Inspection Reports for Pine Village

A survey for re-licensure was conducted at the facility on 11/12/2025.

The survey resulted in a finding of no deficiency citations.

A survey for re-licensure was conducted at the facility on 11/12/25.

The survey resulted in a finding of no deficiency citations.

An offsite revisit survey was conducted on 07/08/25 for all previous deficiencies cited on 05/06/25 to verify correction of prior deficiencies.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 05/23/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.

The Plan of Correction references multiple deficiencies (F757-D, F812-F, F851-F, F880-E) with corrective actions attached, but no specific findings or deficiency details are included in this document.

The inspection was a Health Resurvey conducted to assess compliance with regulatory requirements and verify correction of previous deficiencies.

The facility was found deficient in multiple areas including failure to hold blood pressure medication per physician orders for one resident, improper food storage practices in the kitchen, incomplete and inaccurate submission of staffing information to CMS, and failure to use appropriate barriers while sorting soiled laundry, placing residents at risk for physical decline, foodborne illness, inadequate nurse staffing, and infectious diseases.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-09-24.

All deficiencies have been corrected as of the compliance date of 2024-09-26 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on 09/24/2024.

The Plan of Correction addresses citations identified during the licensure resurvey of the facility on 09/24/2024.

An offsite revisit survey was conducted on 09/29/23 to verify correction of all previous deficiencies cited on 08/31/23.

All deficiencies cited in the prior inspection have been corrected as of the compliance date of 09/15/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on August 31, 2023.

The Plan of Correction addresses multiple deficiencies identified in the linked deficiency report, with corrective actions cross-referenced to each specific deficiency.

The inspection was conducted as a Health Resurvey and Complaint Investigation for facility Pine Village in Moundridge, KS.

The facility was found deficient in multiple areas including failure to develop a complete discharge summary for a resident, failure to assess a resident for safe use of an electric recliner, failure to complete nurse aide performance reviews and in-service training, and failure to ensure appropriate indication and documentation for psychotropic medication use.

The visit included a complaint investigation as indicated by the report's initial comments referencing a Health Resurvey and Complaint Investigation KS00181411.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited in an earlier inspection.

All previously cited deficiencies have been corrected as of the compliance date of 03/21/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The document is a plan of correction related to a resurvey with a complaint (#168823) conducted at the facility on 03/15/23.

The plan of correction addresses findings from a resurvey conducted in response to a complaint at the facility.

The visit was complaint-related, referencing complaint #168823.

The inspection was a resurvey conducted in response to a complaint (#168823) at the facility.

The facility failed to ensure compliance with the State Agency's tuberculosis guidelines for adult care homes, specifically lacking evidence of completion of TB questionnaires upon hire for four staff members.

The visit was triggered by complaint #168823. The facility was found non-compliant with tuberculosis screening requirements, which had the potential to affect all residents.

An offsite revisit survey was conducted on 02/18/22 to verify correction of all previous deficiencies cited on 12/21/21.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 01/26/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted as a Health Resurvey and Complaint investigation #KS00164744.

The facility was found deficient in multiple areas including failure to provide required Medicare non-coverage notices, failure to complete PASARR screening for a resident with mental illness, inadequate fall prevention interventions, unsafe bedrail assessments, and inappropriate use of antipsychotic medications without proper diagnoses.

Complaint #KS00164744 triggered the inspection.

This Plan of Correction is submitted in response to deficiencies cited during a survey conducted on December 21, 2021, to address and correct identified regulatory compliance issues.

The facility identified multiple deficiencies related to discharge planning documentation, PASSAR screening, fall interventions, bed rail safety, and appropriate diagnoses for antipsychotic medications. Corrective actions include staff re-education, audits, monthly reviews, and communication with primary care physicians to ensure compliance and resident safety.

The inspection was conducted as a complaint investigation related to allegations of abuse and failure to report significant bruising on Resident 1's inner thighs.

The facility failed to timely notify the physician and administrative staff about large bruises on Resident 1's inner thighs, which were injuries of unknown origin and possible abuse. Multiple staff failed to report or document these injuries, placing the resident in immediate jeopardy. The resident was later referred for evaluation of possible sexual assault.

The complaint investigations 166646 and 166516 were triggered by allegations of abuse related to bruising on Resident 1. Staff failed to identify and report the bruising as possible abuse. The resident was referred to a hospital for evaluation of possible sexual assault. The deficient practices placed the resident in immediate jeopardy.

This document is a Plan of Correction submitted in response to past noncompliance deficiencies identified in a prior inspection.

The Plan of Correction addresses past noncompliance issues identified under tags F0000, F580-D, and F609-J, all dated 10/21/2021.

A survey for re-licensure was conducted on 2/4/21 at the residential healthcare facility in Moundridge, KS.

The survey resulted in a finding of no deficiency citations.

A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 07/13/2020 to assess compliance with COVID-19 preparation practices.

The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

The special infection control survey for COVID-19 was conducted at the facility on 7/13/2020.

The survey resulted in findings of no deficiency citations.

An offsite revisit survey was conducted on 05/06/2020 for all previous deficiencies cited on 03/02/2020 to verify correction of prior deficiencies.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 03/13/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The document is a Plan of Correction submitted by the facility in response to deficiencies identified related to environmental safety hazards, specifically unsecured scissors and tools in the kitchenette and nurses' desks.

The facility identified unsecured scissors and pipe pliers in the kitchenette and nurses' desks as hazards. Immediate corrective actions included removal and securing of these items, staff re-education on maintaining a hazard-free environment, and implementation of monthly safety checks by Nurse Managers.

The inspection was a Health Resurvey conducted to assess the facility's compliance with accident hazard prevention and supervision requirements.

The facility failed to provide an environment free of accident hazards on one of three halls for 10 cognitively impaired, independently mobile residents. Unsecured tools such as pipe pliers and scissors were found in unlocked drawers in the kitchenette and nurse's desk areas, posing a risk of injury.

The inspection was conducted as a complaint investigation (#145014) regarding allegations of abuse toward a resident by a Certified Nurse Aide (CNA).

The facility failed to protect a resident (R1) from abuse when CNA M was observed inappropriately positioned with his pants unzipped near the resident, placing her in immediate jeopardy. The facility reported the incident to law enforcement and initiated staff education. The deficiency was identified as immediate jeopardy beginning 08/27/2019 and was corrected after staff education.

Complaint investigation #145014 substantiated abuse by CNA M toward Resident 1. Immediate jeopardy was identified starting 08/27/2019. Law enforcement was contacted and staff education was implemented.

This document is a Plan of Correction submitted in response to past noncompliance deficiencies identified on 08/27/2019.

The Plan of Correction addresses past noncompliance issues identified under tags F0000 and F600-J during a prior inspection.

The document is a Plan of Correction submitted in response to a health survey of the facility.

The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

The health survey was conducted as a routine annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

The survey resulted in a finding of no deficiency citations, indicating full compliance with the applicable regulations.

This revisit inspection was conducted to verify that previously reported deficiencies at Pine Village were corrected and to document the dates such corrective actions were accomplished.

The report shows that the deficiencies identified in the prior survey were corrected as of 05/31/2018, with specific regulatory citations noted as completed.

The inspection was a Licensure Resurvey conducted at Pine Village Residential Health Care Facility in Moundridge, Kansas on 4/23/18, 4/24/18, and 4/25/18 to assess compliance with licensing requirements.

The facility failed to ensure negotiated service agreements reflected medication management responsibilities for residents who self-administer medications. Additionally, staff did not document actual clock times for medication administration on the MAR, and staff sometimes left medications with residents without remaining until ingestion.

A revisit inspection was conducted to verify correction of previous deficiencies.

All deficiencies identified in the prior inspection have been corrected and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

A revisit was conducted on 1/17/18 for all previous deficiencies cited on 12/5/17.

All deficiencies have been corrected as of the compliance date of 12/25/17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

Annual resurvey inspection of Pine Village nursing facility to assess compliance with health and safety regulations.

The facility was found deficient in multiple areas including failure to immediately report alleged neglect resulting in injuries, inadequate comprehensive care plans for pain management and fall prevention, failure to revise care plans after falls, expired medications on medication carts, and unsanitary food preparation practices.

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.

The revisit confirmed that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 07/05/2016. No other deficiencies or uncorrected issues were noted.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at Pine Village.

The plan addresses an elopement incident involving residents during exercises held in the Wellness Center, detailing corrective actions including relocating exercises, staff education on elopement policies, and implementation of a 'Wander guard Alert' system.

This Plan of Correction is related to a complaint investigation at Pine Village dated 06/22/2016.

An Abbreviated Survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.

The inspection was conducted as a complaint investigation (#1965) regarding the facility's failure to provide adequate supervision to prevent a resident assessed as an elopement risk from leaving the facility without staff knowledge.

The facility failed to ensure adequate supervision and monitoring of Resident #1, who was at high risk for elopement, resulting in the resident leaving the facility unsupervised for approximately 10-12 minutes. The Wellness Center entrance doors were not alarmed or keypad controlled, and staff did not obtain vital signs after the elopement. These failures placed the resident at increased risk for injury or ill effects.

Complaint investigation #1965 focused on the facility's failure to prevent Resident #1, who was assessed as an elopement risk, from leaving the facility without staff supervision. The resident eloped from the Wellness Center through unalarmed doors and was outside unsupervised for 10-12 minutes. Staff failed to obtain vital signs post-elopement.

The health resurvey and complaint investigation #98482 was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

The investigation resulted in a finding of no deficiency citations with respect to the applicable regulations.

Complaint investigation #98482 was conducted and found no deficiencies.

This document is a Plan of Correction submitted in response to a prior inspection report for the facility.

No deficiencies were cited in the referenced inspection report dated 04/27/2016.

The document is a Plan of Correction related to the Assisted Living/Residential Healthcare resurvey of the facility.

The resurvey resulted in a finding of no deficiency citations.

The health survey was conducted as a routine annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.

The survey resulted in a finding of no deficiency citations with respect to the applicable regulations.

The document is a Plan of Correction submitted in response to a health survey of the facility.

The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.

The Assisted Living/Residential Healthcare resurvey of the facility was conducted to verify compliance and check for deficiencies.

The resurvey resulted in a finding of no deficiency citations.

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.

The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is 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 is not achieved.

This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The report shows that all previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date.

This Plan of Correction document responds to deficiencies cited during a prior survey and outlines the facility's corrective actions and compliance plans to address those deficiencies.

The facility has developed and implemented multiple corrective actions including staff education on dignity, care plan revisions, dental care coordination, infection control policies, and dining services attire to ensure compliance with regulations. Audits and staff training are scheduled to monitor and maintain compliance.

The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall facility regulatory requirements.

The facility was found deficient in multiple areas including failure to maintain resident dignity during care, failure to provide medically-related social services and dental care, failure to revise care plans after status changes, inadequate infection control practices, and failure to maintain sanitary food preparation and service conditions.

This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected.

The report shows that all previously cited deficiencies were corrected as of the revisit date, with corrections completed on 10/05/2012 for multiple regulatory items.

This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey and to demonstrate compliance with state and federal regulations.

The Plan of Correction outlines corrective actions for multiple deficiencies related to notification of changes in resident condition, dignity and respect, care plan updates, post-accident assessments, medication documentation, drug regimen review, and controlled substance monitoring.

The inspection was conducted as a licensure survey of the assisted living facility to assess compliance with pharmacy services regulations.

The facility failed to ensure that drugs and biologicals, specifically insulin and emergency kit medications, were not outdated. One vial of insulin used for a resident was expired, and the emergency kit contained multiple expired medications.

The inspection was conducted as a Health Resurvey and Complaint Investigation for Pine Village facility.

The facility was found deficient in multiple areas including failure to notify family timely after a resident's significant change in condition, failure to maintain resident dignity, failure to revise care plans after changes, inadequate accident hazard prevention and supervision, failure to properly assess and monitor residents after accidents, failure to administer medications as ordered, failure of pharmacist to report drug irregularities, and failure to properly store and label medications.

The inspection included complaint investigations #59717 and #60355.

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.

The report documents that all previously identified deficiencies with ID prefixes F0241, F0280, F0282, and F0329 were corrected by 08/11/2011.

The inspection was conducted as a health resurvey and complaint investigation (#50249) at Pine Village facility.

The facility failed to promote resident dignity during meal assistance, did not provide a resident's representative the right to participate in care planning, failed to implement the care plan for a resident, and did not ensure adequate monitoring of as-needed medications for one resident.

The inspection included complaint investigation #50249. The complaint involved issues related to dignity of care, participation in care planning, care plan implementation, and medication monitoring.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.

The plan addresses medication administration and monitoring deficiencies, including adherence to insulin ordering and medication disposition policies, weekly expiration date checks, staff training, pharmacist oversight, and prohibition of an Emergency Kit in Assisted Living.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions and compliance measures to address those deficiencies.

The Plan of Correction details updates and re-education on policies related to resident abuse, neglect, exploitation, fall prevention, care planning including pain management and heat pack use, medication cart audits, and dining services dress code and storage policies. It includes staff training, competency testing, audits, and monitoring plans to ensure compliance and resident safety.

N059002_pinevilg rs 9-24-24 st2567.pdf