Inspection Reports for Phillips County Retirement Center
1300 STATE STREET, PO BOX 628, KS, 67661-628
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 9, 2016, found no deficiencies during follow-up visits verifying correction of prior issues. Earlier inspections in 2016 showed multiple deficiencies related to resident care, medication management, abuse reporting, staffing, and infection control, including findings of immediate jeopardy and enforcement actions such as denial of payment for new Medicare and Medicaid admissions. Complaint investigations substantiated abuse incidents and failures to report timely, inadequate care planning, and supervision issues. Enforcement remedies and staff retraining were implemented, and plans of correction addressed these concerns with improvements in policies, training, and monitoring. The trend indicates that while serious deficiencies occurred in 2016, the facility took corrective actions resulting in compliance by the most recent inspection.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
14.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
41 residents
Based on a September 2016 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Nov 9, 2016
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 were corrected as of 10/28/2016, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiency correction completion date: Oct 28, 2016
Inspection Report
Follow-Up
Deficiencies: 0
Nov 9, 2016
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 identified by regulation numbers and prefix codes were corrected as of 10/28/2016, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiency correction dates: Oct 28, 2016
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 8
Sep 29, 2016
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to review grievances, abuse allegations, medication management, infection control, and staffing compliance at Phillips County Retirement Center.
Findings
The facility failed to document and resolve grievances, report abuse and exploitation allegations timely, complete criminal background checks for new hires, develop comprehensive care plans including medication interventions, ensure drug regimens were free from unnecessary medications, provide adequate RN coverage, conduct proper pharmacy consultant follow-up, and maintain sanitary conditions in resident rooms.
Complaint Details
The complaint investigation included grievances about missing property, allegations of abuse and exploitation that were not reported timely, and concerns about medication management and infection control.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to document, investigate, and resolve a resident report of missing property. | SS=D |
| Failed to report immediately allegations of abuse and exploitation to administration. | SS=D |
| Failed to complete criminal record checks for 4 of 5 staff hired since 8/2/16. | SS=E |
| Failed to develop a comprehensive care plan for medications for Resident #19. | SS=D |
| Failed to ensure residents were free from unnecessary drugs including inappropriate antipsychotic use and lack of medication monitoring. | SS=E |
| Failed to provide RN coverage for 8 consecutive hours a day, 7 days a week. | SS=F |
| Pharmacy consultant failed to report drug regimen irregularities to Director of Nursing for incomplete behavior monitoring and lack of follow-up on medication recommendations. | SS=D |
| Failed to maintain sanitary environment by improper use of disinfectants, contaminated gloves touching resident items, and inadequate disinfection of cleaning tools. | SS=F |
Report Facts
Residents present: 41
Staff background checks pending: 4
Dates without 8 consecutive RN hours: 7
PRN medication doses without follow-up: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Interviewed regarding grievance and abuse reporting, medication care plans, RN coverage, and pharmacy consultant follow-up |
| Nurse J | Staff Nurse | Interviewed regarding Resident #1's condition and medication awareness |
| Medication Aide C | Medication Aide | Interviewed regarding Resident #29 and Resident #1 care and medication |
| Housekeeping Staff Q | Housekeeping Staff | Observed and interviewed regarding cleaning practices and chemical use |
| Administrative Nurse E | Administrative Nurse | Verified behavior log and pharmacy consultant follow-up issues |
| MDS Coordinator H | MDS Coordinator | Verified care plan deficiencies related to medications |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 29, 2016
Visit Reason
The visit was a resurvey of the Phillips County Retirement Center, an Assisted Living/Residential Healthcare facility, to assess compliance and determine if deficiencies remained.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 29, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Phillips Co Retirement ALF dated 09/29/2016.
Findings
No deficiencies were cited in the referenced inspection report.
Deficiencies (1)
| Description |
|---|
| No deficiencies cited. |
Inspection Report
Enforcement
Deficiencies: 1
Sep 29, 2016
Visit Reason
A Health survey was conducted on September 29, 2016, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, widespread. Due to these deficiencies and a history of noncompliance from a prior abbreviated survey on August 23, 2016, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level, widespread | F |
Report Facts
Denial of payment effective date: Sep 14, 2016
Noncompliance follow-up deadline: Feb 23, 2017
Civil Money Penalty minimum amount: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed letter and contact for questions concerning the instructions contained in the letter |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Aug 23, 2016
Visit Reason
An abbreviated survey was conducted on August 23, 2016, by the Kansas Department for Aging & Disability Services to determine if the Phillips County Retirement Center was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety related to F 223 "L", CFR 483.13(b), and F225 "L", CFR 483.13(c)(1)(ii). Substandard quality of care was determined for deficiencies including F 223, F225, and F226.
Severity Breakdown
L: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Noncompliance with F 223 "L", CFR 483.13(b) | L |
| Noncompliance with F225 "L", CFR 483.13(c)(1)(ii) | L |
| Noncompliance with F226 "F", CFR 483.13(c) | F |
Report Facts
Denial of payment effective date: Sep 14, 2016
Recommended termination date: Feb 23, 2017
Civil Money Penalty minimum amount: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as Complaint Coordinator in the letter |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Aug 23, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of verbal and physical abuse by a nurse aide towards residents, including Resident #1.
Findings
The facility failed to protect residents from verbal and physical abuse by Nurse Aide C, who continued working multiple shifts despite multiple reports of abuse. The facility also failed to thoroughly investigate and report the abuse allegations to the state agency and did not follow its abuse, neglect, and exploitation policies. Immediate jeopardy was abated after Nurse Aide C was suspended and staff received training. The facility's Quality Assessment and Assurance Committee failed to adequately identify and correct these deficiencies.
Complaint Details
The complaint investigation involved allegations of verbal and physical abuse by Nurse Aide C towards Resident #1 and other residents. Multiple staff and resident interviews confirmed abuse incidents. The facility allowed Nurse Aide C to continue working multiple shifts after reports were made. The facility failed to report the allegations to the state agency timely and did not suspend the nurse aide until after the investigation began.
Severity Breakdown
Level L: 2
Level F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to protect residents from verbal and physical abuse by Nurse Aide C who continued working after multiple abuse reports. | Level L |
| Facility failed to investigate and report verbal and physical abuse allegations to the state agency. | Level L |
| Facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property. | Level F |
| Facility failed to maintain a quality assessment and assurance committee that adequately identified and corrected quality deficiencies related to abuse and reporting. | Level F |
Report Facts
Census: 40
Residents sampled for abuse: 4
Date of alleged abuse incident: Aug 14, 2016
Date of inspection: Aug 23, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide C | Nurse Aide | Named in multiple abuse allegations including physical and verbal abuse of residents. |
| Administrative Nurse B | Administrative Nurse | Verified reports of abuse and investigation status; confirmed Nurse Aide C suspension and ongoing work with other residents. |
| Therapy Staff H | Therapy Staff | Reported abuse allegations to Administrative Nurse B and verified resident fear of Nurse Aide C. |
| Nurse Aide A | Nurse Aide | Observed assisting Resident #1 with ambulation. |
| Nurse Aide D | Nurse Aide | Witnessed Nurse Aide C making fun of residents and reported to Nurse F. |
| Nurse Aide E | Nurse Aide | Witnessed Nurse Aide C push a resident into cupboards and reported to charge nurse. |
| Licensed Nurse F | Licensed Nurse | Verified multiple reports of verbal threats by Nurse Aide C but did not report to administration. |
| Nurse Aide G | Nurse Aide | Provided care to Resident #1 and reported abuse allegations to Administrative Nurse B. |
Inspection Report
Life Safety
Deficiencies: 1
Jun 8, 2016
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 '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 at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Sep 8, 2016
Provider agreement termination date: Dec 8, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 3
May 12, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that all previously cited deficiencies, including those under regulations 483.20(d), 483.20(k)(1), 483.25(h), and 483.75(e)(8), were corrected as of 04/06/2016.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.75(e)(8) |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 3
Apr 5, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#98502) and partial extended survey related to the facility's failure to develop comprehensive care plans and ensure adequate supervision of residents at risk for elopement.
Findings
The facility failed to develop a comprehensive care plan including elopement risk interventions for one resident who eloped, fell, and required hospital treatment. The facility also failed to provide adequate supervision to prevent accidents, resulting in immediate jeopardy. Additionally, the facility failed to provide required annual in-service education hours for one nurse aide.
Complaint Details
Complaint #98502 triggered the investigation. The complaint involved failure to develop adequate care plans and supervision leading to resident elopement and injury. Immediate jeopardy was identified due to inadequate supervision.
Severity Breakdown
Level D: 2
Level J: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan including elopement risk interventions for Resident #1 who eloped and was injured. | Level D |
| Failed to ensure adequate supervision to prevent accidents for Resident #1 who eloped, fell in a hospital driveway, and sustained serious injuries. | Level J |
| Failed to provide required 12 hours of yearly in-service education for one nurse aide. | Level D |
Report Facts
Census: 38
Number of residents sampled: 3
Number of CNAs employed: 28
Number of CNAs employed 1+ years: 17
Number of CNAs lacking required education hours: 1
Date of resident elopement: Mar 18, 2016
Date of resident admission: Mar 15, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Verified care plan lacked elopement interventions until after resident eloped |
| Administrative Nurse F | Administrative Nurse | Verified resident was assessed as elopement risk and care plan was updated after elopement |
| Nurse Aide B | Nurse Aide | Witnessed resident eloping from dining room |
| Nurse C | Charge Nurse | Was preparing medications when resident eloped |
| Hospital Nurse D | Hospital Nurse | Found resident lying face down after fall |
| Medical Provider E | Medical Provider | Treated resident for injuries sustained in fall |
| Administrative Staff G | Administrative Staff | Managed door code changes after elopement |
| Office Staff H | Office Staff | Responsible for tracking CNA education hours |
| Administrator G | Administrator | Acknowledged CNA lacked required education hours |
Inspection Report
Plan of Correction
Deficiencies: 3
Apr 5, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Phillips Co Retirement Center.
Findings
The plan outlines corrective actions to address elopement risk assessments, staff training on Abuse Neglect and Exploitation (ANE) and elopement, door alarm code changes, and mandatory monthly employee training via Relias courses.
Complaint Details
This Plan of Correction is related to a complaint investigation at Phillips Co Retirement Center dated 04/05/2016.
Severity Breakdown
D: 2
J: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assess residents for elopement risk upon admission and implement appropriate care plan interventions. | D |
| Failure to ensure staff training on Abuse Neglect and Exploitation (ANE) and elopement policies. | J |
| Failure to ensure all employees complete required monthly Relias training courses. | D |
Report Facts
Deficiency completion dates: Apr 12, 2016
Door alarm code change dates: Mar 18, 2016
Door alarm code change dates: Apr 1, 2016
Staff training dates: Mar 29, 2016
Staff training dates: Mar 30, 2016
CNA training hours: 12
Employee training non-compliance timeframe: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Glendening | Assistant Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 5, 2016
Visit Reason
An Abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety from March 18, 2016 through March 30, 2016 for F323, CFR 483.25(h).
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F323, CFR 483.25(h) resulting in immediate jeopardy to resident health or safety | Immediate Jeopardy |
Report Facts
Denial of payment effective date: Apr 25, 2016
Recommended provider agreement termination date: Oct 5, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to the survey findings and enforcement actions |
Inspection Report
Follow-Up
Deficiencies: 0
Jul 29, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by 07/17/2015 as verified during this revisit.
Report Facts
Deficiency corrections: 12
Inspection Report
Enforcement
Deficiencies: 1
Jun 18, 2015
Visit Reason
A Health survey was conducted to determine if the Phillips County Retirement Center 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 to be at a 'G' level, resulting in enforcement remedies including a denial of payment for new Medicare and Medicaid admissions effective September 18, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found at 'G' level | G |
Report Facts
Denial of Payment effective date: Sep 18, 2015
Termination recommendation date: Dec 18, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter and enforcement coordinator |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 18, 2015
Visit Reason
The Assisted Living/Resident Healthcare resurvey of the facility was conducted to verify compliance and check for deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Routine
Census: 38
Deficiencies: 11
Jun 18, 2015
Visit Reason
The facility underwent a health resurvey to assess compliance with regulatory requirements, including investigation and reporting of allegations of abuse, care planning, medication management, infection control, and resident safety.
Findings
The facility failed to thoroughly investigate and report falls with injury, develop comprehensive care plans for palliative care, revise care plans to reflect physician orders, meet professional standards for medication management, provide necessary care for unresolved pain, ensure a safe environment to prevent accidents, maintain adequate hydration, ensure drug regimens were free from unnecessary drugs, act on pharmacist recommendations, properly label and store medications, and maintain effective infection control practices.
Severity Breakdown
Level 3: 3
Level 2: 8
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate and report 2 falls with injury to the appropriate state agency for Resident #44. | Level 2 |
| Failed to develop a comprehensive care plan for Resident #43 receiving palliative care services. | Level 2 |
| Failed to review and revise care plan for Resident #8 to include physician order to increase fluid intake. | Level 2 |
| Failed to meet professional standards of care by not obtaining a physician ordered urinalysis for Resident #27. | Level 2 |
| Failed to provide necessary care and services for Resident #44 who had continued unresolved pain. | Level 3 |
| Failed to ensure resident environment remained free of accident hazards and failed to complete root cause analysis for Resident #44 with multiple falls including injuries. | Level 2 |
| Failed to provide sufficient fluid intake and monitor hydration status for Resident #8 with history of dehydration and physician orders to increase fluids. | Level 2 |
| Failed to ensure drug regimen was free from unnecessary drugs for Residents #23, #26, and #27 including failure to obtain appropriate diagnoses and follow pharmacy recommendations. | Level 2 |
| Failed to act upon pharmacy consultant recommendations for Residents #23, #26, and #27 in a timely manner. | Level 2 |
| Failed to ensure insulin products and insulin pens were properly labeled and dated, and Tylenol suppositories were improperly stored in the freezer. | Level 3 |
| Failed to maintain an infection control program that prevents spread of infection including improper use of personal protective equipment, improper disposal of contaminated waste, lack of staff training, and inadequate handling of linens and trash. | Level 3 |
Report Facts
Residents reviewed: 11
Residents reviewed for accidents: 4
Falls with injury not reported: 2
Tylenol administrations for pain: 17
Tylenol administrations for pain: 29
Tylenol administrations for pain: 1
Insulin vials observed: 11
Insulin pens observed: 2
Freezer temperature: 28
Inspection Report
Life Safety
Deficiencies: 1
Apr 17, 2015
Visit Reason
A Life Safety Code survey was conducted on April 17, 2015, by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was found to be out of substantial compliance with Life Safety Code requirements.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Life Safety Code deficiencies at 'F' level, widespread, with no harm but potential for more than minimal harm. | F |
Report Facts
Effective date for denial of payments: Jul 17, 2015
Provider agreement termination date: Oct 17, 2015
Plan of Correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 5
May 16, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.25(h), 483.25(l), 483.60(c), 483.60(b), (d), (e), and 483.65 were corrected as of 05/16/2014.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 5
Inspection Report
Renewal
Deficiencies: 0
Apr 16, 2014
Visit Reason
The licensure survey was conducted as a routine renewal inspection of the Phillips County Retirement Center facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 5
Apr 10, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address and correct deficiencies cited in a prior inspection related to medication management, chemical storage, and equipment handling.
Findings
The plan addresses multiple deficiencies including failure to provide drug regimen reviews (GDRs) and risk vs benefit statements for antipsychotic medications, improper chemical storage, failure to flush tube feeding medications correctly, failure to keep drugs and biologicals in locked storage, incorrect medication labeling, and improper storage of nebulizer masks and oxygen tubing.
Severity Breakdown
E: 2
D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide GDR or risk vs benefit statements for the continued use of antipsychotic medications. | D |
| Failed to provide the specific amount of water flushes between each medication administered for a tube feeding. | D |
| Failed to keep all drugs and biologicals in locked storage and ensure the narcotic medications were kept in a double locked compartment. | E |
| Failed to ensure correct medication labeling. | E |
| Failed to properly store 1 resident’s nebulizer mask and 1 resident’s oxygen tubing. | D |
Report Facts
Completion date: Apr 23, 2014
Completion date: May 16, 2014
Completion date: Apr 26, 2014
Number of residents with O2 concentrators: 3
Flush volume: 10
Flush volume: 15
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 5
Apr 9, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements, including safety hazards, medication management, drug regimen review, drug storage, and infection control.
Findings
The facility failed to provide a safe environment by improperly storing hazardous chemicals accessible to residents, failed to ensure gradual dose reductions or risk-benefit statements for antipsychotic medications for sampled residents, failed to follow medication administration protocols including water flushes for tube feeding, failed to maintain proper drug storage and labeling, and failed to properly store oxygen therapy equipment.
Severity Breakdown
SS=E: 2
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to provide a safe environment for 6 cognitively impaired residents by improperly storing hazardous chemicals accessible to residents. | SS=E |
| Facility failed to provide gradual dose reductions or risk versus benefit statements for continued use of antipsychotic medications for 2 of 5 residents sampled for unnecessary medications. | SS=D |
| Facility failed to ensure drug regimen review reports irregularities to physician and director of nursing for 2 residents regarding gradual dose reductions. | SS=D |
| Facility failed to keep all drugs and biologicals in locked storage and ensure narcotic medications were kept in a double locked compartment; failed to ensure correct medication labeling for 2 residents. | SS=E |
| Facility failed to provide sanitary oxygen therapy equipment storage for 2 residents. | SS=D |
Report Facts
Census: 40
Sample size: 13
Residents reviewed for unnecessary medication: 5
Medications administered via feeding tube: 7
Water flush volume: 30
Water flush volume ordered: 60
Medication dose: 5
Medication dose: 25
Medication dose: 20
Medication dose: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Verified chemical storage issues, medication administration concerns, and pharmacist communication failures | |
| Maintenance C | Stated chemicals should be securely stored in locked area | |
| Pharmacist Consultant D | Verified no gradual dose reductions requested for residents' antipsychotic medications | |
| Nurse B | Observed medication administration and verified medication label change procedures | |
| Nurse F | Verified medication cart locking practices | |
| Physician K | Stated expectation for water flushes between medications during tube feeding |
Inspection Report
Follow-Up
Deficiencies: 1
Mar 3, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously identified deficiency with ID prefix F0309 and regulation 483.25 was corrected on 02/07/2014. No other deficiencies are listed.
Deficiencies (1)
| Description |
|---|
| Deficiency identified under regulation 483.25 with ID prefix F0309 |
Report Facts
Deficiency correction date: Feb 7, 2014
Inspection Report
Plan of Correction
Deficiencies: 2
Feb 5, 2014
Visit Reason
This document is a Plan of Correction submitted by Phillips County Retirement Center in response to deficiencies cited in a complaint investigation.
Findings
The plan addresses updates to the bowel evacuation protocol and the implementation of a transportation policy, including staff education, monitoring, and policy review schedules.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Phillips Co Retirement 012814 Complaint.
Deficiencies (2)
| Description |
|---|
| Standing order protocol with the bowel evacuation protocol was outdated and required updating and staff education. |
| Lack of a formal transportation policy for resident transfers outside business hours. |
Report Facts
Complete Date for F0000: Feb 5, 2014
Complete Date for F309-G: Feb 7, 2014
Date protocol updated: Jan 23, 2014
Date protocol sent for signatures: Feb 3, 2014
Date transportation policy formed: Jan 10, 2014
Date transportation policy reviewed: Jan 23, 2014
Date policy reviewed again: Feb 7, 2014
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 2
Jan 28, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#71903) regarding the facility's failure to provide necessary bowel management assessments and medications to prevent constipation, and failure to prevent multiple foot abrasions during transport of an unresponsive resident to the hospital.
Findings
The facility failed to provide appropriate bowel management for Resident #1, who had no documented bowel movements for 5 days despite administration of laxatives and no physician notification. Additionally, the facility failed to safely transport the resident in a wheelchair across a rough, sloping asphalt parking lot to the hospital, resulting in multiple foot abrasions.
Complaint Details
Complaint investigation #71903 focused on Resident #1's bowel management and transport-related injuries. The complaint was substantiated with findings of inadequate care and unsafe transport practices.
Severity Breakdown
SS=G: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide necessary bowel management assessments and medications to prevent constipation for Resident #1. | SS=G |
| Failure to provide necessary care and services to prevent multiple foot abrasions for Resident #1 during transport to hospital while unresponsive. | SS=G |
Report Facts
Census: 46
Days without bowel movement: 5
Medication dosage: 30
Distance to hospital: 75
Slope degree: 10
Inspection Report
Follow-Up
Deficiencies: 1
Apr 8, 2013
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency identified by regulation 28-39-158(a) with ID prefix S0600 was corrected as of 04/08/2013. No other deficiencies are listed.
Deficiencies (1)
| Description |
|---|
| Deficiency previously reported under regulation 28-39-158(a) with ID prefix S0600 |
Report Facts
Deficiencies corrected: 1
Inspection Report
Follow-Up
Deficiencies: 3
Apr 8, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-03-11.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.25(l), 483.60(c), and 483.60(b), (d), (e) were corrected as of 2013-04-08.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 4
Mar 20, 2013
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 deficiencies related to lab monitoring, pharmacy consultant reviews, insulin expiration procedures, and staff education and training.
Severity Breakdown
D: 2
E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Lab monitoring deficiencies requiring ongoing review and follow-up of lab draws and blood sugar parameters. | D |
| Pharmacy consultant deficiencies related to monthly reviews and monitoring completeness and timeliness. | E |
| Insulin expiration procedures not properly followed, requiring implementation of new monitoring and disposal protocols. | D |
| Dietary employee enrollment in Certified Dietary Manager program. | E |
Report Facts
Dates of corrective actions: Mar 21, 2013
Dates of corrective actions: Mar 22, 2013
Dates of corrective actions: Mar 29, 2013
Dates of corrective actions: Apr 8, 2013
Date of employee enrollment: Jun 3, 2013
Inspection Report
Re-Inspection
Census: 48
Deficiencies: 1
Mar 11, 2013
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with dietary services regulations.
Findings
The facility failed to employ a full-time certified dietary manager for the 48 residents. Observations and interviews confirmed that the dietary manager was not certified and had been overseeing the kitchen without a CDM license since January 2013.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to employ a full-time certified dietary manager for the 48 residents. | SS=E |
Report Facts
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff E | Dietary Staff | Verified not certified dietary manager and not enrolled in CDM classes |
| Administrative Staff F | Administrative Staff | Verified Dietary Staff E was not certified and that a Registered Dietician visits monthly |
Inspection Report
Renewal
Deficiencies: 0
Mar 7, 2013
Visit Reason
The licensure resurvey was conducted to assess compliance for renewal of the facility's license.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 1
Oct 31, 2012
Visit Reason
This post-certification revisit was conducted to verify correction of previously cited deficiencies as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit report shows that the previously cited deficiency with regulation 483.10(b)(11) was corrected as of 10/31/2012. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
Report Facts
Deficiency correction date: Oct 31, 2012
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 25, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation.
Findings
The facility developed and revised policies related to Anticoagulation Therapy, including notification procedures for providers when residents experience falls or injuries, especially those on anticoagulation therapy. These policy changes will be reviewed with current and new nursing staff and monitored through routine fall/incident report reviews.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as Phillips Co 101512 Complaint.
Deficiencies (1)
| Description |
|---|
| Deficiency related to Anticoagulation Therapy policy and follow-up after resident falls. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Nathan Glendening | Assistant Administrator | Submitted the Plan of Correction. |
| Irina Strakhova | Added the Plan of Correction. | |
| Mary Jane Kennedy | Modified the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Oct 15, 2012
Visit Reason
The inspection was conducted as a complaint investigation (#60401) regarding the facility's failure to promptly and adequately notify the physician of falls with head trauma and anticoagulation therapy for two sampled residents.
Findings
The facility failed to promptly notify the physician and emergency personnel about two residents who had falls with head trauma while on anticoagulation therapy, resulting in delayed hospital transfer and treatment. Documentation and communication deficiencies were noted regarding elevated PT/INR levels and fall incidents.
Complaint Details
The complaint investigation (#60401) found that the facility did not promptly notify the physician or emergency room about elevated INR levels and head trauma after falls for two residents, delaying critical medical intervention.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to promptly and adequately notify the physician of falls with head trauma and anticoagulation therapy for two residents. | SS=D |
Report Facts
Census: 51
PT/INR lab result: 39.6
PT/INR lab result: 3.89
PT/INR lab result: 3.56
PT/INR lab result: 18.8
PT/INR lab result: 1.74
PT/INR lab result: 30.7
PT/INR lab result: 2.95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse F | Named in the finding for failing to report elevated INR and fall details promptly | |
| Administrative Staff L | Stated that elevated INR and held Coumadin should have been reported immediately | |
| Medical Professional M | Stated facility nurses failed to report elevated INR promptly and commented on risks | |
| Nurse D | Reported facsimile reporting fall and head injury would not be noted until morning |
Inspection Report
Plan of Correction
Deficiencies: 8
N074003 POC 7MQ511
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including grievance policy implementation, ANE reporting, background checks, care planning, antipsychotic medication diagnosis, RN staffing coverage, pharmacy consultant involvement, and housekeeping infection control practices.
Severity Breakdown
D: 4
E: 2
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Grievance policy and procedure created and implemented; social services director to review policy with new residents and at resident council meetings. | D |
| ANE reporting policy reviewed with employee; employee given written notice for failure to report incidents immediately. | D |
| Background checks process improved to verify completion regardless of criminal history. | E |
| New policy and procedure for care planning addressing medication administration record and problem areas of care. | D |
| Education and policy development regarding proper diagnosis for antipsychotic prescriptions; monitoring by DON, ADON, pharmacy consultant, and medical providers. | E |
| Facility advertising to hire part-time RN; nursing schedule rearranged to assure 8 hours of RN coverage daily. | F |
| Pharmacy consultant involvement in monitoring drug regimen irregularities and behavior logs; new behavior log to be implemented. | D |
| Housekeeping staff retrained on chemical use and infection control; information sheet to be placed in housekeeping room; monitoring by housekeeping supervisor and administration. | F |
Report Facts
Dates for corrective actions: Oct 7, 2016
Dates for corrective actions: Oct 10, 2016
Dates for corrective actions: Oct 14, 2016
Dates for corrective actions: Oct 28, 2016
Inspection Report
Plan of Correction
Deficiencies: 9
N074003 POC F43H11
Visit Reason
This document is a Plan of Correction submitted by Phillips Co Retirement Center in response to deficiencies identified in a prior inspection report.
Findings
The Plan of Correction outlines multiple corrective actions including staff re-training on incident reporting, implementation of new policies such as Palliative Care/Hospice, Hydration, Provider Rounds, Pain Management, Root Cause Analysis, Pharmacy Consultant, Medication Tracking, and Infection Control. Responsibilities for implementation and follow-up are assigned to the Director of Nursing (DON), Assistant Director of Nursing (ADON), charge nurses, and other staff.
Severity Breakdown
D: 6
E: 1
F: 1
G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to report incidents as required by state policy | D |
| Lack of a Palliative Care/Hospice Policy | D |
| No Hydration Policy in place | D |
| No Provider Rounds Policy | D |
| Inadequate pain management education and policy review | D |
| Lack of Root Cause Analysis Policy | G |
| No Pharmacy Consultant Policy | D |
| No Medication Tracking Policy for insulin expiration | E |
| Infection control and resident isolation policies not fully followed | F |
Report Facts
Complete Date: Jul 13, 2015
Complete Date: Jul 8, 2015
Complete Date: Jul 15, 2015
Complete Date: Jul 17, 2015
Complete Date: Jun 29, 2015
Complete Date: Jun 23, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Glendening | Assistant Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Plan of Correction
Deficiencies: 4
N074003 POC TW8M11
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at the facility.
Findings
The facility terminated a CNA involved in an incident of abuse, neglect, or exploitation (ANE) on 8/19/16 and updated its ANE policy to include interviewing other residents during investigations and mandating all employees as reporters. Staff were re-trained on the policy and reporting requirements, and resident council meetings were held to emphasize the importance of reporting ANE.
Complaint Details
This Plan of Correction is related to a complaint investigation as indicated by the reference to 'Phillips County complaint revised 08232016'.
Severity Breakdown
L: 2
F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Termination of CNA involved in ANE and updating of ANE policy including staff re-training and resident notification. | L |
| Termination of CNA involved in ANE and updating of ANE policy including staff re-training and resident notification. | L |
| Termination of CNA involved in ANE and updating of ANE policy including staff re-training and resident notification. | F |
| Termination of CNA involved in ANE and updating of ANE policy including staff re-training and resident notification. | F |
Report Facts
Date of CNA termination: Aug 19, 2016
Date of staff training completion: Aug 18, 2016
Date of resident council meeting: Aug 18, 2016
Date of Quality Assurance Committee meeting: Aug 30, 2016
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