Inspection Report Summary
The most recent inspection on November 12, 2025, found no deficiencies. Earlier inspections showed a pattern of deficiencies related to medication management, food safety, documentation accuracy, and infection control, with several instances of incomplete care planning and emergency preparedness issues. Complaint investigations included substantiated cases involving failure to prevent abuse and inadequate supervision, some resulting in immediate jeopardy findings and corrective actions such as staff education and law enforcement involvement. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies effectively, as recent inspections have found no new issues, indicating improvement over time.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
66 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 12, 2025
Visit Reason
A survey for re-licensure was conducted at the facility on 11/12/2025.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 12, 2025
Visit Reason
A survey for re-licensure was conducted at the facility on 11/12/25.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
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.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 5
Date: May 23, 2025
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 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.
Deficiencies (5)
Deficiency F0000 - Completed Plan of Correction submitted
Deficiency F757-D - See attached
Deficiency F812-F - See attached
Deficiency F851-F - See attached
Deficiency F880-E - See attached
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Elmore | Executive Director | Signed and submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 66
Deficiencies: 4
Date: May 6, 2025
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
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.
Deficiencies (4)
Failure to hold blood pressure medications per physician-ordered parameters for one resident.
Failure to store food by professional standards for food service safety in one kitchen.
Failure to submit complete and accurate staffing information through Payroll-Based Journal as required.
Failure to use appropriate barriers while sorting soiled laundry.
Report Facts
Resident census: 66
Sample size: 17
Medication administration dates out of parameters: 5
Days with no RN hours reported: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide R | Certified Medication Aide | Verified medication was out of physician-ordered parameters and stated it should have been held. |
| Licensed Nurse H | Licensed Nurse | Stated CMA should notify nurse when blood pressure was out of parameters. |
| Administrative Nurse D | Administrative Nurse | Stated CMA should notify nurse and hold medication when blood pressure was out of parameters; verified laundry staff should wear barriers. |
| Dietary Staff CC | Dietary Staff | Verified food storage deficiencies and stated food should be covered and labeled. |
| Certified Dietary Manager | Certified Dietary Manager | Stated staff should not leave stored food open to air and should label and date food items. |
| Administrative Staff B | Administrative Staff | Reported first time submitting Payroll-Based Journal information alone and noted possible issues with salaried staff data. |
| Administrative Staff A | Administrative Staff | Reported facility always had RN coverage and noted problems submitting Payroll-Based Journal data. |
| Maintenance/Housekeeping Staff U | Maintenance/Housekeeping Staff | Reported laundry staff used only gloves unless obvious soilage when sorting soiled laundry. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-09-24.
Findings
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.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2024-09-24 and corrected by 2024-09-26
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on 09/24/2024.
Findings
The Plan of Correction addresses citations identified during the licensure resurvey of the facility on 09/24/2024.
Inspection Report
Renewal
Census: 16
Deficiencies: 2
Date: Sep 24, 2024
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance with regulatory requirements for the facility.
Findings
The facility was found deficient in medication labeling where a prescription medication container was not properly labeled according to regulations, and in disaster and emergency preparedness due to failure to perform an annual emergency drill including resident evacuation.
Deficiencies (2)
Prescription medication container was not labeled with a prescription label provided by a dispensing pharmacist for one sampled resident.
Failure to ensure disaster and emergency preparedness by not performing an annual emergency drill with staff and residents including evacuation to a secure location.
Report Facts
Census: 16
Medication administration dates: 21
Sampled residents: 3
Sampled employee records: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Named in findings related to failure to ensure medication labeling and disaster preparedness | |
| Licensed Nurse B | Interviewed and confirmed medication labeling and emergency drill deficiencies | |
| Certified Medication Aide C | Observed medication cart with unlabeled insulin injector pen |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
An offsite revisit survey was conducted on 09/29/23 to verify correction of all previous deficiencies cited on 08/31/23.
Findings
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.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Aug 31, 2023
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on August 31, 2023.
Findings
The Plan of Correction addresses multiple deficiencies identified in the linked deficiency report, with corrective actions cross-referenced to each specific deficiency.
Deficiencies (5)
Overall Plan of Correction
Deficiency F661-D
Deficiency F689-D
Deficiency F730-F
Deficiency F758-D
Inspection Report
Health Resurvey And Complaint Investigation
Census: 72
Deficiencies: 4
Date: Aug 31, 2023
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for facility Pine Village in Moundridge, KS.
Complaint Details
The visit included a complaint investigation as indicated by the report's initial comments referencing a Health Resurvey and Complaint Investigation KS00181411.
Findings
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.
Deficiencies (4)
Failure to develop a discharge summary that included a complete recapitulation of the resident's stay and post discharge plan for Resident 71.
Failure to provide a safe environment by not assessing Resident 16 for safe use of an electric recliner.
Failure to complete performance reviews of all nurse aides, provide regular in-service education based on the outcome of these reviews, and ensure all nurse aides received the required number of in-service training hours per year.
Failure to ensure an appropriate indication for use, or documented physician rationale for continued use of an antipsychotic medication (Seroquel) for Resident 19 with dementia.
Report Facts
Census: 72
Sample size: 18
Falls reviewed: 10
In-service training hours required: 12
Medication dosage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Verified incomplete discharge summary and nurse aide training deficiencies. | |
| Administrative Nurse D | Verified electric recliner assessment was not completed and lack of approved diagnosis for psychotropic medication. | |
| License Nurse G | Observed medication administration to Resident 16. | |
| CNA M | Certified Nurse Aide | Did not complete required 12 hours of in-service training. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited in an earlier inspection.
Findings
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.
Report Facts
Compliance date: Mar 21, 2023
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
The document is a plan of correction related to a resurvey with a complaint (#168823) conducted at the facility on 03/15/23.
Complaint Details
The visit was complaint-related, referencing complaint #168823.
Findings
The plan of correction addresses findings from a resurvey conducted in response to a complaint at the facility.
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
The inspection was a resurvey conducted in response to a complaint (#168823) at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure compliance with tuberculosis guidelines by not completing TB questionnaires upon hire for four staff members.
Report Facts
Residents present: 15
Sampled residents: 3
Sampled employees: 5
Staff lacking TB questionnaire: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA C | Certified Medication Aide | Named in deficiency for lacking TB questionnaire upon hire |
| Dietary Staff D | Dietary Staff | Named in deficiency for lacking TB questionnaire upon hire |
| Dietary Staff E | Dietary Staff | Named in deficiency for lacking TB questionnaire upon hire |
| Dietary Staff F | Dietary Staff | Named in deficiency for lacking TB questionnaire upon hire |
| Licensed Nurse B | Licensed Nurse | Interviewed and confirmed lack of TB questionnaires |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 18, 2022
Visit Reason
An offsite revisit survey was conducted on 02/18/22 to verify correction of all previous deficiencies cited on 12/21/21.
Findings
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.
Report Facts
Previous deficiencies corrected: 0
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 5
Date: Dec 21, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint investigation #KS00164744.
Complaint Details
Complaint #KS00164744 triggered the inspection.
Findings
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.
Deficiencies (5)
Failed to provide Resident 115 or representative the required Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice forms.
Failed to ensure a referral was made promptly to the state PASARR program for Resident 63 with documented mental illness or intellectual disability.
Failed to follow toileting and fall interventions as directed in Resident 29's plan of care, including improper use and placement of motion sensor alarms.
Failed to accurately assess Resident 5's side rails for safe use; siderails had openings too large and should not have been on the bed.
Failed to ensure appropriate diagnoses for the use of antipsychotic medications for Residents 9, 29, and 14, placing them at risk for adverse effects.
Report Facts
Resident sample size: 16
Falls for Resident 29: 3
Motion sensor placement opening size: 7.5
Motion sensor placement opening size: 10
Seroquel dosage for Resident 9: 12.5
Risperdal dosage for Resident 29: 0.5
Seroquel dosage for Resident 14: 50
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Dec 21, 2021
Visit Reason
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.
Findings
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.
Deficiencies (5)
Resident and their representative were talked to prior to discharge about discharge plan but forms were not signed and signatures could not be obtained.
PASSAR screening was completed for resident R63 showing appropriate level of care, with plans for audits and education to ensure compliance.
Nursing staff working with resident R29 will be reeducated on fall interventions to reduce risk of falls and injuries.
Bed rail was removed from resident R5's bed and replaced with correct repositioning device; facility-wide bed safety checks conducted.
Primary care physicians for residents R9, R29, and R14 will be re-faxed to request appropriate diagnoses for antipsychotic medications.
Report Facts
Deficiencies cited: 5
Completion date: Jan 26, 2022
Survey date: Dec 21, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Alejandro Nieto | LNHA | Submitted the Plan of Correction to KDADS |
| Felicia Majewski | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Date: Oct 25, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to notify the physician in a timely manner when staff discovered large bruises on Resident 1's inner thighs.
Failure to immediately report alleged violations involving abuse, neglect, or mistreatment including injuries of unknown origin to the facility administrator.
Report Facts
Census: 70
Dates bruising observed: Bruising noted on 10/12/21 and 10/17/21.
BIMS score: 6
Antibiotic dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Assessed bruising on 10/12/21 but failed to notify family, physician, or Director of Nursing; had a seizure before completing notifications. |
| CMA R | Certified Medication Aide | Identified bruising on 10/12/21 and reported to LN G but failed to report as possible abuse. |
| CNA M | Certified Nurse Aide | Noted bruising on 10/13/21 but failed to report to administrative staff. |
| LN H | Licensed Nurse | Identified bruising and bloody urine on 10/17/21 but failed to report as possible abuse. |
| Consultant Physician GG | Physician | Referred Resident 1 to hospital for possible sexual assault evaluation on 10/19/21. |
| Administrative Nurse D | Administrative Nurse | Expected immediate notification of injuries of unknown origin; verified bruising was not timely reported. |
| Administrative Staff A | Administrator | Was not informed timely about bruising; expected immediate reporting of injuries of unknown origin. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Oct 21, 2021
Visit Reason
This document is a Plan of Correction submitted in response to past noncompliance deficiencies identified in a prior inspection.
Findings
The Plan of Correction addresses past noncompliance issues identified under tags F0000, F580-D, and F609-J, all dated 10/21/2021.
Deficiencies (3)
Past noncompliance under tag F0000
Past noncompliance under tag F580-D
Past noncompliance under tag F609-J
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 4, 2021
Visit Reason
A survey for re-licensure was conducted on 2/4/21 at the residential healthcare facility in Moundridge, KS.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
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.
Findings
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
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.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 7/13/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 6, 2020
Visit Reason
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.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 25, 2020
Visit Reason
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.
Findings
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.
Deficiencies (1)
Unsecured pipe pliers, scissors in the kitchenette and nurses' desks posing accident hazards
Report Facts
Complete Date for Plan of Correction: Mar 13, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Shaw | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 63
Deficiencies: 1
Date: Feb 25, 2020
Visit Reason
The inspection was a Health Resurvey conducted to assess the facility's compliance with accident hazard prevention and supervision requirements.
Findings
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.
Deficiencies (1)
Facility failed to provide an environment free of accident hazards due to unsecured tools (pipe pliers and scissors) in unlocked drawers accessible to residents.
Report Facts
Census: 63
Sample size: 16
Residents at risk: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) R | Stated that pipe pliers and scissors should be in locked drawers | |
| Dietary Staff (DS) BB | Stated scissors should be stored in a locked drawer |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Date: Aug 29, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#145014) regarding allegations of abuse toward a resident by a Certified Nurse Aide (CNA).
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility failed to provide a safe environment and protect residents from abuse when CNA M was observed with pants unzipped and positioned inappropriately with Resident 1, placing her in immediate jeopardy.
Report Facts
Census: 69
BIMS score: 8
Date of incident: Aug 27, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in abuse finding involving Resident 1 |
| CNA N | Certified Nurse Aide | Witnessed the abuse incident and reported it |
| Licensed Nurse G | Licensed Nurse | Notified Administrative Nurse D of abuse concerns and contacted law enforcement |
| Administrative Nurse D | Administrative Nurse | Received abuse report, instructed to call police, and responded to facility |
| Licensed Nurse H | Licensed Nurse | Responded to abuse incident and verified observations |
| Administrative Staff A | Administrative Staff | Notified of immediate jeopardy and provided IJ Template |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 27, 2019
Visit Reason
This document is a Plan of Correction submitted in response to past noncompliance deficiencies identified on 08/27/2019.
Findings
The Plan of Correction addresses past noncompliance issues identified under tags F0000 and F600-J during a prior inspection.
Deficiencies (2)
Past noncompliance under tag F0000
Past noncompliance under tag F600-J
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 25, 2019
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
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.
Deficiencies (1)
No deficiency citations were found during the health survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 25, 2019
Visit Reason
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.
Findings
The survey resulted in a finding of no deficiency citations, indicating full compliance with the applicable regulations.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: May 31, 2018
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 26-41-205 (b)
Deficiency related to regulation 26-41-205 (d) (3)
Inspection Report
Renewal
Census: 18
Deficiencies: 3
Date: Apr 25, 2018
Visit Reason
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.
Findings
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.
Deficiencies (3)
Negotiated service agreements did not reflect medication management responsibilities for residents self-administering medications.
Staff failed to remain with residents until medication ingestion when medications were set up and left for self-administration.
Medication administration records lacked documentation of actual clock times for medication administration.
Report Facts
Census: 18
Residents who self-administer medications: 14
Sample size: 3
Residents in sample who self-administer medications: 2
Dates staff initialed self-administer HS meds: 4
Dates staff initialed self-administer HS meds: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Failed to ensure negotiated service agreements reflected medication management and staff responsibilities | |
| Director of Nursing #B | Confirmed negotiated service agreements lacked medication management and staff did not remain with residents until medication ingestion | |
| Director of Assisted Living #C | Commented on MAR self-administer HS meds box and confirmed medication administration documentation issues |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 17, 2018
Visit Reason
A revisit inspection was conducted to verify correction of previous deficiencies.
Findings
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.
Deficiencies (1)
All previously cited deficiencies have been corrected.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 17, 2018
Visit Reason
A revisit was conducted on 1/17/18 for all previous deficiencies cited on 12/5/17.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 6
Date: Dec 5, 2017
Visit Reason
Annual resurvey inspection of Pine Village nursing facility to assess compliance with health and safety regulations.
Findings
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.
Deficiencies (6)
Failure to immediately report 2 accidents of possible neglect resulting in rib fractures and a head laceration for Resident #22.
Failure to develop a comprehensive care plan addressing pain and use of hot packs for Resident #16.
Failure to revise care plans and implement effective fall prevention interventions for Residents #22 and #60.
Failure to ensure resident environment was free of accident hazards for Residents #16, #22, and #60.
Failure to ensure stock medications were not expired on 2 of 4 medication carts.
Failure to prepare, distribute, and serve food under sanitary conditions in the main kitchen, including uncovered dishware and hair protruding from hairnets.
Report Facts
Resident census: 70
Sample size: 18
Falls with injury: 5
Falls with rib fractures: 2
Expired medication count: 2
Length of hair protruding: 2
Open wound size: 1.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Administrative Nurse | Verified motion sensor issues and fall interventions for Resident #22 |
| Nurse D | Licensed Nurse | Updated care plans and provided wound care for Resident #16 and #22 |
| Nurse G | Nurse Aide | Provided care and observations for Resident #22 |
| Nurse H | Nurse | Reported on Resident #22's condition and fall interventions |
| Nurse I | Nurse | Reported on Resident #22's assistance needs and fall investigations |
| Nurse J | Nurse | Verified fall investigation procedures |
| Certified Medication Aide B | Medication Aide | Verified expired medication on medication cart |
| Certified Medication Aide C | Medication Aide | Verified expired medication on medication cart |
| Dietary Staff N | Dietary Staff | Verified hair protruding from hairnet and improper dishware storage |
| Dietary Staff O | Dietary Staff | Observed hair protruding from hairnet |
| Dietary Staff Q | Dietary Staff | Observed hair protruding from hairnet |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 5, 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
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.
Deficiencies (1)
Deficiency with ID Prefix F0323 related to regulation 483.25(h)
Report Facts
Deficiency correction date: Jul 5, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 22, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at Pine Village.
Complaint Details
This Plan of Correction is related to a complaint investigation at Pine Village dated 06/22/2016.
Findings
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.
Deficiencies (1)
Elopement risk during resident exercises in the Wellness Center due to open doors and resident positioning.
Report Facts
Completion date: Jul 14, 2016
Completion date: Jul 5, 2016
Completion date: Jun 27, 2016
Completion date: Jun 23, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Shaw | Administrator | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 22, 2016
Visit Reason
An Abbreviated Survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious 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.
Deficiencies (1)
Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as Complaint Coordinator and contact person for the survey. |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Jun 22, 2016
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure adequate supervision and accident hazard prevention for Resident #1, an elopement risk, who left the facility without staff knowledge.
Report Facts
Resident census: 74
Resident sample size: 3
Resident BIMS score: 6
Resident BIMS score: 9
Resident antidepressant medication days: 7
Elopement duration: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 27, 2016
Visit Reason
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.
Complaint Details
Complaint investigation #98482 was conducted and found no deficiencies.
Findings
The investigation resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 27, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for the facility.
Findings
No deficiencies were cited in the referenced inspection report dated 04/27/2016.
Deficiencies (1)
No deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 24, 2015
Visit Reason
The document is a Plan of Correction related to the Assisted Living/Residential Healthcare resurvey of the facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 24, 2015
Visit Reason
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.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 24, 2015
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 24, 2015
Visit Reason
The Assisted Living/Residential 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
Life Safety
Deficiencies: 1
Date: Sep 12, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious 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.
Deficiencies (1)
Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Dec 12, 2014
Provider agreement termination date: Mar 12, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Huxman | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
| Joe Ewert | Commissioner | Mentioned in carbon copy (c:) |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Jan 6, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that all previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date.
Deficiencies (7)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(g)(1)
Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.55(b)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Jan 6, 2014
Visit Reason
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.
Findings
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.
Deficiencies (7)
Dignity issues addressed through staff in-service and audits
Coordination of dental care services for Resident #7
Review and revision of Resident #74's care plan and temporary care plans
Review and auditing of skin assessments and care protocols
Revisions and staff education on dining services attire policy
Coordination of dental care and insurance benefit education for residents
Housekeeping policies and staff education on disinfectant use and infection control
Report Facts
Completion date for deficiencies: Jan 6, 2014
QAPI Committee meeting date: Dec 12, 2013
Neighborhood meetings date: Dec 13, 2013
QAPI Committee follow-up meeting date: Jan 9, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Staff O | Social Service Staff | Worked with KanCare liaisons and coordinated dental care and insurance benefit education for Resident #7 |
| Director of Nursing | Director of Nursing | Oversaw dignity education, audits, care plan revisions, and infection control policy implementation |
| Director of Dining Services | Director of Dining Services | Revised dining services attire policy and conducted audits |
| Housekeeping Supervisor | Housekeeping Supervisor | Reviewed and educated staff on housekeeping policies and conducted audits |
| Director of Environmental Services | Director of Environmental Services | Reviewed housekeeping policies and conducted staff education and audits |
| Assistant Life Care Specialist | Assistant Life Care Specialist | Conducted compliance rounds and submitted audits to Director of Nursing |
| Life Care Specialist(s) | Life Care Specialist | Conducted audits of skin assessments and new admissions, reported to Director of Nursing |
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 7
Date: Dec 11, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
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.
Deficiencies (7)
Failure to maintain dignity and respect for Resident #30 during meal assistance by improper use of napkin to wipe nose.
Failure to provide medically-related social services regarding dental needs for Resident #7.
Failure to review and revise care plan for Resident #74 after hospital stay with new skin issues.
Failure to provide timely assessments and care for Resident #74's non-pressure related skin issues.
Failure to prepare, distribute, and serve food under sanitary conditions; staff observed with improper hair coverage.
Failure to provide or obtain routine and emergency dental services for Resident #7.
Failure to maintain infection control program including improper disinfectant contact time, lack of hand hygiene, and improper cleaning of glucometers.
Report Facts
Resident census: 71
Sample size: 15
Bruise size: 3
Bruise size: 2.7
Health shake volume: 240
Water volume: 360
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Nurse | Verified proper nose wiping procedure and care plan deficiencies for Resident #30 and Resident #74 |
| Nurse D | Administrative Nurse | Verified care plan deficiencies and glucometer cleaning issues |
| Housekeeping Staff A | Observed improper disinfectant contact time and hand hygiene | |
| Housekeeping Staff B | Verified disinfectant procedures and hand hygiene expectations | |
| Dietary Staff M | Observed with hair visible outside hairnet during food preparation | |
| Dietary Staff N | Dietary Administrative Staff | Verified hair covering policy and observed noncompliance |
| Nurse C | Nurse | Observed failing to disinfect glucometer between resident uses |
| Social Service Staff O | Verified failure to assist Resident #7 with dental services |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Oct 5, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
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.
Deficiencies (7)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(a)
Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.60(c)
Deficiency related to regulations 483.60(b), (d), (e)
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Sep 24, 2012
Visit Reason
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.
Findings
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.
Deficiencies (7)
Failure to notify legal representative or family in a timely manner of changes in condition or accidents involving injury.
Failure to promote care that maintains or enhances resident dignity and respect, including proper clothing labeling.
Failure to update care plans after falls or changes in condition.
Failure to provide appropriate assessments and care after accidents, including neurological assessments for unwitnessed falls.
Failure to document administration of prn medication (insulin).
Failure of consulting pharmacist to review drug regimens monthly and report irregularities.
Failure to employ or obtain services of a licensed pharmacist to monitor receipt and disposition of controlled drugs.
Report Facts
Completion date for all deficiencies: Oct 5, 2012
Dates of in-service trainings: Licensed nursing staff in-service on 9/27/2012; CNA/CMA meeting on 9/28/2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Huxman | Administrator | Submitted the Plan of Correction |
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 1
Date: Sep 20, 2012
Visit Reason
The inspection was conducted as a licensure survey of the assisted living facility to assess compliance with pharmacy services regulations.
Findings
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.
Deficiencies (1)
Failure to ensure drugs and biologicals were not outdated, including expired insulin used for a resident and expired medications in the emergency kit.
Report Facts
Census: 22
Sample size: 3
Insulin vial stability period: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified expired insulin vial and emergency kit expiration during observation and interview |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 7
Date: Sep 20, 2012
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for Pine Village facility.
Complaint Details
The inspection included complaint investigations #59717 and #60355.
Findings
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.
Deficiencies (7)
Failed to notify resident's family representative in a timely manner after resident #30 had a significant change in condition including a fractured left humerus.
Failed to promote care for residents in a manner that maintained or enhanced dignity for resident #61 by labeling clothing with iron-on labels.
Failed to review and revise care plan for resident #30 after a significant change and fall.
Failed to ensure resident environment was free of accident hazards and failed to provide adequate supervision and assessment after resident #30's fall, including failure to perform neurological assessment.
Failed to ensure resident #71 received extra Novolin Insulin as ordered for blood sugar greater than 250.
Consultant pharmacist failed to report drug irregularities to physician or director of nursing for resident #71.
Failed to ensure insulin and stock medications were not outdated or unlabeled on 2 of 4 halls, including expired Lantus insulin vial and expired stock medications.
Report Facts
Resident census: 74
Sample size: 14
Residents reviewed for accidents: 4
Residents reviewed for unnecessary drugs: 10
Units of Lantus Insulin: 16
Units of Novolin Regular Insulin: 5
Blood sugar readings > 250: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Verified failure to notify resident #30's responsible party timely and failure to update care plan after fall |
| Nurse J | Nurse | Verified care plan was not updated after resident #30's fall and neurological assessment was not completed |
| Nurse I | Nurse | Verified soiled utility room door should be locked and chemicals stored properly; verified expired medications and unlabeled insulin pens |
| Nurse H | Nurse | Verified expired Lantus insulin vial and expired stock medications on medication carts |
| Nurse E | Nurse | Verified lack of documentation for Novolin insulin administration for elevated blood sugars |
| Administrative Nurse A | Administrative Nurse | Verified failure to administer Novolin insulin as ordered and pharmacist failure to report drug irregularities |
| Laundry Staff C | Laundry Staff | Verified laundry usually marks resident clothing and explained labeling practices |
| Social Service Staff D | Social Service Staff | Verified laundry staff mark all resident clothing |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Aug 11, 2011
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 report documents that all previously identified deficiencies with ID prefixes F0241, F0280, F0282, and F0329 were corrected by 08/11/2011.
Deficiencies (4)
Deficiency with ID prefix F0241 related to regulation 483.15(a)
Deficiency with ID prefix F0280 related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency with ID prefix F0282 related to regulation 483.20(k)(3)(ii)
Deficiency with ID prefix F0329 related to regulation 483.25(l)
Report Facts
Deficiencies corrected: 4
Follow-up survey date: Aug 1, 2011
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 4
Date: Aug 1, 2011
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation (#50249) at Pine Village facility.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to promote care for residents in a manner that maintains or enhances dignity in one of three dining rooms.
Failed to provide the resident's representative the right to participate in care planning for 1 of 10 sampled residents.
Failed to implement the care plan for 1 of 10 sampled residents, specifically not leaving the full body sling under the resident after transfer as directed.
Failed to ensure the resident's drug regimen was free from unnecessary drugs by not documenting effectiveness of PRN medications.
Report Facts
Census: 72
Sample size: 10
Residents sampled for unnecessary drugs: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse G | Verified that staff should stay at one table to feed residents during a meal. | |
| Nurse J | Verified the facility did not provide the resident's representative notification of the care plan meeting. | |
| Nurse B | Verified care plan intervention regarding leaving the lift sling in the resident's wheelchair. | |
| Nurse D | Verified staff are to follow up with documentation on the MAR after administering PRN medications. | |
| Certified Nurse Aide E | Indicated the lift sling was to be removed from the wheelchair after resident transfer. | |
| Certified Nurse Aide F | Observed transferring resident with mechanical lift. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N059002 POC K7PR11
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 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.
Deficiencies (1)
Medication administration/monitoring not safe and not documented correctly.
Report Facts
Complete Date: Oct 5, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Rupp | Director of Nursing | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: N059002 POC OCJ911
Visit Reason
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.
Findings
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.
Deficiencies (7)
Written allegations for deficiencies cited during the survey with a facility-wide system to assure compliance.
Resident Abuse Policy updated to include neglect and exploitation, with mandatory staff training and competency testing.
Comprehensive Care Plan updated to include pain management and heat pack use, with audits and checklists for care plans.
Care Plans updated to include fall interventions with 15 and 30 minute checks and bladder/bowel diaries as part of Root Cause Analysis.
Fall risk assessments and meetings established with staff education on fall protocols including post-fall huddles and investigations.
Medication carts audited with removal of expired medications and creation of audit logs.
Dining services staff dress code updated to require bouffant hairnets and policies for dry storage of dishes and utensils created and staff re-educated.
Report Facts
Completion date for deficiencies: Dec 25, 2017
Staff meeting dates: Dec 14, 2017
Fall risk meeting date: Dec 19, 2017
Bladder/bowel diary duration: 72
Fall intervention check intervals: 15
Fall intervention check intervals: 30
Medication audit frequency: 1
In-service date for dining staff re-education: Dec 21, 2017
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