Inspection Reports for
Pioneer Ridge Retirement Community
4851 HARVARD ROAD, LAWRENCE, KS, 66049-3964
Back to Facility ProfileDeficiencies (last 13 years)
Deficiencies (over 13 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
82% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 20
Date: Dec 3, 2025
Visit Reason
Annual inspection of Pioneer Ridge Retirement Community to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity, secure protected health information, proper medication management, care planning, and infection control. Several residents' care plans lacked necessary updates and directions. Medication storage and staff performance evaluations were also deficient.
Deficiencies (20)
F 0550: The facility failed to ensure a dignified care environment for residents with visible urinary catheter bags lacking privacy covers during meal service.
F 0577: The facility failed to post previous state inspection results in a location accessible to residents and visitors.
F 0583: The facility failed to secure protected health information by leaving an unlocked treatment cart with open laptop displaying PHI in a hallway.
F 0602: The facility failed to prevent medication misappropriation involving narcotics by staff, resulting in errors and lack of proper documentation.
F 0628: The facility failed to provide written notice of transfer/discharge and bed hold information to a resident and her legal representative.
F 0656: The facility failed to implement a comprehensive care plan reflecting a resident's incontinence and assistance needs, including use of a Hoyer lift.
F 0657: The facility failed to revise care plans timely to reflect changes in residents' conditions and care needs, including oxygen therapy directions.
F 0684: The facility failed to follow physician orders for daily weight monitoring to assess a resident's congestive heart failure status.
F 0686: The facility failed to ensure pressure ulcer prevention measures including proper use and monitoring of low air loss mattress and heel protectors.
F 0689: The facility failed to provide fall interventions as directed by a resident's care plan, including proper placement of fall mats and bed positioning.
F 0695: The facility failed to ensure physician orders included diagnosis for oxygen therapy and lacked care plan directions for oxygen administration.
F 0698: The facility failed to provide appropriate dialysis care directions and documentation for a resident requiring dialysis.
F 0730: The facility failed to ensure yearly performance evaluations were completed for all Certified Nurse Aides, placing residents at risk for inadequate care.
F 0761: The facility failed to ensure safe medication storage by leaving medication carts unlocked and unsupervised containing medications and PHI.
F 0812: The facility failed to ensure proper food safety practices including maintaining dairy food temperatures, staff wearing hairnets and beard guards, and documenting sanitization chemical and temperature logs.
F 0849: The facility failed to ensure hospice care coordination and documentation of hospice services and supplies in residents' care plans.
F 0880: The facility failed to implement infection prevention and control measures including signage for enhanced barrier precautions, sanitary storage of oxygen cannulas, hand hygiene, and proper handling of blood glucose monitors.
F 0881: The facility failed to develop and implement an effective antibiotic stewardship program including tracking and trending antibiotic use.
F 0882: The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
F 0883: The facility failed to offer or document pneumococcal vaccinations or informed declinations for several residents as per CDC guidelines.
Report Facts
Residents present: 62
Sample residents reviewed: 17
Missing monthly infection control logs: 6
Days missing dish machine and temperature logs: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including medication storage, infection control, hospice coordination, and antibiotic stewardship |
| Licensed Nurse G | Licensed Nurse | Named in findings related to dignity, care plan review, and hospice care |
| Certified Nurse's Aide M | Certified Nurse Aide | Named in findings related to dignity, infection control, and medication administration |
| Licensed Nurse I | Licensed Nurse | Named in findings related to care plan access, oxygen therapy, and hospice care |
| Certified Medication Aide M | Certified Medication Aide | Named in medication cart security finding |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Aug 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of abuse between staff and a resident.
Complaint Details
The complaint involved Resident 1 alleging that Licensed Nurse G jabbed him multiple times with a walking stick during medication administration. The facility investigated but did not report the allegation to the State Agency, believing the resident was not actually harmed. The allegation was substantiated as an abuse reportable event per facility policy.
Findings
The facility failed to report an allegation of abuse involving a staff member and Resident 1 to the State Agency as required. The investigation found conflicting accounts between the resident and staff, with the facility not submitting the allegation to the State Agency despite policy requirements.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. This failure placed a resident at risk for unidentified and ongoing abuse.
Report Facts
Resident census: 67
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in the abuse allegation involving Resident 1 |
| Administrative Nurse D | Administrative Nurse | Noticed injury mark and involved in investigation |
| Administrative Staff A | Administrative Staff | Conducted investigation and made decisions regarding reporting |
| Licensed Nurse H | Licensed Nurse | Provided testimony about reporting procedures |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Date: Mar 19, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding the facility's failure to ensure staff competencies and proper dietary accommodations for residents with allergies, specifically related to Resident 1's anaphylaxis episode caused by a peanut allergy.
Complaint Details
The investigation was triggered by a complaint related to Resident 1's allergic reaction to a peanut butter cookie served despite documented peanut allergies. The complaint was substantiated, revealing failures in staff competency and dietary management.
Findings
The facility failed to ensure staff had the appropriate skills to identify available epinephrine during an anaphylaxis episode and failed to provide Resident 1 a peanut-free meal per documented allergies, resulting in a severe allergic reaction and hospitalization. The facility had epinephrine in vials, not injectable pens, and staff did not verify meal tickets properly.
Deficiencies (2)
F 0726: The facility failed to ensure nurses and nurse aides had the appropriate competencies to identify available epinephrine during Resident 1's anaphylaxis episode, placing residents with allergies at risk.
F 0806: The facility failed to provide Resident 1 a peanut-free meal per documented allergies, resulting in anaphylaxis, hospitalization, and immediate jeopardy to resident health and safety.
Report Facts
Residents in census: 61
Sample size: 9
Facility Incident Report number: 4060
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Responded to Resident 1's allergic reaction and noted inability to locate epinephrine injection pen |
| Dietary Staff CC | Dietary Staff | Delivered meal tray to Resident 1 and noted dessert placement |
| Dietary Staff DD | Dietary Staff | Accidentally placed peanut butter cookie on Resident 1's tray instead of raisin cookie |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding medication kits and staff expectations |
| Certified Nurse Aide M | Certified Nurse Aide | Stated staff expectations to check meal tickets before serving food |
Inspection Report
Routine
Census: 45
Deficiencies: 15
Date: 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 and bed hold notices, inadequate pressure ulcer prevention, improper use of palm splints, fall risk interventions not fully implemented, incomplete incontinence care, unsanitary respiratory equipment storage, incomplete safety assessments for bed rails, failure to notify physicians of abnormal blood glucose levels, missing stop dates on psychotropic medications, incomplete laboratory record keeping, lack of coordinated hospice care plans, and inadequate infection prevention signage and PPE availability.
Deficiencies (15)
F 0558: The facility failed to ensure Resident 45's call light was within reach, leaving her vulnerable to unmet care needs due to inability to call for staff assistance.
F 0623: The facility failed to provide written notice of transfer as soon as practicable for Resident 31's facility-initiated hospital transfer, risking uninformed choices and miscommunication.
F 0625: The facility failed to provide a bed hold notice to Resident 31 or her representative when transferred to the hospital, risking impaired ability to return to the facility or same room.
F 0686: The facility failed to ensure pressure-relieving boots were applied to Resident 45's heels and a pressure-reducing cushion was in Resident 29's wheelchair, increasing risk for pressure ulcers.
F 0688: The facility failed to ensure Resident 45's palm splint was applied, placing her at risk for discomfort and decreased range of motion.
F 0689: The facility failed to ensure fall interventions were implemented per plan of care for Residents 29 and 34, including missing Dycem in recliner, call lights out of reach, unsecured hazardous chemicals, misplaced fall mat, and call light not within reach.
F 0690: The facility failed to assess, identify, and implement interventions for Resident 31's urinary incontinence, placing her at risk for impaired dignity and urinary tract infections.
F 0695: The facility failed to store Resident 21's CPAP mask in a sanitary manner, increasing risk for respiratory infection and complications.
F 0700: The facility failed to ensure Residents 12 and 46 had documented safety assessments for side rail use addressing entrapment risks, consent, and advisement of risks and benefits, placing them at risk for uninformed decisions and impaired safety.
F 0757: The facility failed to notify Resident 21's physician of blood glucose readings outside ordered parameters, risking delayed treatment of hyperglycemia and medication complications.
F 0758: The facility failed to ensure Residents 32 and 34 had stop dates for PRN lorazepam orders, risking unnecessary medication administration and adverse side effects.
F 0775: The facility failed to include physician-ordered laboratory test results for Resident 31 in the clinical record, risking unnecessary tests and delayed treatment.
F 0849: The facility failed to ensure a coordinated hospice plan of care for Resident 45 that included services provided by hospice, placing the resident at risk for inappropriate end-of-life care.
F 0880: The facility failed to implement Enhanced Barrier Precautions signage and PPE for Residents 7 and 32 and failed to store respiratory equipment in a sanitary manner, placing residents at risk for infectious diseases.
F 0883: The facility failed to obtain consent or declinations for Pneumococcal Conjugate Vaccine (PCV20) for Residents 32, 10, 46, and 34, increasing risk for pneumonia complications.
Report Facts
Residents on Enhanced Barrier Precautions: 5
Sample size: 13
Blood glucose readings above 400 ml/dl: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Provided statements on call light placement, pressure ulcer prevention, fall interventions, respiratory equipment storage, bed rail assessments, blood glucose monitoring, PRN medication stop dates, and infection control signage. | |
| Certified Nurse Aide M | Provided statements on call light placement, pressure ulcer prevention, fall interventions, respiratory equipment storage, bed rail safety, and infection control signage. | |
| Administrative Nurse D | Verified missing transfer and bed hold notices, fall interventions, blood glucose monitoring orders, PRN medication stop dates, laboratory record keeping, hospice care coordination, and infection control signage. |
Inspection Report
Routine
Census: 45
Deficiencies: 15
Date: 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 and bed hold notifications, inadequate pressure ulcer prevention, improper use of palm splints, fall risk interventions not fully implemented, incomplete incontinence care, unsanitary storage of respiratory equipment, incomplete safety assessments for bed rails, failure to notify physicians of abnormal blood glucose levels, lack of stop dates on psychotropic medications, incomplete laboratory record keeping, inadequate hospice care coordination, and failure to implement infection control signage and PPE.
Deficiencies (15)
F 0558: The facility failed to ensure Resident R45's call light was within reach, leaving her vulnerable to unmet care needs due to inability to call for staff assistance.
F 0623: The facility failed to provide written notice of transfer as soon as practicable for Resident R31, risking uninformed choices and miscommunication.
F 0625: The facility failed to provide a bed hold notice to Resident R31 or representative when transferred to hospital, risking impaired ability to return to the facility.
F 0686: The facility failed to ensure pressure-relieving boots were applied to Resident R45's heels and a pressure-reducing cushion was in Resident R29's wheelchair, increasing risk for pressure ulcers.
F 0688: The facility failed to ensure Resident R45's palm splint was applied, risking discomfort and decreased range of motion.
F 0689: The facility failed to ensure fall interventions including Dycem in recliner and call lights within reach for Residents R29 and R34, and failed to secure hazardous chemicals, placing residents at risk for falls and accidents.
F 0690: The facility failed to assess, identify, and implement interventions for Resident R31's urinary incontinence, placing her at risk for dignity impairment and urinary tract infections.
F 0695: The facility failed to store Resident R21's CPAP mask in a sanitary manner, increasing risk for respiratory infection and complications.
F 0700: The facility failed to ensure Residents R12 and R46 had documented safety assessments for bed rail use addressing entrapment risks, consent, and advisement of risks and benefits, risking uninformed decisions and impaired safety.
F 0757: The facility failed to notify Resident R21's physician of blood glucose levels outside ordered parameters, risking delayed treatment and medication complications.
F 0758: The facility failed to ensure Residents R32 and R34 had stop dates for PRN lorazepam orders, risking unnecessary medication administration and adverse effects.
F 0775: The facility failed to include physician-ordered laboratory test results for Resident R31 in the clinical record, risking unnecessary tests and delayed treatment.
F 0849: The facility failed to develop and maintain a coordinated plan of care with hospice services for Resident R45, risking inappropriate end-of-life care.
F 0880: The facility failed to implement Enhanced Barrier Precautions signage and PPE for Residents R7 and R32, and failed to store respiratory equipment in a sanitary manner, risking infectious disease transmission.
F 0883: The facility failed to obtain consent or declinations for Pneumococcal Conjugate Vaccine (PCV20) for Residents R32, R10, R46, and R34, increasing risk for pneumonia complications.
Report Facts
Residents on Enhanced Barrier Precautions: 5
Sample size: 13
Blood glucose readings above 400 ml/dl: 4
Residents reviewed for unnecessary medications: 6
Residents reviewed for immunization status: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements regarding call light placement, pressure ulcer prevention, bed rail assessments, respiratory equipment storage, blood glucose monitoring, and psychotropic medication orders. |
| Certified Nurse Aide M | Certified Nurse Aide | Provided statements regarding call light placement, pressure ulcer prevention, fall interventions, respiratory equipment storage, and hospice services. |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding call light placement, bed hold notices, pressure ulcer prevention, fall interventions, blood glucose monitoring, psychotropic medication orders, laboratory test results, respiratory equipment storage, and hospice care coordination. |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 13
Date: Jul 19, 2023
Visit Reason
Annual inspection of Pioneer Ridge Retirement Community to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity, beneficiary notices, accurate assessments, care planning, activity provision, treatment and care according to orders, fall prevention, nutrition monitoring, medication management, food storage, staffing data submission, and infection control practices.
Deficiencies (13)
F 0550: The facility failed to provide dignified care for residents R206 and R30, placing them at risk for decreased psychosocial well-being due to staff discussing private care information in public and inappropriate responses to resident behaviors.
F 0582: The facility failed to provide Resident R6 with required Medicare beneficiary notices upon facility-initiated discharge from Medicare-Part A services, risking delayed care and missed services.
F 0641: The facility failed to complete an accurate Minimum Data Set (MDS) assessment for Resident R9, incorrectly documenting dialysis services, risking inappropriate care planning.
F 0657: The facility failed to revise Resident R42's comprehensive care plan to include oxygen therapy, risking adverse consequences related to respiratory distress.
F 0679: The facility failed to provide weekend activities reflecting residents' interests, placing residents at risk for boredom, isolation, and decreased quality of life.
F 0684: The facility failed to ensure physician ordered daily weights were obtained and monitored for Resident R45 with congestive heart failure, risking unwanted weight/fluid gain and complications.
F 0689: The facility failed to ensure care planned fall interventions were followed for Resident R1 after a fall, including completion of a three-day voiding diary, increasing risk for additional falls and injury.
F 0692: The facility failed to provide consistent weekly weight monitoring for Resident R14 as identified in her nutritional care plan, placing her at risk for complications related to weight loss and malnutrition.
F 0757: The facility failed to ensure physician notification when antihypertensive medication was not administered for Resident R39 and failed to notify physician of blood glucose readings outside parameters for Resident R7, risking unnecessary medication use and complications.
F 0758: The facility failed to ensure Resident R9 did not receive antipsychotic medication for an extended duration without appropriate dose reduction and physician rationale, and failed to ensure Resident R36 had appropriate diagnosis and documentation for antipsychotic use, risking unnecessary medication and side effects.
F 0812: The facility failed to maintain sanitary dietary standards related to food storage, including unlabeled and undated opened food items, placing residents at risk for foodborne illnesses and safety concerns.
F 0851: The facility failed to submit accurate staffing hours data to the federal regulatory agency through Payroll Based Journaling (PBJ) for FY 2022 quarters three and four.
F 0880: The facility failed to ensure proper infection control standards related to hand hygiene, medical equipment storage and cleaning, and catheter care, placing residents at risk for infectious disease complications.
Report Facts
Resident census: 51
Medication refusal days: 8
Medication held days: 6
Missed daily weights: 23
Days Seroquel administered: 35
Blood glucose readings below 70 mg/dl: 22
Unlabeled/undated food items: 7
PBJ inaccurate reporting dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided statements on dignity, care planning, weight monitoring, medication notification, infection control, and staffing data submission |
| Certified Nurse Aide M | Certified Nurse Aide | Provided statements on dignity, weight monitoring, hand hygiene, and resident care observations |
| Licensed Nurse H | Licensed Nurse | Provided statements on dignity, care planning, medication notification, and infection control |
| Administrative Staff B | Administrative Staff | Provided statements on antipsychotic medication management |
| Administrative Staff C | Administrative Staff | Provided statements on dietary food storage practices |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Feb 7, 2023
Visit Reason
The inspection was conducted following a complaint related to a resident fall incident involving improper use of a Sit-To-Stand lift that resulted in injury.
Complaint Details
The investigation was triggered by a complaint regarding a fall of Resident 1 on 01/26/23. The complaint was substantiated as the facility failed to follow the care plan and proper lift procedures, resulting in actual harm to the resident.
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 facility completed corrective actions prior to the survey, including staff training and in-service education.
Deficiencies (1)
F0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. Staff did not follow the care plan requiring two staff members to assist Resident 1 with Sit-To-Stand lift transfers, causing a fall and injury.
Report Facts
Resident census: 49
Staples used: 7
Days hospitalized: 4
Date of fall: Jan 26, 2023
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 21, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2021-11-17.
Findings
All deficiencies have been corrected as of the compliance date of 2021-12-30, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: 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.
Findings
The plan outlines corrective actions for multiple deficiencies including discharge summary documentation, bathing care plans, restorative nursing care, staffing schedules, medication management, food storage, rehabilitative services, and hand hygiene practices. The facility commits to re-education, monitoring, and ongoing compliance audits.
Deficiencies (9)
F0000 Preparation and execution of the plan of correction does not constitute admission or agreement by the provider of the truth of the deficiencies. The facility will implement a system to assure correction and compliance.
F661-D Resident R54 no longer resides in the facility. Re-education on discharge summary criteria will be completed with nurses and monitored weekly.
F677-E Bathing care plans for several residents have been reviewed and will be revised based on preferences. Staff will be re-educated and compliance monitored weekly.
F688-D The restorative nursing care plan for resident R32 has been reviewed and will be revised as necessary. Re-education and weekly monitoring will be conducted.
F725-E Daily staffing schedules have been reviewed and will be revised to ensure sufficient nursing staff. Re-education and weekly compliance reviews will be done.
F761-E All expired, open, and undated medications have been discarded. Re-education on medication labeling and storage will be conducted with staff and monitored weekly.
F812-F All improperly stored food items have been removed. Dietary staff will be re-educated and food storage areas audited three times weekly.
F825-D Resident R204 is receiving rehabilitative services. Re-education of rehabilitative services policy will be completed and therapy orders reviewed weekly.
F880-E All residents may be affected by improper hand hygiene. Re-education and weekly observations of hand hygiene will be conducted.
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 8
Date: Nov 17, 2021
Visit Reason
Health resurvey inspection to evaluate compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility failed to document discharge summaries, provide consistent bathing for multiple residents, ensure restorative care for a resident, maintain sufficient nursing staff for bathing needs, properly store and discard medications, ensure sanitary food storage, provide timely specialized rehabilitative services, and maintain infection prevention and control practices.
Deficiencies (8)
F661 Discharge Summary: The facility failed to document a recapitulation of the facility stay upon discharge for Resident 54, risking interruption in continuity of care.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide consistent bathing for multiple residents, risking poor hygiene and decreased dignity.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to ensure restorative care was performed for Resident 32, risking contractures and decreased self-care ability.
F725 Sufficient Nursing Staff: The facility failed to have sufficient staffing to meet residents' bathing needs, risking poor hygiene and low self-esteem.
F761 Label/Store Drugs and Biologicals: The facility failed to discard expired suppositories, properly store and date insulin vials and pens, and properly store medications, risking ineffective treatment.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to ensure sanitary food storage, allowing food to be exposed to contaminants, risking foodborne illness.
F825 Provide/Obtain Specialized Rehab Services: The facility failed to provide ordered physical and occupational therapy services to Resident 204 in a timely manner, risking physical impairment and decreased mobility.
F880 Infection Prevention & Control: The facility failed to ensure proper hand hygiene during meal service and appropriate glove use during wound care and peri-care for Resident 29, risking cross-contamination and infection.
Report Facts
Resident sample size: 16
Expired acetaminophen suppositories: 16
Expired suppositories by month: 8
Expired suppositories by month: 5
Expired suppositories by month: 2
Expired suppositories by month: 1
Expired suppositories by month: 1
Medication carts: 4
Medication rooms: 2
Resident census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in relation to discharge summary and bathing documentation findings. |
| Administrative Nurse D | Administrative Nurse | Named in relation to discharge summary, bathing, restorative care, and infection control findings. |
| CNA M | Certified Nurse Aide | Named in relation to bathing documentation and infection control findings. |
| Dietary Staff BB | Dietary Staff | Named in relation to food safety and infection control findings. |
| Therapy Consultant HH | Therapy Consultant | Named in relation to delayed therapy services for Resident 204. |
| LN H | Licensed Nurse | Named in relation to wound care and infection control findings. |
| Administrative Nurse K | Administrative Nurse | Named in relation to wound care and infection control findings. |
| CNA N | Certified Nurse Aide | Named in relation to wound care and infection control findings. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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.
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 1
Date: Dec 4, 2019
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements following a prior survey.
Findings
The facility failed to document a recapitulation of a resident's stay upon discharge, specifically for Resident 56. The discharge summary lacked required elements including a full recapitulation of the resident's stay in the electronic medical record.
Deficiencies (1)
F 661: The facility failed to document a recapitulation of Resident 56's stay upon discharge, missing required discharge summary elements in the electronic medical record.
Report Facts
Resident census: 61
Sample size: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statement regarding discharge procedures |
| Administrative Staff A | Administrative Staff | Stated the EMR lacked a recapitulation of the facility stay |
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 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.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 7, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The facility identified issues with call light accessibility for resident 36 and medication administration timing for residents 59 and 61. Corrective actions include staff education, audits, and monitoring to ensure compliance.
Deficiencies (2)
F600: The call light of resident 36 was not accessible and was corrected by adding a clip to keep it within reach. Staff will be educated on call light accessibility and safety.
F759: Medication administration times for Fosamax and Levothyroxine for residents 59 and 61 were adjusted to comply with proper administration guidelines. Staff will receive education on medication administration policies.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 7, 2018
Visit Reason
The visit was a Health survey conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a '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 12/07/2018.
Deficiencies (1)
The most serious deficiency was a 'D' level deficiency, isolated, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Signed the letter regarding acceptance of plan of correction and compliance status. |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Date: 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.
Complaint Details
The visit was complaint-related, involving investigations #KS00127242, #KS00133251, and #KS00134667. Specific substantiation status is not stated.
Findings
The facility failed to ensure one resident had an easily accessible nursing call light, compromising safety. Additionally, the facility had a medication error rate of 7.14%, exceeding the allowed 5%, with two residents receiving medications incorrectly.
Deficiencies (2)
§483.12(a)(1) The facility failed to ensure resident #36 had an easily accessible nursing call light, resulting in an unsafe environment.
§483.45(f)(1) The facility failed to maintain a medication error rate below 5%, with two medication errors affecting residents #59 and #61.
Report Facts
Census: 68
Medication error rate: 7.14
Medication administrations observed: 28
Medication errors: 2
Sample size: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff G | Administered medications incorrectly to residents #59 and #61 | |
| 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
Plan of Correction
Deficiencies: 0
Date: May 22, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated May 22, 2018.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a corrective action plan linked to a previous deficiency report.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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.
Findings
The re-survey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 14, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously cited under regulation numbers 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.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 14, 2017
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Pioneer Ridge Retirement Community.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 26-40-305 (c)(1)(2) and 26-40-305 (e)(1)(2) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-40-305 (c)(1)(2) deficiency was corrected by the revisit date.
Regulation 26-40-305 (e)(1)(2) deficiency was corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 16, 2017
Visit Reason
The visit was a Health survey conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, 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 June 14, 2017.
Deficiencies (1)
The survey found 'E' level deficiencies indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: 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 05/16/2017.
Findings
The Plan of Correction addresses multiple deficiencies including Medicare billing processes, glove use during dressing changes, and facility environmental issues such as exhaust fan and vacuum breaker maintenance in the beauty shop.
Deficiencies (6)
F0000 Execution of this Plan of Correction does not constitute admission or agreement by this provider or truth of the facts alleged. The facility will develop a system to assure continued compliance with cited regulations.
F156-D Residents #1, #2 and #3 are no longer receiving Medicare services and will be given the opportunity to choose billing options. Social services will be re-educated on advising residents about Medicare appeals and billing.
F441-D The process for changing gloves after cleansing an incision and placing a new dressing was reviewed with the licensed nurse. Licensed nurses will be re-educated on glove use and maintaining a safe environment during dressing changes.
S0000 Execution of this Plan of Correction does not constitute admission or agreement by this provider or truth of the facts alleged. The facility will develop a system to assure continued compliance with cited regulations.
S1354-E The exhaust fan in the beauty shop was fixed on 5/10/17 and is operating correctly. The Director of Environmental Services will check the fan weekly and document findings.
S1358-E A vacuum breaker was installed on the shampoo sink on 5/11/17. The Director of Environmental Services will check the beauty shop weekly and document findings.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: May 10, 2017
Visit Reason
The inspection was conducted as a Health Licensure Resurvey and Complaint Investigations #93028, #995918, #97787, and #97692.
Complaint Details
The visit was triggered by multiple complaint investigations (#93028, #995918, #97787, and #97692).
Findings
The facility failed to ensure proper maintenance and safety in the beauty shop, including a non-functioning exhaust fan and lack of a vacuum breaker on the shampoo sink. The facility also failed to provide policies related to maintenance of the beauty shop.
Deficiencies (2)
26-40-305 (c)(1)(2) Heating, ventilation, and air conditioning systems. The facility failed to ensure there was a functioning exhaust fan in the beauty shop.
26-40-305 (e)(1)(2) Plumbing and piping systems. The facility failed to ensure there was a vacuum breaker on the shampoo sink in the beauty shop.
Report Facts
Resident census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff E was interviewed regarding the exhaust fan and vacuum breaker but no full name was provided. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 21, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously identified deficiencies have been corrected as of the dates listed, with no uncorrected deficiencies noted at the time of revisit.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 10, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey related to resident care and skin issues.
Findings
The facility identified deficiencies related to care plan accuracy for residents with wounds and the assessment and treatment of skin issues. The Plan of Correction outlines steps to review and revise care plans, provide staff education, and monitor compliance.
Deficiencies (2)
F280-D Resident #3’s care plan was reviewed and revised and has appropriate interventions addressing resident’s wounds. The facility will review care plans for all residents with wounds to ensure accuracy.
F314-G Resident #3 has been reassessed to ensure skin issues are identified and treated. All residents at risk will be assessed and nursing staff reeducated on prevention, identification, and documentation of skin issues.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 at F314, with a severity level 'G' indicating actual harm that is not immediate jeopardy. The facility was cited for noncompliance related to pressure ulcers and will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.
Deficiencies (1)
F314 Pressure Ulcers: The facility failed to prevent avoidable pressure ulcers and ensure appropriate care to prevent increased complexity of existing pressure ulcers.
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 as contact for questions and informal dispute resolution process. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: 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.
Complaint Details
The visit was triggered by complaint investigation #110561. The complaint involved failure to update care plans and prevent 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 did not consistently apply barrier creams or use pressure reducing devices as planned.
Deficiencies (2)
483.10(c)(2) The facility failed to support the resident's right to participate in the development and implementation of his or her person-centered plan of care.
483.25(b)(1) The facility failed to provide care to prevent pressure ulcers and did not develop and implement timely and effective interventions to prevent 8 facility-acquired pressure ulcers for one resident.
Report Facts
Resident census: 69
Meals offered: 76
Meals refused: 44
Meals with poor intake: 32
Pressure ulcers: 8
Wound measurements: 10.5
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 7, 2016
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 deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with deficiencies at the 'F' severity level indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Dec 7, 2016
Provider agreement termination date: Mar 7, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement actions |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 29, 2016
Visit Reason
This document is a plan of correction submitted by the facility in response to cited deficiencies, outlining corrective actions taken and future compliance measures.
Findings
The facility corrected the deficiency related to dating insulin pens and inhaled medications by dating all such medications and auditing others. Staff were trained on proper labeling and the facility will continue monitoring compliance.
Deficiencies (1)
Tag S3215: The facility failed to date insulin pens and inhaled medications as required. The facility corrected this by dating all such medications and auditing others for compliance.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 29, 2016
Visit Reason
This is a revisit inspection 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 under regulation 26-41-205(h) was corrected as of the revisit date. No other deficiencies or findings are noted.
Deficiencies (1)
Regulation 26-41-205(h) deficiency was corrected as of 2016-04-29.
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 1
Date: Apr 18, 2016
Visit Reason
The inspection was a Health Licensure Resurvey to verify compliance with medication storage regulations.
Findings
The facility failed to ensure medications were properly dated for six residents, with multiple insulin pens and inhalers lacking open dates as required by manufacturer guidelines and facility policy.
Deficiencies (1)
26-41-205 (h) Medication Storage: The facility failed to properly date medications including insulin pens and Advair inhalers for six residents, contrary to manufacturer and facility policy requirements.
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
Follow-Up
Deficiencies: 3
Date: Nov 13, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported 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 483.15(h)(2), 483.25(a)(3), and 483.25(c) were corrected as of 10/01/2015.
Deficiencies (3)
Regulation 483.15(h)(2): Previously cited deficiency corrected as of 10/01/2015.
Regulation 483.25(a)(3): Previously cited deficiency corrected as of 10/01/2015.
Regulation 483.25(c): Previously cited deficiency corrected as of 10/01/2015.
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Oct 1, 2015
Visit Reason
This document is a Plan of Correction submitted by Pioneer Ridge Retirement Community in response to deficiencies cited during a prior survey.
Findings
The facility identified deficiencies related to environmental cleanliness, resident hygiene and bathing preferences, and pressure sore prevention and treatment. Corrective actions include staff education, care plan updates, and ongoing monitoring by facility leadership.
Deficiencies (3)
F253: Rooms on Blue and Red hall were found with denture cups stored improperly and an unidentified resident's tray table was dirty and cluttered. Environmental Services deep cleaned affected areas and implemented weekly rounds to maintain cleanliness and odor control.
F312: Resident #83 did not receive the preferred number of showers weekly. Nursing staff will be educated on bathing preferences and care plans will be updated accordingly. Compliance will be monitored by random resident interviews and documentation review.
F314: Resident #46's care plan for pressure sore prevention and treatment was reviewed and updated. Nursing staff will be educated on timely interventions and documentation. The Director of Nursing will monitor wound measurements weekly to prevent further occurrences.
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 3
Date: Sep 15, 2015
Visit Reason
The inspection was a health resurvey to evaluate compliance with previously identified deficiencies and overall facility conditions.
Findings
The facility failed to maintain sanitary conditions 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 a resident. Multiple housekeeping, care, and treatment deficiencies were documented.
Deficiencies (3)
F 253 Housekeeping and maintenance services were inadequate as evidenced by persistent urine odors in resident rooms and bathrooms, improper storage and labeling of denture cups, and dirty resident tray tables and remotes.
F 312 The facility failed to provide the preferred number of showers weekly for a dependent resident with cognitive impairment, providing fewer than the twice weekly preference.
F 314 The facility failed to promote healing of a pressure ulcer that developed and worsened in size and stage by not ensuring proper placement of a therapy-developed foam device to relieve pressure on the resident's right lateral ankle.
Report Facts
Resident census: 72
Residents sampled: 20
Pressure ulcer wound measurements: 1.5
Inspection Report
Enforcement
Deficiencies: 1
Date: Sep 15, 2015
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 Medicaid programs. The visit was triggered by deficiencies found in the current survey and a prior complaint survey.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy. The facility was noncompliant with F314 related to pressure ulcers, resulting in denial of payment for new Medicare and Medicaid admissions until substantial compliance is achieved.
Deficiencies (1)
Noncompliance with F314 related to pressure ulcers was found, indicating avoidable pressure ulcers occurred and residents did not receive appropriate care to prevent worsening of existing ulcers.
Report Facts
Denial of payment effective date: Oct 7, 2015
Previous survey date: May 28, 2014
Termination recommendation date: Mar 15, 2016
Civil Money Penalty minimum: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement | Signed enforcement letter and contact for questions |
| Jane Weiler | CMS Regional Office | Contact person for questions regarding the matter |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 6, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm, indicating the facility was not in immediate jeopardy of noncompliance.
Deficiencies (1)
The facility was cited for 'D' level deficiencies related to Life Safety Code compliance. These deficiencies were isolated and posed no immediate jeopardy but had potential for more than minimal harm.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Aug 6, 2015
Effective date for provider agreement termination: Nov 6, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process related to cited deficiencies. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 18, 2014
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at Pioneer Ridge Retirement Community.
Findings
The report documents that the previously cited deficiency with regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by 07/18/2014.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 17, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address all deficiencies including F000 cited in a prior inspection.
Findings
The Plan of Correction outlines corrective actions including enrollment of the Director and Assistant Director of Dining Services in a Certified Dietary Manager course with projected completion dates and intent to take certification exams.
Deficiencies (1)
S0000: Plan of Correction submitted for all deficiencies including F000. S0600-C: Director and Assistant Director of Dining Services enrolled in Certified Dietary Manager course with projected completion dates and intent to take certification exams.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Cardwell | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Irina Strakhova | Added and modified the Plan of Correction. |
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 1
Date: Jul 17, 2014
Visit Reason
The visit was a Non-Compliance Revisit to verify correction of previously cited deficiencies related to dietary services.
Findings
The facility failed to employ a full-time certified dietary manager as required by regulation. Staff interviews and observations confirmed the absence of a certified dietary manager at the time of the visit.
Deficiencies (1)
K.A.R. 28-39-158(a)(1) Dietary services require a full-time certified dietary manager. The facility failed to employ a full-time certified dietary manager as of the inspection date.
Report Facts
Resident census: 70
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 under 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.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Jun 27, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to cited deficiencies from a prior inspection. It outlines corrective actions to address and prevent recurrence of identified issues.
Findings
The facility identified deficiencies related to care plan revisions, medication management, wound assessment, fall prevention, sanitary conditions, medication documentation, and dietary management. Corrective actions include staff education, monitoring by the Director of Nursing and Quality Assurance Committee, and procedural updates.
Deficiencies (7)
F280-D Resident #45 no longer requires protective sleeves following a skin tear; care plan was revised accordingly. Nursing staff educated on timely care plan updates when interventions are no longer needed.
Resident #36 had a diuretic medication on hold with physician notification; nurses educated to place interventions on hold in care plans during medication holds. Compliance monitored by DON.
F314-G Wound nurse and nursing staff educated on proper wound assessment and documentation upon admission, including preventive measures and care plan updates. Compliance monitored by DON.
F323-D Resident #75 reassessed for fall prevention; care plan updated with individualized interventions. Nursing staff educated to implement accident prevention measures. Compliance monitored by DON.
F371-E A qualified plumber will provide required air gap for ice machine drainage to ensure sanitary conditions; ice machine temporarily disconnected until repair. Maintenance and administration responsible for compliance.
F425-D Nurses educated on proper documentation of Exelon patch location and rotation; reference tool provided and monitoring ongoing. Compliance overseen by DON.
S0600-F Dietary Manager attending certification course; Registered Dietitian oversees dietary operations and visits twice weekly to ensure resident requirements are met.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 28, 2014
Visit Reason
The visit was a resurvey of the Assisted Living/Residential Healthcare facility to verify compliance and check for deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 1
Date: May 28, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to employ a full-time certified dietary manager as required by regulation. The registered dietitian provided limited supervision, and the dietary manager was scheduled to take certification in October 2014.
Deficiencies (1)
K.A.R. 28-39-158(a)(1) Dietary services require a full-time certified dietary manager. The facility failed to employ a full-time certified dietary manager during the survey period.
Report Facts
Resident census: 67
Inspection Report
Enforcement
Deficiencies: 1
Date: 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 the Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be a 'G' level related to noncompliance with F314, Pressure Ulcers. Enforcement remedies including denial of payment for new Medicare admissions were imposed due to failure to achieve substantial compliance.
Deficiencies (1)
F314 Pressure Ulcers: The facility failed to implement corrective actions to prevent avoidable pressure ulcers and to provide appropriate care to prevent increased complexity of existing pressure ulcers.
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 header |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 19, 2013
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine 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.
Deficiencies (1)
The facility was cited with an 'E' level deficiency, pattern, indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Feb 19, 2014
Provider agreement termination date: May 19, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Kansas Department for Aging and Disability Services. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Mar 12, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies had been corrected.
Findings
The report confirms that all previously reported deficiencies identified on the CMS-2567 were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.10(b)(5)-(10), 483.10(b)(1): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.10(e), 483.75(l)(4): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.15(a): Previously cited deficiencies were corrected by the revisit date.
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 13, 2013
Visit Reason
The inspection was a licensure resurvey of the facility to assess compliance with regulatory requirements.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Census: 74
Deficiencies: 3
Date: Feb 13, 2013
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with regulatory requirements following a prior survey.
Findings
The facility failed to provide adequate notification of changes in Medicare covered services for 3 residents and failed to maintain personal privacy and dignity for 1 resident during care.
Deficiencies (3)
F 156: The facility failed to provide complete descriptions of services no longer covered under Medicare on Advance Beneficiary Notices for 3 residents.
F 164: The facility failed to provide privacy for 1 resident during care, including failure to close the privacy curtain and discussing other residents' care in the resident's presence.
F 241: The facility failed to promote dignity for 1 resident by staff entering the room without permission and exposing the resident during care without proper privacy measures.
Report Facts
Resident census: 74
Sample size: 20
Residents with Medicare notification issues: 3
Residents with privacy and dignity issues: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N023019 POC C8DX11
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified in a prior inspection report for Pioneer Ridge ALF.
Findings
No specific findings or deficiencies are detailed in this document. It serves solely as a plan of correction record with no additional content.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N023019 POC KBTE11
Visit Reason
This document is a Plan of Correction related to a previous inspection or deficiency report for the facility identified as State ID N023019 ASPEN Event ID KBTE11.
Findings
No deficiency details or findings are provided in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N023019 POC SR1X11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to cited deficiencies from a prior inspection.
Findings
The plan addresses deficiencies related to Medicare coverage notices, resident privacy and confidentiality, and staff practices regarding resident interactions and care procedures.
Deficiencies (3)
F156: The facility will provide a complete description of services no longer covered under Medicare in the Resident's Advance Beneficiary Notice, expanding therapy descriptions to OT/PT/ST. The Director of Social Services will monitor and report compliance.
F164: The facility will ensure resident privacy and confidentiality by re-educating staff to close privacy curtains during care and not disclose information about other residents. The Director of Nursing will oversee training and monitoring.
F241: Staff will be re-educated to knock and obtain permission before entering resident rooms, wait to obtain blood sugar until tasks are complete, and not disclose information about other residents. Compliance will be monitored through interviews and education.
Report Facts
Substantial Compliance Date: Mar 12, 2013
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N023019 POC SSDO11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Pioneer Ridge ALF.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N023019 POC WWEN11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey conducted on 12/4/2019.
Findings
The facility asserts that the cited deficiencies do not jeopardize resident health or safety and outlines corrective actions including staff education on discharge planning and documentation, and ongoing monitoring by the Director of Nursing and Administrator.
Deficiencies (2)
F0000: Execution of this Plan of Correction does not constitute admission or agreement by the provider of the facts alleged or conclusions in the Statement of Deficiencies. The facility will develop a system to assure continued compliance and provide the deficiency list to the Quality Assurance committee by 1/8/2020.
F661-D: Resident R56 is no longer in the facility. Licensed nurses and support staff will be educated on discharge planning and documentation of a resident’s stay in the discharge summary. The Director of Nursing and Administrator will monitor compliance through QA meetings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N023019 POC
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility with State ID N023019.
Findings
No deficiency records or details are provided in this Plan of Correction document.
Viewing
Loading inspection reports...
