Deficiencies (last 10 years)
Deficiencies (over 10 years)
21.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
260% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
97% occupied
Based on a July 2024 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 6
Date: Jul 24, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including medication management, dietary services, food safety, hospice care coordination, and immunization policies.
Findings
The facility had multiple deficiencies including failure to ensure a licensed pharmacist identified medication stop dates, lack of a certified dietary manager, improper food storage and safety practices, inadequate coordination of hospice care, and failure to offer the pneumococcal PCV20 vaccination to eligible residents.
Deficiencies (6)
F 0756: The facility failed to ensure the consultant pharmacist identified and reported the lack of a 14-day stop date or required physician documentation for Resident 10's PRN lorazepam medication, placing the resident at risk for unintended psychotropic drug effects.
F 0758: The facility failed to ensure a 14-day stop date or specified duration with rationale for Resident 10's ongoing PRN antianxiety medication, placing the resident at risk for unintended psychotropic drug effects.
F 0801: The facility failed to employ a full-time certified dietary manager for 35 residents, placing residents at risk for inadequate nutrition.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including unlabeled and undated food items and ice buildup in the freezer, placing residents at risk for foodborne illness.
F 0849: The facility failed to ensure a coordinated plan of care between the facility and hospice provider for Resident 10, placing the resident at risk for inappropriate end-of-life care.
F 0883: The facility failed to evaluate eligibility and offer or obtain informed declination for the pneumococcal PCV20 vaccination for residents, placing them at risk for pneumococcal infection and complications.
Report Facts
Residents present: 35
Sample residents reviewed: 12
Residents reviewed for unnecessary medications: 5
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff BB | Dietary Staff / Dietary Manager | Verified not certified dietary manager and acknowledged food safety issues |
| Administrative Nurse D | Administrative Nurse | Verified resident received lorazepam PRN without stop date and pharmacist review issues |
| Administrative Nurse E | Administrative Nurse | Verified lack of hospice care coordination information in facility care plan |
| Administrative Nurse F | Administrative Nurse | Discussed pneumococcal vaccination offering and documentation |
| Certified Medication Aide MM | Certified Medication Aide | Observed administering resident's morning medications |
| Dietary Staff CC | Dietary Staff | Verified kitchen food storage issues |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 2
Date: May 31, 2023
Visit Reason
The inspection was conducted due to a complaint regarding a former Certified Nurses Aide posting a video of a resident's lower legs and feet on social media, violating the resident's privacy.
Complaint Details
The complaint involved a former Certified Nurses Aide who posted a video of Resident 1's feet on social media without consent. The facility did not report the incident to the State Agency, citing that the resident's representative intended to report it. The complaint was substantiated with findings of privacy violation and failure to report.
Findings
The facility failed to protect the privacy of Resident 1 when a former employee posted a video on social media, and failed to report the incident to the State Agency as required. The facility updated its cell phone policy and conducted staff training after the incident.
Deficiencies (2)
F 0583: The facility failed to protect Resident 1's privacy when a former employee posted a video of the resident's lower legs and feet on social media, placing the resident at risk for impaired psycho-social wellbeing and privacy infringement.
F 0609: The facility failed to timely report the incident involving Resident 1's privacy infringement to the State Agency, placing the resident at risk for ongoing abuse or mistreatment.
Report Facts
Resident census: 27
Brief Interview for Mental Status (BIMS) score: 12
Date of incident: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Reported unawareness of the video incident until notified by resident's representative; involved in policy updates |
| Administrative Staff A | Interim Administrator | Acting administrator at time of complaint report; stated facility did not report incident due to resident representative's intent to report |
| CNA M | Certified Nurses Aide | Former employee who posted the video of Resident 1 on social media; terminated prior to complaint |
Inspection Report
Routine
Census: 26
Deficiencies: 7
Date: Jul 6, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, grievance resolution, care planning, fall prevention, restraint use, staffing postings, and infection control.
Findings
The facility had multiple deficiencies including failure to provide a homelike dining environment due to disruptive resident behavior, failure to resolve resident grievances, inadequate care planning for a resident with falls from a power lift recliner, failure to prevent falls, improper assessment and use of bed rails, failure to post daily nurse staffing information, and failure to clean and disinfect shared equipment.
Deficiencies (7)
F 0584: The facility failed to provide comfortable sound levels promoting a homelike dining environment, placing residents at risk for an unpleasant dining experience.
F 0585: The facility failed to follow-up or resolve resident grievances related to disruptive dining behavior, placing residents at risk for unresolved concerns.
F 0657: The facility failed to revise the care plan for Resident 25 regarding safe use of a power lift recliner, placing the resident at risk for accidents and injury.
F 0689: The facility failed to identify and implement interventions to prevent falls for Resident 25 who had two falls from a recliner with injury, placing the resident at risk for further injury.
F 0700: The facility failed to assess Resident 11's side rails for safe use, placing the resident at risk for injury.
F 0732: The facility failed to post the actual scheduled working hours for nursing staff directly responsible for resident care per shift.
F 0880: The facility failed to monitor and adhere to cleaning and disinfecting shared equipment, placing residents at risk for infection.
Report Facts
Residents present: 26
Sample residents reviewed: 13
Falls documented for Resident 25: 2
Bed rail opening size: 15.5
Bed rail opening size: 14.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Verified disruptive behavior of Resident 1 and lack of grievance resolution; verified lack of nurse staffing report posting and lack of cleaning supplies for shared equipment | |
| Certified Nurse Aide M | Certified Nurse Aide | Verified Resident 1 was disruptive during dining |
| Social Service/Activity Staff | Verified Resident 1 was disruptive and loud during meals | |
| Administrative Nurse E | Administrative Nurse | Verified Resident 25 had two falls from power lift chair and care plan was not updated |
| Administrative Nurse Staff E | Administrative Nurse | Verified Resident 11's medical record lacked side rail assessment |
Inspection Report
Routine
Census: 29
Deficiencies: 7
Date: Jan 13, 2021
Visit Reason
Routine inspection of Park Villa nursing home to assess compliance with regulatory standards including resident safety, medication management, infection control, food safety, and immunization policies.
Findings
The facility had multiple deficiencies including failure to post required abuse hotline information, unsafe storage of hazardous chemicals, improper incontinence care increasing UTI risk, failure to notify physician of out-of-parameter blood sugars for a diabetic resident, inadequate cleaning of kitchen freezer, and failure to provide current CDC vaccine information to residents or their representatives.
Deficiencies (7)
F 0575: The facility failed to post the required Kansas Department for Aging and Disability Services Abuse, Neglect, and Exploitation complaint hotline telephone number, placing residents at risk for not reporting incidents.
F 0689: The facility failed to ensure hazardous chemicals were inaccessible to two independently mobile, cognitively impaired residents, placing them at risk for chemical accidents.
F 0690: The facility failed to provide thorough and proper incontinence care during toileting for multiple residents with histories of UTIs, placing them at risk for further infections.
F 0756: The facility's pharmacist consultant failed to notify the physician or director of nursing about out-of-parameter blood sugars for a diabetic resident, placing the resident at risk for lack of physician direction.
F 0757: The facility failed to notify the physician as ordered for out-of-parameter blood sugars for a diabetic resident, placing the resident at risk for lack of appropriate medication management.
F 0812: The facility failed to ensure proper cleaning of one of two upright freezers in the kitchen, placing residents at risk for unhealthy food.
F 0883: The facility failed to provide current CDC influenza and pneumococcal vaccine information to five residents or their representatives, placing residents at risk for making uninformed immunization decisions.
Report Facts
Residents census: 29
Sample residents reviewed: 12
Out of parameter blood sugars: 4
Freezer frost thickness: 1.5
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Administered medication and confirmed lack of physician notification for out-of-parameter blood sugars |
| Administrative Nurse E | Administrative Nurse | Provided statements regarding incontinence care training and verification of hazardous chemical accessibility |
| Administrative Nurse D | Administrative Nurse | Verified pharmacist consultant failed to notify physician of out-of-parameter blood sugars |
| Activity Staff Z | Activity Staff | Verified hazardous chemicals were not locked |
| Dietary Staff BB | Dietary Staff | Verified freezer needed defrosting |
| Administrative Staff A | Administrative Staff | Verified failure to post hotline and freezer defrosting responsibility |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 3, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Findings
The plan addresses the removal of a side rail from the bed of resident #1 and outlines steps to ensure proper installation and assessment of all bed side rails to prevent recurrence.
Deficiencies (1)
F323. The side rail was removed from the bed of resident #1. The facility will ensure all bed side rails are correctly installed and maintained, with assessments upon admission and quarterly thereafter.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Date: May 3, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#114807) regarding the facility's compliance with accident hazard prevention and supervision requirements.
Complaint Details
The complaint investigation #114807 found that the facility failed to assess for entrapment risk from side rails prior to installation for Resident #1. The resident had severe cognitive impairment, was a high fall risk, and had a history of falls. Staff interviews and observations confirmed the lack of assessment and potential safety hazard.
Findings
The facility failed to assess the risk of entrapment from side rails prior to installation for one sampled resident, placing the resident at risk for entrapment and/or injury.
Deficiencies (1)
F 323: The facility did not assess the risk of entrapment from side rails prior to installation for Resident #1, despite the resident's high fall risk and cognitive impairment. The resident's medical record lacked documentation of a side rail assessment, and staff confirmed no such assessment was completed.
Report Facts
Resident census: 30
Sampled residents: 3
Side rail gap dimensions: 12
Side rail gap dimensions: 3.75
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 31, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously reported deficiencies have been corrected as of the revisit date. No uncorrected deficiencies remain.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Mar 23, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a revisit inspection 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.
Deficiencies (3)
The facility failed to date frozen meat and vegetables in the store room freezer. The kitchen freezer refrigerator contained open undated products without date labels.
The facility failed to maintain safe and sanitary storage in refrigerators and freezers. Food preparation equipment such as toasters, food processors, stove, and surrounding areas needed cleaning.
The facility failed to prepare and serve food under sanitary conditions in the kitchen. Staff require training on proper handling and preparation of food using HACCP procedures.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 23, 2017
Visit Reason
A first revisit was conducted on March 23, 2017, for the February 14, 2017 Health survey to determine compliance with Federal participation requirements for nursing homes 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 effective March 31, 2017.
Deficiencies (1)
The most serious deficiency was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of Payment effective date: Mar 7, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated findings |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 23, 2017
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended if substantial compliance was not achieved.
Deficiencies (1)
The facility was found to have deficiencies at an 'F' level under the Life Safety Code survey, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Jun 23, 2017
Provider agreement termination date: Sep 23, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in enforcement actions |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 12
Date: Mar 23, 2017
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies were corrected as of the revisit date. Each deficiency is identified by regulation number and marked as completed.
Deficiencies (12)
483.10(g)(14): Previously cited deficiency corrected as of 03/23/2017.
483.10(a)(1): Previously cited deficiency corrected as of 03/23/2017.
483.10(e)(6): Previously cited deficiency corrected as of 03/23/2017.
483.10(c)(2)(i-ii,iv,v)(3), 483.21(b)(2): Previously cited deficiency corrected as of 03/23/2017.
483.24, 483.25(k)(l): Previously cited deficiency corrected as of 03/23/2017.
483.24(a)(2): Previously cited deficiency corrected as of 03/23/2017.
483.25(b)(1): Previously cited deficiency corrected as of 03/23/2017.
483.25(e)(1)-(3): Previously cited deficiency corrected as of 03/23/2017.
483.45(d)(e)(1)-(2): Previously cited deficiency corrected as of 03/23/2017.
483.45(c)(1)(3)-(5): Previously cited deficiency corrected as of 03/23/2017.
483.45(b)(2)(3)(g)(h): Previously cited deficiency corrected as of 03/23/2017.
483.80(a)(1)(2)(4)(e)(f): Previously cited deficiency corrected as of 03/23/2017.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 1
Date: 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, placing 31 residents at risk for foodborne illnesses. Observations included undated opened food packages, food contamination during preparation, and unsanitary kitchen equipment.
Deficiencies (1)
483.60(i)(1)-(3) Food procurement, storage, preparation, and serving were not conducted under sanitary conditions. The kitchen had numerous opened, undated frozen food packages and food contamination during preparation was observed.
Report Facts
Resident census: 31
Inspection Report
Plan of Correction
Deficiencies: 13
Date: 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.
Findings
The facility was cited for multiple deficiencies including lack of documentation for changing medical status, failure to maintain resident dignity, failure to notify residents of room changes, inadequate medication administration and documentation, facility-acquired pressure ulcers, improper catheter care, expired and unlabeled medications, and infection control issues. Corrective actions include staff re-education, policy revisions, and monitoring by QA nurse and DON.
Deficiencies (13)
F157-D: Lack of documentation related to changing medical status of Resident #23. Staff will receive in-service training on documentation standards.
F241-D: Resident #18 was left with a soiled shirt causing dignity issues; staff failed to document refusals to change clothing. Staff will be re-educated on maintaining resident dignity.
F247-D: Failure to notify Resident #30 of room change and Resident #6 of new roommate prior to changes. Staff will use notification forms and be re-educated.
F280-D: POC failed to identify black box warning for antipsychotic medication for Resident #36; issues with PRN medication administration and skin integrity management. Policies will be revised and staff re-educated.
F309-G: Resident #23 had a documented decline in health without proper documentation. Staff will receive mandatory training on reporting declines.
F312-E: Facility staff did not properly document ADLs on 5 of 8 sampled residents. Care tracker updated and staff educated on reporting refusals.
F314-D: Residents #35, #9, and #38 had facility-acquired pressure ulcers. Skin assessment policies will be reinforced and staff re-educated.
F315-D: Residents #3 and #9 did not receive proper catheter care or handling of urinary drainage bags. Staff will be re-educated on catheter care and standard precautions.
F329-D: Residents #36, #12, and #23 were given PRN medications without assessment or reason. Policy revised to require licensed nurse assessment before administration.
F371-F: Dietary staff meeting held to discuss proper food storage, preparation, and serving under sanitary conditions. Policies on standard precautions reviewed.
F428-D: Pharmacist consultant and clinical team to review medication administration procedures and monitor compliance. Re-assessment of medications planned.
F431-E: Expired and unlabeled medications found during survey; issues resolved immediately. Staff re-educated on proper medication labeling.
F441-F: Resident #3 received care not following standard precautions; laundry staff improperly handled linens; neglect in recording water temperatures. Staff re-educated and new policies implemented.
Report Facts
BIM score: 13
Sampled residents with ADL documentation issues: 5
Residents with facility-acquired pressure ulcers: 3
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 12
Date: Feb 14, 2017
Visit Reason
Health Resurvey and Complaint Investigation #111266 and #111073 conducted due to complaints and concerns about resident care and facility compliance.
Complaint Details
Complaint investigation revealed multiple deficiencies related to resident care, medication management, infection control, and facility operations.
Findings
The facility failed to notify physicians of resident condition changes, provide adequate personal hygiene and bathing, ensure proper room/roommate change notifications, revise care plans for medication use and pressure ulcers, maintain sanitary food storage and preparation, provide proper catheter care, and ensure appropriate medication assessments for prn drugs.
Deficiencies (12)
F157: Facility failed to notify physician of Resident #23's condition decline requiring hospitalization.
F241: Facility failed to promote dignity by not assisting Resident #18 to change soiled shirt.
F247: Facility failed to notify Residents #30 and #6 of room or roommate changes prior to the moves.
F280: Facility failed to revise care plans for Residents #36 and #35 regarding prn antipsychotic medication and pressure ulcer care.
F309: Facility failed to adequately assess and seek physician involvement for Resident #23's change in condition resulting in hospitalization.
F312: Facility failed to provide scheduled bathing and personal hygiene for Residents #17, #18, #26, #11, and #5 as planned.
F314: Facility failed to prevent development and worsening of pressure ulcers for Residents #35, #9, and #38.
F315: Facility failed to provide appropriate catheter care for Residents #3 and #9 to prevent urinary tract infections.
F329: Facility failed to provide adequate assessments before administration of prn antipsychotic, antianxiety, and pain medications for Residents #12, #23, and #36.
F371: Facility failed to store, prepare, distribute and serve food under sanitary conditions, including expired and unlabeled foods in the kitchen.
F428: Facility failed to ensure insulin vials were dated when opened and emergency medication kits contained expired medications.
F441: Facility failed to provide a safe, sanitary environment to prevent infection transmission, including improper catheter care and inadequate laundry infection control.
Report Facts
Resident census: 34
Deficiencies cited: 12
Expired food items: 48
Medication administrations without assessment: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Nurse | Named in medication administration and assessment deficiencies for Resident #36 |
| Administrative Nurse A | Administrative Nurse | Verified multiple deficiencies including medication assessments, infection control, and catheter care |
| Administrative Nurse B | Administrative Nurse | Involved in findings related to Resident #23's condition and pressure ulcer care |
| Medication Aide E | Medication Aide | Named in medication administration without assessment for Resident #36 |
| Medication Aide F | Medication Aide | Named in medication administration without assessment for Resident #36 |
| Nurse Aide R | Nurse Aide | Named in improper catheter care and infection control |
| Dietary Staff M | Dietary Staff | Observed with poor food handling and glove use |
| Dietary Manager N | Dietary Manager | Verified expired and unlabeled foods in kitchen |
| Laundry Staff U | Laundry Staff | Named in lack of infection control training and improper linen handling |
| Maintenance Staff V | Maintenance Staff | Named in failure to document laundry water temperatures |
| Social Service Staff P | Social Service Staff | Named in laundry infection control procedures |
Inspection Report
Enforcement
Deficiencies: 0
Date: 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. Based on these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions.
Report Facts
Denial of payment effective date: Mar 7, 2017
Timeframe for substantial compliance: 6
Civil Money Penalty minimum amount: 5000
Hearing request deadline: 60
IDR submission deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact for questions regarding the enforcement action and instructions |
Inspection Report
Enforcement
Deficiencies: 0
Date: Feb 14, 2017
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 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.
Report Facts
Denial of payment effective date: Mar 7, 2017
Timeframe for substantial compliance: 6
Civil Money Penalty threshold: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact for questions regarding enforcement action |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: 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, building maintenance, wound care, catheter care, dietary services, medication administration, and food storage violations. The facility outlines corrective actions, staff training, and monitoring plans to resolve these issues.
Deficiencies (11)
F164-F: A privacy curtain will be installed to shield the Director of Nursing's desk and computer monitor from view when not in use. Staff discussions of resident-related issues will not be conducted in the presence of other residents.
F241-E: Resident #23's cognitive status and clothing protector use were addressed, including staff training and modifications to the CareTracker system to document clothing protector changes after meals.
F253-E: Building maintenance issues such as gouges in sheetrock and broken floor tiles will be repaired or addressed through a comprehensive plan, with immediate repairs prioritized.
F309-D: Nursing staff digitally removed feces from Resident #35 without a physician's order; policy will be revised to require such orders and staff will be trained accordingly.
F314-D: Two residents had facility-acquired pressure ulcers; wound care procedures have been enhanced with weekly assessments and monitoring by the Assistant Director of Nursing.
F315-D: Facility policy on Urinary Catheter Care was violated; in-service training will be conducted to review catheter care policies and procedures.
F325-E: Residents will be provided thickened liquids per physician orders; dietary and nursing staff will be trained and monitored to ensure proper consistency.
F329-D: Resident #34 received multiple PRN anti-psychotic medications without documentation of non-pharmaceutical interventions; policy revised to require documentation and staff training.
F364-D: Meal service protocol was revised to provide more one-on-one assistance and active supervision, including monitoring food temperatures with a laser thermometer.
F371-F: Food storage violations were found; dietary policies will be reviewed and revised, including facial hair standards for employees and staff training on dietary assistance.
F372-F: Dumpster lids were secured and staff will be reminded of the importance of keeping trash containers closed.
Report Facts
Dates for corrective actions and trainings: Multiple dates between 2016-02-09 and 2016-02-26 for completion of corrective actions and staff in-service trainings.
Number of residents referenced: 4
Number of deficiency tags addressed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Scott | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 11
Date: 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 privacy violations, dignity and respect issues, housekeeping and maintenance deficiencies, inadequate care and services for residents, pressure ulcer prevention and treatment failures, improper catheter care, failure to provide correct thickened liquids, unnecessary drug use without adequate monitoring, improper food temperature maintenance, unsanitary food handling, and improper garbage disposal.
Deficiencies (11)
F164: The facility failed to provide privacy for resident clinical records for all 28 residents.
F241: The facility failed to promote dignity and respect for residents by not frequently changing soiled clothing protectors, placing incontinent pads in public areas, and providing inadequate assistance during meals.
F253: The facility failed to maintain a sanitary and orderly environment due to broken floor tiles, gouged walls, cracked floors, and missing light fixture covers on two resident hallways.
F309: The facility failed to provide necessary care for wheelchair positioning and bowel management for two residents, including unawareness of digital stool removal and improper positioning.
F314: The facility failed to prevent pressure ulcers for two residents, did not document weekly wound assessments, and failed to implement timely preventative measures.
F315: The facility failed to provide proper catheter care to prevent infection and secure catheter tubing for a resident with a history of UTIs.
F325: The facility failed to provide physician-ordered thickened liquids of correct consistency for four residents and lacked procedures to guide staff on thickener amounts.
F329: The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not using non-pharmacological interventions prior to administering antipsychotics and failing to monitor medication effectiveness.
F364: The facility failed to maintain food at proper temperatures for a resident's meal, resulting in food served at unsafe temperatures.
F371: The facility failed to prepare, distribute, and serve food under sanitary conditions, including uncovered and undated food in refrigerators, improper hair restraints for kitchen staff, and poor hand hygiene by staff assisting residents with meals.
F372: The facility failed to properly dispose of garbage and refuse by having dumpsters without functioning lids on all observed days.
Report Facts
Deficiencies cited: 11
Residents sampled: 22
Residents census: 28
Food temperature: 87
Food temperature: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide I | Nurse Aide | Named in findings related to improper hand hygiene and food handling during meal assistance |
| Administrative Nurse A | Administrative Nurse | Verified multiple findings including catheter care, dignity issues, and food temperature problems |
| Nurse E | Nurse | Provided statements regarding resident care and therapy |
| Dietary Staff C | Dietary Staff | Verified food handling and thickener procedures |
| Dietary Staff O | Dietary Staff | Observed preparing and serving food without proper facial hair covering |
| Maintenance Staff D | Maintenance Staff | Verified dumpsters had broken lids |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 3, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously reported have been corrected as of the dates indicated. No new deficiencies are listed in this document.
Deficiencies (1)
Regulation 483.25(h) deficiency identified by tag F0323 was corrected by 10/09/2015.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 24, 2015
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation related to resident safety and accident prevention at the facility.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Park Villa 091615 Complaint.
Findings
The facility identified deficiencies related to the minimization of accidents and hazards, specifically regarding the use of assistive devices and supervision. The plan includes staff in-service training and implementation of a proactive assessment and intervention system to prevent avoidable falls and accidents.
Deficiencies (2)
F0000 Preparation and execution of this plan of correction does not constitute an admission of the truth of the alleged deficiencies. The plan is prepared solely to comply with federal and state law requirements.
F323 requires a systems approach to minimize accidents and hazards by providing appropriate supervision and assistive devices based on resident needs. The facility will hold an in-service and establish a working group to implement proactive strategies for resident safety.
Report Facts
Complete Date for Plan of Correction: Oct 9, 2015
Incident Date: Sep 24, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Scott | Administrator | Submitted the Plan of Correction. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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 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.
Report Facts
Denial of Payment 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
Abbreviated Survey
Deficiencies: 0
Date: 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 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.
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
Date: Sep 16, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#90422) regarding concerns about resident safety during mechanical lift transfers.
Complaint Details
Complaint investigation #90422 found substantiated evidence that the facility's failure to safely transfer Resident #1 with the mechanical lift caused a fracture.
Findings
The facility failed to ensure a safe transfer using the sit to stand mechanical lift, resulting in a fracture for one resident. Observations, interviews, and record reviews documented bruising, swelling, and a displaced fracture caused by improper use of the lift.
Deficiencies (1)
483.25(h) The facility failed to ensure a safe transfer for Resident #1 using the sit to stand mechanical lift, resulting in a significant fracture to the resident's upper arm.
Report Facts
Resident census: 33
Inspection Report
Follow-Up
Deficiencies: 5
Date: 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 various regulations including 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)
Regulation 483.10(b)(11): Previously cited deficiency was corrected by the revisit date.
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiency was corrected by the revisit date.
Regulation 483.25: Previously cited deficiency was corrected by the revisit date.
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date.
Regulation 483.25(l): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jul 8, 2015
Visit Reason
This document is a Plan of Correction submitted by Park Villa in response to a complaint survey identifying deficiencies in regulatory compliance.
Findings
The plan addresses multiple deficiencies related to communication with physicians and families, reporting and investigation of mistreatment or abuse, implementation of physician orders, and resident safety issues such as falls. The facility plans to conduct in-service training sessions for licensed and non-licensed staff to improve compliance and ongoing monitoring through chart audits and committee reviews.
Deficiencies (5)
F157: Lack of accurate and timely communications to physicians and families. Training scheduled for licensed staff and CMAs/CNAs to address this issue.
F225: Failure to accurately and timely report incidents of suspected or observed mistreatment, neglect, or abuse and lack of appropriate investigation. Training and daily clinical meetings planned to improve reporting.
F309: Lack of accurate and timely implementation of physicians' orders and feedback to physicians. Training and chart audits planned to ensure compliance.
F323: Inadequate analysis of resident safety issues, including falls. A fall committee will review falls and initiate training on root cause analysis.
F329: Lack of accurate and timely implementation of physicians' orders and feedback regarding treatment and lab reports. Training and chart audits planned for ongoing compliance.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 5
Date: Jun 24, 2015
Visit Reason
The inspection was conducted as a result of complaint investigations #87599, #87595, and #87314.
Complaint Details
The inspection was complaint-driven based on investigations #87599, #87595, and #87314. The complaints involved failure to notify physicians of changes, failure to investigate and report abuse and neglect, failure to provide adequate care and monitoring, unsafe environment leading to falls and injuries, and unnecessary medication administration.
Findings
The facility failed to notify physicians of significant changes, failed to thoroughly investigate and report incidents of abuse and falls, failed to provide timely assessments and monitoring, failed to maintain a safe environment free of accident hazards, and failed to prevent unnecessary medication administration.
Deficiencies (5)
F 157: The facility failed to notify Resident #3's physician of lab results and a newly acquired skin tear to the resident's head.
F 225: The facility failed to thoroughly investigate and report incidents involving Resident #3's skin tear and Resident #4's resident-to-resident altercation.
F 309: The facility failed to provide timely and thorough assessment and monitor intake and output as ordered for Resident #3, who had a change in status.
F 323: The facility failed to provide an environment free of accident hazards and failed to identify root causes of falls for Residents #1 and #3, resulting in injuries including a fracture and skin tear.
F 329: The facility failed to ensure Resident #3 was free from unnecessary medications by administering an antibiotic despite a negative urinary analysis.
Report Facts
Resident census: 30
Skin tear size: 4
Medication dosage: 500
Medication duration: 10
BIMS score: 12
BIMS score: 8
BIMS score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Nurse | Verified Resident #3 had a UTI and physician ordered antibiotics; acknowledged failure to notify physician of skin tear. |
| Nurse C | Nurse | Verified receipt of physician's antibiotic order and UA for Resident #3; acknowledged failure to follow up on negative UA results. |
| Administrative Nurse D | Administrative Nurse | Verified failures in notification, investigation, and reporting for Residents #3 and #4; confirmed lack of root cause analysis for falls. |
| Nurse B | Nurse | Observed Resident #1 fall and verified lack of assessment and monitoring. |
| Nurse Aide A | Nurse Aide | Reported Resident #3's lethargy and aspiration; noted personal alarm use. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 31, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the prior survey conducted on 2015-03-02.
Findings
The report documents that all previously cited deficiencies identified by regulation numbers F0225, F0241, F0314, F0353, and F0441 were corrected as of the revisit date 2015-03-31.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Mar 31, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-03-02.
Findings
The revisit confirmed that all previously cited deficiencies identified by regulation numbers 483.13(c), 483.15(a), 483.25(c), 483.30(a), and 483.65 were corrected as of 2015-03-31.
Deficiencies (5)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.15(a): Previously cited deficiency was corrected by the revisit date.
Regulation 483.25(c): Previously cited deficiency was corrected by the revisit date.
Regulation 483.30(a): Previously cited deficiency was corrected by the revisit date.
Regulation 483.65: Previously cited deficiency was corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 11, 2015
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at Park Villa facility, addressing alleged deficiencies identified during the complaint survey.
Findings
The plan outlines corrective actions including staff in-services on fall reporting, dignity and respect, scope of practice, and infection control. Staffing challenges and measures to improve CNA staffing and compliance monitoring were also addressed.
Deficiencies (6)
F0000 Preparation and execution of this plan of correction does not constitute admission or agreement with the alleged deficiencies. The plan will be reviewed by the Quality Assurance Committee by March 31, 2015.
F225-D An in-service for charge nurses will be held to review fall reporting criteria and a Fall and Investigation Committee will conduct root cause analyses for falls and incidents by March 31, 2015.
F241-D Staff received in-service training on dignity and respect of individuality on March 5, 2015, focusing on care during activities of daily living with ongoing education through the PEAK 2.0 program.
F314-D An in-service discussed scope of practice and teamwork among licensed staff, emphasizing repositioning residents to prevent or heal pressure ulcers with compliance monitored by nursing and rehabilitation staff.
F353-E Staffing includes 12 RNs and LPNs and 19 CNAs, with efforts to improve CNA staffing through advertising and wage surveys. Night shift staffing was adjusted to ensure one licensed nurse and two CNAs/CMAs from March 1, 2015.
F441-E A medical waste container with a red biohazard bag was placed in a resident's room. Infection control policy will be reviewed in an in-service and compliance monitored by nursing and housekeeping supervisors.
Report Facts
Number of RNs and LPNs: 12
Number of CNAs: 19
Night shift staffing ratio: 0.75
Effective night shift staffing: 1
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 5
Date: Mar 2, 2015
Visit Reason
Complaint Investigation #83867 was conducted to investigate allegations of failure to fully investigate and report resident falls and other care concerns.
Complaint Details
Complaint Investigation #83867 focused on allegations of failure to investigate and report resident falls and other care deficiencies. The allegations were substantiated as the facility failed to properly investigate and report falls and other care issues.
Findings
The facility failed to fully investigate and report two resident falls resulting in injury, failed to promote dignity and respect for residents, failed to provide proper treatment for a pressure ulcer, failed to maintain sufficient nursing staff, and failed to maintain proper infection control with handling of soiled dressings.
Deficiencies (5)
F 225: The facility 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.
F 241: The facility failed to promote care that maintained or enhanced dignity and respect for residents, including announcing a resident's weight aloud and standing over residents during meals.
F 314: The facility failed to provide necessary treatment and services to promote healing and prevent infection of a pressure ulcer when an unlicensed nurse removed the dressing from Resident #1's pressure ulcer.
F 353: The facility failed to provide sufficient nursing staff on a daily basis to meet residents' needs and promote their well-being.
F 441: The facility failed to provide a safe, sanitary environment when a soiled dressing was not disposed of properly in a biohazard bag.
Report Facts
Resident census: 36
Sample size: 5
Falls reviewed: 3
Licensed nurse and CNA staffing: 1
Days with 1 nurse and 1 CNA on night shift: 7
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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.
Deficiencies (1)
F314 Pressure Ulcers deficiency was cited due to noncompliance with prevention and care requirements. The facility must implement corrective actions to prevent avoidable pressure ulcers and ensure appropriate care to prevent worsening of existing ulcers.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective March 31, 2015.
Deficiencies (1)
F314 Pressure Ulcers deficiency was cited due to noncompliance with prevention and care requirements. The facility must implement corrective actions to prevent avoidable pressure ulcers and ensure appropriate care to prevent worsening of existing ulcers.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 29, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously reported were corrected as of the revisit date. The report lists multiple regulatory citations with correction completion dates of 12/29/2014.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Dec 29, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior CMS-2567 survey report dated 12/1/14. It outlines corrective actions to address identified issues and ensure compliance with regulatory requirements.
Findings
The Plan of Correction addresses multiple deficiencies including skin and wound care management, incident investigation procedures, capital improvements for bathing facilities, equipment repairs, implementation of electronic medical records, mattress and bed frame adjustments, dietary cleaning schedules, and controlled substances policy compliance.
Deficiencies (8)
F157-D: The facility's skin and wound care management protocols require staff training and monitoring to ensure proper physician contact, care plan updates, and skin assessments for residents.
F225-D: Policies on accidents, incidents, and abuse require updates to clarify review responsibilities and include root cause analysis, with staff training planned.
F242-D: A committee was established to address capital improvements related to bathing facilities, including replacement of inoperable whirlpools and remodeling options.
F253-E: Most cited deficiencies corrected except for pending installation of a sink vanity covering and replacement end caps for sit-to-stand lifts ordered but not yet installed.
F280-D: Implementation of an electronic medical records system with Active Risk Management allows real-time incident reporting and plan of care modifications.
F323-D: A mattress replacement required resizing the bed frame; adjustments were made promptly and documentation forms updated to include bed frame fit.
F371-F: A new Certified Dietary Manager implemented comprehensive cleaning schedules and staff training to maintain sanitary food service conditions.
F431-D: Controlled substances policy requires dual counts each shift; a count error prompted policy review and additional weekly reconciliation procedures.
Report Facts
Plan of Correction completion date: Dec 29, 2014
New Dietary Manager start date: Oct 15, 2014
Policy references dates: Dec 10, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Scott | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Dec 29, 2014
Visit Reason
This is a post-certification revisit to verify that previously identified deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies listed by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory citations.
Deficiencies (8)
Regulation 483.10(b)(11): Previously cited deficiency corrected as of 12/29/2014.
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiency corrected as of 12/29/2014.
Regulation 483.15(b): Previously cited deficiency corrected as of 12/29/2014.
Regulation 483.15(h)(2): Previously cited deficiency corrected as of 12/29/2014.
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiency corrected as of 12/29/2014.
Regulation 483.25(h): Previously cited deficiency corrected as of 12/29/2014.
Regulation 483.35(i): Previously cited deficiency corrected as of 12/29/2014.
Regulation 483.60(b), (d), (e): Previously cited deficiency corrected as of 12/29/2014.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 1, 2014
Visit Reason
The visit was a Health survey conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
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 was not immediate jeopardy.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 8
Date: Dec 1, 2014
Visit Reason
Health resurvey inspection to evaluate compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility failed to notify a resident's physician timely regarding a burn blister, failed to thoroughly investigate incidents, failed to provide whirlpool baths as requested by residents, failed to maintain sanitary housekeeping and maintenance, failed to update care plans after falls, failed to ensure a safe environment free of accident hazards, failed to maintain sanitary food preparation areas, and failed to properly manage and reconcile medications including expired stock and controlled substances.
Deficiencies (8)
F157: Facility failed to notify Resident #18's physician timely regarding a large blister from a possible burn and delayed obtaining physician orders for care.
F225: Facility failed to thoroughly investigate 3 incident investigations, lacking witness statements to identify root causes and prevent recurrence.
F242: Facility failed to provide whirlpool baths to 2 residents who preferred them due to inoperable whirlpool tubs.
F253: Facility failed to maintain sanitary housekeeping and maintenance including dirty air vent filters, chipped paint, rusty shower caulking, and damaged lift equipment.
F280: Facility failed to update Resident #15's care plan after a fall to include clear instructions on frequency of visual checks to prevent future falls.
F323: Facility failed to ensure environment free of accident hazards including a large unsafe gap between Resident #13's mattress and headboard and inadequate fall prevention instructions for Resident #15.
F371: Facility failed to prepare and serve food under sanitary conditions including dirty stove, oven, and lint in light covers in the kitchen.
F431: Facility failed to discard expired medications and accurately reconcile controlled medications in medication room and cart.
Report Facts
Resident census: 34
Blister size: 3.8
Blister size: 3.5
Fall incident date: Aug 19, 2014
Fall incident time: 2230
Medication expiration date: 201410
Medication expiration date: 201409
Medication count discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Nurse | Verified expired medication and medication count discrepancy |
| Nurse L | Nurse | Verified medication count discrepancy |
| Administrative Nurse A | Administrative Nurse | Verified delayed physician notification, unsafe bed gap, whirlpool inoperability, and medication policies |
| Dietary Manager N | Dietary Manager | Verified kitchen sanitation deficiencies |
| Maintenance Staff F | Maintenance Staff | Verified air vent and whirlpool maintenance issues |
| Nurse C | Nurse | Verified incident investigations and fall prevention practices |
| Nurse Aide D | Nurse Aide | Verified whirlpool inoperability and incident findings |
| Nurse Aide M | Nurse Aide | Reported staff watch Resident #15 during sitting |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 1, 2014
Visit Reason
A Health 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 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 and was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
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.
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 27, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was found to have 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Nov 27, 2014
Provider agreement termination date: Feb 27, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 27, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, 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.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Nov 27, 2014
Provider agreement termination date: Feb 27, 2015
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 6, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from an earlier survey were corrected by the facility.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers and prefix codes were corrected as of 10/16/2013.
Report Facts
Correction completion date: Oct 16, 2013
Follow-up survey date: Nov 6, 2013
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 20
Date: Sep 16, 2013
Visit Reason
Health Resurvey and Complaint Investigation conducted to assess compliance with resident rights, abuse reporting, dignity, environment, assessments, care planning, medication management, infection control, and safety.
Complaint Details
Complaint investigation revealed multiple deficiencies including failure to provide private telephone access, failure to report incidents, inadequate care and dignity, unsafe environment, incomplete assessments and care plans, medication errors, infection control lapses, and unsanitary food preparation.
Findings
The facility was found deficient in multiple areas including failure to provide private telephone access, failure to report incidents to the state agency, failure to promote dignity and proper care, inadequate dining environment, poor housekeeping and maintenance, incomplete assessments and care plans, inadequate pain management, unsafe medication storage and administration, infection control lapses, and unsanitary food preparation conditions.
Deficiencies (20)
483.10(k) The facility failed to provide telephone access for residents where calls could be made without being overheard.
483.13(c) The facility failed to report to the state agency an unwitnessed fall and a resident to resident altercation for a cognitively impaired resident.
483.15(a) The facility failed to promote dignity for a resident by not maintaining cleanliness and proper care.
483.15(h)(1) The facility failed to provide a homelike dining environment for residents.
483.15(h)(2) The facility failed to maintain a sanitary, orderly, and comfortable interior environment.
483.20(b)(1) The facility failed to complete a Care Area Assessment for a resident's annual MDS assessment.
483.20(d)(3), 483.10(k)(2) The facility failed to revise the care plan for a resident regarding Occupational Therapy recommendations for positioning.
483.25 The facility failed to provide necessary care and services to maintain highest well-being for residents regarding pain assessment and proper positioning.
483.25(a)(3) The facility failed to provide necessary services to maintain good personal hygiene and grooming for a resident.
483.25(h) The facility failed to ensure adequate supervision to prevent accidents for residents with cognitive impairment and failed to ensure assistive devices were free from hazards.
483.25(h) The facility failed to ensure chemicals were stored in a locked cabinet away from cognitively impaired residents.
483.25(h) The facility failed to ensure medication room door was locked and medications were not left unattended.
483.25(l) The facility failed to ensure the medication regimen was managed and monitored to promote or maintain the resident's highest practicable well-being.
483.35(d)(1)-(2) The facility failed to provide fluids at the proper temperature for residents.
483.35(i) The facility failed to prepare food under sanitary conditions including dust, open windows, spider webs, and unclean equipment.
483.55(b) The facility failed to provide routine dental services and oral care to a resident.
483.60(a),(b) The facility failed to provide pharmaceutical services assuring accurate acquiring, receiving, dispensing and administering of drugs.
483.60(b),(d),(e) The facility failed to store medications and biologicals in locked compartments and at proper temperatures.
483.65 The facility failed to establish and maintain an Infection Control Program to prevent disease and infection transmission including hand hygiene and sanitary medication pass.
483.70(h) The facility failed to ensure a sanitary and comfortable environment due to a strong foul sewer odor in the activity room.
Report Facts
Resident census: 28
Fall risk score: 25
Fall risk score: 18
Medication refusal count: 15
Medication refusal count: 4
Refrigerator temperature: 52
Milk temperature: 52
Chocolate milk temperature: 50
Orange juice temperature: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Staff Nurse | Verified telephone access, medication room door left open, medication storage, and resident falls |
| Administrative Staff C | Verified telephone privacy need, odor complaint, medication storage, and fall reporting | |
| Administrative Nurse B | Verified fall incidents, medication administration, care plan issues, and infection control lapses | |
| Medication Aide E | Left medications unattended on medication cart and failed hand hygiene during medication pass | |
| Nurse Aide J | Reported lack of knowledge about resident ambulation assistance | |
| Nurse Aide L | Reported resident behaviors and difficulty redirecting | |
| Nurse Aide M | Reported resident behaviors and difficulty redirecting | |
| Medication Aide M | Observed providing catheter care without proper hand hygiene | |
| Dietary Staff H | Verified meal serving on trays and dinnerware left on trays | |
| Dietary Manager I | Verified improper fluid temperatures | |
| Maintenance Staff K | Verified foul odor in activity room | |
| Social Service Staff O | Observed improper resident positioning |
Inspection Report
Plan of Correction
Deficiencies: 18
Date: Aug 15, 2013
Visit Reason
This document is a Plan of Correction submitted by Park Villa Nursing Home in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including care plan updates, reporting of unwitnessed falls and resident altercations, personal hygiene care, dining experience improvements, environmental maintenance, medication management, and staff education to prevent recurrence.
Deficiencies (18)
F174-E: Care plans for residents #9 and #24 will be updated to ensure privacy during phone use and staff will be educated on the updated policy.
F225-D: The unwitnessed fall of 8-15-2013 and resident altercation of 8-29-2013 involving resident #23 will be investigated and reported to KDADS with updated policies and staff education.
F241-E: Care plans for resident #4 and other cognitively impaired residents will be updated to ensure continuous monitoring and personal hygiene care with staff re-education.
F252-E: Dining experience enhancements include eliminating trays on tables, using cloth tablecloths, offering bread and desserts, and playing soft music with staff training on new standards.
F253-E: Environmental maintenance includes cleaning and repairs in resident bathrooms, rooms, and facility floors with monthly rounds by administration and maintenance.
F272-D: Care Area Assessment for resident #18 will be completed and care plans audited and updated with staff education on reporting procedures.
F280-D: Foot support devices provided for resident #4's wheelchair per OT recommendations with ongoing assessments and care plan updates.
F309-D: Care plans for resident #23 and #4 updated for pain assessment and non-pharmacological interventions with staff training on assistance techniques.
F312-D: New clothing purchased for resident #7 with staff education on grooming and clothing repair procedures.
F323-D: Care plans updated for resident #23 to include bed alarm and monitoring; medication security improved with staff education on safety policies.
F329-D: Medication review and adjustments for resident #23 with policy changes on medication refusals and staff education.
F364-E: Dietary department will serve fluids at proper temperatures and eliminate trays with food or fluids left on tables, supported by new policies and staff training.
F371-E: Kitchen and nutritional center deep cleaning completed with new dietary policies and staff education to prevent recurrence.
F412-D: Resident #7 scheduled for dental appointment with care plan updated and staff educated on oral care.
F425-D: Medication label for resident #31 corrected with facility-wide medication label review and staff education.
F431-D: Medication room door locked with new refrigerator purchased and staff educated on medication storage policies.
F441-E: Staff educated on hand hygiene and new policies for storage and use of open containers during medication passes.
F465-E: Plumbing contractor engaged to investigate sewer smell in activity room with city collaboration planned and corrective actions assigned.
Report Facts
Date of unwitnessed fall: Aug 15, 2013
Date of resident altercation: Aug 29, 2013
Plan of correction completion date: Oct 16, 2013
Staff in-service date: Sep 26, 2013
Dietary staff in-service date: Sep 24, 2013
Resident #7 dental appointment: Oct 14, 2013
Medication label review education date: Sep 26, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cassidy | Administrator | Administrator submitting the Plan of Correction and responsible for measuring compliance |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: 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. It outlines corrective actions to address alleged deficiencies and ensure compliance with regulatory requirements.
Findings
The plan addresses multiple deficiencies related to resident care plans, assessments, medication management, occupational therapy, kitchen cleanliness, infection control, and staff education. The facility commits to audits, staff training, and ongoing monitoring to prevent recurrence of issues.
Deficiencies (11)
F272-D: The Care Area Assessment for resident #22 will be completed and used to update the resident's individualized care plan. All care plans and MDSs will undergo professional audit and ongoing review.
F275-D: Resident #24 has been assessed with an annual comprehensive assessment (MDS). All resident MDSs will be audited to ensure assessments occur at least every 12 months.
F278-E: MDS corrections were made for residents #1, #22, #28, and #31 to accurately reflect pressure ulcers, falls, rehabilitation, and ADL function. All MDSs will be audited for accuracy.
F279-D: Comprehensive care plans were developed or updated for residents #28 and #29. All care plans will be audited at least every 90 days to ensure comprehensiveness and individualization.
F311-D: Resident #28 was reassessed for Occupational Therapy with treatment orders. All residents will be assessed for restorative nursing services with weekly professional consultant reviews.
F329-E: Care plans for multiple residents will be updated to include Black Box warnings and ensure residents are free from unnecessary medications or excessive doses. A dry chalk board will track physician follow-ups.
F371-E: The kitchen will be thoroughly cleaned and supervised by certified dietary manager. A cleaning checklist and staff education on food safety will be implemented and monitored weekly.
F406-D: Resident #28 reassessed for Occupational Therapy with treatment orders and ongoing evaluation. Weekly meetings will review restorative nursing programs for all residents.
F441-D: The facility purchased EPA-registered disinfectant for glucometer cleaning. Staff will be educated on hand washing, disinfection, and environmental cleaning procedures with weekly risk management monitoring.
F520-E: Weekly and quarterly reviews with the medical director will ensure care plans and MDSs are individualized, comprehensive, and accurate. The kitchen will be kept clean under certified dietary manager supervision.
S0600-C: The kitchen cleaning schedule will be reviewed and updated by certified dietary manager and consultant. Staff education on food safety will continue, and dietary manager certification is in progress.
Report Facts
Complete Date: Jul 21, 2012
Inspection Report
Follow-Up
Deficiencies: 10
Date: Jul 21, 2012
Visit Reason
This visit was 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
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Deficiencies (10)
Regulation 483.20(b)(1) deficiency was corrected by 07/21/2012.
Regulation 483.20(b)(2)(iii) deficiency was corrected by 07/21/2012.
Regulation 483.20(g)-(j) deficiency was corrected by 07/21/2012.
Regulation 483.20(d), 483.20(k)(1) deficiency was corrected by 07/21/2012.
Regulation 483.25(a)(2) deficiency was corrected by 07/21/2012.
Regulation 483.25(l) deficiency was corrected by 07/21/2012.
Regulation 483.35(i) deficiency was corrected by 07/21/2012.
Regulation 483.45(a) deficiency was corrected by 07/21/2012.
Regulation 483.65 deficiency was corrected by 07/21/2012.
Regulation 483.75(o)(1) deficiency was corrected by 07/21/2012.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 21, 2012
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected as of 07/21/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 21, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously reported were corrected as of the revisit date. The report lists multiple regulatory citations with correction completion dates of 07/21/2012.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 21, 2012
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected as of 07/21/2012.
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 1
Date: Jun 21, 2012
Visit Reason
The inspection was 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 the 29 residents. Observations revealed unsanitary conditions in the kitchen including dirty refrigerators, freezers, and equipment, as well as undated opened food containers.
Deficiencies (1)
28-39-158(a) Dietary services require a full-time certified dietary manager and adequate supervision. The facility failed to employ a full-time certified dietary manager and maintain sanitary kitchen conditions.
Report Facts
Census: 29
Food container size: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Staff J | Observed preparing and serving food; not a certified dietary manager but enrolled in certification courses | |
| Staff O | Certified Dietary Manager | Employed as certified dietary manager and helps oversee kitchen while current dietary manager is enrolled in certification course |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015005 POC VR4S11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified by State ID N015005 and Event ID VR4S11.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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