Inspection Report Summary
The most recent inspection on April 14, 2025, found the facility in compliance with all regulations and no deficiencies were cited. Prior inspections showed a pattern of deficiencies primarily related to care planning, pain management, staffing documentation, psychotropic medication use, food sanitation, and infection control, with corrective actions implemented after each survey. Complaint investigations were generally unsubstantiated, except for a notable substantiated case in 2019 involving inadequate care for residents with pressure ulcers and urinary incontinence. Enforcement actions occurred in earlier years, including denial of payment for new admissions due to deficiencies related to physical restraints and safety hazards, but no fines or license suspensions were listed in the available reports. The trend indicates improvement over time, with recent inspections showing correction of prior issues and compliance maintained at the latest survey.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
24.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
312% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
38 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 14, 2025
Visit Reason
An offsite revisit survey was conducted on 04/14/25 for all previous deficiencies cited on 03/05/25.
Findings
All deficiencies have been corrected as of the compliance date of 04/11/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 6
Mar 24, 2025
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during a prior inspection. It outlines corrective actions to address identified issues related to care planning, pain management, staffing information, psychotropic medication use, food sanitation, and infection control.
Findings
The Plan of Correction details multiple deficiencies including inadequate interdisciplinary care plans for pain management, incomplete nurse staffing information, improper use of psychotropic medications, food procurement and sanitation issues, and infection prevention lapses. The facility has implemented corrective actions such as revising care plans, staff training, new documentation procedures, and enhanced monitoring to ensure compliance.
Severity Breakdown
D: 3
C: 1
F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to develop and implement comprehensive care plans including non-pharmacologic interventions for pain. | D |
| Inadequate pain management and lack of staff instruction on non-pharmacologic interventions. | D |
| Incomplete posting and documentation of nurse staffing information. | C |
| Use of unnecessary psychotropic medications without proper monitoring and documentation. | D |
| Food procurement, storage, preparation, and serving not sanitary; food items not properly covered or dated. | F |
| Infection prevention and control deficiencies including improper storage of supplies and inadequate PPE procedures. | F |
Report Facts
Plan of Correction completion date: 2025
Retention period for staffing records: 18
Number of residents referenced in care plan deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Dawne Altis | Added Plan of Correction | |
| Lori Mouak | Modified Plan of Correction |
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 6
Mar 5, 2025
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans with non-pharmacologic pain interventions, failure to provide adequate pain management, failure to post accurate nurse staffing information, failure to monitor side effects of psychotropic medications, failure to store and serve food in a sanitary manner, and failure to maintain an effective infection prevention and control program.
Complaint Details
The visit included a complaint investigation as indicated by the Health Resurvey and Complaint Investigation citations 192114 and 191821.
Severity Breakdown
SS=D: 3
SS=C: 1
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to complete a resident-centered comprehensive care plan including non-pharmacologic interventions for pain for one resident. | SS=D |
| Failure to offer non-pharmaceutical interventions for pain for one resident with chronic pain. | SS=D |
| Failure to post accurate, publicly accessible, and identifiable nurse staffing information daily. | SS=C |
| Failure to monitor side effects of psychotropic and antipsychotic medications for residents receiving these drugs. | SS=D |
| Failure to store, prepare, and serve food in a sanitary manner, including undated and unsealed food items in storage and serving areas. | SS=F |
| Failure to establish and maintain an infection prevention and control program, including incontinent products on bathroom floors, improperly disposed PPE, clutter in resident rooms, and medication cards stored on the floor. | SS=F |
Report Facts
Resident census: 38
Residents sampled: 15
Medication administrations: 7
Medication administrations: 4
Medication administrations: 15
Medication administrations: 7
Medication cards: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Confirmed lack of non-pharmacologic pain interventions and failure to monitor side effects of psychotropic medications. |
| Certified Nurse Aide N | Certified Nurse Aide | Reported resident had back pain and would notify nurse for pain medication. |
| Dietary Manager BB | Dietary Manager | Acknowledged undated and unsealed food items in storage and stated she would discard inappropriate items. |
Inspection Report
Renewal
Deficiencies: 0
Oct 25, 2023
Visit Reason
The visit was a Re-Licensure survey conducted for the assisted living facility on 10/25/23.
Findings
The Re-Licensure survey resulted in no deficiencies for the facility.
Inspection Report
Renewal
Deficiencies: 0
Oct 25, 2023
Visit Reason
The visit was a Re-Licensure survey for the assisted living facility Prairie Sunset Home Inc conducted on 10/25/2023.
Findings
The survey resulted in no deficiencies for the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 16, 2023
Visit Reason
A revisit survey was conducted on 08/16/23 to verify correction of all previous deficiencies cited on 06/14/23.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 07/10/23, 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: 6
Jun 24, 2023
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during a regulatory inspection conducted on June 14, 2023, and finalized June 24, 2023.
Findings
The Plan of Correction addresses multiple deficiencies related to care plan timing and revision, ADL care for dependent residents, accident hazards and fall prevention, bowel/bladder incontinence management, food procurement and sanitation, and immunization compliance. The facility outlines corrective actions, staff training, and monitoring plans to ensure compliance.
Severity Breakdown
D: 4
G: 1
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Care Plan Timing and Revision - Interdisciplinary Care Plan for resident #28 amended to include fall prevention approaches. | D |
| ADL Care Provided for Dependent Residents - Added ADL supportive interventions including daily shaving and nail care to resident #30's care plan. | D |
| Free of Accident Hazards/Supervision/Devices - Care plan for resident #28 amended with fall prevention and toileting interventions. | G |
| Bowel/Bladder Incontinence, Catheter, UTI - Added toileting plan and 3-day voiding diary to resident #30's care plan. | D |
| Food Procurement, Store/Prepare/Serve-Sanitary - Omissions reviewed and corrected; staff retrained on sanitation and food storage. | F |
| Influenza and Pneumococcal Immunizations - Vaccine consent forms obtained and vaccination clinic initiated. | D |
Report Facts
Completion date: 2023
Inspection date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 7
Jun 14, 2023
Visit Reason
Health resurvey inspection conducted to assess compliance with care plan revisions, ADL care, accident hazards, bowel/bladder incontinence, RN staffing, food safety, and immunization requirements.
Findings
The facility failed to revise care plans related to falls, provide consistent ADL care, implement timely fall prevention interventions, maintain individualized toileting plans, ensure 8-hour RN coverage daily, properly store food and discard expired items, and document pneumococcal vaccine education and administration for residents.
Severity Breakdown
SS=D: 4
SS=G: 1
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to revise care plans for Resident 28 related to multiple falls. | SS=D |
| Failed to provide care consistent with standard practice for grooming and hygiene for Resident 30. | SS=D |
| Failed to provide timely and appropriate fall prevention interventions for Resident 28 with multiple falls and fractured humerus. | SS=G |
| Failed to provide individualized toileting plan for Resident 28 to maintain continence. | SS=D |
| Failed to provide RN coverage for at least eight consecutive hours daily on six days in the last two months. | SS=F |
| Failed to properly store food in kitchen refrigerators and dry storage, including uncovered foods, expired items, boxes on floor, and missing temperature logs. | SS=F |
| Failed to ensure residents or representatives received education regarding pneumococcal vaccine benefits and risks, and failed to document vaccine administration or refusal for three residents. | SS=D |
Report Facts
Facility census: 31
Residents sampled: 12
Days without 8-hour RN coverage: 6
Expired food items: 5
Residents lacking pneumococcal vaccination: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse J | Licensed Nurse | Reported not adding new interventions to care plans following falls |
| Administrative Nurse B | Administrative Nurse | Verified lack of continuous 8-hour RN coverage and expected care plan revisions with falls |
| Certified Nurse Aide K | Certified Nurse Aide | Shower aide assigned to showers, confirmed documentation requirements |
| Certified Nurse Aide H | Certified Nurse Aide | Reported resident not safe to ambulate alone and lack of toileting plan |
| Certified Nurse Aide G | Certified Nurse Aide | Reported resident needed reminders and was not mobile after broken arm |
| Dietary Staff D | Dietary Staff | Confirmed boxes on floor due to recent delivery and responsibility to check expiration dates |
| Dietary Staff C | Dietary Staff | Confirmed staff responsibility to discard expired foods and cover/dating opened items |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 26, 2022
Visit Reason
The visit was a resurvey of the assisted living facility conducted on 04/25/22 - 04/26/22.
Findings
The resurvey resulted in no deficiencies being found at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 25, 2022
Visit Reason
This document represents the provider's plan of correction following a resurvey of the assisted living facility conducted on April 25-26, 2022.
Findings
The resurvey conducted on April 25-26, 2022, resulted in no deficiencies for the assisted living facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 3, 2022
Visit Reason
An offsite revisit survey was conducted on 01/03/22 to verify correction of all previous deficiencies cited on 11/04/21.
Findings
All deficiencies have been corrected as of the compliance date of 12/17/21, 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: 6
Nov 23, 2021
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during an inspection of Prairie Sunset Home, addressing various cited deficiencies and outlining corrective actions.
Findings
The Plan of Correction details corrective actions for multiple deficiencies including oxygen administration and tubing replacement, missing discharge summaries, respiratory care, drug regimen review and reporting irregularities, and food procurement and sanitation practices. The facility asserts substantial compliance and outlines staff training and monitoring plans.
Severity Breakdown
D: 5
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Oxygen administration and tubing replacement not properly documented or scheduled | D |
| Missing discharge summary recapitulation for a resident | D |
| Respiratory/tracheostomy care and suctioning deficiencies related to oxygen delivery tubing | D |
| Drug regimen review irregularities related to blood pressure monitoring and physician notification | D |
| Drug regimen included unnecessary drugs | D |
| Food procurement, storage, preparation, and serving sanitation concerns | F |
Report Facts
Completion date: Dec 17, 2021
Inspection meeting date: Nov 23, 2021
QAPI Committee meeting date: Nov 19, 2021
Consecutive blood pressure readings: 3
Number of residents cited for oxygen tubing replacement: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction | |
| Jessica Patterson | Modified Plan of Correction | |
| Director of Nursing | Director of Nursing | Responsible for monitoring compliance and meeting with staff regarding plan of correction |
| Medical Director | Discussed oxygen administration and blood pressure protocols during QAPI meeting | |
| RN Admission Coordinator | Reviewed discharge summaries and assigned discharge recapitulation responsibility | |
| Dietary Manager | Responsible for monitoring food procurement and sanitation compliance |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 6
Nov 4, 2021
Visit Reason
The inspection was a health resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for oxygen use, failure to document discharge summaries, inadequate respiratory care related to oxygen equipment changes, failure to report and monitor blood pressure irregularities for residents on antihypertensive medications, and unsanitary food storage and preparation practices.
Severity Breakdown
SS=D: 5
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan including oxygen use for Resident 23. | SS=D |
| Failed to document a discharge summary including a recapitulation of Resident 41's stay upon discharge. | SS=D |
| Failed to provide necessary respiratory care by not changing disposable oxygen equipment for Residents 23 and 27 as per policy and professional standards. | SS=D |
| Failed to ensure pharmacist identified and reported missing documentation concerning physician notifications for blood pressures exceeding parameters for Residents 35 and 36. | SS=D |
| Failed to ensure drug regimen was free from unnecessary drugs by not adequately monitoring blood pressure medications and notifying physicians of out-of-parameter blood pressures for Residents 35 and 36. | SS=D |
| Failed to store and prepare food under sanitary conditions including improper food storage, unclean kitchen equipment, undocumented refrigerator/freezer temperatures, and dietary staff not properly restraining hair. | SS=F |
Report Facts
Facility census: 35
Sample size: 12
Oxygen flow rate: 2
Oxygen flow rate: 4
Missing temperature log entries: 19
Missing temperature log entries: 1
Expired cheese: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide F | CNA | Interviewed regarding oxygen use and tubing changes for Resident 23 |
| Certified Medication Aide H | CMA | Interviewed regarding oxygen tubing replacement and documentation for Resident 23 |
| Licensed Nurse I | LN | Interviewed regarding oxygen use, tubing changes, and blood pressure monitoring for Residents 23, 35, and 36 |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding expectations for care plans, oxygen use, and blood pressure notifications |
| Certified Medication Aide D | CMA | Interviewed regarding blood pressure monitoring and medication administration for Resident 35 |
| Consultant Pharmacist Q | Consultant Pharmacist | Interviewed regarding pharmacist responsibilities and concerns about blood pressure notifications |
| Certified Medication Aide E | CMA | Interviewed regarding blood pressure monitoring and medication administration for Resident 36 |
| Dietary Staff R | Dietary Staff | Observed preparing sandwiches with improper glove use and hair restraint |
| Dietary Staff T | Dietary Staff | Observed with hair not fully restrained |
| Dietary Staff S | Dietary Staff | Interviewed regarding hairnet and glove policies |
Inspection Report
Routine
Deficiencies: 0
Dec 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a Targeted Infection Control Survey/COVID-19 Focused Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Aug 19, 2020
Visit Reason
A Focused Infection Control Survey 2 (FICS2) was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 29, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 22, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Kansas Department for Aging and Disability Services (KDADS) on 06/22/2020.
Findings
The facility was found to be in compliance with Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 6, 2020
Visit Reason
An offsite revisit survey was conducted on 03/06/20 to verify correction of all previous deficiencies cited on 01/09/20.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 02/15/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies corrected: 0
Inspection Report
Plan of Correction
Deficiencies: 7
Jan 9, 2020
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during the inspection conducted on January 9, 2020.
Findings
The Plan of Correction addresses multiple deficiencies related to care plan revisions, blood sugar monitoring, discharge summaries, respiratory care, dementia treatment, and drug regimen reviews. The facility outlines corrective actions including staff training, policy updates, and ongoing monitoring to ensure compliance.
Severity Breakdown
D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Notify of Changes (Injury/Decline/Room, etc.) related to blood sugar parameters and insulin administration | D |
| Care Plan Timing and Revision for diabetic residents including insulin administration and glucose monitoring | D |
| Discharge Summary recapitulation missing for Resident #36 | D |
| Respiratory/Tracheostomy Care and Suctioning - oxygen delivery tubing replacement and documentation | D |
| Treatment/Service for Dementia - documentation and non-pharmacological interventions for behaviors | D |
| Drug Regimen Review - identification and reporting irregularities, focus on insulin/blood glucose monitoring | D |
| Drug Regimen is Free from Unnecessary Drugs - monitoring and reporting related to insulin and blood glucose | D |
Report Facts
Staff trained: 47
Completion date: Feb 15, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 7
Jan 9, 2020
Visit Reason
The inspection was a health resurvey of Prairie Sunset Home Inc to assess compliance with regulatory requirements including care plans, notification of changes, respiratory care, dementia care, and medication management.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of critical blood sugar levels, failure to revise care plans to include insulin use and blood glucose monitoring, lack of discharge summary documentation, inadequate respiratory care labeling, insufficient monitoring of dementia-related behaviors, and failure to ensure proper drug regimen review and response to medication irregularities.
Severity Breakdown
SS=D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to notify physician when Resident 24's blood sugars were higher than 450 mg/dl as ordered. | SS=D |
| Failed to revise care plan to include monitoring and use of insulin for Resident 30 with diabetes mellitus. | SS=D |
| Failed to document a discharge summary recapitulation for Resident 36 upon discharge. | SS=D |
| Failed to provide oxygen therapy in a sanitary manner by not labeling oxygen tubing with change date for Resident 25. | SS=D |
| Failed to monitor behaviors related to dementia for Residents 27, 16, and 17. | SS=D |
| Failed to ensure reporting of drug irregularities including lack of blood sugar monitoring and behavior monitoring to physician and director of nursing for Residents 30, 27, and 17. | SS=D |
| Failed to ensure Resident 30 received supplemental insulin as ordered when blood glucose levels were above 400 mg/dl on multiple occasions. | SS=D |
Report Facts
Census: 36
Sample size: 13
Blood sugar incidents > 400 mg/dl: 26
Missed insulin administrations: 5
Behavior incidents: 16
Behavior incidents: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Performed blood glucose monitoring and insulin administration for Resident 30; interviewed regarding blood sugar notification procedures |
| Administrative Nurse C | Administrative Nurse | Interviewed regarding blood sugar notification, behavior monitoring, and oxygen therapy procedures |
| Certified Medication Aide B | Certified Medication Aide | Interviewed regarding blood sugar monitoring and behavior monitoring |
| Consultant Pharmacist K | Consultant Pharmacist | Conducted drug regimen reviews and identified medication irregularities |
| Certified Nursing Assistant E | Certified Nursing Assistant | Reported on resident behaviors and monitoring |
| Certified Nursing Assistant H | Certified Nursing Assistant | Reported on resident behaviors and care |
Inspection Report
Re-Inspection
Deficiencies: 6
Sep 3, 2019
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with completion dates documented for each.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 26-41-202 (a) |
| Deficiency related to regulation 26-41-204 (a) |
| Deficiency related to regulation 26-41-205 (d) (4) |
| Deficiency related to regulation 26-41-205 (g) (3) |
| Deficiency related to regulation 26-41-207 (b) (5-6) (c) |
| Deficiency related to regulation 28-39-254 |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 22, 2019
Visit Reason
A revisit survey was conducted on 7/22-7/23/19 for all previous deficiencies cited on 5/28/19 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 6/18/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Renewal
Census: 12
Deficiencies: 6
Jul 9, 2019
Visit Reason
The inspection was a licensure resurvey for the assisted living facility conducted over multiple days in July 2019.
Findings
The inspection identified multiple deficiencies including failure to ensure negotiated service agreements included outside services and payment responsibilities, inadequate licensed nurse coordination of necessary health care services for residents, lack of documented training and competency for medication aides performing blood sugar testing, improper labeling of over-the-counter medications, failure to comply with tuberculosis screening guidelines for employees and residents, and unsecured chemicals accessible to cognitively impaired residents.
Severity Breakdown
SS=E: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Negotiated service agreements did not include services provided by outside sources and responsible party for payment for 2 of 3 sampled residents regarding therapy services. | SS=E |
| Licensed nurse failed to provide or coordinate necessary health care services meeting residents' needs related to falls, bed assistive devices, cognition, transfer assistance, toileting, and personal hygiene for 3 of 4 sampled residents. | SS=E |
| Licensed nurse failed to orient and instruct certified medication aides in blood sugar testing and failed to document competency. | SS=E |
| Over-the-counter medications were not labeled with the resident's full name for 7 residents; some medications were unlabeled or labeled only with room number or first name. | SS=E |
| Facility failed to comply with tuberculosis screening guidelines for newly hired employees and residents, including delayed 2-step TB testing and lack of annual TB screening documentation. | SS=E |
| Chemicals in unlocked cabinets in kitchenette were accessible to residents, including cognitively impaired residents, posing safety risks. | SS=E |
Report Facts
Census: 12
Number of residents with managed medications: 7
Number of sampled residents: 3
Number of sampled medication aides: 2
Number of residents with unlabeled OTC medications: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse D | Licensed Nurse | Named in findings related to negotiated service agreements, health care coordination, medication aide training, tuberculosis screening, and chemical safety |
| Certified Medication Aide B | Certified Medication Aide | Named in findings related to lack of documented training and competency for blood sugar testing |
| Certified Medication Aide F | Certified Medication Aide | Named in findings related to lack of documented training and competency for blood sugar testing |
| Certified Medication Aide C | Certified Medication Aide | Interviewed regarding blood sugar testing and medication labeling |
| Business Office Manager K | Business Office Manager | Interviewed regarding tuberculosis testing records |
Inspection Report
Plan of Correction
Deficiencies: 2
May 28, 2019
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited in the inspection report dated May 28, 2019.
Findings
The Plan of Correction addresses deficiencies related to pressure ulcer prevention and treatment, bowel and bladder incontinence, catheter use, and urinary tract infections. The facility implemented corrective actions including staff training, updated assessments, revised care plans, and ongoing monitoring to ensure compliance and improve resident care.
Deficiencies (2)
| Description |
|---|
| Deficiency related to treatment and services to prevent and heal pressure ulcers. |
| Deficiency related to bowel/bladder incontinence, catheter use, and urinary tract infections. |
Report Facts
Completion date: Jun 18, 2019
Training completion deadline: Jun 30, 2019
Inspection date: May 28, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
May 28, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of inadequate care for residents with pressure ulcers and urinary incontinence.
Findings
The facility failed to provide appropriate care for residents with pressure ulcers by not completing weekly skin assessments and wound measurements as per facility policy. Additionally, the facility failed to ensure residents with urinary incontinence received adequate services and assistance to maintain or restore continence, lacking individualized toileting plans and voiding diaries.
Complaint Details
The complaint investigations KS00140536 and KS00141417 focused on inadequate care for pressure ulcers and urinary incontinence in sampled residents.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete weekly skin assessments and wound measurements for residents with pressure ulcers. | SS=G |
| Failure to provide appropriate treatment and services to residents with urinary incontinence to maintain or restore continence. | SS=D |
Report Facts
Residents sampled: 4
Residents with pressure ulcers: 3
Residents with urinary incontinence: 3
Days without skin assessments: 18
Days without skin assessments: 16
Days without skin assessments: 37
Days without skin assessments: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed failure to complete weekly skin assessments and lack of individualized toileting plans. |
| Medical Director F | Medical Director | Denied knowledge of failures in weekly skin assessments and wound staging. |
| Direct Care Staff C | Reported staff assist residents to toilet when requested; could not verbalize individualized toileting plans. | |
| Direct Care Staff D | Reported staff assist residents on two-hour rotation or when asked; could not verbalize individualized toileting plans. | |
| Direct Care Staff E | Reported resident #1 tells staff when needing to toilet; resident experiences occasional urinary incontinence. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 31, 2019
Visit Reason
The inspection included a complaint survey conducted on 2019-01-23 to 2019-01-24 for complaints #KS00136958, #KS00126859, and #KS00122621.
Findings
No deficiency citations were found related to applicable regulations under 42 CFR Part 483, Subpart B. The allegations made in the complaints were not substantiated and no noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaints #KS00136958, #KS00126859, and #KS00122621 were investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 23, 2019
Visit Reason
A complaint survey was conducted on 2019-01-23 to 2019-01-24 for complaints #KS00136958, #KS00126859, and #KS00122621.
Findings
The health survey resulted in no deficiency citations and no noncompliance was found. The allegations made in the complaints were not substantiated and the facility is in compliance with all regulations surveyed.
Complaint Details
Complaints #KS00136958, #KS00126859, and #KS00122621 were investigated and found to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 1
Aug 18, 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 revisit confirmed that the previously cited deficiency under regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of 08/18/2017. No other deficiencies were noted.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(d)(1)(2)(n)(1)-(3) previously cited and corrected |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 16, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Aug 16, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding the facility's failure to ensure adequate supervision and accident hazard prevention for a resident with a known history of wandering who exited the building without staff's knowledge.
Findings
The facility failed to accurately assess the resident's elopement risk and implement effective interventions to supervise the resident, resulting in the resident leaving the facility unnoticed. Multiple staff notes, interviews, and observations documented the resident's wandering behaviors and the incident of elopement. The facility lacked a specific elopement policy and had no assessment addressing elopement risk, only wandering risk.
Complaint Details
The complaint investigation (ID 5Z4E11) focused on a resident with bipolar disorder and dementia who eloped from the facility on 8/3/17. The resident was found just stepping onto the street outside the facility. Staff intervened and returned the resident inside. The investigation revealed inadequate assessment and supervision related to elopement risk.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff accurately assessed the resident and developed interventions to supervise the whereabouts of a resident with a known history of wandering who exited the building without staff's knowledge. | SS=D |
Report Facts
Resident census: 35
Resident wandering risk assessment score: 3
Frequency of visual checks: 15
Date of resident admission: Jul 31, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Direct Care Staff | Witnessed resident elopement and intervened to prevent resident from leaving the street |
| Nurse G | Licensed Nurse | Responded to elopement incident, assisted resident back inside, and notified administration |
| Social Service Staff D | Social Service Staff | Provided 1:1 supervision, communicated with resident's family, and reported on resident behaviors |
| Licensed Nurse F | Licensed Nurse | Reported on wandering assessments and facility policies |
| Administrative Nurse B | Administrative Nurse | Reported on wandering assessment and facility policies |
| Administrative Staff A | Administrative Staff | Reported on facility cameras and door security improvements |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 10, 2017
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited related to an elopement incident and safety concerns involving confused residents potentially leaving the facility without staff knowledge.
Findings
The Plan of Correction details actions taken to improve resident safety, including disabling certain entrances to control access, revising the elopement policy, conducting elopement risk assessments, increasing observation of at-risk residents, revising the resident handbook, posting warning signs, and purchasing new security equipment to prevent elopement incidents.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Prairie Sunset complaint 08162017.
Deficiencies (1)
| Description |
|---|
| Free of Accident Hazards/ Supervision/Devices—Visitors and family members advised about risks of residents exiting without staff knowledge and measures taken to control entry/exit points. |
Report Facts
Residents identified as consistently walking without purpose: 4
Board of Directors approved funding: 40000
Staff inservice timing: 1330
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction to KDADS on August 18, 2017. |
| Shirley Boltz | Contact person for Plan of Correction assistance and involved in submission. | |
| Director of Nursing | Director of Nursing | Conducted meetings with CNAs and Charge Nurses to discuss inspection findings and corrective actions. |
| Assistant Director of Nurses | Assistant Director of Nurses | Instructed charge nurses on completion and timing of new Elopement Assessment form. |
Inspection Report
Follow-Up
Deficiencies: 2
Jul 27, 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 had been corrected.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.60(b), (d), (e) and 483.75(o)(1) were corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Follow-Up
Deficiencies: 1
Jul 27, 2017
Visit Reason
This revisit inspection was 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 26-40-303 (b)(i)(ii)(iii)(iv)(c) was corrected as of 07/27/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) |
Inspection Report
Plan of Correction
Deficiencies: 3
Jul 24, 2017
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during a state and federal revisit inspection conducted on July 24, 2017.
Findings
The Plan of Correction addresses multiple deficiencies including medication labeling and storage, Quality Assurance and Performance Improvement (QAPI) committee activities, and nursing facility support systems such as call light cords. Corrective actions include staff re-education, policy reviews, and ongoing monitoring by designated staff.
Severity Breakdown
E: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Drug Records, Label/Store Drugs & Biologicals—A USE BY date was immediately labeled on the four bubble packaged medications cited. Open dates were written on the inhalers as well. | E |
| QAA Committee-Members/Meet Quarterly/Plans—QAPI Committee addressed deficiencies, completed action plans, and monitors effectiveness of corrective actions. | F |
| Nursing Facility Support System—The call light cord that was too short was immediately replaced with one long enough to be accessible. | E |
Report Facts
Completion date: Jul 27, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction. |
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 24, 2017
Visit Reason
A first revisit was conducted on July 24, 2017, for the June 20, 2017 Health survey to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, 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 July 27, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| An 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Denial of Payment for New Admissions (D.DOPNA) effective date: Jul 11, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to enforcement and compliance |
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 24, 2017
Visit Reason
This document reports on a first revisit conducted on July 24, 2017, following a June 20, 2017 health survey to verify if the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The revisit found the most serious deficiency to be an 'F' level deficiency. Due to these deficiencies, a denial of payment for new Medicare and Medicaid admissions was imposed effective July 11, 2017, and termination of the provider agreement was recommended if substantial compliance is not achieved by December 20, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency | F |
Report Facts
Denial of payment effective date: Jul 11, 2017
Provider agreement termination recommendation date: Dec 20, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Follow-Up
Deficiencies: 12
Jul 24, 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 had been corrected.
Findings
All previously cited deficiencies were corrected as of 07/19/2017, with completion dates documented for each regulation cited.
Deficiencies (12)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.15(e)(1) |
| Deficiency related to regulation 483.20(g)-(j) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.30(a) |
| Deficiency related to regulation 483.35(d)(1)-(2) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.70(f) |
Report Facts
Deficiencies corrected: 12
Inspection Report
Follow-Up
Deficiencies: 1
Jul 24, 2017
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.
Findings
The report confirms that the previously identified deficiency with regulation 26-40-305 (3) was corrected as of 07/19/2017. No other deficiencies or issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-305 (3) corrected |
Report Facts
Deficiency correction date: Jul 19, 2017
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 1
Jul 24, 2017
Visit Reason
The visit was a non-compliance revisit to verify correction of previously cited deficiencies related to emergency call button accessibility in the facility's common bathing rooms.
Findings
The facility failed to have an emergency call button or pull cord within reach of residents in the shower located in the 400 hall common bathing room. Observations and interviews confirmed the call light cord was too short for residents using the shower chair, but maintenance staff replaced it with a longer cord during the revisit.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have an emergency call button or pull cord within reach of residents in the shower located in the 400 hall common bathing room. | SS=E |
Report Facts
Facility census: 36
Residents residing in 100, 300, and 400 halls: 26
Length of call light cord: 6
Length of call light cord: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff D | Interviewed about the call light cord being too short for residents using the shower chair | |
| maintenance staff C | Measured the shower cord and planned to install a longer cord | |
| administrative nursing staff B | Interviewed about the accessibility of the call light cord to residents and staff |
Inspection Report
Re-Inspection
Deficiencies: 5
Jul 11, 2017
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were completed.
Findings
All previously identified deficiencies listed by regulation numbers were corrected as of the revisit date, with completion dates noted as 07/11/2017.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-205 (g) (2) |
| Deficiency related to regulation 26-41-205 (h) |
| Deficiency related to regulation 26-41-206 (d) |
| Deficiency related to regulation 26-41-207 (a) (b) |
| Deficiency related to regulation 28-39-255 |
Inspection Report
Plan of Correction
Deficiencies: 12
Jun 20, 2017
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during a state inspection on June 20, 2017. The plan outlines corrective actions to address various compliance issues identified in the inspection.
Findings
The Plan of Correction details multiple credible allegations of compliance related to abuse/neglect reporting, dignity and respect during meal assistance, call light accessibility, assessment accuracy, accident hazard prevention, nutrition status maintenance, medication management, staffing adequacy, food safety, drug regimen review, and nurse call system functionality. The facility has implemented training, policy revisions, new staff positions, and monitoring procedures to ensure ongoing compliance.
Deficiencies (12)
| Description |
|---|
| Failure to properly report and investigate allegations of abuse, neglect, and exploitation; new policy and training implemented. |
| Inadequate assistance during meals; new meal service policy and staff training implemented. |
| Resident call lights not consistently within reach; staff directed to ensure accessibility and trained accordingly. |
| Assessment inaccuracies for Resident #1; new MDS initiated and care plan updated. |
| Unsafe access to hazardous chemicals; doors locked and staff reminded of safety protocols. |
| Unplanned weight loss in residents; new nutrition protocols and staff position added to monitor weights. |
| Medication administration errors; staff counseling and updated medication records. |
| Insufficient nursing staff per care plans; new restorative nursing position added and staffing reviewed. |
| Food preparation and sanitation issues; booster heater temperature adjusted and staff retrained. |
| Drug regimen review irregularities; pharmacist notified and medication monitoring enhanced. |
| Nurse call system malfunctions; call lights verified and maintenance procedures established. |
| Electrical safety issues; GFCI outlet installed and maintenance verifies outlet safety. |
Report Facts
Completion date: Jul 10, 2017
Inspection date: Jun 20, 2017
Staffing hours per resident day: 5
Staffing hours per resident day: 5.85
Weight of Resident #34: 107.8
Medication expiration date: 1
Booster heater temperature: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction to KDADS. |
Inspection Report
Enforcement
Deficiencies: 0
Jun 20, 2017
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 the most serious deficiency at a level of actual harm that is not immediate jeopardy, resulting in denial of payment for new Medicare and Medicaid admissions effective July 11, 2017, with no opportunity to correct deficiencies before remedies are imposed.
Report Facts
Denial of payment effective date: Jul 11, 2017
Termination recommendation date: Dec 20, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact for questions concerning instructions in the letter |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 2
Jun 20, 2017
Visit Reason
The inspection was a health resurvey to assess compliance with nursing facility regulations, specifically focusing on emergency call systems and electrical safety in hydrotherapy units.
Findings
The facility failed to have accessible emergency call buttons or pull cords in the 200 hall bathing rooms, with cords tied up preventing resident use. Additionally, the hydrocullator was plugged into a non-GFCI outlet, posing an electrical hazard. The facility lacked policies regarding call cord accessibility and electrical equipment use.
Severity Breakdown
Level E: 1
Level F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to have an emergency call button or pull cord within reach of residents in the 200 hall bathing room for the tub and shower; call cords were tied up preventing use. | Level E |
| Failed to ensure the hydrocullator was plugged into a ground-fault circuit interrupter (GFCI) outlet, posing an electrical hazard. | Level F |
Report Facts
Facility census: 35
Residents on 200 hall: 9
Resident bathing showers and/or tubs: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Direct care staff | Confirmed residents could not activate call light due to tied cords |
| Maintenance A | Confirmed cords were tied because they were too long; confirmed hydrocullator outlet lacked GFCI | |
| Administrative nurse G | Administrative nurse | Stated expectation for staff to ensure call light accessibility |
| Administrative staff B | Confirmed hydrocullator outlet was not GFCI and unplugged the device |
Inspection Report
Plan of Correction
Deficiencies: 5
Jun 12, 2017
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during a prior inspection conducted on June 12, 2017.
Findings
The Plan of Correction addresses multiple deficiencies including medication labeling, medication storage, food preparation, infection control, and housekeeping and sanitation. Each deficiency was corrected with specific actions such as removal of expired medications, staff retraining, and policy reviews, with ongoing monitoring by designated staff.
Deficiencies (5)
| Description |
|---|
| Medication Labeling - Pharmacy now includes expiration dates on blister pack medications and staff verify expiration dates upon receipt. |
| Medication Storage - Expired iodine removed from medication cart; staff counseled and trained on checking expiration dates. |
| Food Preparation - Uncovered food items discarded; staff and residents reminded to properly cover and label food in refrigerators/freezers. |
| Infection Control - Booster heater temperature controls adjusted; staff retrained on dishwasher operation and documentation. |
| Housekeeping and Sanitation - Door locked per policy; staff counseled on keeping chemicals secure and out of residents' reach. |
Report Facts
Completion date: Jul 11, 2017
Inspection date: Jun 12, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 8
Deficiencies: 5
May 31, 2017
Visit Reason
The inspection was an Assisted Living Licensure resurvey to assess compliance with medication labeling, storage, food preparation, infection control, housekeeping, and sanitation regulations.
Findings
The facility failed to ensure medication blister packs had expiration dates, expired medications were removed, food was stored safely, dishes were sanitized at proper temperatures, infection control policies were followed, and hazardous chemicals were secured. These deficiencies potentially affected all 8 residents in the assisted living unit.
Severity Breakdown
Level E: 1
Level F: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Medication blister packs lacked expiration dates, preventing staff from monitoring expired medications. | Level E |
| Expired iodine medication was found in the medication cart, indicating failure to remove expired medications. | Level F |
| Food was stored unsafely with an uncovered jar of pickles, uncovered ice cream, and no thermometer inside refrigerator or freezer. | Level F |
| Dishwasher water temperature was below the required 180°F to properly sanitize dishes and utensils. | Level F |
| Housekeeping closet containing hazardous chemicals was left unlocked and accessible to residents. | Level F |
Report Facts
Facility census: 8
Expired medication date: 201602
Dishwasher rinse temperature: 140.2
Dishwasher rinse temperature: 154.2
Dishwasher rinse temperature: 146
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Direct Care Staff | Mentioned in relation to monitoring expired medications and housekeeping duties |
| Staff N | Dietary Staff | Reported dishwasher temperature and washing dishes |
| Staff M | Dietary Staff | Reported dishwasher temperature issues and corrective actions |
| Administrative Nurse B | Administrative Nursing Staff | Expected staff to check for expired medications and lock housekeeping closet |
| Direct Care Staff W | Certified to pass medications | Interviewed about lack of expiration dates on blister packs |
| Licensed Nursing Staff Q | Licensed Nursing Staff | Interviewed about inability to know medication expiration dates |
| Administrative Nursing Staff K | Administrative Nursing Staff | Confirmed blister packs lacked expiration dates |
| Administrative Nursing Staff G | Administrative Nursing Staff | Confirmed blister packs lacked expiration dates and expected pharmacy to provide them |
| Pharmacy Representative HH | Pharmacy Representative | Explained pharmacy's policy on expiration dates on blister packs |
| Dietary Staff D | Dietary Staff | Found thermometers in refrigerator and described temperature monitoring |
Inspection Report
Follow-Up
Deficiencies: 2
May 1, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 and Plan of Correction.
Findings
The revisit confirmed that the deficiencies identified under regulations 483.12(a)(3)(4)(c)(1)-(4) and 483.12(b)(1)-(3), 483.95(c)(1)-(3) were corrected by 04/26/2017.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.12(a)(3)(4)(c)(1)-(4) |
| Deficiency related to regulations 483.12(b)(1)-(3) and 483.95(c)(1)-(3) |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Mar 28, 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 deficiencies at a level of substandard care, specifically citing F225 and F226, resulting in enforcement remedies including denial of payment for new Medicare and Medicaid admissions.
Severity Breakdown
F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficiency related to F225, CFR 483.12(a)(3)(4)(c)(1)-(4) | F |
| Deficiency related to F226, CFR 483.12(b)(1)-(3), 483.95(c)(1)-(3) | F |
Report Facts
Denial of payment effective date: Apr 19, 2017
Non-compliance correction deadline: Sep 28, 2017
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to instructions for Informal Dispute Resolution and contact for questions |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 28, 2017
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to a complaint investigation related to allegations of staff-to-resident abuse and mistreatment.
Findings
The investigation found the allegations of abuse against two staff members to be unsubstantiated. The facility revised its abuse, neglect, and exploitation (ANE) policies to clarify reporting requirements and prohibited use of technology that demeans residents. Staff training and monitoring procedures were implemented to ensure compliance.
Complaint Details
The complaint investigation involved allegations of abuse by two staff members (Staff E and Staff P) who were suspended pending investigation. The allegations were found unsubstantiated after interviews and review by the nurse surveyor and administration.
Report Facts
Date of staff suspension: Mar 21, 2017
Date of resident interviews: Mar 22, 2017
Date of mandatory staff inservice: Apr 7, 2017
Date of Quality Assurance meeting: Apr 4, 2017
Date of follow-up Quality Assurance meeting: Apr 27, 2017
Date of National Volunteer Week presentation: Apr 25, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Alleged perpetrator suspended pending investigation | |
| Staff P | Alleged perpetrator suspended pending investigation | |
| AARON KELLEY | Administrator | Submitted Plan of Correction and held staff meetings |
| Licensed Social Worker | LBSW | Conducted resident interviews and assigned as primary contact for ANE reports |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Mar 28, 2017
Visit Reason
Partial extended survey conducted for investigation of complaints KS00107452 and KS00113456 regarding allegations of staff to resident abuse/mistreatment.
Findings
The facility failed to immediately report multiple allegations of staff to resident abuse/mistreatment to the State survey and certification agency, failed to thoroughly investigate the allegations, failed to protect all residents during ongoing investigations, and failed to submit investigation results within required timeframes. The facility also lacked adequate written policies addressing abuse, neglect, and exploitation, including specific reporting requirements related to reasonable suspicion of crimes and mental abuse involving social media.
Complaint Details
The investigation was triggered by complaints KS00107452 and KS00113456 involving allegations of staff to resident abuse by Direct Care Staff E toward residents #1 and #2. The facility failed to report, investigate, and protect residents as required. Administrative Staff A was aware of the allegations but did not report or investigate them and allowed the alleged perpetrator to continue working without suspension.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to immediately report allegations of staff to resident abuse/mistreatment, failed to thoroughly investigate allegations, failed to protect residents during investigations, and failed to submit investigation results timely. | SS=F |
| Failed to develop and implement written policies for abuse, neglect, and exploitation that included specific information on reporting reasonable suspicion of a crime to law enforcement and mental abuse related to unauthorized photographs/video recordings shared on social media. | SS=F |
Report Facts
Census: 32
Residents sampled: 4
Allegations of abuse: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff E | Named as alleged perpetrator of abuse/mistreatment in multiple allegations. | |
| Administrative Staff A | Facility administrator aware of allegations but failed to report, investigate, or suspend alleged perpetrator. |
Inspection Report
Life Safety
Deficiencies: 1
Dec 1, 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 in the facility to be 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found at "F" level with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: 2017
Effective date for provider agreement termination: 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 9
Nov 23, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by their regulation numbers were corrected as of the revisit date 11/23/2015.
Deficiencies (9)
| Description |
|---|
| Deficiency identified under regulation 483.15(a) |
| Deficiency identified under regulation 483.20(b)(1) |
| Deficiency identified under regulation 483.25(l) |
| Deficiency identified under regulation 483.25(n) |
| Deficiency identified under regulation 483.35(i) |
| Deficiency identified under regulation 483.60(c) |
| Deficiency identified under regulation 483.65 |
| Deficiency identified under regulation 483.75(m)(2) |
| Deficiency identified under regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 9
Inspection Report
Follow-Up
Deficiencies: 2
Nov 23, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiencies identified in the prior survey were corrected as of the revisit date, with specific corrections noted under regulation 28-39-160.
Deficiencies (2)
| Description |
|---|
| Deficiency identified under regulation 28-39-160 with ID prefix S0740 |
| Deficiency identified under regulation 28-39-160 with ID prefix S0750 |
Inspection Report
Plan of Correction
Deficiencies: 11
Nov 23, 2015
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 has outlined corrective actions for multiple deficiencies including resident assessments, infection control, medication monitoring, dietary staff training, immunizations, and safety procedures. A new MDS coordinator has been hired to oversee many of these corrective actions.
Severity Breakdown
D: 4
E: 5
F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Resident re-educated about removing motion alarm and motion sensor removed. | D |
| Care assessments not done appropriately or timely; new MDS coordinator hired to improve process. | E |
| Black box warnings on care plans not properly placed; new MDS coordinator responsible for correction. | D |
| Influenza and pneumococcal immunizations not properly tracked; new MDS coordinator assigned responsibility. | D |
| Dietary staff retrained on glove use and food handling; policies updated per Kansas food code. | E |
| Psychotropic medication monitoring book being developed to monitor irregularities. | D |
| New MDS coordinator also infection control officer responsible for annual education and infection tracking. | F |
| Disaster drill was misclassified as fire drill; improved staff training planned. | F |
| Quality Assurance committee to meet monthly with new MDS coordinator to improve compliance. | F |
| Magnetic locks on doors to special care unit to be turned off to allow free movement of residents. | E |
| Admission policies and staff training to apply to skilled nursing wing with extra training for challenging residents. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | Listed as contact person for Plan of Correction assistance |
| Rexmaris | Administrator | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Oct 26, 2015
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 'F' level deficiencies, widespread, 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, resulting in a finding of substantial compliance effective November 23, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date of substantial compliance: Nov 23, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and communicated the survey results |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 5
Oct 26, 2015
Visit Reason
The inspection was conducted as a licensure resurvey and complaint investigations #2302, #1649, and #2278.
Findings
The facility failed to develop admission and discharge criteria specific to the diagnosis, behavior, or clinical needs of residents in the Special Care Unit (SCU), lacked written physician orders for placement, did not inform residents or legal representatives in writing about SCU services, failed to provide specific staff training and in-service education for SCU needs, and did not have policies and procedures for SCU operation.
Complaint Details
The visit included complaint investigations #2302, #1649, and #2278 as part of the licensure resurvey.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to develop admission and discharge criteria specific to diagnosis, behavior, or clinical needs for residents in the Special Care Unit and lack of written physician orders for placement. | SS=E |
| Failure to inform residents or legal representatives in writing of the programs and services available in the Special Care Unit that differ from other sections. | SS=E |
| Failure to provide staff training specific to the needs of residents in the Special Care Unit and failure to document completion of such training in employee records. | SS=E |
| Failure to provide in-service training specific to the needs of residents in the Special Care Unit at regular intervals. | SS=E |
| Failure to develop and make available policies and procedures for operation of the Special Care Unit to clinical care staff. | SS=E |
Report Facts
Facility census: 40
Special Care Unit census: 9
Residents sampled in SCU: 4
Inspection Report
Re-Inspection
Deficiencies: 8
Sep 1, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Prairie Sunset Home Inc. were corrected.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f) |
| Deficiency related to regulation 26-41-101 (f) (2) |
| Deficiency related to regulation 26-41-101 (l) |
| Deficiency related to regulation 26-41-201 (c) |
| Deficiency related to regulation 26-41-202 (d) |
| Deficiency related to regulation 26-41-205 (a) (1) |
| Deficiency related to regulation 26-41-205 (l) |
| Deficiency related to regulation 26-41-205 (l) (4) |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 8
Aug 28, 2015
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home ALF in response to deficiencies cited during a prior survey.
Findings
The plan addresses multiple deficiencies including staff conduct involving inappropriate language, incomplete background check documentation, missing public survey availability, and missed or incomplete resident assessments and medication reviews. Corrective actions include staff reprimands, improved documentation practices, scheduling assessments, and pharmacist medication reviews.
Severity Breakdown
F: 2
C: 1
D: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Staff used inappropriate language around residents and made a disrespectful comment. | F |
| Background check documentation was not properly printed and filed prior to employment. | F |
| Most recent survey was not available for public viewing due to staff moving the notebook. | C |
| Failure to maintain current Functional Capacity Screenings (FCS) documentation. | D |
| Missed Nutritional Status Assessments (NSA) which have now been completed. | D |
| Lack of assessments for residents who self-administer medications on admission and annually. | D |
| Consultant pharmacist did not review self-administered medications quarterly as required. | D |
| Consultant pharmacist had not been reviewing all assisted living residents' medications timely. | D |
Report Facts
Complete Date: Sep 1, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Rexmaris | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 8
Aug 18, 2015
Visit Reason
The inspection was conducted as an Assisted Living/Residential Healthcare Licensure resurvey and complaint surveys #90089 and #89987, including investigation of a grievance filed by resident #1 regarding an allegation of verbal abuse by direct care staff D.
Findings
The facility failed to ensure staff implemented the abuse, neglect, and exploitation policy regarding verbal abuse allegations by staff. The facility also failed to perform timely pre-employment registry checks, failed to make the most recent survey results readily available to residents, failed to annually review functional capacity screenings and negotiated service agreements for residents, failed to assess competency for self-administration of medications, and failed to ensure quarterly pharmacist medication regimen reviews for residents, including those self-administering medications.
Complaint Details
The complaint investigation was triggered by a grievance filed by resident #1 alleging verbal abuse by direct care staff D, including being called 'too stupid to talk to' and other verbal mistreatment occurring around 5/26/15 to 5/27/15. The facility failed to report the allegation to the State Agency at the time it occurred and failed to take appropriate disciplinary action.
Severity Breakdown
F: 2
C: 1
D: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure staff implemented the facility abuse, neglect and exploitation policy for a grievance filed by resident #1 regarding an allegation of verbal abuse by direct care staff D. | F |
| Failed to perform pre-employment registry checks for 1 of 5 staff reviewed. | F |
| Failed to ensure the results of the most recent State survey were available to residents without having to ask. | C |
| Failed to annually review functional capacity screenings for 1 of 3 residents reviewed. | D |
| Failed to annually review negotiated service agreements for 3 of 3 residents reviewed. | D |
| Failed to ensure staff completed an evaluation of competency for 1 of 1 residents reviewed for self-administration of medications. | D |
| Failed to ensure the pharmacist reviewed medication regimens at least quarterly for 2 of 2 residents who received medications from the facility. | D |
| Failed to ensure the pharmacist offered medication regimen reviews at least quarterly for 1 resident who self-administered medications. | D |
Report Facts
Residents present: 12
Days delayed for registry check: 19
Months since last pharmacy medication review: 5
Months since last negotiated service agreement review: 31
Months since last functional capacity screening review: 26
Months since last pharmacy medication review for self-administering resident: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff D | Direct Care Staff | Named in verbal abuse allegation against resident #1 |
| Administrative nurse A | Administrative Nurse | Interviewed regarding abuse allegations, registry checks, and medication reviews |
| Administrative staff B | Administrative Staff | Interviewed regarding abuse allegations and medication reviews |
| Direct care staff G | Direct Care Staff | Registry check performed 19 days after hire |
| Direct care staff C | Direct Care Staff | Interviewed regarding medication self-administration |
| Pharmacy consultant F | Pharmacy Consultant | Interviewed regarding medication regimen reviews |
Inspection Report
Follow-Up
Deficiencies: 5
Jul 29, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by their regulation numbers were corrected by the revisit date of 07/29/2015, as documented in the report.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.13(a) |
| Deficiency related to regulation 483.20(b)(2)(iii) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.30(a) |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 5
May 27, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a revisit complaint survey at Prairie Sunset Home.
Findings
The plan outlines corrective actions for multiple deficiencies including resident use of a Merri walker device, timeliness of MDS assessments, fall investigations, staffing improvements, and Quality Assurance committee oversight to ensure ongoing compliance and resident safety.
Complaint Details
This plan of correction is related to a revisit complaint survey.
Severity Breakdown
D: 3
F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident's use of Merri walker device to be reassessed and limited to safe durations with proper documentation. | D |
| Timeliness of MDS records to be improved with oversight by D.O.N. and A.D.O.N. | D |
| Fall investigations to be managed by D.O.N. with timely completion and weekly reporting. | D |
| Addition of CNA staff positions and use of agency staffing to ensure adequate resident care. | F |
| Quality Assurance committee to increase monitoring of falls, medication errors, and resident concerns with weekly reports. | F |
Report Facts
Corrective action completion dates: Jun 1, 2015
Maximum time resident to be in Merri walker device: 90
Maximum daily uses of Merri walker device: 5
Fall investigation witness statement return timeframe: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rexmaris | Administrator | Administrator responsible for oversight and reporting in multiple corrective actions. |
| Irina Strakhova | Person who added and modified the Plan of Correction document. |
Inspection Report
Follow-Up
Deficiencies: 2
May 12, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report documents that the previously cited deficiencies identified by regulation numbers 483.20(c) and 483.30(b) were corrected as of 05/12/2015.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(c) |
| Deficiency related to regulation 483.30(b) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Re-Inspection
Deficiencies: 1
May 12, 2015
Visit Reason
The revisit was conducted to verify that the facility had achieved and maintained compliance with Federal requirements following an Abbreviated survey.
Findings
The revisit found the most serious deficiencies to be an 'F' level deficiency related to the use of physical restraints. Remedies including denial of payment for new Medicare/Medicaid admissions and recommendation for termination of the provider agreement were imposed.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance at F221 related to the use of physical restraints. | F |
Report Facts
Denial of Payment effective date: Denial of Payment for new Medicare/Medicaid admissions imposed effective June 12, 2015
Provider agreement termination date: Recommendation for termination of provider agreement on September 12, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Weiler | CMS Survey & Certification Branch | Contact person for questions regarding the matter |
| Mary Jane Kennedy | Complaint Coordinator | Named in relation to complaint coordination |
| Joe Ewert | Commissioner, Survey, Certification and Credentialing Commission | Recipient of written requests for Informal Dispute Resolution |
Inspection Report
Follow-Up
Deficiencies: 2
May 12, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as indicated in the Plan of Correction.
Findings
The report shows that deficiencies previously reported under regulations 483.20(c) and 483.30(b) were corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(c) |
| Deficiency related to regulation 483.30(b) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 5
May 12, 2015
Visit Reason
The visit was a non-compliance revisit to assess corrections related to previous deficiencies including physical restraints, comprehensive assessments, fall investigations, staffing sufficiency, and quality assurance.
Findings
The facility failed to ensure resident #103 remained free from a non-medically necessary physical restraint (merry walker), failed to complete a comprehensive annual assessment for resident #103, failed to thoroughly investigate falls and implement appropriate interventions for residents #101, #102, and #103, failed to provide sufficient nursing staff to meet resident needs and answer call lights timely, and failed to develop and implement an effective Quality Assessment and Assurance (QAA) program.
Severity Breakdown
SS=D: 3
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure resident #103 remained free from the physical restraint of the merry walker and failed to ensure the resident spent no more than 2 hours at a time in the merry walker as care planned. | SS=D |
| Facility failed to complete a comprehensive assessment of resident #103 at least once every 366 days. | SS=D |
| Facility failed to thoroughly investigate all falls and implement appropriate interventions for residents #103, #101, and #102. | SS=D |
| Facility failed to provide sufficient nursing staff to provide nursing care to all residents in accordance with resident care plans and failed to answer call lights in a timely manner. | SS=F |
| Facility failed to develop and implement an effective Quality Assessment and Assurance (QAA) program to identify and correct quality deficiencies. | SS=F |
Report Facts
Facility census: 36
Falls reported: 21
Falls in SCU: 15
Call light duration: 12
Call light duration: 8
Call light duration: 11
Call light duration: 2
Fall risk score: 20
Fall risk score: 19
Fall risk score: 26
Fall risk score: 27
Fall risk score: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Nursing Staff | Reported monitoring of fall investigations, staffing, and QAA meetings; provided input on plans to correct deficiencies. |
| Staff C | Direct Care Staff | Provided care and supervision to resident #103, assisted with merry walker use, and reported on restraint and fall prevention practices. |
| Staff D | Direct Care Staff | Reported staffing shortages on SCU, one-on-one care needs, and challenges in managing multiple alarms and residents. |
| Staff G | Licensed Nursing Staff | Reported on fall investigations, resident assessments, and responsibilities for updating care plans. |
| Staff H | Licensed Nursing Staff | Reported expectations for resident supervision, fall prevention interventions, and documentation. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Mar 12, 2015
Visit Reason
An Abbreviated survey 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 at 'G' level related to the use of physical restraints (F221). Enforcement remedies including denial of payment for new Medicare admissions were imposed due to noncompliance.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance at F221, Restraints, indicating inappropriate use of physical restraints. | G |
Report Facts
Denial of payment effective date: Jun 12, 2015
Noncompliance correction deadline: Sep 12, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rex Maris | Administrator | Named as facility administrator |
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 5
Mar 12, 2015
Visit Reason
The inspection was conducted as a complaint investigation triggered by multiple complaint surveys (#84055, #84295, #83051, and #82996).
Findings
The facility failed to ensure residents were free from unnecessary physical restraints, failed to complete quarterly assessments timely, failed to provide adequate supervision and assistance to prevent falls resulting in injuries, failed to use gait belts during transfers, and failed to maintain sufficient nursing staff including registered nurses for required hours.
Complaint Details
The inspection was based on complaint surveys #84055, #84295, #83051, and #82996. The facility was cited for multiple deficiencies related to resident safety, restraint use, fall prevention, and staffing.
Severity Breakdown
SS=D: 2
SS=G: 1
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure resident #3 remained free from non-medically necessary physical restraints, specifically related to the use and monitoring of a merry walker. | SS=D |
| Facility failed to complete quarterly MDS assessments for resident #3 at least every 3 months. | SS=D |
| Facility failed to ensure 3 residents (#1, #2, #3) received adequate supervision and assistance to prevent accidents, resulting in fractures and injuries. | SS=G |
| Facility failed to provide sufficient nursing staff to provide services to attain or maintain the highest practicable well-being of residents. | SS=F |
| Facility failed to provide a registered nurse for at least 8 consecutive hours a day, 7 days a week. | SS=F |
Report Facts
Facility census: 40
Resident falls: 74
Fall risk assessments: 9
Fall risk assessments: 3
Merry walker checks: 30
Call light response time: 10
Call light response time: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Direct Care Staff | Reported resident #3 tipped the merry walker over and described resident's fall history. |
| Staff E | Direct Care Staff | Reported resident #3's frequent use of merry walker and supervision practices. |
| Staff F | Licensed Nursing Staff | Reported expectations for merry walker use and staffing concerns. |
| Staff C | Administrative Nursing Staff | Reported on staffing levels, fall investigations, and resident assessments. |
| Staff I | Direct Care Staff | Reported on resident #1's gait belt use and fall circumstances. |
| Staff H | Direct Care Staff | Reported on resident #1's fall history and gait belt use. |
| Staff K | Direct Care Staff | Reported toileting and merry walker use for resident #3. |
| Staff M | Licensed Nurse | Reported staffing shortages and inability to leave unit to assess other residents. |
| Physician Extender G | Physician Extender | Attributed resident #2's fracture to fall and poor bone quality. |
| Physician Staff J | Physician | Reported resident #1's hip fracture and severe osteoporosis. |
| Administrative Staff B | Administrative Staff | Reported lack of clock-in/out records for administrative nursing staff. |
Inspection Report
Life Safety
Deficiencies: 1
Oct 8, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jan 8, 2015
Provider agreement termination date: Apr 8, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report and is the enforcement coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 15
Jul 15, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, July 15, 2014.
Deficiencies (15)
| Description |
|---|
| Deficiency related to regulation 483.10(c)(6) |
| Deficiency related to regulation 483.15(e)(1) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.20(k)(3)(i) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(e)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 15
Inspection Report
Re-Inspection
Deficiencies: 2
Jul 9, 2014
Visit Reason
This report documents a revisit inspection to verify correction of previously cited deficiencies at Prairie Sunset Home Inc.
Findings
The revisit inspection confirmed that previously reported deficiencies identified by regulation numbers 26-43-101(g) and 26-43-205(h) were corrected as of 07/09/2014.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-43-101(g) |
| Deficiency related to regulation 26-43-205(h) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Enforcement
Deficiencies: 1
Jul 2, 2014
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 'F' level, widespread, 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, resulting in a finding of substantial compliance effective July 15, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date of substantial compliance: Jul 15, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Plan of Correction
Deficiencies: 17
Jul 2, 2014
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during a prior survey conducted on July 2, 2014.
Findings
The Plan of Correction outlines corrective actions to address multiple deficiencies related to care planning, medication administration, fall interventions, staff education, and facility safety measures. The facility commits to staff re-education, system improvements, and ongoing monitoring to ensure compliance and resident safety.
Severity Breakdown
D: 9
E: 4
F: 2
: 2
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to return money to proper parties within 30 days | D |
| Call light cords shortened, preventing reach to residents | E |
| CAA assessments not completed timely due to MDS coordinator absence | D |
| Nurses require further education on Care Planning with EHR system | D |
| Charge nurse responsible for fall investigations and care plan updates | D |
| Charge nurse to create initial care plan upon admission | D |
| Re-education on nursing system Alert feature for skin condition documentation | D |
| Requirement to revise care plans immediately after resident falls | D |
| Nursing staff education on care plan updates after falls | E |
| Cleaning supplies not stored properly in locked areas | — |
| Blood pressure guidelines reviewed and parameter guide placed on med carts | D |
| Incorrect medication admission information entry causing system errors | — |
| Staff reminded to wear hair nets and serve plated food properly | E |
| Initial resident information entered incorrectly into system | D |
| Monthly medication stock check and discard of outdated medications | E |
| Housekeeping staff trained on new cleaning chemicals capable of killing MRSA and C.diff | F |
| Development of Quality Assurance tools and weekly QA committee meetings | F |
Report Facts
Deficiency completion dates: Jul 9, 2014
Deficiency completion dates: Jul 15, 2014
Deficiency completion date: Jul 11, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| REXMARIS | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| IRINASTRAKHOVA | Added and modified Plan of Correction |
Inspection Report
Routine
Census: 32
Deficiencies: 16
Jul 2, 2014
Visit Reason
Routine health resurvey inspection of Prairie Sunset Home Inc to assess compliance with health and safety regulations, including resident care, medication management, environment safety, and infection control.
Findings
The inspection identified multiple deficiencies including failure to convey resident funds within 30 days of death, inaccessible call light in whirlpool room, incomplete comprehensive assessments and care plans, failure to revise care plans after falls and skin issues, inadequate skin assessments and monitoring, failure to maintain resident environment free of hazards, improper medication management including inadequate monitoring and documentation, failure to follow chemical cleaning protocols, and ineffective quality assurance processes.
Severity Breakdown
SS=D: 11
SS=E: 4
SS=F: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failure to convey resident funds within 30 days of death. | SS=D |
| Call light cord in whirlpool room did not reach the tub, inaccessible to residents. | SS=E |
| Failure to complete comprehensive standardized assessment for resident #41. | SS=D |
| Failure to develop accurate comprehensive care plans for sampled residents. | SS=D |
| Failure to revise care plans related to falls and skin issues for residents #15, #22, and #41. | SS=D |
| Failure to develop initial care plan for resident #37. | SS=D |
| Failure to provide necessary care and services to maintain skin integrity for residents #3 and #15. | SS=D |
| Failure to provide services to maintain resident #17's current level of range of motion. | SS=D |
| Failure to maintain resident environment free of accident hazards and ensure hazardous chemicals inaccessible. | SS=E |
| Failure to ensure residents #23 and #41 received necessary fall prevention interventions and environment safety. | SS=E |
| Failure to ensure resident #23 received adequate blood pressure monitoring and insulin administration per physician orders. | SS=D |
| Failure to ensure resident #29 had appropriate indications for psychotropic medications, monitoring of behaviors, and inclusion of black box warnings in care plan. | SS=D |
| Failure to ensure medications in storage were not outdated and insulin/tuberculin vials were properly labeled with open and expiration dates. | SS=D |
| Failure to follow manufacturer's recommendations for chemical use during cleaning of resident rooms including MRSA precaution rooms. | SS=E |
| Failure to serve food under sanitary conditions including failure to wear hair restraints and contamination of plates and utensils. | SS=E |
| Failure to develop and implement effective Quality Assessment and Assurance program action plans to address identified concerns and improve resident care. | SS=F |
Report Facts
Resident census: 32
Residents sampled: 14
Deficiency severity counts: 16
Days late for CAA completion: 13
Days late for care plan completion: 6
Missed insulin administrations: 6
Blood pressure readings: 76
Blood pressure readings: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Reported responsibility for care plan completion and fall investigation |
| Staff D | Licensed Nurse | Reported on fall risk assessments and medication monitoring |
| Staff I | Direct Care Staff | Reported on resident ambulation and skin condition reporting |
| Staff K | Licensed Nurse | Reported on medication monitoring and care plan responsibilities |
| Staff L | Licensed Nurse | Reported on fall investigation and care plan updates |
| Staff M | Administrative Staff | Reported on QAA committee meetings and action plans |
| Staff P | Dietary Staff | Reported on food serving procedures and hair net use |
| Staff V | Housekeeping Staff | Reported on cleaning procedures and chemical use |
| Consultant Pharmacist U | Consultant Pharmacist | Reported on medication review and black box warning monitoring |
Inspection Report
Re-Inspection
Census: 11
Deficiencies: 2
Jul 2, 2014
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with state regulations related to policies and procedures availability and medication storage.
Findings
The facility failed to post a notice of the availability of policies and procedures accessible to residents and the public, and failed to discard an expired stock bottle of Tylenol found in the medication room.
Severity Breakdown
SS=C: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to post a notice of availability of the facility's policies and procedures in a place readily accessible to residents and the public. | SS=C |
| Failed to discard outdated stock bottle of Tylenol stored in the medication room. | SS=E |
Report Facts
Census: 11
Medication rooms: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff B | Confirmed failure to post notice of policies and procedures and verified expired Tylenol was available | |
| Administrative Nurse A | Administrative Nurse | Confirmed no system in place to check medication expiration dates |
Inspection Report
Life Safety
Deficiencies: 1
Jul 26, 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 deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Oct 26, 2013
Provider agreement termination date: Jan 26, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 0
May 23, 2013
Visit Reason
This is a post-certification revisit to verify that previously identified deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected by 04/26/2013 as confirmed during this revisit.
Report Facts
Deficiencies corrected: 12
Inspection Report
Renewal
Deficiencies: 0
Mar 27, 2013
Visit Reason
The document is a licensure resurvey of the facility to assess compliance for renewal purposes.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 10
Mar 27, 2013
Visit Reason
Annual health resurvey of Prairie Sunset Home Inc to assess compliance with state and federal regulations related to resident care, safety, and facility operations.
Findings
The facility had multiple deficiencies including failure to report and investigate abuse allegations, inadequate policies on abuse reporting, failure to revise care plans after resident falls, improper use of fall prevention devices, lack of education on immunizations, unsafe equipment, lack of emergency call system in public restroom, absence of medical director contract, and insufficient nurse aide inservice training.
Severity Breakdown
Level F: 4
Level E: 4
Level D: 1
Level C: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to report, investigate, and prevent further abuse while investigations were in progress. | Level F |
| Failure to develop and implement written policies and procedures for reporting suspicion of a crime committed against any resident. | Level C |
| Failure to review and revise care plans with each fall for sampled residents. | Level E |
| Failure to thoroughly investigate falls and implement new interventions to minimize risk for falls and injuries. | Level E |
| Failure to provide education regarding benefits and risks of influenza and pneumococcal immunizations and failure to offer immunizations to some residents. | Level E |
| Failure to have a full body lift in safe operating condition for residents requiring mechanical lifts. | Level D |
| Failure to have an emergency call light system from the public restroom to the nurses' station. | Level E |
| Failure to use resources effectively and efficiently to maintain highest practicable well-being of residents. | Level F |
| Failure to ensure continuing competence of nurse aides by providing minimum 12 hours of inservice per year based on performance reviews. | Level F |
| Failure to have a current contract with a physician to serve as medical director. | Level F |
Report Facts
Facility census: 32
Residents sampled for care plans: 26
Residents sampled for accidents: 5
Nurse aides reviewed: 5
Inservice hours provided: 16
Inservice hours for CNA S: 3
Inservice hours for CNA D: 9
Inservice hours for CNA T: 2
Inservice hours for CNA U: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Interviewed regarding abuse reporting, fall investigations, immunization education, nurse aide inservice, and medical director contract | |
| Direct Care Staff G | Mentioned in abuse allegation and fall prevention device use | |
| Staff D | Interviewed regarding fall risk, care plan adherence, and call light placement | |
| Licensed Nurse E | Interviewed regarding fall risk and use of alarms | |
| Staff N | Interviewed regarding full body lift equipment failure | |
| Staff P | Rehabilitation Staff | Interviewed regarding resident transfers and staff training |
| Staff A | Interviewed regarding fall investigations and care plan revisions | |
| Licensed Staff J | Interviewed regarding motion sensor use and resident reaction | |
| Direct Care Staff I | Interviewed regarding visual checks and fall history | |
| Administrative Staff B | Interviewed regarding call light accessibility and restroom emergency call system | |
| Licensed Staff E | Interviewed regarding call light placement and resident confusion | |
| Direct Care Staff H | Interviewed regarding public restroom use | |
| Direct Care Staff M | Interviewed regarding facility no lift policy and lift equipment status | |
| Direct Care Staff O | Interviewed regarding lift equipment status | |
| Licensed Staff L | Interviewed regarding resident transfers without lift |
Inspection Report
Plan of Correction
Deficiencies: 2
N078017 POC KJ9V11
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 has developed and implemented corrective actions to address cited deficiencies, including posting policies and procedures visibly, and instituting monthly medication stock checks to discard outdated medications.
Severity Breakdown
Level C: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain visible notice of policies and procedures and recent survey results. | Level C |
| Failure to properly manage medication stock, including discarding outdated bottles. | Level E |
Report Facts
Complete Date for S0000: Jul 9, 2014
Complete Date for S2030-C: Jul 7, 2014
Complete Date for S2235-E: Jul 9, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rexmaris | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 5
N078017 POC NXL811
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home addressing deficiencies cited during a prior survey.
Findings
The facility outlines corrective actions for deficiencies related to restraint orders, quarterly MDS assessments, fall prevention education, staffing levels during flu outbreaks, and proper documentation of charge nurse shifts. The facility plans to implement education, monitoring, and consulting to ensure compliance.
Severity Breakdown
D: 2
G: 1
F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Lack of proper physician's order and documentation for use of a merri-walker as a restraint. | D |
| Failure to complete quarterly MDS assessments for restraints properly and timely. | D |
| Need for staff education on MDS assessments, fall prevention, fall documentation, and care planning. | G |
| Insufficient staffing during flu outbreak leading to concerns about resident care. | F |
| Failure of the Director of Nursing to clock in while working as charge nurse, despite documentation of work performed. | F |
Report Facts
Staffing ratio: 3.79
Completion date: Apr 3, 2015
Completion date: Apr 10, 2015
Completion date: Apr 13, 2015
Completion date: Mar 24, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| REXMARIS | Administrator | Submitted the Plan of Correction. |
| D.O.N. | Director of Nursing | Responsible for monitoring restraints, staffing, and documentation compliance. |
| A.D.O.N. | Assistant Director of Nursing | Responsible for monitoring restraints, staffing, and documentation compliance. |
Inspection Report
Plan of Correction
Deficiencies: 11
N078017 POC HOGR11
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home addressing deficiencies cited during a prior survey.
Findings
The facility outlines corrective actions for multiple deficiencies including staff training on abuse recognition and reporting, care plan revisions after resident falls, proper documentation of immunizations, maintenance of equipment such as lifts and motion sensors, and improved communication with contractors. The facility commits to substantial compliance by specified dates in April 2013.
Severity Breakdown
F: 6
E: 3
D: 1
C: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to recognize, report, investigate, and document alleged resident abuse, neglect, and/or exploitation. | F225-F |
| Lack of policy and training on reporting suspected crimes against elders. | F226-C |
| Improper revision of resident care plans after falls and inadequate use of motion sensors. | F280-E |
| Failure to properly investigate and revise care plans with new interventions after falls. | F323-E |
| Improper documentation of immunization education and administration. | F334-E |
| Lifts not properly maintained; new batteries ordered and weekly testing instituted. | F456-D |
| Call light installation and communication issues during construction project. | F463-E |
| Need for in-service training on abuse investigation, fall care plan revisions, and immunization documentation. | F490-F |
| Tracking and documentation of in-service attendance for nursing staff. | F497-F |
| Lack of contract with Medical Director; contract to be signed and maintained. | F501-F |
| Quality Assurance committee to review survey results and ensure follow-up on abuse reports. | F520-F |
Report Facts
In-service attendance target: 85
Dates for substantial compliance: 2013
Lift battery use start date: 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| REXMARIS | Administrator | Submitted the Plan of Correction and responsible for monitoring compliance |
| Shirley Boltz | Contact person for Plan of Correction assistance |
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