse | Verified receipt of physician's antibiotic order and UA; did not follow up with physician on negative UA results; verified Resident #4's behaviors and room change |
| Administrative Nurse D | Administrative Nurse | Verified failures to notify physician, investigate incidents, and report resident to resident behaviors; verified lack of thorough investigations and root cause analyses |
| Nurse B | Nurse | Observed Resident #1 fall and verified lack of voiding pattern completion |
| Nurse Aide A | Nurse Aide | Reported Resident #3 was lethargic and aspirated; confirmed resident had personal alarm |
| Nurse Aide F | Nurse Aide | Stated staff ensure Resident #1 is toileted to prevent falls |
| Nurse Aide H | Nurse Aide | Reported Resident #3 became more confused starting 5/29/15 |
| Nurse Aide I | Nurse Aide | Reported Resident #3 became more irritable starting 5/29/15 |
Inspection Report
Follow-Up
Deficiencies: 5
Mar 31, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers F0225, F0241, F0314, F0353, and F0441 were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.30(a) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 5
Inspection Report
Abbreviated Survey
Deficiencies: 1
Mar 2, 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 Medicare and/or Medicaid programs.
Findings
The survey found E level deficiencies indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective March 31, 2015.
Severity Breakdown
E level: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314 related to Pressure Ulcers, indicating the need for improved systems to prevent avoidable pressure ulcers and ensure appropriate care. | E level |
Report Facts
Effective date of substantial compliance: Mar 31, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the survey information |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 5
Mar 2, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#83867) focusing on allegations of abuse, neglect, mistreatment, and failure to report and investigate incidents properly.
Findings
The facility failed to fully investigate and report falls resulting in injury, failed to promote dignity and respect for residents, failed to provide adequate treatment for a pressure ulcer, failed to maintain sufficient nursing staff, and failed to maintain a sanitary environment regarding disposal of soiled dressings.
Complaint Details
The visit was triggered by Complaint Investigation #83867 involving allegations of abuse, neglect, mistreatment, and failure to report and investigate incidents properly. The investigation found substantiated failures in investigation, reporting, treatment, staffing, dignity, and infection control.
Severity Breakdown
SS=D: 2
SS=E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to fully investigate and report an unwitnessed fall resulting in a fractured shoulder for Resident #4 and a fall with injury for Resident #5. | SS=D |
| Failed to promote care for residents in a manner that maintains or enhances dignity and respect, including announcing a resident's weight aloud and staff standing over residents during meals. | SS=D |
| Failed to provide treatment and services to promote healing and prevent infection for Resident #1's stage 4 pressure ulcer, including unlicensed staff removing dressings and failure to reposition every 2 hours. | SS=E |
| Failed to provide sufficient nursing staff on the night shift to meet residents' needs, with multiple days having only one licensed nurse and one CNA. | SS=E |
| Failed to provide a safe, sanitary environment by improperly disposing of a soiled dressing from a resident's pressure ulcer, not using a biohazard bag as required. | SS=E |
Report Facts
Census: 36
Sample size: 5
Falls reviewed: 3
Licensed nurse and CNA staffing: 1
Days with insufficient staffing: 7
Inspection Report
Follow-Up
Deficiencies: 8
Dec 29, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that all previously identified deficiencies have been corrected as of the revisit date, with correction completion dates listed for each cited regulation.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.15(b) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(b), (d), (e) |
Report Facts
Deficiencies corrected: 8
Inspection Report
Enforcement
Deficiencies: 1
Dec 1, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an "F" level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 29, 2014.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were 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 letter as Enforcement Coordinator for Kansas Department for Aging & Disability Services |
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 8
Dec 1, 2014
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies and to verify corrective actions.
Findings
The facility was found deficient in timely physician notification of a resident's burn/blister, incomplete investigations of incidents, failure to provide preferred whirlpool baths due to inoperable tubs, inadequate housekeeping and maintenance, failure to revise care plans after falls, unsafe resident environment hazards, and improper medication management including expired and inaccurately reconciled controlled substances.
Severity Breakdown
SS=D: 6
SS=E: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to notify Resident #18's physician timely regarding a large blister from a possible burn. | SS=D |
| Failed to thoroughly investigate allegations of neglect and incidents for Residents #18 and #27. | SS=D |
| Failed to provide whirlpool baths to residents #11 and #12 due to inoperable whirlpool tubs. | SS=D |
| Failed to maintain sanitary and orderly environment including air vents, shower, and lift equipment. | SS=E |
| Failed to revise Resident #15's care plan after a fall to include adequate instructions for visual checks. | SS=D |
| Failed to ensure resident environment free of accident hazards including large gap between mattress and headboard for Resident #13 and inadequate visual check instructions for Resident #15. | SS=D |
| Failed to prepare and serve food under sanitary conditions; kitchen stove and oven were dirty and light covers had lint. | SS=F |
| Failed to discard expired medications and accurately reconcile controlled medications in medication room and cart. | SS=D |
Report Facts
Deficiencies cited: 8
Resident census: 34
Blister size: 3.8
Blister size: 3.5
Medication expiration date: 201410
Medication expiration date: 201409
Medication count discrepancy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Verified expired medication and medication count discrepancy. | |
| Nurse L | Verified expired medication and medication count discrepancy. | |
| Administrative Nurse A | Verified delayed physician notification, whirlpool inoperability, housekeeping issues, and medication reconciliation expectations. | |
| Nurse C | Verified burn notification policy and visual checks for Resident #15. | |
| Nurse Aide D | Reported finding blister on Resident #18 and whirlpool inoperability. | |
| Maintenance Staff F | Verified whirlpool inoperability and housekeeping deficiencies. | |
| Dietary Manager N | Verified kitchen sanitation deficiencies. | |
| Physician O | Primary Physician | Stated expectation for timely notification and orders for Resident #18's burn. |
Inspection Report
Plan of Correction
Deficiencies: 8
Dec 1, 2014
Visit Reason
This Plan of Correction document responds to deficiencies cited in the 12/1/14 CMS-2567 survey report for Park Villa, addressing corrective actions for multiple identified deficiencies.
Findings
The document outlines corrective actions for deficiencies related to skin and wound care management, incident investigations, facility capital improvements, equipment repairs, electronic medical records implementation, dietary management, and controlled substances policies. The facility commits to staff training, policy updates, monitoring compliance, and physical improvements.
Severity Breakdown
D: 6
E: 1
F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Skin and wound care management protocols and follow-up procedures were deficient. | D |
| Incident investigation and reporting policies required clarification and staff training. | D |
| Capital improvements needed for bathing facilities and whirlpool equipment. | D |
| Maintenance and replacement of bathroom sink vanity covering and sit to stand lift end caps were incomplete. | E |
| Implementation of electronic medical records and Active Risk Management report system was in progress. | D |
| Bed frame adjustment needed for new mattress on Resident #13's bed. | D |
| Dietary cleaning schedules and staff training were newly implemented. | F |
| Controlled substances count error and policy review with additional reconciliation procedures planned. | D |
Report Facts
Deficiencies cited: 8
Plan of Correction completion date: Dec 29, 2014
New Certified Dietary Manager start date: Oct 15, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Scott | Administrator | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Life Safety
Deficiencies: 1
Aug 27, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Denial of payments effective date: Nov 27, 2014
Provider agreement termination date: Feb 27, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Scott | Administrator | Named as facility administrator in the report. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Joe Ewert | Commissioner | Mentioned in copy list as Commissioner of KDADS. |
Inspection Report
Follow-Up
Deficiencies: 18
Nov 6, 2013
Visit Reason
The visit was conducted as a post-certification revisit to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report documents that all previously identified deficiencies were corrected by 10/16/2013, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (18)
| Description |
|---|
| Deficiency related to regulation 483.10(k),(l) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.15(h)(1) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(d)(1)-(2) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.55(b) |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(h) |
Report Facts
Deficiencies corrected: 18
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 18
Sep 16, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with resident rights, safety, care, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to provide private telephone access, failure to report incidents, dignity and respect issues, unsafe and unsanitary environment, incomplete assessments and care plans, inadequate pain management, improper medication storage and administration, infection control lapses, and unsafe physical environment with strong odors.
Complaint Details
The visit was triggered by a complaint investigation #68433.
Severity Breakdown
SS=E: 7
SS=D: 10
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to provide telephone access for residents where calls could be made without being overheard. | SS=E |
| Failure to report an unwitnessed fall and a resident to resident altercation to the state agency. | SS=D |
| Failure to promote dignity and respect for residents, including failure to maintain cleanliness and personal hygiene. | SS=E |
| Failure to provide a homelike dining environment; meals served on trays with dishes left on trays. | SS=E |
| Failure to maintain a sanitary, orderly, and comfortable interior environment; including damaged walls, floors, and bathrooms. | SS=E |
| Failure to complete comprehensive Care Area Assessments (CAAs) for residents. | SS=D |
| Failure to revise care plan according to Occupational Therapy recommendations for positioning. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable well-being including pain assessment and proper positioning. | SS=D |
| Failure to provide assistance with grooming and dressing as outlined in care plan. | SS=D |
| Failure to provide adequate supervision and prevent accidents for residents with history of falls and cognitive impairment. | SS=D |
| Failure to provide fluids at proper temperature during meals. | SS=E |
| Failure to store, prepare, distribute and serve food under sanitary conditions including presence of dust, food particles, flies, and open food containers. | SS=E |
| Failure to provide routine dental services and oral care including lack of toothbrush and no dentist for resident with broken teeth. | SS=D |
| Failure to provide medications as ordered by physician, including discrepancies between medication labels and orders. | SS=D |
| Failure to store medications and biologicals in locked compartments and at proper temperature; medication room door propped open; unattended medications on cart accessible to residents. | SS=D |
| Failure to accurately assess resident for causal factors including pain prior to administering medications for behaviors. | SS=D |
| Failure to maintain infection control including improper hand hygiene during catheter care and medication pass, uncovered food on medication cart, and improper storage of blood specimen. | SS=E |
| Failure to investigate and address strong foul sewer odor in resident activity area. | SS=E |
Report Facts
Census: 28
Fall risk score: 25
Fall risk score: 18
Medication refusal count: 7
Medication refusal count: 4
Medication refusal count: 2
Milk temperature: 52
Milk temperature: 50
Juice temperature: 54
Medication refrigerator temperature: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Staff Nurse | Verified telephone access issues, medication room door left open, medication storage issues, and resident medication administration |
| Administrative Staff C | Verified telephone privacy needs, failure to report incidents, environmental hazards, and foul odor in activity room | |
| Administrative Nurse B | Administrative Nurse | Verified failure to report incidents, medication administration discrepancies, medication storage issues, supervision lapses, and infection control failures |
| Medication Aide E | Medication Aide | Left medications unattended on medication cart and failed to wash hands between residents during medication pass |
| Nurse Aide J | Nurse Aide | Uncertain about resident assistance needs and rarely attends nursing report |
| Nurse Aide L | Nurse Aide | Reported resident behaviors and difficulty redirecting resident |
| Nurse Aide M | Nurse Aide | Reported resident behaviors and difficulty redirecting resident |
| Dietary Staff H | Dietary Staff | Verified meal serving on trays and dinnerware left on trays |
| Dietary Manager I | Dietary Manager | Verified improper fluid temperatures |
| Maintenance Staff K | Maintenance Staff | Verified foul odor in activity room and environmental hazards |
| Social Service Staff O | Social Service Staff | Improperly repositioned resident by pushing on shoulder |
| Medication Aide M | Medication Aide | Performed catheter care without proper hand hygiene |
Inspection Report
Plan of Correction
Deficiencies: 18
Aug 15, 2013
Visit Reason
This document is a Plan of Correction submitted by Park Villa Nursing Home in response to deficiencies cited in a prior inspection report, addressing various care and facility issues to ensure compliance with regulatory standards.
Findings
The plan outlines corrective actions for multiple deficiencies including care plan updates, resident privacy, fall investigations, personal hygiene care, dining experience improvements, facility maintenance, medication management, and staff education to prevent recurrence of cited issues.
Severity Breakdown
E: 9
D: 8
Deficiencies (18)
| Description | Severity |
|---|---|
| Care plans for residents #9 and #24 updated to ensure privacy during phone use. | E |
| Investigation and reporting of unwitnessed fall and resident altercation involving resident #23. | D |
| Care plan for resident #4 updated for continuous monitoring and personal hygiene care. | E |
| Enhancement of dining experience including no trays left on tables and improved meal presentation. | E |
| Cleaning and repairs in resident bathrooms and facility areas including painting and floor repairs. | E |
| Completion of Care Area Assessment for resident #18 and audit of all care plans and MDSs. | D |
| Provision of foot support devices for resident #4's wheelchair and care plan updates. | D |
| Care plan updates for resident #23 regarding pain assessment and non-pharmacological interventions. | D |
| Provision of new clothing for resident #7 and staff education on grooming and dressing. | D |
| Care plan updates for resident #23 including use of bed alarm and supervision measures. | D |
| Medication review and adjustments for resident #23 with policy changes on refusals. | D |
| Dietary department to serve fluids at proper temperature and enhance dining environment. | E |
| Deep cleaning of kitchen and nutritional center with new dietary policies. | E |
| Dental appointment scheduled for resident #7 and oral care plan updates. | D |
| Medication label correction for resident #31 and review of all medication labels. | D |
| Medication room door to remain locked and purchase of new refrigerator with freezer. | D |
| Education on hand hygiene and proper storage of open containers during medication passes. | E |
| Investigation and remediation of sewer smell in activity room with collaboration from city and contractor. | E |
Report Facts
Deficiencies cited: 17
Plan of correction completion date: Oct 16, 2013
Staff in-service date: Sep 26, 2013
Dietary staff in-service date: Sep 24, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cassidy | Administrator | Named as responsible for measuring substantial compliance and submitting the plan of correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 10
Jul 21, 2012
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All deficiencies previously cited have been corrected as of the revisit date, with corrections completed on 07/21/2012 for multiple regulatory items.
Deficiencies (10)
| Description |
|---|
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(b)(2)(iii) |
| Deficiency related to regulation 483.20(g)-(j) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.45(a) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 10
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 21, 2012
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected.
Findings
The report indicates that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited and corrected |
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 11
Jul 21, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report, outlining corrective actions to address the alleged deficiencies.
Findings
The plan details corrective actions for multiple deficiencies including care area assessments, comprehensive assessments, MDS accuracy, care plan updates, occupational therapy reassessments, medication warnings, kitchen cleanliness, infection control, and ongoing audits and monitoring to ensure compliance.
Severity Breakdown
D: 5
E: 5
C: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Care Area Assessment for resident #22 will be completed and used to update the resident's individualized care plan. | D |
| Resident #24 has been assessed and an annual comprehensive assessment, MDS, has been done. | D |
| MDS for Resident #1 corrected to not show presence of pressure ulcer; MDS for resident #22 corrected for falls assessment; MDS for resident #28 corrected for rehabilitation/restorative services; MDS for resident #31 corrected for ADL function. | E |
| Comprehensive care plan for Resident #29 developed; care plan for resident #28 updated for community return plan. | D |
| Resident #28 re-assessed for Occupational Therapy with treatment orders for upper extremity exercise for right hand for 30 days. | D |
| Care plans for residents #12, #14, #24, #28, #29, #31, and #33 updated to include Black Box warnings for medications; review to ensure residents free from unnecessary medications or excessive doses. | E |
| Kitchen thoroughly cleaned and supervised by certified dietary manager; cleaning schedule reviewed and checklist developed; staff education on food storage, preparation, and sanitary food service conducted. | E |
| Resident #28 re-assessed for Occupational Therapy with treatment orders for upper extremity exercise for right hand for 30 days with re-assessment planned. | D |
| Facility purchased EPA registered disinfectant for glucometer cleaning; strict environmental cleaning procedures using CDC recommended cleaners implemented; staff in-service on hand washing, disinfection, and cleaning conducted. | D |
| Weekly and as needed reviews with medical director to ensure care plans and MDSs are individualized, comprehensive, and accurate; audits and schedules established; kitchen cleanliness monitored weekly; weekly risk management meetings conducted. | E |
| Kitchen cleaning schedule reviewed and updated; certified dietary manager enrolled in certification courses; designated person to monitor dietary manager to ensure sanitary concerns addressed. | C |
Report Facts
Completion date: Jul 21, 2012
Assessment frequency: 12
Care plan audit frequency: 90
Occupational Therapy treatment duration: 30
Dietary manager certification completion timeframe: 201302
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cassidy | Administrator | Submitted the Plan of Correction |
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 1
Jun 21, 2012
Visit Reason
The inspection was conducted as a health resurvey for the facility to assess compliance with dietary services regulations.
Findings
The facility failed to employ a full-time certified dietary manager for its 29 residents and had multiple sanitary concerns in the kitchen, including unclean refrigerators, freezers, ovens, and undated opened food containers.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to employ a full-time certified dietary manager and inadequate supervision to identify and address sanitary concerns in the kitchen. | SS=C |
Report Facts
Census: 29
Food container size: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Staff J | Observed preparing and serving food; verified not a certified dietary manager but enrolled in certification courses | |
| Staff O | Certified Dietary Manager | Employed as certified dietary manager, helps oversee kitchen while current dietary manager is enrolled in certification course |
Inspection Report
Plan of Correction
Deficiencies: 6
N015005 POC 2CS111
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Park Villa.
Findings
The plan outlines corrective actions including staff in-services on reporting falls, dignity and respect, scope of practice, and infection control. It also details staffing levels and measures to improve CNA recruitment and compliance monitoring.
Severity Breakdown
D: 3
E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Preparation and execution of this plan of correction does not consist of an admission or agreement by this provider of the truth of the facts alleged or the conclusion set forth in the Statement of Deficiencies. | — |
| An in-service of charge nurses will be held to review criteria for reporting falls and formation of a Fall and Investigation Committee to conduct root cause analysis. | D |
| An in-service was conducted regarding dignity and respect of individuality with focus on care during activities of daily living. | D |
| An in-service discussion on scope of practice and importance of repositioning residents to prevent pressure ulcers. | D |
| Staffing includes 12 RNs and LPNs, 19 CNAs, with efforts to increase CNA pool and maintain staffing on night shifts. | E |
| A container for medical wastes with red biohazard bag was placed in resident's room and infection control policy to be reviewed. | E |
Report Facts
Number of RNs and LPNs employed: 12
Number of CNAs employed: 19
Number of administrative staff certified as CNAs/CMAs: 3
Night shift staffing ratio: 75
Effective date for night shift staffing: Mar 1, 2015
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