Inspection Reports for Pioneer Ridge Retirement Community

An offsite revisit survey was conducted on 01/21/22 to verify correction of all previous deficiencies cited on 11/17/21.

All deficiencies cited in the prior inspection have been corrected as of the compliance date of 12/30/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

Annual health resurvey of Pioneer Ridge Retirement Community to assess compliance with federal regulations including resident care, staffing, medication management, infection control, and food safety.

The facility was cited for multiple deficiencies including failure to document discharge summaries, inconsistent bathing care for multiple residents, insufficient restorative nursing care, inadequate staffing to meet resident bathing needs, improper medication storage and labeling, unsanitary food storage conditions, delayed provision of ordered therapy services, and lapses in infection prevention and control practices.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection conducted on November 17, 2021.

The plan outlines corrective actions for multiple deficiencies related to discharge summaries, bathing care plans, restorative nursing care, staffing schedules, medication management, food storage, rehabilitative services, and hand hygiene. The facility commits to re-education of staff, monitoring compliance through audits and reviews, and reporting results to the Quality Assurance Committee.

A revisit survey was conducted to verify correction of all previous deficiencies cited on 12/04/2019.

All deficiencies cited in the prior inspection have been corrected as of 01/08/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies cited during a survey conducted on December 4, 2019, at the facility.

The facility disputes the alleged deficiencies but has developed a facility-wide system to assure continued compliance with regulations and will provide the deficiency list to the Quality Assurance committee for review and action.

The inspection was a Health Resurvey conducted to evaluate compliance with discharge summary requirements.

The facility failed to document a recapitulation of the resident's stay upon discharge, specifically for Resident 56, despite documentation of diagnoses, therapies, and discharge instructions. The facility's discharge policy lacked clear nurse responsibilities for summarizing the resident's stay.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-11-07.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2018-12-07, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey of the facility.

The facility identified issues related to call light accessibility for resident #36 and medication administration timing for residents #59 and #61. Corrective actions include staff education, system improvements, and ongoing monitoring to ensure compliance.

A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found a single 'D' level deficiency, isolated, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-12-07.

The inspection was conducted as a Health Resurvey and Complaint Investigations related to allegations of abuse, neglect, and medication errors at the facility.

The facility failed to ensure one resident had an easily accessible nursing call light, compromising a safe environment. Additionally, the facility had a medication error rate of 7.14%, with two residents receiving medications not in accordance with physician orders.

The visit included complaint investigations #KS00127242, #KS00133251, and #KS00134667 related to abuse, neglect, and medication errors.

A re-survey for licensure was conducted on 5/21/18 and 5/22/18 at the assisted living facility in Lawrence, KS.

The re-survey resulted in a finding of no deficiency citations.

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

The report confirms that the deficiencies previously cited under regulations 483.10(d)(3)(g)(1)(4)(5)(13)(16)(18) and 483.80(a)(1)(2)(4)(e)(f) were corrected as of the revisit date.

This revisit report documents the correction of previously cited deficiencies at Pioneer Ridge Retirement Community, verifying that corrective actions were completed as of the revisit date.

The report confirms that previously reported deficiencies identified by regulation numbers 26-40-305 (c)(1)(2) and 26-40-305 (e)(1)(2) have been corrected and the corrective actions were completed on 06/14/2017.

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

The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction as of June 14, 2017.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on May 16, 2017.

The Plan of Correction addresses multiple deficiencies including Medicare billing processes, glove use during dressing changes, and environmental issues such as exhaust fan and vacuum breaker repairs. The facility outlines corrective actions, re-education plans, and monitoring procedures to ensure compliance.

The inspection was conducted as a Health Licensure Resurvey and Complaint Investigations #93028, #995918, #97787, and #97692.

The facility failed to ensure there was a functioning exhaust fan in the beauty shop and failed to have a vacuum breaker (water backflow prevention device) installed on the shampoo sink in the beauty shop. Additionally, the facility did not provide a policy related to maintenance of the beauty shop.

The visit was triggered by multiple complaint investigations (#93028, #995918, #97787, and #97692).

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

The report confirms that the deficiencies previously cited under regulations 483.10(c)(2)(i-ii,iv,v)(3), 483.21(b)(2), and 483.25(b)(1) have been corrected as of 02/10/2017.

This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey related to a revised complaint dated 02/02/2017.

The facility identified deficiencies related to care plans addressing residents' wounds and skin issues. The Plan of Correction outlines actions including review and revision of care plans, staff education, reassessment of residents, and ongoing monitoring by the Director of Nursing and Administrator.

This Plan of Correction is related to deficiencies cited from a revised complaint investigation dated 02/02/2017.

An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be F314, with a severity level of 'G', indicating actual harm that is not immediate jeopardy. The facility was found noncompliant with pressure ulcer prevention and care requirements.

The inspection was conducted as a complaint investigation #110561 regarding the facility's care planning and treatment related to pressure ulcers.

The facility failed to update the care plan with timely and effective interventions to prevent the development of 8 facility-acquired pressure ulcers for one cognitively impaired resident. The care plan lacked documentation of the resident's eating ability and did not reflect new wounds or interventions. Staff failed to consistently apply barrier cream and use pressure reducing devices as planned.

The inspection was triggered by complaint investigation #110561. The facility was found deficient in care planning and treatment related to pressure ulcers for resident #3.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.

The report confirms that the previously cited deficiency related to regulation 26-41-205(h) was corrected as of 04/29/2016. No other deficiencies or findings are documented.

The inspection was a Health Licensure Resurvey to assess compliance with medication storage regulations.

The facility failed to ensure medications were properly dated for six residents, with multiple insulin injector pens and an inhaler lacking open dates, violating manufacturer and facility policies.

The document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection, specifically related to medication labeling and dating.

The facility corrected the deficiency by dating all insulin pens and inhaled medications and auditing all other resident medications to ensure compliance. Staff were re-educated on proper labeling and dating procedures, and monitoring will continue through the quality improvement team.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that deficiencies previously cited under regulations 483.15(h)(2), 483.25(a)(3), and 483.25(c) were corrected by 10/01/2015.

A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs. The survey found serious deficiencies requiring enforcement remedies.

The facility was found to have deficiencies at a level of actual harm but not immediate jeopardy, specifically related to pressure ulcers (F314). Due to prior noncompliance, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions.

The inspection was a health resurvey to assess compliance with regulatory requirements related to housekeeping, maintenance, activities of daily living care, and pressure sore prevention and treatment.

The facility failed to maintain a sanitary and odor-free environment in resident rooms, failed to provide adequate bathing care to a dependent resident, and failed to properly prevent and treat a pressure ulcer that developed and worsened in size and stage due to improper use of a pressure-relieving foam device.

This document is a Plan of Correction submitted by Pioneer Ridge Retirement Community in response to deficiencies cited during a survey conducted on 2015-09-15.

The Plan of Correction addresses deficiencies related to environmental cleanliness, resident hygiene preferences, and pressure sore prevention and treatment. The facility outlines corrective actions including deep cleaning, staff education, care plan updates, and ongoing monitoring to ensure compliance.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be isolated 'D' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy.

This revisit report documents the follow-up inspection to verify that previously reported deficiencies have been corrected.

The report confirms that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 07/18/2014.

This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit confirmed that all previously reported deficiencies related to regulations 483.20(d)(3), 483.10(k)(2), 483.25(c), 483.25(h), 483.35(i), and 483.60(a),(b) were corrected as of the revisit date.

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

The Plan of Correction outlines corrective actions including staff enrollment in Certified Dietary Manager courses and collaboration with a Registered Dietician to address deficiencies.

The visit was a Non-Compliance Revisit to assess the facility's compliance with dietary services regulations, specifically regarding staffing requirements for a certified dietary manager.

The facility failed to employ a full-time certified dietary manager as required by regulation. Interviews and observations confirmed the absence of a certified dietary manager, with staff scheduled to take certification tests in the future.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report, outlining corrective actions to address and prevent recurrence of the cited deficiencies.

The plan details corrective actions including revision of care plans, staff education on medication and wound care, monitoring by the Director of Nursing and Quality Assurance Committee, and maintenance repairs to ensure compliance with regulations and resident safety.

The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be at a 'G' level related to pressure ulcers (F314). Enforcement remedies including denial of payment for new Medicare admissions were imposed due to noncompliance, with recommendations for corrective actions to prevent avoidable pressure ulcers and improve care.

The inspection was a Health Resurvey to assess compliance with dietary services regulations, specifically regarding staffing and certification of the dietary manager.

The facility failed to employ a full-time certified dietary manager as required. The dietary staff was scheduled to take the certification test in October 2014, and a registered dietitian visited one to two times weekly to assist with menus.

The visit was a resurvey of the Assisted Living/Residential Healthcare facility to assess compliance and verify correction of previous deficiencies.

The resurvey resulted in a finding of no deficiency citations.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

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

The revisit confirmed that the deficiencies identified in prior surveys were corrected as of the revisit date.

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

The plan outlines corrective actions for deficiencies related to Medicare service descriptions, resident privacy and confidentiality, and staff practices regarding resident interactions and information disclosure.

The inspection was a Health Resurvey to assess compliance with regulatory requirements related to resident rights, privacy, and dignity.

The facility failed to provide adequate notification of changes in Medicare covered services for 3 residents, failed to maintain personal privacy for 1 resident during care, and failed to promote dignity and respect for the same resident by not knocking before entering and discussing other residents' care in their presence.

The licensure resurvey was conducted to assess compliance for renewal of the facility's license.

The licensure resurvey of the facility resulted in a finding of no deficiency citations.