Deficiencies (last 15 years)
Deficiencies (over 15 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
89% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
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 11/12/2025.
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 to verify correction of all previous deficiencies cited on 2025-05-06.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2025-05-23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
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 addresses multiple deficiencies identified in the linked deficiency report for Pine Village RS. Specific corrective actions are referenced but not detailed in this document.
Deficiencies (5)
F0000: The completed Plan of Correction is attached and available upon request.
F757-D: See attached Plan of Correction for details on corrective actions.
F812-F: See attached Plan of Correction for details on corrective actions.
F851-F: See attached Plan of Correction for details on corrective actions.
F880-E: See attached Plan of Correction for details on corrective actions.
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 to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility was found deficient in medication administration related to holding blood pressure medication per physician orders, food storage safety, payroll-based journal staffing submissions, and infection prevention practices related to laundry handling.
Deficiencies (4)
F757 Drug Regimen is Free from Unnecessary Drugs. The facility failed to hold blood pressure medication per physician-ordered parameters for one resident, placing the resident at risk for physical decline.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to store food by professional standards, including uncovered food items and unlabeled, undated produce, placing residents at risk for foodborne illness.
F851 Payroll Based Journal. The facility failed to submit complete and accurate staffing information to CMS, with missing RN hours reported despite documented coverage, risking inadequate nurse staffing identification.
F880 Infection Prevention & Control. The facility failed to use appropriate barriers while sorting soiled laundry, placing residents at risk of infectious diseases.
Report Facts
Resident census: 66
Sample residents reviewed: 17
Days with missing RN hours: 6
Uncovered food items: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide R | Certified Medication Aide | Verified medication was out of physician-ordered parameters |
| 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 barrier use |
| Dietary Staff CC | Dietary Staff | Verified uncovered food findings in freezer |
| Certified Dietary Manager | Certified Dietary Manager | Stated food should be covered and labeled before refrigeration |
| Administrative Staff B | Administrative Staff | Reported first time submitting PBJ data alone and possible payroll submission issues |
| Administrative Staff A | Administrative Staff | Reported adequate RN coverage despite PBJ data issues |
| Maintenance/Housekeeping Staff U | Maintenance/Housekeeping Staff | Reported laundry staff used only gloves unless obvious soilage |
Inspection Report
Routine
Census: 66
Deficiencies: 4
Date: May 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to medication administration, food storage, staffing data submission, infection control, and other facility operations.
Findings
The facility was found deficient in holding blood pressure medication per physician orders for one resident, storing food safely in the kitchen, submitting accurate staffing information to CMS, and using appropriate barriers while sorting soiled laundry. These deficiencies placed residents at risk for physical harm, foodborne illness, inadequate nurse staffing, and infectious diseases.
Deficiencies (4)
F 0757: The facility failed to hold blood pressure medication for Resident 30 when blood pressure readings were below physician-ordered parameters, risking physical decline.
F 0812: The facility failed to store food properly by leaving food uncovered and unlabeled in the kitchen, risking foodborne illness.
F 0851: The facility failed to submit complete and accurate staffing information to CMS for several days, risking unidentified inadequate nurse staffing.
F 0880: The facility failed to use appropriate barriers while sorting soiled laundry, risking transmission of infectious diseases.
Report Facts
Resident census: 66
Sample size: 17
Resident census: 65
PBJ report days with no RN hours: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) R | Verified medication was out of physician-ordered parameters | |
| Licensed Nurse (LN) H | Stated CMA should notify nurse when blood pressure was out of parameters | |
| Administrative Nurse D | Stated CMA should notify nurse and hold medication when blood pressure was out of parameters; verified laundry barrier use | |
| Dietary Staff (DS) CC | Verified food storage deficiencies | |
| Certified Dietary Manager (CDM) | Stated food should not be left open and must be labeled and dated | |
| Administrative Staff B | Discussed PBJ submission issues | |
| Administrative Staff A | Discussed PBJ submission issues and RN coverage | |
| Maintenance/Housekeeping Staff U | Described laundry sorting practices |
Inspection Report
Re-Inspection
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 cited in the prior inspection have been corrected as of the compliance date 2024-09-26. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
This 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 state regulations for the facility.
Findings
The facility failed to ensure prescription medication containers were properly labeled by a dispensing pharmacist for one resident. Additionally, the facility did not perform an annual emergency drill including evacuation of all residents to a secure location.
Deficiencies (2)
KAR 26-41-205 (g) (2) Medication Labeling: The facility failed to ensure prescription medication containers were labeled with a pharmacist-provided label for one resident's insulin injector pen.
KAR 26-41-104 (d) Disaster and Emergency Preparedness: The facility failed to perform an annual emergency drill including evacuation of all residents to a secure location.
Report Facts
Resident census: 16
Sampled residents: 3
Sampled employee records: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named as responsible for failure to ensure medication labeling and emergency preparedness | |
| Licensed Nurse B | Interviewed and confirmed medication labeling and emergency drill deficiencies | |
| Certified Medication Aide C | Observed during medication cart inspection |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/31/23.
Findings
All deficiencies 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.
Inspection Report
Plan of Correction
Deficiencies: 0
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. Specific corrective actions are cross-referenced to each cited deficiency.
Inspection Report
Routine
Census: 72
Deficiencies: 4
Date: Aug 31, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident discharge summaries, accident prevention, nurse aide training, and psychotropic medication use at the nursing facility.
Findings
The facility failed to develop complete discharge summaries, assess residents for safe use of electric lift recliners, ensure nurse aides completed required in-service training, and provide appropriate documentation for psychotropic medication use. These deficiencies placed residents at risk for missed care opportunities, preventable accidents, inadequate care, and unnecessary medication use.
Deficiencies (4)
F0661: The facility failed to develop a discharge summary that included a complete recapitulation of Resident 71's stay and post discharge plan, risking missed care opportunities.
F0689: The facility failed to assess Resident 16 for safe use of an electric lift recliner, placing the resident at risk for preventable accidents or injury.
F0730: The facility failed to complete performance reviews and provide required in-service training hours for nurse aides employed at least one year, risking inadequate care.
F0758: The facility failed to ensure an appropriate indication for use or required documentation for continued use of Seroquel for Resident 19 with dementia, risking unnecessary psychotropic medication use.
Report Facts
Census: 72
Sample size: 18
Certified Nurse Aide in-service training hours missing: 1
Residents reviewed for accidents: 10
Residents reviewed for unnecessary medications: 5
Inspection Report
Routine
Census: 72
Deficiencies: 4
Date: Aug 31, 2023
Visit Reason
Routine inspection of Pine Village nursing home to assess compliance with regulatory requirements including discharge summaries, accident prevention, staff training, and medication management.
Findings
The facility failed to develop complete discharge summaries, assess safe use of electric recliners, ensure nurse aides completed required in-service training, and provide appropriate documentation for psychotropic medication use. These deficiencies placed residents at risk for missed care opportunities, preventable accidents, inadequate care, and unnecessary medication use.
Deficiencies (4)
F0661: The facility failed to develop a discharge summary that included a complete recapitulation of the resident's stay and post discharge plan, placing the resident at risk for missed care opportunities.
F0689: The facility failed to assess a resident for safe use of an electric lift recliner, placing the resident at risk for preventable accidents or injury.
F0730: The facility failed to complete performance reviews and provide required in-service training hours for nurse aides, placing residents at risk for inadequate care.
F0758: The facility failed to ensure an appropriate indication for use or required documentation for continued use of an antipsychotic medication, placing the resident at risk for unnecessary psychotropic medications.
Report Facts
Resident census: 72
Sample size: 18
Residents reviewed for accidents: 10
Certified Nurse Aide missing training hours: 1
Psychotropic medication sample: 5
Medication dosage: 25
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 4
Date: Aug 31, 2023
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for Pine Village nursing facility.
Complaint Details
The visit was a complaint investigation combined with a health resurvey. The complaint involved issues with discharge summaries, resident safety, nurse aide training, and psychotropic medication use.
Findings
The facility failed to develop complete discharge summaries, assess residents for safe use of equipment, complete nurse aide performance reviews and in-service training, and ensure appropriate use and documentation of psychotropic medications. These deficiencies placed residents at risk for missed care opportunities, injury, inadequate care, and unnecessary medication use.
Deficiencies (4)
F 661 Discharge Summary: The facility failed to develop a discharge summary that included a complete recapitulation of the resident's stay and post discharge plan for Resident 71.
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to assess Resident 16 for safe use of an electric lift recliner, placing the resident at risk for injury.
F 730 Nurse Aide Performance Review: The facility failed to complete performance reviews and provide required in-service education for all nurse aides, placing residents at risk for inadequate care.
F 758 Free from Unnecessary Psychotropic Medications/PRN Use: The facility failed to ensure an appropriate indication for use or documented physician rationale for continued use of Seroquel for Resident 19 with dementia.
Report Facts
Resident census: 72
Sample size: 18
Residents reviewed for accidents: 10
Certified Nurse Aide missing training hours: 1
Residents reviewed for unnecessary medications: 5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited during an earlier inspection.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 2023-03-21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 15
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
This was a resurvey conducted with a complaint (#168823) at the facility.
Complaint Details
The inspection was triggered by a complaint (#168823).
Findings
The facility failed to ensure compliance with the State Agency's tuberculosis guidelines for adult care homes, as employee records lacked evidence of completion of TB questionnaires upon hire for four staff members.
Deficiencies (1)
KAR 26-41-207 (b)(5-6)(c) Infection Control Policies: The facility failed to ensure employees with communicable diseases or infected skin lesions did not come in contact with residents or resident care equipment, and failed to provide required TB screening and education. Employee records for four staff lacked evidence of TB questionnaire completion upon hire.
Report Facts
Resident census: 15
Sampled residents: 3
Newly hired employees reviewed: 5
Employees with missing TB questionnaire: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA C | Certified Medication Aide | Named in deficiency for missing TB questionnaire upon hire. |
| Dietary Staff D | Dietary Staff | Named in deficiency for missing TB questionnaire upon hire. |
| Dietary Staff E | Dietary Staff | Named in deficiency for missing TB questionnaire upon hire. |
| Dietary Staff F | Dietary Staff | Named in deficiency for missing TB questionnaire upon hire. |
| Licensed Nurse B | Licensed Nurse | Interviewed and confirmed missing TB questionnaires for staff. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
This document is a plan of correction submitted in response to a resurvey with a complaint (#168823) conducted at the facility on 03/15/23.
Complaint Details
The resurvey was conducted following a complaint (#168823).
Findings
The plan of correction addresses findings from the resurvey related to the complaint investigation conducted on 03/15/23.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 18, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 12/21/21.
Findings
All deficiencies 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.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Dec 21, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on December 21, 2021.
Findings
The plan addresses multiple deficiencies including issues with discharge plan documentation, PASSAR screening completion, fall interventions, bed rail safety, and appropriate diagnoses for antipsychotic medications. The facility outlines corrective actions such as staff re-education, audits, and ongoing monitoring to ensure compliance.
Deficiencies (5)
F582-D: Resident and their representative were talked to prior to discharge about discharge plan but forms were not signed and signatures could not be obtained. Facility staff were re-educated on Medicare Denial Notices policy to improve informed decision-making.
F645-D: A PASSAR screening was completed for resident R63 showing appropriate level of care. Social worker and designee will audit charts and be educated on PASSAR policy to ensure compliance.
F689-D: Nursing staff working with resident R29 will be reeducated on fall interventions and care plan revision policy. Interventions will be communicated via EMR alerts and reviewed weekly to prevent further falls.
F700-D: Bed rail was removed from resident R5's bed and replaced with correct repositioning device. Facility-wide bed safety checks and staff education on bed entrapment zones will be conducted quarterly.
F758-D: Primary care physicians for residents R9, R29, and R14 will be re-faxed to request appropriate diagnoses for antipsychotic medications. Nurse Manager will review pharmacy reports and follow up monthly on non-compliance.
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 5
Date: Dec 21, 2021
Visit Reason
The inspection was conducted as an annual survey of the nursing home to assess compliance with Medicare and Medicaid regulations, including review of resident care, safety, and medication use.
Findings
The facility had multiple deficiencies including failure to provide required Medicare non-coverage notices, incomplete PASARR screening for a resident with mental illness, inadequate fall prevention interventions, unsafe bed rail assessments, and inappropriate diagnoses for antipsychotic medication use in three residents.
Deficiencies (5)
F 0582: The facility failed to provide Resident 115 or their representative with required Medicare Non-Coverage and Advance Beneficiary Notice forms before discharge, risking uninformed decisions about skilled care continuation.
F 0645: The facility failed to ensure a timely PASARR Level 2 screening referral for Resident 63 with documented mental illness, placing the resident at risk for inadequate care.
F 0689: The facility failed to follow toileting and fall interventions for Resident 29, including improper use of motion sensors, resulting in multiple falls and injury risk.
F 0700: The facility failed to accurately assess and identify safety risks of side rails for Resident 5, placing the resident at risk for accident and injury.
F 0758: The facility failed to ensure appropriate diagnoses for antipsychotic medication use for Residents 9, 14, and 29, increasing risk for adverse side effects.
Report Facts
Resident census: 63
Sample size: 16
Falls: 3
Medication doses: 50
Medication doses: 12.5
Medication doses: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified PASARR assessment absence and medication diagnosis issues |
| Licensed Nurse G | Licensed Nurse | Provided information on medication monitoring and fall interventions |
| Certified Nurse Aide M | Certified Nurse Aide | Observed assisting Resident 29 with ambulation |
| Certified Medication Aide R | Certified Medication Aide | Reported on motion sensor use for Resident 29 |
Inspection Report
Re-Inspection
Census: 63
Deficiencies: 5
Date: Dec 21, 2021
Visit Reason
Health Resurvey and Complaint #KS00164744 re-inspection to verify compliance with prior deficiencies and complaint investigation.
Complaint Details
Complaint #KS00164744 triggered the health resurvey and re-inspection.
Findings
The facility failed to provide required Medicare non-coverage notices to a discharged resident, failed to complete a PASARR Level 2 screening for a resident with mental illness, failed to follow toileting and fall prevention interventions for a resident with multiple falls, failed to properly assess and maintain bedrails for safe use, and failed to ensure appropriate diagnoses for antipsychotic medication use in three residents.
Deficiencies (5)
F582: The facility failed to provide Resident 115 or representative the required Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice forms before discharge, risking uninformed decisions about skilled care continuation.
F645: The facility failed to promptly refer Resident 63 for a Level 2 PASARR screening despite documented mental illness, risking inadequate care and treatment.
F689: The facility failed to follow toileting and fall prevention interventions for Resident 29, including improper use of motion sensors, resulting in multiple falls and injury risk.
F700: The facility failed to accurately assess and ensure safe use of side rails for Resident 5, with rails having openings too large and posing entrapment risk.
F758: The facility failed to ensure appropriate diagnoses for antipsychotic medication use for Residents 9, 29, and 14, placing them at risk for inappropriate treatment and adverse effects.
Report Facts
Resident census: 63
Sample size: 16
Falls: 3
Medication dosage: 12.5
Medication dosage: 0.5
Medication dosage: 50
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 injuries of unknown origin for Resident 1.
Complaint Details
The complaint investigations 166646 and 166516 were triggered by failure of staff to identify and report significant bruising on Resident 1 as possible abuse. Multiple staff members failed to notify administrative staff or the physician in a timely manner. The resident was later referred for evaluation of possible sexual assault.
Findings
The facility failed to timely notify the physician and administrative staff about significant bruising and injuries of unknown origin on Resident 1, which were identified on multiple occasions between 10/12/21 and 10/17/21. Staff failed to recognize and report these injuries as possible abuse, resulting in immediate jeopardy to the resident.
Deficiencies (2)
F 580: The facility failed to notify the physician in a timely manner when staff discovered large bruises on Resident 1's inner thighs on 10/12/21 and 10/17/21, placing the resident at risk for abuse or neglect.
F 609: The facility failed to ensure staff identified an injury of unknown origin as possible abuse and immediately reported it to the facility administrator, placing Resident 1 in immediate jeopardy.
Report Facts
Resident census: 70
BIMS score: 6
Dates of bruising observations: Bruises observed on 10/12/21, 10/13/21, 10/17/21, and 10/19/21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Assessed bruising on 10/12/21 but failed to notify physician or family and had a seizure before completing charting |
| 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 | Observed 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 and verified bruising was not timely reported |
| Administrative Staff A | Administrator | Was not informed timely about bruising; expected immediate reporting of injuries of unknown origin |
| LN K | Licensed Nurse | Observed bruising on 10/19/21 and notified physician |
| LN I | Licensed Nurse | Called to check on bruising and notified physician |
| CMA S | Certified Medication Aide | Received report of bruising on 10/18/21 but had not seen bruises before |
| LN J | Licensed Nurse | Did not receive report of bruising on 10/13/21 |
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 during a prior inspection.
Findings
The plan addresses past noncompliance issues identified under tags F0000, F580-D, and F609-J, with corrective actions completed by 10/21/2021.
Deficiencies (3)
Tag F0000 relates to past noncompliance issues requiring correction.
Tag F580-D relates to past noncompliance issues requiring correction.
Tag F609-J relates to past noncompliance issues requiring correction.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 4, 2021
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in the inspection report dated 02/04/2021 for Pine Village ALF.
Findings
No specific findings or deficiencies are detailed in this Plan of Correction document. It references the linked deficiency report but contains no records or descriptions itself.
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 4, 2021
Visit Reason
A survey for re-licensure was conducted at the residential healthcare facility to assess compliance for license renewal.
Findings
The survey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Plan of Correction
Deficiencies: 1
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.
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.
Deficiencies (1)
F0000: The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 during the targeted infection control survey conducted on 07/13/2020.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
The facility underwent a special infection control survey for COVID-19.
Findings
The survey conducted on 07/13/2020 resulted in findings of no deficiency citations.
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 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
Re-Inspection
Deficiencies: 0
Date: May 6, 2020
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2020-03-02.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2020-03-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
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 during a prior inspection.
Findings
The facility identified hazards including unsecured scissors and pipe pliers in kitchenettes and nurse desks. Immediate removal of hazards and implementation of monthly safety checks and staff re-education were planned to ensure compliance.
Deficiencies (1)
F689-E: The pipe pliers, scissors in the kitchenette, silver scissors and red handled scissors were unsecured and posed a hazard. These items were removed and placed in a locked drawer on 2.25.2020.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Shaw | Administrator | Administrator involved in hazard checks and submission of Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Re-Inspection
Census: 63
Deficiencies: 1
Date: Feb 25, 2020
Visit Reason
The visit was a health resurvey to assess compliance with safety and accident hazard regulations in the facility.
Findings
The facility failed to provide an environment free of accident hazards on one of three halls for 10 cognitively impaired, independently mobile residents. Several hazardous items such as pipe pliers and scissors were found in unlocked drawers in the kitchenette and nurse's desk area.
Deficiencies (1)
F 689: The facility failed to maintain an environment free of accident hazards by leaving pipe pliers and scissors in unlocked drawers accessible to residents. This placed 10 cognitively impaired, independently mobile residents at risk for injury.
Report Facts
Resident census: 63
Sample size: 16
Cognitively impaired residents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) | Stated that pipe pliers and scissors should be in locked drawers | |
| Dietary Staff (DS) | 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 at the facility.
Complaint Details
Complaint investigation #145014 was substantiated with findings of abuse involving CNA M and Resident 1. Immediate jeopardy was identified starting 08/27/2019.
Findings
The facility failed to protect a resident (R1) from abuse by a Certified Nurse Aide (CNA M), who was observed inappropriately positioned with the resident and with his pants unzipped. The incident was reported to law enforcement and the facility implemented immediate staff education.
Deficiencies (1)
F600: The facility failed to ensure residents were free from abuse when CNA M was observed with his pants unzipped and positioned inappropriately with Resident 1, placing her in immediate jeopardy.
Report Facts
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in abuse finding involving Resident 1. |
| CNA N | Certified Nurse Aide | Reported the abuse incident and observed CNA M with Resident 1. |
| LN G | Licensed Nurse | Notified Administrative Nurse D of abuse concerns and contacted law enforcement. |
| Administrative Nurse D | Administrative Nurse | Instructed to call police and responded to the facility immediately. |
| LN H | Licensed Nurse | Responded to the abuse incident and verified observations. |
Inspection Report
Plan of Correction
Deficiencies: 1
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 addresses past noncompliance issues identified under tags F0000 and F600-J during a prior inspection.
Deficiencies (1)
Tag F0000 indicates past noncompliance issues requiring correction. Tag F600-J indicates additional past noncompliance requiring correction.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 25, 2019
Visit Reason
The annual health survey was conducted to assess compliance with 42 CFR Part 483, Subpart B requirements for long term care facilities.
Findings
The survey resulted in no deficiency citations for the facility, indicating full compliance with applicable regulations.
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 a long term care facility.
Findings
The health survey resulted in a finding of no deficiency citations related to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Deficiencies (1)
The health survey found no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 11, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: May 31, 2018
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report shows that previously cited deficiencies identified by regulation numbers 26-41-205 (b) and 26-41-205 (d)(3) were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-205 (b) deficiency was corrected by the revisit date.
Regulation 26-41-205 (d)(3) deficiency was corrected by the revisit date.
Inspection Report
Renewal
Census: 18
Deficiencies: 3
Date: Apr 25, 2018
Visit Reason
The inspection was a Licensure Resurvey at Pine Village Residential Health Care Facility in Moundridge, Kansas, conducted 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 services for residents who self-administer medications. Staff did not document actual clock times for medication administration on the MAR, and staff did not remain with residents until medications were ingested when medications were set up for self-administration.
Deficiencies (3)
KAR 26-41-205(b) The Administrator failed to ensure negotiated service agreements reflected medication management and identified responsibility for administration and management of selected medications for residents who self-administer medications.
KAR 26-41-205(d)(3) The Administrator failed to ensure staff who prepared medications remained with residents until medications were ingested for residents who self-administered medications.
KAR 26-41-205(d)(3) The Administrator failed to ensure actual clock times were documented on the medication administration record for medications administered by staff.
Report Facts
Resident census: 18
Residents self-administering medications: 14
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed lack of negotiated service agreement reflecting medication management and responsibility | |
| Director of Nursing #B | Confirmed lack of negotiated service agreement and medication administration documentation | |
| Director of Assisted Living #C | Provided clarification on MAR initialing practices and medication administration documentation |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 17, 2018
Visit Reason
A revisit was conducted on 2018-01-17 to verify correction of all previous deficiencies cited on 2017-12-05.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2017-12-25, 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: 1
Date: Jan 17, 2018
Visit Reason
This document is a plan of correction submitted following a revisit inspection to address previously identified deficiencies.
Findings
A revisit was conducted and all deficiencies have been corrected. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Deficiencies (1)
A revisit was conducted and all deficiencies have been corrected. No new noncompliance was found.
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 federal regulations and resident care standards.
Findings
The facility failed to immediately report alleged neglect resulting in injuries, did not develop or revise comprehensive care plans adequately, failed to prevent multiple resident falls with injuries, allowed expired medications on medication carts, and failed to maintain sanitary food preparation and serving conditions.
Deficiencies (6)
F609: Facility failed to immediately report 2 accidents of possible neglect resulting in rib fractures and a head laceration for Resident #22.
F656: Facility failed to develop a comprehensive care plan addressing pain management and safe use of hot packs for Resident #16.
F657: Facility failed to revise care plans and implement effective fall prevention interventions for Residents #22 and #60.
F689: Facility failed to maintain a resident environment free of accident hazards and provide adequate supervision to prevent falls and injuries for Residents #16, #22, and #60.
F761: Facility failed to ensure stock medications on medication carts were not expired, placing residents at risk for ineffective medication administration.
F812: Facility failed to prepare, distribute, and serve food under sanitary conditions, including uncovered dishware and staff with hair not fully restrained.
Report Facts
Resident census: 70
Falls with injury: 5
Falls: 8
Expired medication: 2
Heat pack injury size: 1.2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 14, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey related to a complaint investigation.
Findings
The plan addresses an elopement incident involving residents during exercises in the Wellness Center. The facility implemented immediate corrective actions including relocating exercises, staff education on elopement policies, and adding a 'Wander guard Alert' to daily forms.
Deficiencies (1)
F323-D Immediate action following the elopement included relocating resident exercises to coded exit areas and educating Wellness Center staff on elopement awareness and procedures. A teachable moment was provided to all staff to review elopement policies and procedures.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 5, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the deficiencies previously cited have been corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected and completed by 07/05/2016.
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 regarding inadequate supervision of Resident #1 who eloped from the facility through an unmonitored Wellness Center entrance.
Findings
The facility failed to ensure adequate supervision and monitoring of Resident #1, who was at high risk for elopement. The Wellness Center entrance doors were not alarmed or monitored, allowing the resident to leave the facility unnoticed for approximately 10-12 minutes. Staff also failed to obtain vital signs after the elopement incident.
Deficiencies (1)
483.25(h) The facility failed to ensure Resident #1, assessed as an elopement risk, had adequate supervision to prevent leaving the facility without staff knowledge. The Wellness Center automatic entrance doors were not alarmed or monitored, and staff did not assess the resident's vital signs after the elopement.
Report Facts
Resident census: 74
Duration resident outside without staff knowledge: 10
Date of MDS assessment: Jun 11, 2016
Number of residents reviewed for elopement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Center Staff B | Verified one of the inside double doors was left open on the day Resident #1 eloped. | |
| Wellness Center Staff A | Reported the inside double door was open during morning swimming lessons and did not see Resident #1 when leading exercises. | |
| Nurse D | Was working the day of the elopement and confirmed the Wellness Center entrance lacked alarm and camera monitoring. | |
| Administrative Nurse E | Visited with Wellness Center staff regarding the elopement and verified lack of alarm and camera monitoring at the Wellness Center entrance. | |
| Nurse Aide C | Performed visual checks and assisted Resident #1 to wheelchair before the elopement. | |
| Administrative Staff F | Expressed opinion on keypad lock and monitoring of Wellness Center entrance. |
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 indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Deficiencies (1)
The facility had a 'D' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 27, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for regulatory compliance purposes.
Findings
No deficiencies were cited in the related inspection report dated 04/27/2016.
Inspection Report
Deficiencies: 0
Date: Apr 27, 2016
Visit Reason
The health resurvey and complaint investigation #98482 was conducted to assess compliance with 42 CFR Part 483, Subpart B requirements for long term care facilities.
Complaint Details
Complaint investigation #98482 was conducted and found no deficiencies.
Findings
The investigation resulted in no deficiency citations related to applicable regulations.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 24, 2015
Visit Reason
The inspection was conducted as a health survey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations related to the applicable regulations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 24, 2015
Visit Reason
The document is a Plan of Correction submitted following an Assisted Living/Residential Healthcare resurvey of the facility.
Findings
The resurvey resulted in a finding of no deficiency citations for the facility.
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, for long term care facilities.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 24, 2015
Visit Reason
The visit was a resurvey of the Assisted Living/Residential Healthcare facility to verify compliance following a prior inspection.
Findings
The resurvey resulted in a finding of no deficiency citations at the facility.
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 complied 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 to address these deficiencies.
Deficiencies (1)
The facility was cited with an 'F' level deficiency indicating widespread noncompliance with Life Safety Code requirements, posing potential for more than minimal harm without immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Dec 12, 2014
Provider agreement termination date: Mar 12, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Jim Huxman | Administrator | Facility administrator named in the report. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 6, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jan 6, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey and to demonstrate how the facility will achieve and maintain compliance with regulations.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies related to dignity in care, dental services, care planning, skin assessments, dining services attire, and housekeeping infection control policies. The facility commits to staff education, audits, and policy revisions to ensure compliance.
Deficiencies (8)
F0000 This Plan of Correction constitutes written allegations for the deficiencies cited and outlines the facility's commitment to compliance and staff education.
F241-D Staff will be educated on dignity issues through meetings and mandatory sign-offs, with ongoing audits by the Director of Nursing.
F250-D Social Service Staff will coordinate with KanCare liaisons to assist Resident #7 with dental services and inform residents about insurance benefits.
F280-D Resident #74's care plan will be reviewed and revised by the interdisciplinary team to address skin issues, with staff education on temporary care plans.
F309-D Resident #74's skin assessments will be audited for accuracy and timeliness, with staff education and ongoing monitoring.
F371-F The Director of Nursing and Dining Services revised the Appropriate Attire policy for dining staff, with education and audits to ensure compliance.
F412-D Social Service Staff will work with KanCare liaisons to assist Resident #7 with dental care and document treatment discussions.
F441-E Housekeeping and Environmental Services will review and educate staff on disinfectant contact times, hand hygiene, and cleaning protocols, with audits to ensure compliance.
Report Facts
Completion date for deficiencies: Jan 6, 2014
QAPI Committee meeting date: Dec 12, 2013
Neighborhood Team Meetings date: Dec 13, 2013
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 regulatory requirements.
Findings
The facility was found deficient in multiple areas including dignity and respect for residents, provision of medically-related social services, care planning and revision, provision of care and services, food sanitation, dental services, and infection control practices.
Deficiencies (7)
F241: The facility failed to maintain dignity and respect for Resident #30 by using a napkin/clothing protector worn by the resident to wipe his/her nose during a meal.
F250: The facility failed to provide medically-related social services regarding dental services for Resident #7, specifically assistance with obtaining a lower partial denture.
F280: The facility failed to review and revise the care plan for Resident #74 after a hospital stay when the resident developed a non-pressure related skin issue.
F309: The facility failed to provide timely assessments and ongoing care for Resident #74's non-pressure related skin issue related to an IV infiltration prior to readmission.
F371: The facility failed to prepare, distribute, and serve food under sanitary conditions, as dietary staff were observed with hair not fully covered during food preparation and service.
F412: The facility failed to provide or obtain dental services for Resident #7, who needed assistance with replacement of a bottom partial denture.
F441: The facility failed to maintain a safe, sanitary environment to prevent infection spread, including improper disinfectant contact time, lack of hand hygiene by housekeeping staff, and failure to properly disinfect glucometers as per manufacturer guidelines.
Report Facts
Resident census: 71
Sample size: 15
Blood units transfused: 2
Skin wound size: 3
Skin wound size: 2.7
Skin breakdown size: 1
Health shake volume: 240
Water volume: 360
Inspection Report
Follow-Up
Deficiencies: 7
Date: Oct 5, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as documented in 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 the revisit date of 10/05/2012.
Deficiencies (7)
Regulation 483.10(b)(11) deficiency was corrected by 10/05/2012.
Regulation 483.15(a) deficiency was corrected by 10/05/2012.
Regulations 483.20(d)(3) and 483.10(k)(2) deficiencies were corrected by 10/05/2012.
Regulation 483.25(h) deficiency was corrected by 10/05/2012.
Regulation 483.25(l) deficiency was corrected by 10/05/2012.
Regulation 483.60(c) deficiency was corrected by 10/05/2012.
Regulations 483.60(b), (d), and (e) deficiencies were corrected by 10/05/2012.
Inspection Report
Plan of Correction
Deficiencies: 8
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.
Findings
The facility outlines corrective actions to ensure compliance with regulations, including staff in-services, policy reviews, and monitoring by coordinators and quality assurance teams.
Deficiencies (8)
F0000 This Plan of Correction constitutes written allegations of compliance for deficiencies cited. The facility will implement a system to assure continued compliance and present deficiencies to the Quality Assurance Committee.
F157-D The facility will notify legal representatives or family members timely of changes in condition or accidents involving residents. Licensed staff will review notification policies and sign acknowledgment.
F241-D The facility will promote care that maintains or enhances resident dignity and respect, including proper clothing labeling and staff training on dignity and laundry policies.
F280-D The facility will develop and update care plans after falls or changes in condition, reviewed quarterly, annually, and after significant changes, monitored by coordinators and QA teams.
F323-E The facility will ensure appropriate assessments and care after accidents, including neurological assessments for unwitnessed falls, and maintain a safe environment by securing harmful chemicals.
F329-D The facility will ensure documentation of prn medication (insulin) administration, emphasizing the importance of documentation in staff in-services and monthly audits.
F428-D The consulting pharmacist will review each resident's drug regimen monthly and report irregularities to the Director of Nursing and attending physician, with monitoring by HIM and QA Coordinator.
F431-E The facility must employ a licensed pharmacist to monitor receipt and disposition of controlled drugs, maintaining and reconciling records, with policy review at in-service.
Report Facts
Completion date for all deficiencies: Oct 5, 2012
Dates of staff in-services: Licensed nursing staff in-service on 9/27/2012; CNA/CMA meeting on 9/28/2012
Inspection Report
Census: 22
Deficiencies: 1
Date: Sep 20, 2012
Visit Reason
The inspection was a licensure survey conducted to assess compliance with pharmacy services regulations in the assisted living facility.
Findings
The facility failed to ensure that drugs and biologicals, including insulin and emergency kit medications, were not outdated. Specifically, expired insulin was used for a resident and the emergency kit contained multiple expired medications.
Deficiencies (1)
28-39-156(f) Pharmacy services regulation was not met as the facility failed to ensure drugs and biologicals were not outdated, including expired insulin used for a resident and expired medications in the emergency kit.
Report Facts
Resident census: 22
Sample size: 3
Expired insulin vial date: Jul 7, 2012
Emergency kit expiration date: Sep 30, 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified expired insulin vial and emergency kit expiration during inspection |
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 facility regulatory compliance.
Complaint Details
The inspection included a complaint investigation identified by complaint numbers #59717 and #60355.
Findings
The facility failed to notify a resident's family in a timely manner after a significant change in condition, failed to maintain resident dignity by improper labeling of clothing, failed to revise care plans after changes in condition, failed to ensure adequate assessment after accidents, failed to administer prescribed insulin doses, and failed to properly store and monitor medications including expired stock and insulin.
Deficiencies (7)
F 157: The facility failed to notify Resident #30's legal representative timely after a significant change in condition including a fractured left humerus.
F 241: The facility failed to maintain dignity for Resident #61 by labeling clothing with iron-on name tags on socks, which was not respectful.
F 280: The facility failed to review and revise Resident #30's care plan after a fall and significant change in condition.
F 323: The facility failed to ensure Resident #30 received appropriate assessment and care after an unwitnessed fall and failed to secure hazardous chemicals.
F 329: The facility failed to administer Novolin Regular Insulin as ordered for Resident #71 when blood sugar was greater than 250.
F 428: The facility's consultant pharmacist failed to report drug irregularities regarding Resident #71's insulin administration to the physician or director of nursing.
F 431: The facility failed to ensure insulin vials and stock medications were not outdated or unlabeled, including expired Lantus insulin and stock medications on multiple halls.
Report Facts
Resident census: 74
Sample size: 14
Blood sugar readings above 250: 9
Expired medication dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified failure to notify family timely and failure to update care plan after fall | |
| Nurse J | Verified care plan was not updated and neurological assessment was not completed after fall | |
| Nurse E | Verified lack of documentation for insulin administration | |
| Administrative Nurse A | Verified insulin administration failures and pharmacist reporting failures | |
| Nurse H | Verified expired insulin vial and stock medication | |
| Nurse I | Verified unlabeled insulin pens and expired stock medication | |
| Laundry Staff C | Verified laundry labeling practices for resident clothing | |
| Social Service Staff D | Verified laundry staff mark all resident clothing |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 11, 2011
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that all previously cited deficiencies identified by regulation numbers F0241, F0280, F0282, and F0329 were corrected as of the revisit date.
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 related to the facility's compliance with care standards and resident rights.
Complaint Details
The inspection included a complaint investigation (#50249) related to resident care and dignity.
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 care plans for some residents, and did not ensure proper monitoring of as-needed medications.
Deficiencies (4)
F 241: The facility failed to promote care for residents in a manner that maintained or enhanced dignity in one of three dining rooms, with staff moving between tables during meal assistance.
F 280: The facility failed to provide the resident's representative the right to participate in care planning for one sampled resident.
F 282: The facility failed to implement the care plan for one resident by not leaving the full body sling under the resident after transfer as directed.
F 329: The facility failed to ensure one resident's drug regimen was free from unnecessary drugs by not documenting the effectiveness of as-needed medication administration.
Report Facts
Census: 72
Sampled residents: 10
Residents sampled for unnecessary drugs: 9
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N059002 POC K7PR11
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of the assisted living facility.
Findings
The plan addresses medication administration and monitoring deficiencies, including adherence to insulin ordering, medication disposition policies, and expiration date checks. It also notes that an Emergency Kit is not allowed in Assisted Living.
Deficiencies (1)
S0570-E Assisted Living will provide medication administration and monitoring that is safe and documented correctly. Licensed nurses will follow insulin ordering and medication disposition policies and check expiration dates weekly.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Rupp | Director of Nursing | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N059002 POC LRDU11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a corrective action plan reference.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N059002 POC 90PS11
Visit Reason
This document is a plan of correction related to a prior deficiency report for a facility identified as ASPEN with Event ID 90PS11.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: N059002 POC OCJ911
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey and to outline corrective actions to ensure compliance with state and federal regulations.
Findings
The Plan of Correction details updates to policies on resident abuse, neglect, and exploitation, care plan revisions including pain management and fall interventions, staff education and competency testing, medication cart audits, and dining services dress code and storage policies. It includes specific corrective actions, staff training, audits, and monitoring plans to address identified deficiencies.
Deficiencies (8)
F0000: This Plan of Correction constitutes written allegations for the deficiencies cited and outlines the facility's commitment to develop and implement a system to assure continued compliance with regulations by December 25, 2017.
F609-D: The Resident Abuse Policy was updated to include neglect and exploitation, with mandatory staff training and competency testing, immediate reporting of injuries, and weekly audits of residents to ensure proper investigation and reporting.
F656-D: The Comprehensive Care Plan was updated to include pain management and proper use of warm packs, with audits and checklists implemented to ensure compliance and ongoing monitoring.
F657-D: Care Plans were updated to include fall interventions such as 15- and 30-minute checks and bladder/bowel diaries as part of root cause analysis, with documented checks reviewed in high risk meetings.
F689-G: A Heat Pack Policy was developed and distributed requiring nursing staff to acknowledge understanding before returning to work, with care plans updated accordingly and ongoing staff education.
F689-GX1: The Fall Policy was updated to require 30-minute checks and bladder/bowel diaries for residents identified as fall risks upon admission or readmission, with staff education and competency testing required.
F761-E: On-site correction involved removal of expired medications from medication carts, with implementation of a Medication Audit Log and monthly audits by certified medication aides and coordinators.
F812-F: Dining services staff dress code was updated to require bouffant style hairnets covering all hair, with policy updates on dish and utensil storage and staff re-education and competency testing.
Report Facts
Completion date: Dec 25, 2017
Staff meeting dates: Dec 14, 2017
Staff meeting dates: Dec 15, 2017
Fall risk meeting date: Dec 19, 2017
Medication audit frequency: 1
Fall intervention check intervals: 15
Fall intervention check intervals: 30
Bladder/bowel diary duration: 72
Medication cart audit date: Nov 28, 2017
Staff re-education date: Dec 21, 2017
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N059002 POC DO8K11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Pine Village.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Viewing
Loading inspection reports...
