Inspection Reports for Pioneer Ridge Retirement Community
4851 HARVARD ROAD, LAWRENCE, KS, 66049-3964
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 21, 2022 found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections showed a pattern of deficiencies related mainly to resident care, including inconsistent bathing and restorative nursing, medication storage and labeling, infection control, and food storage issues. Complaint investigations were generally unsubstantiated, with no enforcement actions, fines, or license suspensions listed in the available reports. Earlier enforcement remedies were imposed in 2014 and 2015 related to pressure ulcer care, but more recent inspections indicate these issues were addressed. The facility appears to have improved over time, correcting prior deficiencies and maintaining compliance in the latest survey.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
11.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
62 residents
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 16
Dec 3, 2025
Visit Reason
The inspection was conducted as part of the annual regulatory oversight of Pioneer Ridge Retirement Community to assess compliance with healthcare facility regulations, including resident rights, care plans, medication management, infection control, and other standards.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified care regarding urinary catheter privacy, failure to post previous inspection results, failure to secure protected health information, medication misappropriation, incomplete care plans, failure to follow physician orders for daily weights, inadequate pressure ulcer care, fall prevention interventions not consistently implemented, lack of physician indication for oxygen therapy, inadequate dialysis care documentation, unsafe medication storage, food safety violations, incomplete hospice service coordination, infection prevention and control program deficiencies, and lack of a qualified infection preventionist.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Potential for minimal harm: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure a dignified care environment for residents with urinary catheters by not providing privacy covers for urinary collection bags during meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post previous state inspection information in a location accessible to residents and visitors. | Level of Harm - Potential for minimal harm |
| Failed to secure protected health information (PHI) by leaving treatment cart laptop open with resident information visible and unattended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent medication misappropriation involving narcotics by staff, resulting in errors in medication administration records and subsequent staff termination. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide written notice of transfer/discharge and bed hold information to resident and legal representative upon facility-initiated transfer to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a comprehensive care plan that meets all resident needs, including activities of daily living, incontinence, and transfer assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plans timely to reflect changes in resident conditions and care needs, including oxygen therapy and pressure injury prevention. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician orders for daily weights were followed for monitoring congestive heart failure, with missing weight documentation on multiple days. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevention, including proper use and monitoring of low air loss mattress and heel protectors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate fall prevention interventions as directed by care plan, including proper placement of fall mats and bed positioning. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician indication for oxygen administration and lacked care plan direction for oxygen therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe medication storage by leaving medication carts unlocked and unsupervised, exposing medications and resident information. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure coordination and documentation of hospice services, supplies, and equipment in resident care plans and communication binders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement an effective infection prevention and control program, including failure to identify residents on enhanced barrier precautions, improper storage of oxygen nasal cannulas, inadequate hand hygiene, and lack of barriers for blood glucose monitors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to designate a qualified infection preventionist responsible for the infection prevention and control program. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement policies and procedures for flu and pneumonia vaccinations, including failure to offer or document declinations or contraindications for pneumococcal vaccines. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 62
Sample size: 17
Medication administration missing weights: 7
Medication carts inspected: 6
Medication carts unsecured: 3
Residents on Enhanced Barrier Precautions: 9
Missing infection control logs: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in findings related to dignified care, care plan access, and hospice care documentation |
| Certified Nurse's Aide M | Certified Nurse's Aide | Named in findings related to dignified care, care plan access, fall prevention, hand hygiene, and medication administration |
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including dignified care, medication misappropriation, care plan review, infection control, and hospice coordination |
| Licensed Nurse J | Licensed Nurse | Named in findings related to PHI security and medication cart supervision |
| Licensed Nurse I | Licensed Nurse | Named in findings related to narcotic counts, care plan access, oxygen therapy, dialysis care, and infection control |
| Certified Medication Aide M | Certified Medication Aide | Named in medication cart security findings |
| Dietary Staff EE | Dietary Staff | Named in food safety findings related to milk temperature and hairnet use |
| Dietary Staff CC | Dietary Staff | Named in food safety findings related to handling glasses |
| Dietary Staff DD | Dietary Staff | Named in food safety findings related to beard guard use |
| Dietary Staff BB | Dietary Staff | Named in food safety findings related to hairnet use and temperature monitoring |
| Administrator A | Administrator | Named in findings related to CNA performance evaluations and hospice coordination |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Aug 20, 2025
Visit Reason
The facility conducted an investigation following an allegation of abuse between staff member LN G and Resident 1 (R1), specifically regarding failure to report the allegation to the State Agency as required.
Findings
The facility failed to report an allegation of abuse involving LN G and R1 to the State Agency, placing R1 at risk for unidentified and ongoing abuse. The investigation included review of grievances, interviews, video surveillance, and staff statements, concluding that the allegation was not reported despite facility policy requiring timely reporting.
Complaint Details
The complaint investigation was triggered by an allegation from Resident 1 that Licensed Nurse G jabbed him multiple times with a walking stick during medication administration. The facility investigated through interviews, grievance review, and video surveillance but failed to report the allegation to the State Agency as required. The allegation was substantiated as an allegation but was not reported due to a recommendation received by Administrative Staff A.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 67
Sample size: 3
Date of incident: Aug 12, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in abuse allegation and investigation |
| Administrative Nurse D | Administrative Nurse | Noticed mark on resident and involved in investigation |
| Administrative Staff A | Administrative Staff | Spoke with LN G and involved in investigation and reporting decisions |
| Licensed Nurse H | Licensed Nurse | Provided statement about reporting allegations |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Mar 19, 2025
Visit Reason
The inspection was conducted following a complaint related to a resident (R1) who suffered an anaphylaxis allergic reaction after being served a peanut butter cookie despite documented peanut allergies. The investigation focused on staff competency in identifying epinephrine availability and adherence to dietary restrictions.
Findings
The facility failed to ensure staff had the appropriate skills and knowledge to identify the available epinephrine during R1's anaphylaxis episode and failed to provide R1 a peanut-free meal per his documented allergies. This resulted in R1's severe allergic reaction, hospitalization, and placed residents with allergies at risk. The facility also lacked a policy on staff competencies and did not follow dietary restrictions properly.
Complaint Details
The complaint investigation was triggered by an incident where Resident 1 was served a peanut butter cookie despite documented peanut allergies, resulting in an anaphylaxis allergic reaction and hospitalization. The facility failed to provide epinephrine in the form of an injectable pen during the emergency and lacked staff competency in identifying available epinephrine. The complaint was substantiated with findings of immediate jeopardy to resident health and safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure staff possessed the appropriate skills and knowledge to identify the available epinephrine during Resident 1's anaphylaxis episode. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the staff provided Resident 1 a peanut-free meal per his reported allergies, resulting in anaphylaxis and hospitalization. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Census: 61
Sample size: 9
Facility Incident Report Number: 4060
Date of emergency medical treatment: Mar 6, 2025
Date of Care Plan: Mar 6, 2025
Date of Communication Note: Mar 7, 2025
Date of Facility Incident Report: Mar 11, 2025
Date of Staff Witness Statement: Mar 12, 2025
Date of Staff Witness Statement: Mar 13, 2025
Date of inspection: Mar 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Responded to Resident 1's allergic reaction, noted inability to find epinephrine pen, called EMS |
| Dietary Staff CC | Dietary Staff | Delivered Resident 1's meal tray, noted no dessert initially |
| Dietary Staff DD | Dietary Staff | Assisted in plating food, accidentally placed peanut butter cookie on Resident 1's tray |
| Administrative Nurse D | Administrative Nurse | Stated staff expectations regarding medication kits and meal verification |
| Dietary Staff BB | Dietary Staff | Described electronic meal ticket system and staff responsibilities |
| Certified Nurse Aide M | Certified Nurse Aide | Stated staff expectations to check meal tickets before serving food |
| Dietary Staff EE | Dietary Staff | Inspected meal tickets during meal plating |
Inspection Report
Routine
Census: 45
Deficiencies: 15
Oct 17, 2024
Visit Reason
Routine inspection of Pioneer Ridge Retirement Community to assess compliance with healthcare regulations including resident care, safety, medication management, infection control, and hospice services.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach, lack of timely transfer and bed hold notifications, inadequate pressure ulcer prevention, improper use of palm splints, fall prevention interventions, urinary incontinence management, respiratory equipment sanitation, psychotropic medication management, laboratory record keeping, hospice care coordination, infection control signage, and pneumococcal vaccination consent.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure Resident 45 had a call light within reach, leaving her vulnerable to unmet care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely written notice for facility-initiated transfer for Resident 31, risking uninformed choices. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide bed hold notice to Resident 31 when transferred to hospital, risking impaired ability to return to facility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pressure-reducing cushion was in Resident 29's wheelchair and offloading boots on Resident 45's heels, increasing risk of pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident 45's palm splint was applied, risking discomfort and decreased range of motion. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure fall prevention interventions including Dycem and call light placement for Resident 29 and fall mat and call light for Resident 34, and failed to secure hazardous chemicals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess, identify, and implement interventions for Resident 31's urinary incontinence, risking dignity and urinary tract infections. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store Resident 21's CPAP mask in a sanitary manner, increasing risk for respiratory infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure documented safety assessments, consent, and risk/benefit advisement for side rail use for Residents 12 and 46, risking uninformed decisions and impaired safety. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure notification to Resident 21's physician for blood glucose levels outside ordered parameters, risking delayed treatment and medication complications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure as-needed lorazepam orders for Residents 32 and 34 had required 14-day stop dates, risking unnecessary medication administration and adverse effects. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to include physician-ordered laboratory test results for Resident 31 in clinical record, risking unnecessary tests and delayed treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure coordinated hospice plan of care for Resident 45, risking inappropriate end-of-life care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement Enhanced Barrier Precautions signage and PPE for Residents 7 and 32, and failed to store respiratory equipment in a sanitary manner, risking infectious disease transmission. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain consent or declinations for Pneumococcal Conjugate Vaccine (PCV20) for Residents 32, 10, 46, and 34, increasing risk for pneumonia complications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in sample: 13
Residents affected: 45
Blood glucose readings above 400 ml/dl: 4
PRN lorazepam stop date duration: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements regarding call light placement, pressure ulcer prevention, fall prevention, respiratory equipment sanitation, blood glucose monitoring, and medication stop dates |
| Certified Nurse's Aide M | Certified Nurse's Aide | Provided statements regarding call light placement, pressure ulcer prevention, fall prevention, respiratory equipment sanitation, and hospice services |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding call light placement, bed hold notices, pressure ulcer prevention, fall prevention, respiratory equipment sanitation, blood glucose monitoring, medication stop dates, laboratory results, and hospice care coordination |
| Certified Nurse's Aide N | Certified Nurse's Aide | Noted hazardous chemicals should be secured in locked area |
| Administrative Staff A | Administrative Staff | Verified lack of written transfer and bed hold notices for Resident 31 |
Inspection Report
Routine
Census: 45
Deficiencies: 15
Oct 17, 2024
Visit Reason
Routine inspection of Pioneer Ridge Retirement Community to assess compliance with healthcare regulations including resident care, safety, medication management, infection control, and hospice services.
Findings
The facility had multiple deficiencies including failure to ensure call lights were within reach, lack of timely transfer notifications, inadequate pressure ulcer prevention, improper use of palm splints, unsafe environment hazards, incomplete incontinence care, improper respiratory equipment storage, lack of safety assessments for bed rails, failure to notify physicians of abnormal blood glucose levels, incomplete laboratory records, inadequate hospice care coordination, failure to implement infection control signage, and failure to obtain pneumococcal vaccine consents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure Resident 45 had a call light within reach, leaving her vulnerable to unmet care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely written notice for Resident 31's facility-initiated transfer to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide bed hold notice to Resident 31 when transferred to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pressure-reducing cushion was in Resident 29's wheelchair and offloading boots on Resident 45's heels. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident 45's palm splint was applied, risking discomfort and decreased range of motion. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe environment free from accident hazards including unsecured cleaning chemicals and missing fall interventions for Residents 29 and 34. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess, identify, and implement interventions related to Resident 31's incontinence, increasing risk for urinary tract infections. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident 21's CPAP mask was stored in a sanitary manner, increasing risk for respiratory infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safety assessments for use of side rails for Residents 12 and 46 including entrapment risk, consent, and advisement of risks and benefits. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify Resident 21's physician of blood glucose readings outside ordered parameters, risking delayed treatment and medication complications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure stop dates for PRN lorazepam orders for Residents 32 and 34, risking unnecessary medication administration and adverse effects. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to include physician-ordered laboratory test results for Resident 31 in clinical record, risking unnecessary tests and delayed treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a coordinated plan of care with hospice services for Resident 45, risking inappropriate end-of-life care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement Enhanced Barrier Precautions signage and PPE for Residents 7 and 32 and failed to store respiratory equipment in a sanitary manner. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain consent or declinations for Pneumococcal Conjugate Vaccine (PCV20) for Residents 32, 10, 46, and 34, increasing risk for pneumonia complications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in sample: 13
Residents affected: 45
Blood glucose readings above 400 ml/dl: 4
PRN lorazepam stop date duration: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements on call light placement, pressure ulcer prevention, respiratory equipment storage, bed rail safety, blood glucose monitoring, and PRN lorazepam stop dates |
| Certified Nurse's Aide M | Certified Nurse's Aide | Provided statements on call light placement, pressure ulcer prevention, fall interventions, respiratory equipment storage, and fall mat placement |
| Administrative Nurse D | Administrative Nurse | Provided statements on call light placement, bed hold notices, pressure ulcer prevention, palm splint use, fall interventions, hazardous chemical storage, blood glucose monitoring, PRN lorazepam stop dates, laboratory test results, hospice care coordination, and infection control signage |
| Certified Nurse's Aide N | Certified Nurse's Aide | Noted hazardous chemicals should be secured in locked area |
| Certified Nurse's Aide | Certified Nurse's Aide | Stated staff should place CPAP mask on bedside table |
Inspection Report
Routine
Census: 51
Deficiencies: 13
Jul 19, 2023
Visit Reason
Routine inspection of Pioneer Ridge Retirement Community to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, incomplete beneficiary notices, inaccurate resident assessments, incomplete care plans, inadequate weekend activities, failure to obtain and monitor daily weights, failure to follow fall interventions, inconsistent medication administration and notification, inappropriate psychotropic medication use, unsanitary food storage, inaccurate staffing data submission, and lapses in infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Potential for minimal harm: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide dignified care for residents R206 and R30, including inappropriate staff communication and response to resident needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide Resident R6 with required Notice of Medicare Non-coverage and Advanced Beneficiary Notice forms upon discharge from Medicare-Part A services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete an accurate Minimum Data Set (MDS) assessment for Resident R9, incorrectly documenting dialysis services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise Resident R42's comprehensive care plan to include administration of oxygen therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide activities on weekends reflecting residents' interests and preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician ordered daily weights were obtained and monitored for Resident R45 with congestive heart failure. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure care planned fall interventions were followed for Resident R1 after a fall, including completion of a three-day voiding diary. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent weekly weight monitoring as identified on Resident R14's nutritional care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician notification when antihypertensive medication was not administered for Resident R39 and blood sugars were outside parameters for Resident R7. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement gradual dose reductions and limit PRN antipsychotic medication use for Resident R9 and failed to ensure appropriate indication and documentation for continued antipsychotic use for Resident R36. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain sanitary dietary standards related to food storage, including unlabeled and undated opened food items. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to submit accurate staffing hours to the federal regulatory agency through Payroll Based Journaling (PBJ) for FY 2022 quarters three and four. | Level of Harm - Potential for minimal harm |
| Failed to ensure proper infection control standards related to hand hygiene, medical equipment storage/cleaning, and catheter care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 51
Medication refusal days: 8
Medication held days: 6
Missed daily weight days: 23
Weight loss: 13.6
Weight loss: 9
Weight loss: 6
Blood glucose readings below 70 mg/dl: 22
PBJ inaccurate reporting dates: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse's Aide M | Certified Nurse Aide | Named in findings related to dignified care, fall interventions, hand hygiene, and weight monitoring |
| Licensed Nurse H | Licensed Nurse | Named in findings related to dignified care, oxygen therapy care plan, medication administration, and infection control |
| Administrative Nurse D | Administrative Nurse | Named in findings related to dignified care, oxygen therapy care plan, medication administration, fall interventions, infection control, and staffing |
| Certified Medication Aide R | Certified Medication Aide | Named in findings related to dignified care |
| Certified Nurse Aide N | Certified Nurse Aide | Named in findings related to dignified care |
| Social Service X | Social Service | Named in findings related to beneficiary notices |
| Certified Nurse's Aide O | Certified Nurse Aide | Named in infection control findings |
| Dietary BB | Dietary Staff | Named in findings related to food storage |
| Administrative Staff C | Administrative Staff | Named in findings related to food storage and dietary oversight |
| Administrative Staff A | Administrative Staff | Named in findings related to food storage and staffing data submission |
| Administrative Nurse B | Administrative Nurse | Named in findings related to staffing data submission |
| Licensed Nurse G | Licensed Nurse | Named in findings related to blood glucose monitoring |
| Administrative Staff B | Administrative Staff | Named in findings related to psychotropic medication management |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Feb 7, 2023
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident involving improper use of a Sit-To-Stand lift that resulted in injury.
Findings
The facility failed to ensure staff followed the care plan requiring two staff members to assist with the Sit-To-Stand lift transfer, resulting in Resident 1 falling and sustaining a scalp laceration requiring emergency hospitalization and staples. The investigation found the lift sling became dislodged during transfer when only one staff member assisted.
Complaint Details
The investigation was complaint-driven, triggered by a fall incident on 01/26/23 where Resident 1 fell from a Sit-To-Stand lift due to improper staff assistance. The complaint was substantiated with findings of actual harm.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff provided care planned fall interventions for Resident 1, specifically requiring two staff members to assist with Sit-To-Stand lift transfers. | Level of Harm - Actual harm |
Report Facts
Residents at risk for falls in sample: 3
Staples required for scalp laceration: 7
Resident height: 73
Resident weight: 205
Days hospitalized: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nurse Aide | Reported details of the fall and signed notarized witness statement describing the incident |
| LN G | Licensed Nurse | Found Resident 1 on floor after fall, documented observations, and called 911 |
| LN I | Licensed Nurse | Responded to shower room after fall and activated emergency medical services |
| CNA M | Certified Nurse Aide | Demonstrated use of Sit-To-Stand lift and stated two people are typically used |
| Administrative Nurse D | Administrative Nurse | Assisted with investigation and noted omission if CNA N operated lift alone |
| Administrative Staff A | Administrative Staff | Acknowledged improper use of lift and staff training |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 21, 2022
Visit Reason
An offsite revisit survey was conducted on 01/21/22 to verify correction of all previous deficiencies cited on 11/17/21.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 8
Nov 17, 2021
Visit Reason
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.
Findings
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.
Severity Breakdown
SS=D: 3
SS=E: 4
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to document a recapitulation of the facility stay upon discharge for Resident 54. | SS=D |
| Failure to provide consistent bathing for multiple residents (R17, R51, R154, R27, R32, R33, and R41), risking poor hygiene and decreased dignity. | SS=E |
| Failure to ensure restorative care was performed for Resident 32, risking contractures and decreased mobility. | SS=D |
| Insufficient nursing staff to meet resident bathing needs, risking poor hygiene and low self-esteem. | SS=E |
| Failure to discard expired suppository medications; improper storage and dating of insulin vials and pens; and improper medication storage. | SS=E |
| Failure to ensure sanitary food storage with food exposed to water leaks and uncovered food items, risking foodborne illness. | SS=F |
| Failure to provide ordered physical and occupational therapy services to Resident 204 in a timely manner, risking physical impairment and decreased mobility. | SS=D |
| Failure to ensure proper hand hygiene during meal service and appropriate glove use and hand hygiene during wound care and peri-care for Resident 29, risking cross-contamination and infection. | SS=E |
Report Facts
Residents reviewed for bathing: 9
Expired acetaminophen suppositories: 16
Expired medication storage dates missing: 10
Bathing refusals and 'Not Applicable' documentation: 31
Bathing refusals and 'Not Applicable' documentation: 25
Bathing refusals and 'Not Applicable' documentation: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in findings related to discharge summary documentation and bathing oversight. |
| Administrative Nurse D | Administrative Nurse | Named in findings related to discharge summary, bathing schedule, restorative therapy notification, and infection control. |
| Certified Nurse Aide M | Certified Nurse Aide | Named in findings related to bathing documentation and refusals. |
| Therapy Consultant HH | Therapy Consultant | Named in findings related to delayed therapy services for Resident 204. |
| Dietary Staff BB | Dietary Staff | Named in findings related to food service hand hygiene and food contamination. |
| Licensed Nurse H | Licensed Nurse | Named in findings related to wound care and infection control. |
| Administrative Nurse K | Administrative Nurse | Named in findings related to wound care and infection control. |
| Certified Nurse Aide N | Certified Nurse Aide | Named in findings related to wound care and infection control. |
Inspection Report
Plan of Correction
Deficiencies: 9
Nov 17, 2021
Visit Reason
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.
Findings
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.
Severity Breakdown
D: 3
E: 4
F: 1
: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Preparation and execution of the plan of correction does not constitute admission or agreement by this provider of the truth of the facts set forth in the statement of deficiencies. | — |
| Resident R54 no longer resides within the facility; re-education of discharge summary criteria and weekly audits planned. | D |
| Bathing care plans reviewed and revised based on resident preferences; re-education and weekly monitoring planned. | E |
| Restorative nursing care plan for R32 reviewed and revised as necessary; re-education and weekly monitoring planned. | D |
| Daily staffing schedules reviewed and revised to ensure sufficient nursing staff; re-education and weekly monitoring planned. | E |
| All expired, open, and undated medications discarded; re-education and weekly audits of medication storage planned. | E |
| All improperly stored food items removed; re-education and thrice-weekly audits of food storage planned. | F |
| Resident R204 receiving rehabilitative services; re-education and weekly review of therapy orders planned. | D |
| Improper hand hygiene during meal services, wound care, and peri-care addressed with re-education and weekly observations. | E |
Report Facts
Deficiencies cited: 9
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 21, 2020
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 12/04/2019.
Findings
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.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 4, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a survey conducted on December 4, 2019, at the facility.
Findings
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.
Severity Breakdown
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Execution of this Plan of Correction does not constitute admission or agreement by this provider of truth of the facts alleged, or the conclusions set forth in the Statement of Deficiencies. | — |
| R56 is no longer in the facility. Licensed nurses and support staff will be educated on discharge planning and documentation. | D |
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 1
Dec 4, 2019
Visit Reason
The inspection was a Health Resurvey conducted to evaluate compliance with discharge summary requirements.
Findings
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document a recapitulation of the resident's stay upon discharge. | SS=D |
Report Facts
Census: 61
Sample size: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statement regarding discharge instructions and progress notes |
| Administrative Staff A | Administrative Staff | Stated that Resident 56's EMR lacked a recapitulation of the facility stay |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 25, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-11-07.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 7, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey of the facility.
Findings
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.
Deficiencies (2)
| Description |
|---|
| Call light of resident 36 was not accessible; a clip was added to keep it within reach. |
| Medication administration times for Fosamax and Levothyroxine were not in accordance with physician orders and were corrected. |
Report Facts
Resident number: 36
Resident number: 59
Resident number: 61
Date: Dec 7, 2018
Date: Nov 21, 2018
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 7, 2018
Visit Reason
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.
Findings
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.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A 'D' level deficiency, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Author of the report and contact person regarding the survey findings. |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Nov 7, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations related to allegations of abuse, neglect, and medication errors at the facility.
Findings
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.
Complaint Details
The visit included complaint investigations #KS00127242, #KS00133251, and #KS00134667 related to abuse, neglect, and medication errors.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure resident #36 had an easily accessible nursing call light, compromising safety. | SS=D |
| Medication error rate exceeded 5%, with errors involving administration of Fosamax and Levothyroxine not following physician orders. | SS=D |
Report Facts
Census: 68
Sample size: 18
Medication administrations observed: 28
Medication error rate: 7.14
Medication errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff G | Administered medications incorrectly leading to medication errors | |
| direct care staff M | Stated call lights should always be within reach of residents | |
| licensed staff H | Stated call lights should always be within reach of residents | |
| administrative staff D | Expected nursing staff to place call lights within reach and confirmed medication administration errors |
Inspection Report
Re-Inspection
Deficiencies: 0
May 22, 2018
Visit Reason
A re-survey for licensure was conducted on 5/21/18 and 5/22/18 at the assisted living facility in Lawrence, KS.
Findings
The re-survey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 2
Jun 14, 2017
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 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.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.10(d)(3)(g)(1)(4)(5)(13)(16)(18) |
| Deficiency related to regulation 483.80(a)(1)(2)(4)(e)(f) |
Inspection Report
Re-Inspection
Deficiencies: 2
Jun 14, 2017
Visit Reason
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.
Findings
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.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-40-305 (c)(1)(2) |
| Deficiency related to regulation 26-40-305 (e)(1)(2) |
Inspection Report
Re-Inspection
Deficiencies: 1
May 16, 2017
Visit Reason
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.
Findings
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.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'E' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter and contact person for the survey findings. |
Inspection Report
Plan of Correction
Deficiencies: 4
May 16, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on May 16, 2017.
Findings
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.
Deficiencies (4)
| Description |
|---|
| Residents #1, #2 and #3 are no longer receiving Medicare services; process for billing and appeals reviewed. |
| Process for changing gloves after cleansing an incision and placing a new dressing was reviewed and licensed nurses will be re-educated. |
| Exhaust fan in the beauty shop was fixed and is operating correctly; weekly checks to be documented. |
| Vacuum breaker installed on shampoo sink; weekly checks to be documented. |
Report Facts
Deficiency correction deadline: Jun 14, 2017
Survey date: May 16, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Annbell | Administrator | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
May 10, 2017
Visit Reason
The inspection was conducted as a Health Licensure Resurvey and Complaint Investigations #93028, #995918, #97787, and #97692.
Findings
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.
Complaint Details
The visit was triggered by multiple complaint investigations (#93028, #995918, #97787, and #97692).
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure there was a functioning exhaust fan in the beauty shop. | SS=E |
| Failed to ensure there was a vacuum breaker (water backflow prevention device) installed on the shampoo sink in the beauty shop. | SS=E |
Report Facts
Census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff E verified the exhaust fan did not function and the vacuum breaker was not installed. |
Inspection Report
Follow-Up
Deficiencies: 2
Mar 21, 2017
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 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.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.10(c)(2)(i-ii,iv,v)(3), 483.21(b)(2) |
| Deficiency related to regulation 483.25(b)(1) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Feb 10, 2017
Visit Reason
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.
Findings
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.
Complaint Details
This Plan of Correction is related to deficiencies cited from a revised complaint investigation dated 02/02/2017.
Deficiencies (2)
| Description |
|---|
| Care plan was reviewed and revised with appropriate interventions addressing resident's wounds. |
| Resident reassessed to ensure skin issues identified, treatments in place, and measures for healing and prevention. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ann Bell | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Feb 2, 2017
Visit Reason
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.
Findings
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.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314 related to pressure ulcers, indicating actual harm but not immediate jeopardy. | G |
Report Facts
Denial of payment effective date: Feb 22, 2017
Compliance deadline: Aug 2, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to complaint coordination and instructions for informal dispute resolution |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Feb 2, 2017
Visit Reason
The inspection was conducted as a complaint investigation #110561 regarding the facility's care planning and treatment related to pressure ulcers.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to update the care plan with timely and effective interventions to prevent 8 facility-acquired pressure ulcers for one resident. | SS=D |
| Failed to develop and implement timely and effective interventions to prevent 8 facility-acquired pressure ulcers for one resident. | SS=G |
Report Facts
Census: 69
Pressure ulcers: 8
Meals offered: 76
Meals refused: 44
Meals poorly consumed: 32
Wound measurements: 10.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physician KK | Physician | Provided progress notes and assessed wounds on resident #3 |
| Staff O | Direct care staff who assisted resident #3 and reported on care practices | |
| Staff P | Direct care staff who assisted resident #3 with toileting and cleansing | |
| Licensed nursing staff I | Licensed Nurse | Assisted resident #3 with toileting and acknowledged lack of pressure reducing cushion |
| Licensed nursing staff G | Licensed Nurse | Reported on resident #3's deep tissue injuries and care practices |
| Dietician DD | Dietician | Made nutritional recommendations and followed up with resident #3 |
| Administrative nursing staff D | Administrative Nurse | Oversaw care plan updates and expected application of barrier cream |
Inspection Report
Life Safety
Deficiencies: 1
Sep 7, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Dec 7, 2016
Provider agreement termination date: Mar 7, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and responsible for licensure certification and enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 1
Apr 29, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-41-205(h) previously cited and now corrected |
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 1
Apr 18, 2016
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with medication storage regulations.
Findings
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.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure medications were properly dated for six residents' insulin pens and inhalers. | SS=E |
Report Facts
Resident census: 52
Residents with undated medications: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff D | Interviewed regarding responsibility for dating insulin pens and Advair inhalers |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 11, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Failure to date insulin pens and inhaled medications as required. |
Report Facts
Date correction completed: Apr 11, 2016
In-service training date: Apr 26, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Ann Bell | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 3
Nov 13, 2015
Visit Reason
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.
Findings
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.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(c) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Enforcement
Deficiencies: 1
Sep 15, 2015
Visit Reason
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.
Findings
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.
Severity Breakdown
Level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314, Pressure Ulcers | Level of actual harm |
Report Facts
Denial of payment effective date: Oct 7, 2015
Noncompliance history date: May 28, 2014
Termination recommendation date: Mar 15, 2016
Civil Money Penalty minimum amount: 5000
IDR request deadline days: 10
Hearing request deadline days: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Cardwell | Administrator | Facility administrator named in the report |
| Irina Strakhova | Enforcement | Enforcement official signing the report |
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 3
Sep 15, 2015
Visit Reason
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.
Findings
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.
Severity Breakdown
Level E: 1
Level D: 1
Level G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to maintain sanitary and odor-free resident rooms, including improper storage and labeling of denture cups and inadequate cleaning of resident items. | Level E |
| Failure to provide the preferred number of showers weekly for a dependent resident with cognitive impairment. | Level D |
| Failure to develop and implement timely interventions to prevent development and promote healing of an unstageable pressure ulcer that worsened in size and stage. | Level G |
Report Facts
Resident census: 72
Resident sample size: 20
Pressure ulcer wound measurements: 1.5
Pressure ulcer wound measurements: 1.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Nursing Staff | Instructed staff on denture cup handling and foam device placement; reported resident refusal of foam device |
| Staff R | Direct Care Staff | Reported improper denture cup storage and lack of bathing interventions for resident #83 |
| Staff Q | Direct Care Staff | Acknowledged dirty resident items and described foam wedge use for pressure ulcer prevention |
| Staff O | Direct Care Staff | Observed positioning of resident with foam device and unaware of pressure ulcer prevention interventions |
| Staff H | Licensed Nursing Staff | Provided wound care and observed improper foam device placement |
| Staff I | Licensed Nursing Staff | Reported wound care interventions and lack of heel floating |
| Staff J | Licensed Nursing Staff | Reported wound treatment and foam block use; confirmed resident did not refuse foam block |
| Staff S | Direct Care Night Staff | Reported limited night care and unawareness of resident's pressure ulcers |
| Staff T | Direct Care Staff | Described bathing scheduling based on resident preferences |
| Staff Y | Housekeeping Staff | Reported cleaning of resident tray tables and remotes |
| Staff C | Administrative Nursing Staff | Requested care plan revision and staging of wound |
| Staff HH | Therapy Consultant | Provided evaluation and training regarding foam device for pressure ulcer prevention |
| Physician II | Physician | Expected staff to follow therapy recommendations and notify of refusals |
| Dietary Consultant GG | Dietary Consultant | Reported resident's nutritional status as normal |
Inspection Report
Plan of Correction
Deficiencies: 3
Sep 15, 2015
Visit Reason
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.
Findings
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.
Severity Breakdown
D: 2
G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Denture cups were set inside one another and resident's tray table was dirty and cluttered. | D |
| Resident #83 did not receive the preferred number of showers weekly. | D |
| Resident #46's care plan for pressure sore prevention and treatment required review and updates. | G |
Report Facts
Substantial Compliance Date: Oct 1, 2015
Education Date: Sep 29, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Cardwell | Administrator | Submitted the Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
May 6, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be isolated 'D' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Isolated 'D' level deficiencies found during the Life Safety Code survey | D |
Report Facts
Effective date for denial of payments: Aug 6, 2015
Provider agreement termination date: Nov 6, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 18, 2014
Visit Reason
This revisit report documents the follow-up inspection to verify that previously reported deficiencies have been corrected.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited was corrected. |
Report Facts
Deficiency correction date: Jul 18, 2014
Inspection Report
Follow-Up
Deficiencies: 0
Jul 17, 2014
Visit Reason
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.
Findings
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.
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 2
Jul 17, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report for the facility Pioneer Ridge.
Findings
The Plan of Correction outlines corrective actions including staff enrollment in Certified Dietary Manager courses and collaboration with a Registered Dietician to address deficiencies.
Deficiencies (2)
| Description |
|---|
| All deficiencies including F000 |
| Dietary services deficiencies addressed by staff training and certification plans |
Report Facts
Projected completion date: Oct 31, 2014
Projected completion date: Aug 31, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Steven Cardwell | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 1
Jul 17, 2014
Visit Reason
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.
Findings
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.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to employ a full-time certified dietary manager. | SS=C |
Report Facts
Census: 70
Inspection Report
Plan of Correction
Deficiencies: 7
Jun 27, 2014
Visit Reason
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.
Findings
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.
Severity Breakdown
D: 4
G: 1
E: 1
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Resident #45 no longer requires protective sleeves; care plan revised accordingly. | D |
| Resident #36 had a diuretic medication on hold with Black Box Warning; nursing staff educated to update care plans accordingly. | D |
| Wound nurse educated on proper wound assessment and documentation upon admission. | G |
| Resident #75 reassessed and interventions to prevent falls revised and implemented. | D |
| Air gap required for ice machine drainage repaired; ice machine temporarily disconnected until fixed. | E |
| Nurses educated on proper documentation of Exelon patch location and rotation requirements. | D |
| Dietary Manager attending certification course; Registered Dietitian overseeing dietary services. | F |
Report Facts
Substantial Compliance Date: Jun 27, 2014
Inspection Report
Annual Inspection
Deficiencies: 1
May 28, 2014
Visit Reason
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.
Findings
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.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314, Pressure Ulcers | G |
Report Facts
Denial of payment effective date: Aug 28, 2014
Termination recommendation date: Nov 28, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Cardwell | Administrator | Named as facility administrator in the report |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 1
May 28, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations, specifically regarding staffing and certification of the dietary manager.
Findings
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.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to employ a full-time certified dietary manager. | SS=F |
Report Facts
Census: 67
Inspection Report
Re-Inspection
Deficiencies: 0
May 28, 2014
Visit Reason
The visit was a resurvey of the Assisted Living/Residential Healthcare facility to assess compliance and verify correction of previous deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Life Safety
Deficiencies: 1
Nov 19, 2013
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 '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.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. | E |
Report Facts
Effective date for denial of payments: Feb 19, 2014
Provider agreement termination date: May 19, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 3
Mar 12, 2013
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 had been corrected.
Findings
The revisit confirmed that the deficiencies identified in prior surveys were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency identified under regulation 483.10(b)(5) - (10), 483.10(b)(1) |
| Deficiency identified under regulation 483.10(e), 483.75(l)(4) |
| Deficiency identified under regulation 483.15(a) |
Report Facts
Correction completion date: Mar 12, 2013
Inspection Report
Plan of Correction
Deficiencies: 3
Mar 12, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to cited deficiencies in a prior inspection report.
Findings
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.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Incomplete description of services covered under Medicare in the Resident's Advance Beneficiary Notice. | D |
| Failure to ensure resident privacy and confidentiality during care. | D |
| Staff not consistently knocking before entering resident rooms, improper timing of blood sugar checks, and disclosing information about other residents. | D |
Report Facts
Substantial Compliance Date: Mar 12, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Cardwell | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Re-Inspection
Census: 74
Deficiencies: 3
Feb 13, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements related to resident rights, privacy, and dignity.
Findings
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.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide adequate notification of changes in Medicare covered services for 3 residents (#113, #34, #126). | SS=D |
| Failed to provide personal privacy for resident #26 during care, including failure to close privacy curtain and discussing other residents' care in front of the resident. | SS=D |
| Failed to promote dignity and respect for resident #26 by entering the room without knocking or permission and discussing other residents' care in the resident's presence. | SS=D |
Report Facts
Census: 74
Sample size: 20
Residents with notification deficiency: 3
Residents with privacy and dignity deficiencies: 1
Inspection Report
Renewal
Deficiencies: 0
Feb 13, 2013
Visit Reason
The licensure resurvey was conducted to assess compliance for renewal of the facility's license.
Findings
The licensure resurvey of the facility resulted in a finding of no deficiency citations.
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