Inspection Reports for
Prairie Sunset Home
601 E. MAIN STREET, PRETTY PRAIRIE, KS, 67570
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
25 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
317% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
88% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-03-05.
Findings
All deficiencies have been corrected as of the compliance date of 2025-04-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 17, 2025
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction addresses multiple deficiencies including care plan revisions for pain management, nurse staffing information posting, psychotropic medication monitoring, food procurement and sanitation, and infection prevention and control. The facility outlines corrective actions, staff training, and ongoing monitoring to ensure compliance.
Deficiencies (6)
F656: The interdisciplinary care plan for resident #17 was amended to include staff instruction and non-pharmacologic interventions for pain. A checklist of non-pharmacological interventions was developed for staff use.
F697: The interdisciplinary care plan for resident #17 was amended to include staff instruction and non-pharmacologic interventions for pain management.
F732: A new two-page Nurse Staffing Information form was developed to document staffing per regulation. Staffing records are maintained for 18 months and made available upon request.
F758: The care plans for residents #26 and #34 were amended to include monitoring for adverse drug interactions. The attending physician for resident #18 was notified of a medication stop date.
F812: Food procurement, storage, preparation, and serving practices were reviewed and corrected. Staff were retrained on food labeling, dating, and sanitation requirements.
F880: Infection prevention and control omissions were reviewed and corrected. Staff received additional training on PPE use and storage of supplies off the floor.
Report Facts
Plan of Correction completion date: 2025
Staffing record retention period: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 6
Date: Mar 5, 2025
Visit Reason
Annual inspection of Prairie Sunset Home Inc to assess compliance with regulatory requirements including care planning, medication management, staffing, food safety, and infection control.
Findings
The facility failed to complete comprehensive resident-centered care plans including non-pharmacologic pain interventions, failed to monitor side effects of psychotropic and antidepressant medications, failed to post accurate daily nurse staffing information, failed to store and serve food in a sanitary manner, and failed to maintain an effective infection prevention and control program in some resident halls.
Deficiencies (6)
F 0656: The facility failed to develop and implement a complete care plan including non-pharmacologic interventions for pain for Resident 14.
F 0697: The facility failed to provide safe, appropriate pain management by not initiating non-pharmacologic pain interventions for Resident 17 with chronic pain.
F 0732: The facility failed to post accurate, publicly accessible, and identifiable daily nurse staffing information for 38 residents.
F 0758: The facility failed to monitor side effects of psychotropic and antidepressant medications for Residents 26, 34, and 18, including failure to obtain a stop date for an antianxiety medication.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner, including undated and unsealed food items in storage and refrigeration areas, risking food-borne illness.
F 0880: The facility failed to establish and maintain an infection prevention and control program, with issues including incontinent products on bathroom floors, improperly disposed PPE, clutter in resident rooms, and medication boxes on the floor.
Report Facts
Residents reported: 38
Residents sampled: 15
Medication administrations: 7
Medication administrations: 4
Medication administrations: 15
Medication administrations: 7
Medication cards: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) N | Reported Resident 14 had back pain and would notify nurse for pain medication | |
| Administrative Nurse D | Confirmed lack of non-pharmacologic pain interventions and lack of monitoring for medication side effects | |
| Dietary Manager BB | Dietary Manager | Acknowledged undated and unsealed food items were unacceptable and would be discarded |
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 6
Date: Mar 5, 2025
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to assess compliance with care plan development, pain management, nurse staffing information posting, psychotropic medication monitoring, food safety, and infection control.
Complaint Details
The visit was triggered by a complaint investigation combined with a health resurvey.
Findings
The facility failed to complete comprehensive care plans including non-pharmacologic pain interventions for residents with chronic pain, did not offer non-pharmaceutical pain interventions, failed to post accurate nurse staffing information, failed to monitor side effects of psychotropic medications, failed to store and serve food in a sanitary manner, and failed to maintain an effective infection prevention and control program in resident halls.
Deficiencies (6)
F 656: The facility failed to complete a resident-centered comprehensive care plan including non-pharmacologic interventions for pain for one resident.
F 697: The facility failed to offer non-pharmaceutical pain interventions for one resident with chronic pain.
F 732: The facility failed to post accurate, publicly accessible nurse staffing information daily for 38 residents.
F 758: The facility failed to monitor five residents for side effects of psychotropic and antipsychotic medications and failed to obtain a stop date for an antianxiety medication.
F 812: The facility failed to store, prepare, and serve food in a sanitary manner, including undated and unsealed food items in storage and food service areas.
F 880: The facility failed to maintain an infection prevention and control program, with incontinent products on bathroom floors, improperly disposed PPE, clutter in resident rooms, and medication cards stored on the floor.
Report Facts
Resident census: 38
Residents sampled: 15
Medication administrations: 7
Medication administrations: 15
Medication administrations: 75
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
The visit was a Re-Licensure survey for the assisted living facility conducted on 10/25/23.
Findings
The survey resulted in no deficiencies for the facility.
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
The inspection 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
Date: Aug 16, 2023
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-06-14.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2023-07-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 6
Date: Jun 14, 2023
Visit Reason
Annual inspection of Prairie Sunset Home Inc nursing facility to assess compliance with regulatory standards including care planning, resident hygiene, fall prevention, toileting plans, food safety, and vaccination protocols.
Findings
The facility failed to revise care plans for falls, provide consistent personal hygiene care, implement timely fall prevention interventions, develop individualized toileting plans, store food safely, and ensure pneumococcal vaccination education and documentation for residents.
Deficiencies (6)
F 0657: The facility failed to revise care plans for Resident 28 related to multiple falls and did not update interventions after each fall incident.
F 0677: The facility failed to provide care consistent with professional standards for Resident 30 to maintain good grooming and personal hygiene related to showers, nail care, and facial hair removal.
F 0689: The facility failed to provide timely and appropriate fall prevention interventions for Resident 28, who had multiple falls including a fractured humerus.
F 0690: The facility failed to provide an individualized toileting plan for Resident 28 to ensure continence and prevent urinary tract infections.
F 0812: The facility failed to properly store food in the kitchen, including uncovered foods, expired items, boxes on the floor, and missing temperature logs, risking food borne illness.
F 0883: The facility failed to provide education or documentation of pneumococcal vaccination or declination for three residents, including Residents 26, 23, and 35.
Report Facts
Residents in census: 31
Residents in sample: 12
Expired yogurt tubs: 5
Missing temperature log dates: 2
Residents lacking pneumococcal vaccination: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse J | Licensed Nurse | Reported failure to update care plans following falls for Resident 28 |
| Administrative Nurse B | Administrative Nurse | Reported expectations for care plan revisions and vaccination offering |
| Certified Nurse Aide K | Certified Nurse Aide | Assigned shower aide who reported not recently showering Resident 30 |
| Dietary Staff D | Dietary Staff | Reported boxes on floor due to recent delivery and responsibility for checking expiration dates |
| Dietary Staff C | Dietary Staff | Confirmed food storage violations and staff responsibilities |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 7
Date: Jun 14, 2023
Visit Reason
Re-survey inspection to evaluate compliance with previously cited deficiencies and overall facility regulatory compliance.
Findings
The facility was found deficient in multiple areas including failure to revise care plans after resident falls, inadequate assistance with activities of daily living, failure to prevent accidents and falls, lack of individualized toileting plan, insufficient RN coverage, improper food storage and handling, and failure to provide pneumococcal vaccine education and documentation.
Deficiencies (7)
F 657: The facility failed to revise care plans for Resident 28 related to multiple falls, lacking updated interventions after each fall incident.
F 677: The facility failed to provide care consistent with professional standards for Resident 30, including inadequate assistance with bathing, nail care, and facial hair removal.
F 689: The facility failed to provide timely and appropriate interventions to prevent further falls for Resident 28, who had multiple falls including one resulting in a fractured humerus.
F 690: The facility failed to provide an individualized toileting plan for Resident 28 to maintain continence and prevent urinary tract infections.
F 727: The facility failed to provide Registered Nurse coverage for at least eight consecutive hours daily on six days in the last two months.
F 812: The facility failed to properly store food in the kitchen, including uncovered foods, expired items, boxes on the floor, and missing temperature logs, risking foodborne illness.
F 883: The facility failed to ensure residents or their representatives received education regarding pneumococcal vaccine benefits and risks, and lacked documentation of vaccine receipt or refusal for three residents.
Report Facts
Facility census: 31
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 Resident 28's care plan following falls |
| Administrative Nurse B | Administrative Nurse | Verified lack of continuous RN coverage and commented on care plan revisions and vaccination education |
| Certified Nurse Aide K | Certified Nurse Aide | Assigned to showers, confirmed not recently showering Resident 30 |
| Certified Nurse Aide H | Certified Nurse Aide | Assisted Resident 28, unaware of silent alarm usage |
| Certified Nurse Aide G | Certified Nurse Aide | Reported Resident 28's mobility and fall history, unaware of silent alarm |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jun 14, 2023
Visit Reason
The 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.
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 implemented corrective actions including staff training, care plan amendments, and ongoing monitoring by leadership.
Deficiencies (6)
F657: Care Plan timing and revision deficiencies were addressed by immediate amendments to resident care plans and staff training on fall prevention interventions.
F677: ADL care deficiencies were corrected by adding supportive interventions such as daily shaving and nail care to resident care plans and nurse aide task lists.
F689: Accident hazards and supervision deficiencies were addressed by updating care plans with fall prevention strategies and initiating a 3-day voiding diary for resident #28.
F690: Bowel/bladder incontinence and catheter care deficiencies were corrected by adding toileting plans and voiding diaries to resident care plans and staff task lists.
F812: Food procurement and sanitary practices deficiencies were reviewed and corrected, including staff retraining and improved food storage procedures.
F883: Influenza and pneumococcal immunization deficiencies were addressed by reviewing medical records, obtaining consents, and initiating vaccination clinics.
Report Facts
Completion date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 26, 2022
Visit Reason
The visit was a resurvey of the assisted living facility conducted on 04/25/22 - 04/26/22 to verify compliance.
Findings
The resurvey resulted in no deficiencies for the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 25, 2022
Visit Reason
This document is a plan of correction submitted following a resurvey of an 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
Date: Jan 3, 2022
Visit Reason
An offsite revisit survey was conducted 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.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Nov 4, 2021
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during an inspection conducted on November 4, 2021.
Findings
The Plan of Correction addresses multiple deficiencies including oxygen administration and tubing replacement, missing discharge summary recapitulation, respiratory care, drug regimen review and reporting irregularities, unnecessary drug use, and food procurement and sanitation practices. The facility implemented corrective actions and monitoring plans to ensure compliance.
Deficiencies (6)
F656: The interdisciplinary care plan for resident #23 was updated to include oxygen administration and tubing replacement, with schedules added to the treatment administration record.
F661: The missing discharge summary recapitulation for resident #41 was corrected and procedures were implemented to ensure future discharge summaries include required information.
F695: Oxygen delivery tubing was immediately replaced for residents #23 and #27, and a schedule for tubing changes was established and documented on the medication administration record.
F756: The consultant pharmacist was directed to focus on blood pressure monitoring and physician notification protocols were updated to require notification after three consecutive abnormal readings.
F757: Staff were trained on new blood pressure protocols requiring reporting of abnormal readings and physician notification for critical or repeated out-of-range values.
F812: Food service staff were retrained on sanitary food handling, including hair covering, glove use, temperature logs, and proper storage to maintain food safety.
Report Facts
Completion date: Dec 17, 2021
Inspection date: Nov 4, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction. |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 6
Date: Nov 4, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Prairie Sunset Home Inc, including care planning, discharge procedures, respiratory care, medication management, and food safety.
Findings
The facility failed to develop comprehensive care plans for oxygen use, document discharge summaries, provide appropriate respiratory care including timely oxygen tubing changes, ensure pharmacist notification of abnormal blood pressures, and maintain sanitary food storage and preparation practices. These deficiencies posed minimal harm but affected multiple residents.
Deficiencies (6)
F 0656: The facility failed to develop a comprehensive care plan including oxygen use for Resident 23, lacking interventions and documentation for oxygen therapy.
F 0661: The facility failed to document a discharge summary including a recapitulation of Resident 41's stay upon discharge.
F 0695: The facility failed to provide safe respiratory care by not changing disposable oxygen equipment monthly for Residents 23 and 27, and not changing nebulizer masks monthly for Resident 27.
F 0756: The facility failed to ensure the pharmacist identified and reported missing documentation concerning physician notifications for blood pressures exceeding parameters for Residents 35 and 36.
F 0757: The facility failed to ensure adequate monitoring of antihypertensive medications by not notifying physicians of blood pressures exceeding ordered parameters for Residents 35 and 36.
F 0812: The facility 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.
Report Facts
Residents in census: 35
Residents in sample: 12
Residents reviewed for oxygen use: 5
Residents reviewed for unnecessary medications: 5
Missing temperature log entries: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse I | Licensed Nurse | Interviewed regarding oxygen tubing changes and medication monitoring |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding care plan expectations, oxygen use, and medication monitoring |
| Certified Nurse Aide F | Certified Nurse Aide | Interviewed regarding oxygen use for Resident 23 |
| Certified Medication Aide H | Certified Medication Aide | Interviewed regarding oxygen tubing changes |
| Consultant Pharmacist Q | Consultant Pharmacist | Interviewed regarding pharmacist review and physician notification |
| Dietary Staff R | Dietary Staff | Observed and interviewed regarding food preparation and hygiene |
| Dietary Staff T | Dietary Staff | Observed regarding hair restraint |
| Dietary Staff S | Dietary Staff | Interviewed regarding hair covering and glove use policies |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 6
Date: Nov 4, 2021
Visit Reason
The inspection was a health resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility failed to develop a comprehensive care plan including oxygen use for a resident, failed to document discharge summaries, failed to provide proper respiratory care including changing oxygen tubing and nebulizer masks, failed to ensure pharmacist reporting and physician notification for blood pressure irregularities, and failed to maintain sanitary food procurement, storage, and preparation practices.
Deficiencies (6)
F 656: The facility failed to develop a comprehensive care plan including oxygen use for Resident 23.
F 661: The facility failed to document a discharge summary including a recapitulation of Resident 41's stay upon discharge.
F 695: The facility failed to provide necessary respiratory care by not changing oxygen tubing and nebulizer masks as required for Residents 23 and 27.
F 756: The facility failed to ensure the pharmacist identified and reported missing documentation concerning physician notifications for blood pressures exceeding parameters for Residents 35 and 36.
F 757: The facility failed to ensure adequate monitoring of antihypertensive medications when staff did not notify the physician as ordered for blood pressures greater than 180/115 mmHg for Residents 35 and 36.
F 812: The facility failed to properly store food items, clean kitchen equipment, document refrigerator and freezer temperatures, and ensure dietary staff properly restrained hair.
Report Facts
Facility census: 35
Deficiency sample size: 12
Residents reviewed for oxygen use: 5
Missing temperature log entries: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide F | Certified Nurse Aide | Interviewed regarding oxygen use and tubing changes for Resident 23 |
| Certified Medication Aide H | Certified Medication Aide | Interviewed regarding oxygen tubing replacement and documentation for Resident 23 |
| Licensed Nurse I | Licensed Nurse | 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 |
| Consultant Pharmacist Q | Consultant Pharmacist | Interviewed regarding pharmacist reporting and physician notification for blood pressure irregularities |
| Certified Medication Aide D | Certified Medication Aide | Interviewed regarding blood pressure monitoring and medication administration for Resident 35 |
| Certified Medication Aide E | Certified Medication Aide | Interviewed regarding blood pressure monitoring and medication administration for Resident 36 |
| Dietary Staff R | Dietary Staff | Observed preparing food 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 hair covering and glove use policies |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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
Abbreviated Survey
Deficiencies: 0
Date: 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
Routine
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
The visit was a special infection control survey for COVID-19 conducted at the facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
This document is a plan of correction related to deficiencies identified in a prior inspection report dated 2020-06-23 for Prairie Sunset facility.
Findings
No specific findings or deficiencies are detailed in this plan of correction document itself; it references a prior deficiency report but contains no records or descriptions.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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
Date: Mar 6, 2020
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2020-01-09.
Findings
All deficiencies have been corrected as of the compliance date of 2020-02-15, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: 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 blood sugar monitoring, care plan revisions, discharge summaries, respiratory care, dementia treatment, and drug regimen reviews. The facility implemented corrective actions including staff training, policy updates, and enhanced documentation procedures.
Deficiencies (7)
F580: The attending physician for Resident #24 was notified of oversight in blood sugar parameters. Standing Orders/Protocols were adopted as policy to guide blood sugar monitoring and insulin administration.
F657: The interdisciplinary care plan for Resident #30 was updated to include insulin administration and glucose monitoring. All diabetic residents' care plans were reviewed for compliance.
F661: A new interdisciplinary discharge summary form was implemented to correct missing discharge summary recapitulations for Resident #36 and future discharges.
F695: Oxygen delivery tubing was replaced for Resident #25 and all residents receiving supplemental oxygen. The oxygen policy was updated to ensure proper labeling and documentation.
F744: A new Behavior Intervention form was developed to document non-pharmacological interventions for dementia-related behaviors, with follow-up by Charge Nurses and supervisory RNs.
F756: The Consultant Pharmacist was directed to monitor insulin/blood glucose monitoring and behavior charting irregularities. Quality control audits and medication reviews were enhanced.
F757: The Consultant Pharmacist was provided with deficiency information related to insulin and blood glucose monitoring. Standing Orders/Protocols were adopted and communicated to attending physicians.
Report Facts
Staff trained: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Administrator who submitted the Plan of Correction. |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 7
Date: Jan 9, 2020
Visit Reason
The inspection was a health resurvey to evaluate compliance with previously identified deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of critical blood sugar levels, failure to revise care plans for diabetic residents, inadequate discharge summaries, improper oxygen therapy sanitation, insufficient monitoring of dementia-related behaviors, and failure to ensure proper drug regimen review and follow-up on irregularities.
Deficiencies (7)
F580: The facility failed to notify the physician when Resident 24's blood sugars exceeded 450 mg/dl as ordered.
F657: The facility failed to revise the care plan to include blood glucose monitoring and insulin use for Resident 30 with diabetes mellitus.
F661: The facility failed to document a discharge summary recapitulation for Resident 36 upon discharge.
F695: The facility failed to provide oxygen therapy in a sanitary manner by not labeling oxygen tubing with change dates for Resident 25.
F744: The facility failed to adequately monitor and document behaviors related to dementia for Residents 1, 16, and 27.
F756: The facility failed to ensure reporting of drug irregularities, including lack of blood sugar monitoring and behavior follow-up, to the physician and director of nursing for Residents 17, 27, and 30.
F757: The facility failed to prevent unnecessary medications by not administering supplemental insulin as ordered for Resident 30 when blood glucose levels exceeded 400 mg/dl.
Report Facts
Resident 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 | Named in relation to blood sugar monitoring and insulin administration for Resident 30 |
| Administrative Nurse C | Administrative Nurse | Named in relation to blood sugar notification and behavior monitoring |
| Consultant Pharmacist K | Consultant Pharmacist | Named in relation to drug regimen review and identification of irregularities |
| Certified Medication Aide B | Certified Medication Aide | Named in relation to blood sugar monitoring and behavior monitoring |
| Certified Nursing Assistant E | Certified Nursing Assistant | Named in relation to behavior monitoring |
| Certified Nursing Assistant H | Certified Nursing Assistant | Named in relation to behavior monitoring |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 17, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder for the Plan of Correction related to the referenced event.
Inspection Report
Follow-Up
Deficiencies: 6
Date: 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 were corrected as of the revisit date. The report lists multiple regulation citations with completed corrections.
Deficiencies (6)
26-41-202 (a): Previously cited deficiency corrected as of 09/03/2019.
26-41-204 (a): Previously cited deficiency corrected as of 09/03/2019.
26-41-205 (d) (4): Previously cited deficiency corrected as of 09/03/2019.
26-41-205 (g) (3): Previously cited deficiency corrected as of 09/03/2019.
26-41-207 (b) (5-6) (c): Previously cited deficiency corrected as of 09/03/2019.
28-39-254: Previously cited deficiency corrected as of 09/03/2019.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 22, 2019
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-05-28.
Findings
All deficiencies have been corrected as of the compliance date of 2019-06-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 12
Deficiencies: 6
Date: Jul 9, 2019
Visit Reason
Licensure resurvey of an assisted living facility conducted over multiple days in July 2019.
Findings
The facility failed to ensure negotiated service agreements included outside services and payment responsibilities, failed to provide or coordinate necessary health care services for residents with varying needs, failed to properly train medication aides for blood sugar testing, failed to label over-the-counter medications with resident names, failed to comply with tuberculosis screening guidelines for employees and residents, and failed to secure chemicals to protect cognitively impaired residents.
Deficiencies (6)
KAR 26-41-202 (a) The facility failed to ensure negotiated service agreements included services provided by outside sources and the party responsible for payment for 2 of 3 sampled residents regarding therapy services.
KAR 26-41-204 (a) The facility failed to ensure a licensed nurse provided or coordinated necessary health care services meeting the needs of 3 of 4 sampled residents related to falls, bed assistive devices, cognition, transfer assistance, toileting, and personal hygiene.
KAR 26-41-205 (d) (4) The facility failed to ensure licensed nurse orientation and competency documentation for blood sugar testing for 2 certified medication aides.
KAR 26-41-205 (g) (3) The facility failed to ensure over-the-counter medications were labeled with the resident's full name for 7 residents.
K.A.R 26-207 (c) The facility failed to comply with tuberculosis guidelines for adult care homes for newly hired employees and residents, including delayed or missing TB skin tests and annual screenings.
KAR 28-39-254 (a) The facility failed to secure chemicals in unlocked cabinets accessible to residents, posing a safety risk to cognitively impaired residents.
Report Facts
Census: 12
Number of opened OTC medications: 10
Number of opened OTC medications: 12
Number of opened OTC medications: 14
Number of opened OTC medications: 1
Number of opened OTC medications: 1
Number of opened OTC medications: 7
Number of opened OTC medications: 5
Days delayed for TB skin test: 45
Days delayed for TB skin test: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse D | Named in multiple findings including failure to ensure negotiated service agreements, coordination of health care services, orientation and competency documentation for CMAs, and chemical safety. | |
| Certified Medication Aide B | Certified Medication Aide | Failed to have documented training and competency for blood sugar testing. |
| Certified Medication Aide F | Certified Medication Aide | Failed to have documented training and competency for blood sugar testing. |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: 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.
Complaint Details
The inspection findings represent the results of complaint investigations KS00140536 and KS00141417.
Findings
The facility failed to provide appropriate care to residents with pressure ulcers by not completing weekly skin assessments or properly measuring and staging wounds. Additionally, the facility failed to provide adequate services and assistance to maintain or restore urinary continence for three sampled residents, lacking individualized toileting plans and voiding diaries.
Deficiencies (2)
F686: The facility failed to complete weekly skin assessments and consistent wound measurements and staging for residents with pressure ulcers, leading to inadequate prevention and treatment of pressure ulcers.
F690: The facility failed to ensure residents with urinary incontinence received appropriate assessment, individualized toileting plans, and assistance to maintain or restore continence.
Report Facts
Residents in sample: 4
Residents with pressure ulcers: 3
Residents with urinary incontinence: 3
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 28, 2019
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during the inspection conducted on May 28, 2019.
Findings
The Plan of Correction addresses deficiencies related to pressure ulcer prevention and treatment, bowel and bladder incontinence management, and related care plan updates. The facility implemented corrective actions including staff training, updated assessments, enhanced documentation, and ongoing monitoring to ensure compliance and improve resident care.
Deficiencies (2)
F686 - Treatment and services to prevent and heal pressure ulcers were deficient. The facility initiated immediate corrective actions including new assessments, staff training, and enhanced wound care protocols.
F690 - Deficiencies in bowel and bladder incontinence management, catheter use, and UTI prevention were identified. The facility updated policies, conducted assessments, and revised care plans accordingly.
Report Facts
Completion date: Jun 18, 2019
Inspection date: May 28, 2019
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 31, 2019
Visit Reason
The plan of correction document addresses the findings from a health survey and a complaint survey conducted on 2019-01-23 to 2019-01-24 for multiple complaints.
Complaint Details
The complaint survey was conducted for complaints #KS00136958, #KS00126859, and #KS00122621. The allegations were not substantiated.
Findings
The health survey found no deficiency citations related to long term care regulations. The complaint allegations were not substantiated and no noncompliance was found; the facility was in compliance with all surveyed regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 31, 2019
Visit Reason
The inspection was conducted as a complaint survey on 2019-01-23 to 2019-01-24 for complaints #KS00136958, #KS00126859, and #KS00122621.
Complaint Details
The complaints investigated were not substantiated and no noncompliance was found.
Findings
No deficiency citations were found related to the applicable regulations under 42 CFR Part 483, Subpart B. The allegations made in the complaints were not substantiated and the facility was found to be in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 18, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(d)(1)(2)(n)(1)-(3) deficiency was corrected by the revisit date of 08/18/2017.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Aug 16, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding a resident elopement incident.
Complaint Details
The complaint investigation 5Z4E11 was triggered by an incident where resident #1, with severe cognitive impairment and a high risk for wandering, exited the facility without staff knowledge. The investigation included review of physician orders, assessments, care plans, nurse and social service notes, staff interviews, and observations.
Findings
The facility failed to ensure staff accurately assessed and supervised a resident with a known history of wandering, resulting in the resident exiting the building without staff's knowledge. Multiple observations, interviews, and record reviews documented the resident's wandering behaviors and the facility's inadequate interventions.
Deficiencies (1)
F 323: The facility failed to ensure staff accurately assessed the resident and planned interventions to supervise the whereabouts of a resident with a known history of wandering when the resident exited the building without staff's knowledge.
Report Facts
Resident census: 35
Wandering resident assessment score: 3
Frequency of visual checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Direct Care Staff | Witnessed resident outside the facility and intervened to prevent elopement |
| Nurse G | Licensed Nurse | Responded to elopement incident and assisted resident back inside |
| Social Service Staff D | Social Service Staff | Provided 1:1 supervision and communicated with resident's family about the elopement |
| Licensed Nurse F | Licensed Nurse | Reported on wandering assessments and facility policies |
| Administrative Nurse B | Administrative Nurse | Notified of elopement incident and interviewed regarding assessment policies |
| Administrative Staff A | Administrative Staff | Reviewed video footage and reported on facility door security improvements |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 10, 2017
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to a complaint investigation related to resident elopement and safety concerns.
Complaint Details
This Plan of Correction addresses a complaint investigation related to resident elopement risks and supervision failures. The facility submitted a credible allegation of compliance with corrective actions.
Findings
The facility implemented multiple corrective actions including disabling certain entrances, revising the elopement policy, conducting elopement risk assessments, increasing observation checks, and improving visitor sign-in procedures to prevent residents from exiting without staff knowledge.
Deficiencies (1)
F323 - Visitors and family members were not adequately supervised to prevent confused residents from following them out exits without staff knowledge, posing elopement risks.
Report Facts
Residents identified as consistently walking without purpose: 4
Board of Directors approved funding: 40000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 27, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.60(b), (d), (e) and 483.75(o)(1) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 483.60(b), (d), (e) deficiencies were corrected by the revisit date.
Regulation 483.75(o)(1) deficiencies were corrected by the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 27, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) deficiency was corrected as of 2017-07-27.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: 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 and monitoring plans have been implemented to ensure compliance and prevent recurrence.
Deficiencies (3)
F431: A USE BY date was immediately labeled on bubble packaged medications and open dates on inhalers. Staff were instructed to verify expiration dates and store opened inhalers properly. Pharmacy changed blister pack expiration dating to one year unless shorter is required.
F520: The QAPI Committee addressed cited deficiencies, completed action plans, and monitors effectiveness of corrective actions. Staff were re-educated on reporting issues to supervisors for QAPI review and follow-up.
S1166: The call light cord that was too short was replaced. Staff were instructed to keep cords accessible and notify maintenance of issues. Policies on call light operation and maintenance will be reviewed annually and during staff orientation.
Inspection Report
Follow-Up
Deficiencies: 12
Date: Jul 24, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of 07/19/2017, with corrective actions completed for each cited regulation.
Deficiencies (12)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected by 07/19/2017.
Regulation 483.15(a) deficiency was corrected by 07/19/2017.
Regulation 483.15(e)(1) deficiency was corrected by 07/19/2017.
Regulation 483.20(g)-(j) deficiency was corrected by 07/19/2017.
Regulation 483.25(h) deficiency was corrected by 07/19/2017.
Regulation 483.25(i) deficiency was corrected by 07/19/2017.
Regulation 483.25(l) deficiency was corrected by 07/19/2017.
Regulation 483.30(a) deficiency was corrected by 07/19/2017.
Regulation 483.35(d)(1)-(2) deficiency was corrected by 07/19/2017.
Regulation 483.35(i) deficiency was corrected by 07/19/2017.
Regulation 483.60(c) deficiency was corrected by 07/19/2017.
Regulation 483.70(f) deficiency was corrected by 07/19/2017.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 24, 2017
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the previously cited deficiency under regulation 26-40-305 (3) was corrected as of 07/19/2017. No other deficiencies are listed as outstanding.
Deficiencies (1)
Regulation 26-40-305 (3) deficiency was corrected by 07/19/2017.
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 1
Date: Jul 24, 2017
Visit Reason
This 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. 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.
Deficiencies (1)
26-40-303 (b)(i)(ii)(iii)(iv)(c) P E - Nursing facility support system requires an emergency call button or pull cord next to each resident-use toilet, shower, and bathtub. The facility failed to have a pull cord within reach of residents in the 400 hall common shower.
Report Facts
Facility census: 36
Residents in 100, 300, and 400 halls: 26
Call light cord length: 6
Call light cord length: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff D | Stated the call light cord was too short for residents who showered in the shower chair | |
| maintenance staff C | Measured the shower cord and planned to install a longer cord | |
| administrative nursing staff B | Stated the call light needed to be accessible to the resident during a shower |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 24, 2017
Visit Reason
This document reports the results of a first revisit conducted on July 24, 2017, following a June 20, 2017 health survey to verify the facility's 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.
Report Facts
Denial of payment effective date: Jul 11, 2017
Provider agreement termination date: Dec 20, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed letter regarding enforcement and survey results |
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Jul 11, 2017
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Deficiencies (5)
26-41-205 (g) (2): Previously cited deficiency corrected as of 07/11/2017.
26-41-205 (h): Previously cited deficiency corrected as of 07/11/2017.
26-41-206 (d): Previously cited deficiency corrected as of 07/11/2017.
26-41-207 (a) (b): Previously cited deficiency corrected as of 07/11/2017.
28-39-255: Previously cited deficiency corrected as of 07/11/2017.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 2
Date: Jun 20, 2017
Visit Reason
The inspection was a health resurvey to verify compliance with previously identified deficiencies related to emergency call systems and electrical safety.
Findings
The facility failed to have accessible emergency call buttons or pull cords in the 200 hall bathing rooms, and call cords were improperly tied up preventing resident use. Additionally, the hydrocullator was plugged into a non-GFCI outlet, posing an electrical hazard.
Deficiencies (2)
26-40-303 (b)(i)(ii)(iii)(iv)(c) Nursing facility support system: The facility 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, and call cords were tied up preventing resident access.
26-40-305 (3) Electrical requirements: The hydrocullator was plugged into a standard outlet lacking ground-fault circuit interrupter protection, posing a hazard to residents.
Report Facts
Facility census: 35
Residents on 200 hall: 9
Resident bathing rooms: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff L | Confirmed residents could not activate call light due to tied cords | |
| Maintenance staff A | Confirmed call cords were tied due to being too long and outlet lacked GFCI | |
| Administrative nurse G | Stated expectation for staff to ensure call light accessibility | |
| Administrative staff B | Confirmed unplugging hydrocullator from non-GFCI outlet |
Inspection Report
Plan of Correction
Deficiencies: 15
Date: 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 reporting, dignity and respect during meal assistance, call light accessibility, assessment accuracy, accident prevention, nutrition status, medication management, staffing adequacy, food safety, and maintenance of safety equipment. The facility has implemented training, policy revisions, new staff roles, and monitoring procedures to address these deficiencies.
Deficiencies (15)
F225: The facility revised abuse, neglect, and exploitation (ANE) policies and assigned the social services designee as the primary contact for reporting and investigating allegations. Staff received additional training on ANE reporting requirements.
F241: The facility directed support staff to assist certified staff during meals and developed a new meal service policy to ensure dignified dining experiences. Staff received mandatory training on these procedures.
F246: Staff were instructed to ensure residents' call lights are within reach, with mandatory training held to reinforce this requirement and related policy changes.
F278: A new Minimum Data Set (MDS) was initiated for a resident with dental problems, and care plans were updated. The care plan coordinator is scheduled for additional training to improve assessment accuracy.
F323: The facility secured hazardous chemicals and reminded staff to keep storage areas locked to prevent resident access to hazards.
F325: The facility implemented interventions to prevent falls, including therapy services and care plan modifications, with the social services designee assigned to lead investigations of serious injuries.
F329: Medication administration records and care plans were updated to include targeted behaviors and pain level documentation for a resident.
F353: A new Rehabilitation and Fitness Director position was added to reinforce direct care staffing and restorative nursing programs to improve resident function and reduce falls.
F364: Food and nutrition staff were retrained on pureed food preparation to ensure proper nutrition, with policies reviewed annually.
F371: The dishwasher temperature controls were adjusted and staff retrained on testing and documenting dish machine operations to ensure sanitary food service.
F428: Medication administration records were updated, and staff received counseling related to missed blood glucose tests. The consultant pharmacist was advised to enhance drug regimen reviews.
F431: The pharmacy added expiration dates to blister pack medications, and staff were instructed to verify these dates upon receipt and note opening dates for certain medications.
F463: Nurse call lights were verified as working properly, with batteries changed as needed. Policies for operation and maintenance are reviewed annually.
S1166: Call light cords were shortened to prevent hazards, and staff were instructed to notify maintenance immediately of any issues. Policies for maintenance are reviewed annually.
S1364: A GFCI outlet was installed for the hydrocullator, and maintenance verifies all electrical outlets work properly with service covers to prevent accidents.
Report Facts
Inspection date: Jun 20, 2017
Plan of Correction completion date: Jul 10, 2017
Staffing hours per resident day: 5
Staffing hours per resident day: 5.85
Medication scale weight capacity (lbs): 660
Medication scale weight accuracy (lbs): 0.2
Medication scale step height (inches): 2
Inservice training time: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Administrator who submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 0
Date: 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. Due to these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions.
Report Facts
Enforcement effective date: Jul 11, 2017
Enforcement review period: 6
Termination recommendation date: Dec 20, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact for questions regarding enforcement action and instructions |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 20, 2017
Visit Reason
A first revisit was conducted on July 24, 2017 for the June 20, 2017 Health survey to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies 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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
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 communicated findings |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: 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.
Findings
The Plan of Correction addresses multiple deficiencies including medication labeling, medication storage, food preparation, infection control, and housekeeping and sanitation. Each corrective action includes staff training, policy reviews, and ongoing monitoring by designated staff.
Deficiencies (5)
S3213 Medication Labeling—The pharmacy now includes expiration dates on all blister pack medications, and staff verify expiration dates upon receipt.
S3215 Medication Storage—Iodine was removed from the medication cart, staff were counseled on checking expiration dates, and additional training was provided.
S3298 Food Preparation—Uncovered food items were discarded, staff were reminded to properly cover and label food, and temperatures are logged twice daily.
S3305 Infection Control—Dishwasher temperature controls were adjusted, staff retrained on testing and documenting machine operations, and competency was verified.
S3390 Housekeeping and Sanitation—A door was locked per policy after being left unlocked, staff were counseled, and reminders were given about chemical safety.
Inspection Report
Re-Inspection
Census: 8
Deficiencies: 5
Date: Jun 12, 2017
Visit Reason
The inspection was a licensure resurvey of an assisted living facility 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, did not remove expired medications from stock, stored food unsafely, failed to sanitize dishes properly due to low dishwasher temperatures, and did not secure hazardous chemicals by locking the housekeeping closet. These deficiencies potentially affected all 8 residents.
Deficiencies (5)
26-41-205 (g)(2) Medication Labeling: The facility failed to ensure medication blister packs had expiration dates, affecting 7 residents receiving medications from a specific pharmacy.
26-41-205 (h) Medication Storage: The facility failed to remove expired medications from the medication cart, including a bottle of iodine expired since 2/2016.
26-41-206 (d) Food Preparation: The facility failed to store food safely by having an uncovered jar of pickles, uncovered ice cream in the freezer, and no thermometer inside the refrigerator or freezer.
28-39-255 Housekeeping and Sanitation: The facility failed to lock the housekeeping closet containing hazardous chemicals accessible to residents.
26-41-207 (a)(b) Infection Control: The facility failed to properly sanitize dishes due to dishwasher water temperatures below the required 180°F, affecting all residents served from the kitchen.
Report Facts
Facility census: 8
Expired medication date: 201602
Dishwasher rinse temperature: 140.2
Dishwasher rinse temperature: 154.2
Dishwasher rinse temperature: 146
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 1, 2017
Visit Reason
This visit was 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
The report confirms that all previously identified deficiencies have been corrected as of April 26, 2017.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Mar 28, 2017
Visit Reason
Partial extended survey conducted for investigation of complaints KS00107452 and KS00113456 regarding allegations of staff to resident abuse/mistreatment.
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 allegations were not reported timely, investigated thoroughly, or acted upon to protect residents. Administrative Staff A failed to report or investigate and allowed the alleged perpetrator to continue working.
Findings
The facility failed to immediately report multiple allegations of staff to resident abuse 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. Additionally, the facility's abuse, neglect, and exploitation policy lacked specific details on reporting reasonable suspicion of crimes to law enforcement and mental abuse related to unauthorized photographs or videos shared on social media.
Deficiencies (2)
483.12(a)(3)(4)(c)(1)-(4) The facility failed to immediately report 3 allegations of staff to resident abuse, failed to thoroughly investigate the allegations, failed to protect residents during investigations, and failed to submit investigation results within 5 working days.
483.12(b)(1)-(3), 483.95(c)(1)-(3) The facility failed to develop and implement written policies that included specific requirements for reporting reasonable suspicion of crimes to law enforcement and detailed information on mental abuse related to unauthorized photographs or videos shared on social media.
Report Facts
Resident census: 32
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 | Failed to report, investigate allegations, and allowed alleged perpetrator to continue working. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Mar 28, 2017
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to a complaint investigation conducted on 03/28/2017.
Complaint Details
The visit was complaint-related regarding allegations of staff-to-resident abuse. The allegations were investigated and found unsubstantiated by the nurse surveyor and administration.
Findings
The Plan of Correction addresses allegations of staff-to-resident abuse which were investigated and found unsubstantiated. The facility revised policies on abuse, neglect, and exploitation (ANE), enhanced staff training, and implemented procedures to ensure timely reporting and investigation of allegations.
Deficiencies (3)
F0000 Preparation, submission, and implementation of the Plan of Correction does not constitute admission or agreement to the alleged deficiencies. The plan outlines steps for compliance and quality improvement.
F225 Investigate/Report Allegations: Two staff members were suspended pending investigation of abuse allegations, which were later unsubstantiated. The licensed social worker was assigned as the primary contact for ANE reports and investigations.
F226 Develop/Implement Abuse/Neglect Policies: The facility revised the ANE policy to specify reporting timelines and prohibit use of technology to demean residents. Staff training and resident rights discussions were enhanced.
Report Facts
Date of complaint investigation: Mar 28, 2017
Suspension date of alleged perpetrators: Mar 21, 2017
Completion date of Plan of Correction: Apr 26, 2017
Mandatory inservice date: Apr 7, 2017
Volunteer Week presentation date: Apr 25, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kelley | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 regulatory tags. The facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions.
Deficiencies (1)
F225, CFR 483.12(a)(3)(4)(c)(1)-(4) and F226, CFR 483.12(b)(1)-(3), 483.95(c)(1)-(3) were cited for substandard quality of care requiring corrections.
Report Facts
Denial of payment effective date: Apr 19, 2017
Noncompliance correction deadline: Sep 28, 2017
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as contact for questions regarding the enforcement action and informal dispute resolution |
Inspection Report
Life Safety
Deficiencies: 1
Date: Dec 1, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited with deficiencies at an 'F' level under the Life Safety Code survey, indicating issues with compliance to federal fire safety regulations.
Inspection Report
Follow-Up
Deficiencies: 9
Date: Nov 23, 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 regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory citations.
Deficiencies (9)
Regulation 483.15(a): Deficiency previously cited was corrected by the revisit date.
Regulation 483.20(b)(1): Deficiency previously cited was corrected by the revisit date.
Regulation 483.25(l): Deficiency previously cited was corrected by the revisit date.
Regulation 483.25(n): Deficiency previously cited was corrected by the revisit date.
Regulation 483.35(i): Deficiency previously cited was corrected by the revisit date.
Regulation 483.60(c): Deficiency previously cited was corrected by the revisit date.
Regulation 483.65: Deficiency previously cited was corrected by the revisit date.
Regulation 483.75(m)(2): Deficiency previously cited was corrected by the revisit date.
Regulation 483.75(o)(1): Deficiency previously cited was corrected by the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Nov 23, 2015
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at Prairie Sunset Home Inc.
Findings
The report documents that deficiencies previously cited under regulation 28-39-160 with ID prefixes S0740 and S0750 were corrected as of 11/23/2015.
Deficiencies (2)
Regulation 28-39-160 deficiency with ID prefix S0740 was corrected on 11/23/2015.
Regulation 28-39-160 deficiency with ID prefix S0750 was corrected on 11/23/2015.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Nov 23, 2015
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home to address deficiencies cited during a prior survey.
Findings
The facility identified multiple deficiencies related to resident assessments, infection control, medication monitoring, dietary staff training, and emergency drills. Corrective actions include hiring a new MDS coordinator, staff retraining, and improved monitoring systems.
Deficiencies (12)
F0000 The facility will develop and implement a system to assure corrections and continued compliance with regulations. The Quality Assurance Committee will review the deficiency list for appropriate actions.
F241-D A resident was re-educated about the consequences of removing a motion alarm, and the motion sensor was removed. Consent and assessments will be ensured before placing motion sensors near residents.
F272-E A new MDS coordinator was hired to ensure care assessments are done appropriately and timely, supervised by the DON and Administrator.
F329-D A new MDS coordinator will ensure black box warnings on care plans are properly placed and monitored by the DON.
F334-D All residents have been offered influenza immunizations, and the MDS coordinator will track immunizations and follow up on pneumococcal vaccines.
F371-E Dietary staff received mandatory retraining on glove use and food handling. The CDM will monitor compliance and train new staff.
F428-D A psychotropic medication monitoring book is being developed to assist the pharmacist and ensure appropriate medication orders, maintained by the MDS coordinator and DON.
F441-F The new MDS coordinator will serve as infection control officer, responsible for annual education, infection tracking, and committee reporting, monitored by Administrator and DON.
F518-F The disaster drill was conducted using a fire drill form; future training and drills will be improved and conducted by designated staff.
F520-F The Quality Assurance committee will increase meeting frequency and rely on timely information from the new MDS coordinator to assure compliance.
S0740-E The special care unit is licensed as skilled nursing; magnetic locks on doors will be turned off to allow free resident movement, with admission policies applied uniformly.
S0750-E The skilled nursing wing will have magnetic locks turned off for free resident movement, with staff training applied facility-wide and additional training for challenging residents.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 26, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the plan of correction. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Oct 26, 2015
Visit Reason
The inspection was conducted as a licensure resurvey and complaint investigations #2302, #1649, and #2278.
Complaint Details
The inspection included 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). The facility also failed to have written physician orders for placement in the SCU, inform residents or their legal representatives in writing about SCU services, provide staff training specific to SCU residents' needs, and make policies and procedures for SCU operation available to clinical staff.
Deficiencies (4)
28-39-160 OTHER RESIDENT SERVICES: The facility failed to develop admission and discharge criteria specific to diagnosis, behavior, or clinical needs for residents in the Special Care Unit and lacked written physician orders for placement for 4 sampled residents.
28-39-160 OTHER RESIDENT SERVICES: The facility failed to inform residents or legal representatives in writing of the programs and services available in the Special Care Unit that differ from other sections of the facility.
28-39-160 OTHER RESIDENT SERVICES: The facility failed to provide staff training specific to the needs of residents in the Special Care Unit and failed to document completion of such training in employee records.
28-39-160 OTHER RESIDENT SERVICES: The facility failed to provide in-service training specific to the Special Care Unit residents' needs at regular intervals and failed to make clinical care staff policies and procedures for the Special Care Unit available.
Report Facts
Facility census: 40
Special Care Unit census: 9
Residents sampled: 4
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 1, 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
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: 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, background checks, availability of the most recent survey for public viewing, and timely completion of required assessments and medication reviews.
Deficiencies (8)
S3025-F: Staff used curse words around residents and referred to a resident's argument as stupid, though not directly calling the resident stupid. The incident was investigated and staff was suspended during the investigation.
S3027-F: Background check was performed online prior to employment but the screen was not printed and placed in the staff file before hiring.
S3055-C: The most recent survey was not available for public viewing because a staff member moved the notebook without knowledge.
S3081-D: A person's FCS and other FCS documents were current but this was missed; corrective action includes electronic calendar reminders.
S3092-D: NSA assessments were missed but have now been completed; future assessments will be tracked electronically.
S3175-D: Assessments for residents who self-administer medications are now performed on admission and annually, with electronic scheduling to track them.
S3225-D: Consultant pharmacist will now review medications of residents who self-administer quarterly as required.
S3229-D: Consultant pharmacist will immediately start reviewing all assisted living residents' medications and ensure timely completion.
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 8
Date: 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.
Complaint Details
The complaint involved an allegation of verbal abuse by direct care staff D toward resident #1, including derogatory remarks and failure to report the incident to the State Agency in a timely manner. The resident reported harassment and discrimination related to his/her visual impairment.
Findings
The facility failed to ensure staff implemented the abuse, neglect, and exploitation policy, 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, failed to assess competency for self-administration of medications, and failed to ensure quarterly pharmacist medication regimen reviews for residents.
Deficiencies (8)
KAR 26-41-101(f) Staff treatment of residents. The facility failed to ensure staff implemented the abuse, neglect, and exploitation policy for a grievance filed by resident #1 regarding verbal abuse by direct care staff D.
KAR 26-41-101(f)(2) Staff treatment of residents. The facility failed to perform pre-employment registry checks for direct care staff D, hired 19 days before the registry check was completed.
KAR 26-41-101(l) Survey report. The facility failed to ensure the most recent State survey results were available to residents in a public area without having to ask.
KAR 26-41-201(c)(1) Functional capacity screen reassessment. The facility failed to annually review functional capacity screenings for resident #1; last review was over 2 years prior.
KAR 26-41-202(d)(1) Negotiated service agreement revisions. The facility failed to annually review negotiated service agreements for residents #1, #2, and #3; last reviews were over 1 year old.
KAR 26-41-205(a)(1) Self administration of medication. The facility failed to complete an evaluation of competency for resident #1 who self-administered medications.
KAR 26-41-205(l) Medication regimen review frequency. The facility failed to ensure pharmacist medication regimen reviews were conducted at least quarterly for residents #2 and #3.
KAR 26-41-205(l)(4) Medication regimen review self administration. The facility failed to ensure the pharmacist offered quarterly medication regimen reviews for resident #1 who self-administered medications.
Report Facts
Facility census: 12
Days delay in registry check: 19
Months since last pharmacy review: 5
Months since last NSA review: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff D | Direct care staff | Named in verbal abuse allegation toward resident #1 |
| Administrative nurse A | Administrative nurse | Interviewed regarding abuse allegation, registry checks, and medication reviews |
| Administrative staff B | Administrative staff | Interviewed regarding abuse allegation and medication reviews |
| Direct care staff C | Direct care staff | Interviewed regarding resident medication administration |
| Direct care staff G | Direct care staff | Registry check performed late after hire |
| Pharmacy consultant F | Pharmacy consultant | Interviewed regarding medication regimen reviews |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 29, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of the revisit date. Corrections were completed for multiple regulatory requirements.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: 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 facility has outlined corrective actions addressing multiple deficiencies including resident use of a Merri walker device, timeliness of MDS assessments, fall investigations, staffing levels, and Quality Assurance committee oversight.
Deficiencies (6)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations and provide the deficiency list to the Quality Assurance Committee for review.
F221: The resident's use of a Merri walker device will be reassessed and limited to 1.5 hours at a time, up to 5 times daily, with family consultation and physician orders to reduce usage safely.
F275: The Administrator and D.O.N. will ensure timely completion of MDS assessments with weekly monitoring and consultant support to prevent delays.
F323: The D.O.N. will oversee fall investigations to determine root causes and ensure timely completion of reports within 4 working days, with consultant assistance as needed.
F353: Additional CNA staff positions will be added to special care and nursing home units, with staff training on dementia care and communication to improve resident care.
F520: The Quality Assurance committee will increase oversight of falls, medication errors, and resident concerns with weekly reviews and a stricter agenda to improve resident safety.
Report Facts
Complete Date: Jun 1, 2015
Complete Date: May 29, 2015
Complete Date: May 27, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rexmaris | Administrator | Named as responsible for oversight and reporting in multiple corrective actions |
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 12, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report confirms that deficiencies previously cited under regulations 483.20(c) and 483.30(b) were corrected as of the revisit date.
Deficiencies (2)
Regulation 483.20(c): Previously cited deficiency was corrected by the revisit date.
Regulation 483.30(b): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: 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.
Deficiencies (1)
F221 Restraints: The facility was noncompliant with requirements ensuring residents are free from unnecessary physical restraints, placing residents at risk for urinary incontinence, skin breakdown, accidents, increased agitation, and social isolation.
Report Facts
Civil Money Penalty: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jane Weiler | CMS Survey & Certification Branch | Contact person for questions regarding the matter. |
| Mary Jane Kennedy | Complaint Coordinator | Contact person for instructions related to the Informal Dispute Resolution process. |
| Joe Ewert | Commissioner, Survey, Certification and Credentialing Commission | Recipient of written requests for Informal Dispute Resolution. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 12, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated in the Plan of Correction.
Findings
The report confirms that the deficiencies previously reported under regulations 483.20(c) and 483.30(b) were corrected by the revisit date of 05/12/2015.
Deficiencies (2)
Regulation 483.20(c): Previously cited deficiency was corrected by 05/12/2015.
Regulation 483.30(b): Previously cited deficiency was corrected by 05/12/2015.
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 5
Date: May 12, 2015
Visit Reason
Revisit inspection to verify correction of previous deficiencies related to physical restraints, comprehensive assessments, fall investigations, staffing, 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 assessment annually for resident #103, failed to thoroughly investigate falls and implement interventions for residents #101, #102, and #103, and failed to provide sufficient nursing staff to meet resident needs. The Quality Assessment and Assurance (QAA) committee failed to develop and implement an effective system to correct identified quality deficiencies.
Deficiencies (5)
F221: The facility failed to ensure resident #103 remained free from the physical restraint of the merry walker and failed to limit use to no more than 2 hours at a time as care planned.
F275: The facility failed to complete a comprehensive assessment of resident #103 at least once every 366 days.
F323: The facility failed to thoroughly investigate falls and implement appropriate interventions for residents #101, #102, and #103 to prevent further falls.
F353: The facility failed to provide sufficient nursing staff to provide nursing care and supervision to prevent falls and answer call lights in a timely manner.
F520: The facility failed to develop and implement an effective Quality Assessment and Assurance (QAA) system to identify and correct quality deficiencies related to resident care.
Report Facts
Facility census: 36
Falls reported: 21
Falls in SCU: 15
Call light duration: 12
Call light duration: 8
Bed alarm 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 fall investigations, staffing, and QAA activities |
| Staff C | Direct Care Staff | Reported supervision and care of resident #103 related to merry walker use |
| Staff D | Direct Care Staff | Reported staffing shortages and care challenges in SCU |
| Staff G | Licensed Nursing Staff | Reported fall investigations and resident assessments |
| Staff H | Licensed Nursing Staff | Reported expectations for resident #103 care and fall prevention |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 5
Date: Mar 12, 2015
Visit Reason
Complaint surveys were conducted to investigate allegations related to resident safety, use of restraints, fall prevention, and staffing adequacy at Prairie Sunset Home Inc.
Complaint Details
The complaint surveys #84055, #84295, #83051, and #82996 were conducted due to concerns about resident safety, use of restraints, fall prevention, and staffing adequacy.
Findings
The facility failed to ensure resident #3 was free from non-medically necessary physical restraints, failed to complete quarterly assessments timely, and failed to provide adequate supervision and assistance to prevent falls for residents #1, #2, and #3. The facility also failed to maintain sufficient nursing staff and failed to provide an RN for at least 8 consecutive hours daily, 7 days a week.
Deficiencies (5)
483.13(a) The facility failed to ensure resident #3 remained free from non-medically necessary physical restraints by using a merry walker as a restraint without proper assessment and documentation.
483.20(c) The facility failed to complete quarterly MDS assessments for resident #3 at least every 3 months.
483.25(h) The facility failed to ensure adequate supervision and assistance to prevent accidents for residents #1, #2, and #3, resulting in falls and fractures, and failed to investigate causal factors for falls.
483.30(a) The facility failed to provide sufficient nursing staff to provide services to attain or maintain the highest practicable well-being of residents.
483.30(b) The facility failed to provide a registered nurse for at least 8 consecutive hours a day, 7 days a week.
Report Facts
Facility census: 40
Resident falls: 74
Fall risk assessments: 9
Fall risk assessments: 3
Fall risk assessments: 4
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at the facility to be at 'G' level related to the use of physical restraints. Enforcement remedies including denial of payment for new Medicare admissions were imposed due to noncompliance.
Deficiencies (1)
F221 Restraints: The facility was noncompliant with requirements ensuring residents are free from unnecessary physical restraints, which increase risks such as urinary incontinence, skin breakdown, accidents, agitation, and social isolation.
Report Facts
Denial of payment effective date: Jun 12, 2015
Termination recommendation date: Sep 12, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 8, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, and not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process and recipient of plan of correction submissions. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 15, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of the revisit date. Each deficiency is identified by regulation number and correction completion date.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jul 9, 2014
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
The report documents that deficiencies identified in prior inspections have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-43-101(g) deficiency identified by code S2030 was corrected on 07/09/2014.
Regulation 26-43-205(h) deficiency identified by code S2235 was corrected on 07/09/2014.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 7, 2014
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.
Deficiencies (3)
S0000: The facility will develop and implement a system to assure correction and continued compliance with regulations and provide the deficiency list to the Quality Assurance Committee for review.
S2030-C: Policies, procedures, and the most recent survey notice have been placed beside residents' mailboxes to ensure visibility, with responsibility assigned to the Administrator and/or D.O.N.
S2235-E: Monthly medication room stock checks will be conducted by the CMA to identify and discard outdated medications, with documentation and follow-up by the D.O.N.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Rexmaris | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Jul 2, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey conducted on July 2, 2014.
Findings
The plan outlines corrective actions to address multiple deficiencies including care planning, medication administration, fall interventions, staff education, and environmental safety. The facility commits to staff re-education, system improvements, and ongoing monitoring to ensure compliance.
Deficiencies (15)
F160-D: The office manager missed returning money to proper parties within 30 days as required by policy. The Office Manager and Administrator will ensure this does not recur.
F246-E: Call light cords were shortened and now have been lengthened to reach residents in the whirlpool. Maintenance will check all call lights monthly.
F272-D: MDS coordinator absence caused delays in completing CAAs. The Director of Nursing will now cover these duties to ensure timely completion.
F279-D: Nurses will receive education on care planning with the Point Click Care EHR system to improve compliance and admission evaluations.
F281-D: Charge nurses must investigate falls and update care plans immediately. A fall intervention library is available in the EHR system to assist nursing staff.
F2810-D: Nurses will be trained to create initial care plans upon admission using the EHR system. A check sheet for third shift charge nurses will ensure compliance.
F309-D: Staff will be re-educated on using the Alert feature in the nursing system to document and follow up on skin conditions properly.
F318-D: Nursing staff will be educated to revise care plans immediately after resident falls and implement interventions to prevent further falls.
F323-E: Nursing staff will be re-educated on revising and updating care plans promptly as indicated by resident needs and incidents.
F329-D: Blood pressure guidelines were reviewed and medication admission entries corrected to ensure proper system alerts and monitoring.
F371-E: Staff were reminded to wear hair nets and serve food properly; re-education will be provided to ensure compliance.
F428-D: New resident information was entered incorrectly into the system; education and checklists will ensure accurate data entry.
F431-E: A new procedure requires monthly medication stock checks and discarding outdated bottles with documentation and follow-up.
F441-F: Housekeeping staff received in-service training on new cleaning chemicals capable of killing MRSA and C.diff, with MSDS sheets provided.
F520-F: A Quality Assurance committee meets weekly to address falls, care plans, medication errors, and other issues between quarterly meetings.
Report Facts
Deficiencies cited: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| REXMARIS | Administrator | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 2, 2014
Visit Reason
The visit was a Health survey conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be '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, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the plan of correction. |
Inspection Report
Routine
Census: 32
Deficiencies: 14
Date: Jul 2, 2014
Visit Reason
Routine health survey inspection of Prairie Sunset Home Inc to assess compliance with federal regulations for nursing homes.
Findings
The facility had multiple deficiencies including failure to convey resident funds timely upon death, inaccessible call light in whirlpool room, incomplete comprehensive assessments and care plans, failure to revise care plans after falls, inadequate skin assessments and monitoring, failure to maintain resident environment free of hazards, unnecessary medications without proper monitoring, improper medication storage and labeling, unsanitary food service practices, and ineffective quality assurance program.
Deficiencies (14)
F160: The facility failed to convey 1 of 3 deceased resident's personal funds to the appropriate party within 30 days of death.
F246: The call light cord in the whirlpool room on the 400 hall did not reach the tub, failing to accommodate resident needs.
F272: The facility failed to complete a comprehensive assessment for 1 of 14 sampled residents within 14 days of admission.
F279: The facility failed to accurately develop comprehensive care plans for 1 sampled resident, lacking specific directions for range of motion and other needs.
F280: The facility failed to revise care plans related to falls and skin issues for 3 residents and failed to develop an initial care plan for 1 resident.
F309: The facility failed to provide necessary care and services to maintain skin integrity and prevent bruising for 2 residents.
F318: The facility failed to provide services to maintain or improve range of motion for 1 resident with contractures.
F323: The facility failed to maintain a safe environment free of accident hazards for residents, including unlocked chemical storage and therapy room doors, and failed to implement fall prevention strategies.
F329: The facility failed to ensure 3 residents did not receive unnecessary medications due to inadequate monitoring, improper indications, and lack of black box warning monitoring.
F371: The facility failed to serve food under sanitary conditions when staff failed to wear hair restraints and contaminated plates and utensils while serving residents.
F428: The facility failed to ensure the consultant pharmacist identified and reported drug irregularities related to blood pressure monitoring, psychotropic medication use, behavior monitoring, and black box warnings.
F431: The facility failed to ensure medications in storage were not outdated and failed to label insulin and tuberculin vials with open and expiration dates.
F441: The facility failed to follow manufacturer's instructions for chemical use during cleaning of resident rooms, including MRSA precaution rooms, risking spread of infection.
F520: The facility failed to develop and implement effective Quality Assessment and Assurance plans to address identified quality deficiencies.
Report Facts
Resident census: 32
Deficiencies cited: 13
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 | Interviewed regarding fall risk, care plan revisions, and medication monitoring |
| Staff L | Licensed Nurse / MDS Coordinator | Interviewed regarding care plan revisions and fall investigations |
| Staff K | Licensed Nurse | Interviewed regarding medication monitoring and black box warnings |
| Staff V | Housekeeping Staff | Observed cleaning MRSA precaution room without following wet time instructions |
| Staff P | Dietary Staff | Interviewed regarding food service sanitary practices |
| Consultant Pharmacist U | Consultant Pharmacist | Interviewed regarding medication review and black box warnings |
Inspection Report
Census: 11
Deficiencies: 2
Date: Jul 2, 2014
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with state regulations for an assisted living facility.
Findings
The facility failed to post a notice of the availability of policies and procedures accessible to residents and the public. Additionally, the facility failed to discard an expired stock bottle of Tylenol found in the medication room.
Deficiencies (2)
26-43-101(g) Availability of Policies and Procedures. The facility failed to post a notice of the availability of policies and procedures in a place accessible to residents and the public.
26-43-205(h) Medication Storage. The facility failed to discard an expired stock bottle of Tylenol stored in the medication room.
Report Facts
Census: 11
Medication rooms: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff B | Confirmed failure to post notice and verified expired medication availability | |
| Administrative Nurse A | Administrative Nurse | Confirmed no system to check medication expiration dates |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 26, 2013
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be widespread 'F' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for widespread 'F' level deficiencies indicating serious noncompliance with Life Safety Code requirements. These deficiencies have no immediate jeopardy but have potential for more than minimal harm.
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
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated survey certification. |
Inspection Report
Follow-Up
Deficiencies: 11
Date: May 23, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All deficiencies previously reported were corrected by 04/26/2013 as documented by the correction completion dates for each cited regulation.
Deficiencies (11)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) was corrected on 04/26/2013.
Regulation 483.13(c) was corrected on 04/26/2013.
Regulations 483.20(d)(3) and 483.10(k)(2) were corrected on 04/26/2013.
Regulation 483.25(h) was corrected on 04/26/2013.
Regulation 483.25(n) was corrected on 04/26/2013.
Regulation 483.70(c)(2) was corrected on 04/26/2013.
Regulation 483.70(f) was corrected on 04/26/2013.
Regulation 483.75 was corrected on 04/26/2013.
Regulation 483.75(e)(8) was corrected on 04/26/2013.
Regulation 483.75(i) was corrected on 04/26/2013.
Regulation 483.75(o)(1) was corrected on 04/26/2013.
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 11
Date: Mar 27, 2013
Visit Reason
Annual health resurvey inspection of Prairie Sunset Home Inc to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility failed to report and investigate abuse allegations, develop adequate abuse policies, revise care plans after falls, investigate falls thoroughly, provide immunization education, maintain essential equipment, ensure resident call systems function properly, maintain a medical director contract, and conduct effective quality assurance activities.
Deficiencies (11)
F225: The facility failed to report, investigate, and prevent further abuse during investigations, affecting all residents.
F226: The facility failed to develop and implement policies for reporting suspicion of crimes against residents and employee rights.
F280: The facility failed to review and revise care plans after each fall for multiple residents, missing new interventions.
F323: The facility failed to investigate falls thoroughly and implement interventions to minimize fall risks and injuries for sampled residents.
F334: The facility failed to provide education on benefits and risks of influenza and pneumococcal immunizations and failed to offer immunizations to some residents.
F456: The facility failed to maintain full body lifts in safe operating condition for residents requiring mechanical lifts.
F463: The facility failed to provide an emergency call system in an unlocked public restroom accessible to independently mobile residents.
F490: The facility failed to use resources effectively to maintain resident well-being, including failures in abuse reporting, policy development, care plan revision, fall investigations, immunization education, equipment maintenance, and call system availability.
F497: The facility failed to ensure continuing competence of nurse aides by providing required inservice training based on performance reviews.
F501: The facility failed to have a current contract with a medical director responsible for resident care policies and coordination of medical care.
F520: The facility failed to maintain a quality assessment and assurance committee that meets quarterly and develops plans to correct quality deficiencies.
Report Facts
Facility census: 32
Deficiency counts: 11
Inservice hours: 16
Inservice hours: 3
Inservice hours: 9
Inservice hours: 2
Inservice hours: 6
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 27, 2013
Visit Reason
The visit was a licensure resurvey to assess compliance for renewal of the facility's license.
Findings
The licensure resurvey resulted in a finding of no deficiency citations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078017 POC 2KZL11
Visit Reason
This document is a Plan of Correction related to a prior inspection report for Prairie Sunset Home Inc. assisted living facility concerning COVID-19 dated 7.29.2020.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078017 POC 55H711
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No specific findings are detailed in this document; it serves as a corrective action response to prior deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078017 POC H6FF11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of Prairie Sunset Home.
Findings
No specific findings or deficiencies are detailed in this document. It serves solely as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078017 POC JUCS11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report.
Findings
No specific findings are detailed in this document; it serves as a corrective action plan linked to a previous deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078017 POC FQHK11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: N078017 POC HOGR11
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during a prior survey.
Findings
The plan outlines corrective actions including staff in-service training on abuse recognition and reporting, care plan revisions after resident falls, proper documentation of immunizations, equipment maintenance, and improved communication with contractors. The facility aims to achieve substantial compliance by specified dates in April 2013.
Deficiencies (12)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations, reviewed by the Quality Assurance Committee.
F225: An in-service will be required for all staff on recognizing, reporting, investigating, and documenting alleged resident abuse, neglect, and exploitation.
F226: A new policy on reporting suspected crimes against elders has been adopted and will be addressed in staff in-service.
F280: Staff will be trained to revise care plans with new interventions after each fall and ensure call lights and motion sensors are properly maintained and within reach.
F323: Nursing staff will be trained to investigate falls and update care plans with new interventions, and maintain proper use of motion sensors.
F334: Nursing staff will be educated on proper documentation of immunization education and administration in the new nursing software.
F456: New batteries for lifts have been ordered and are in use; lifts will be tested weekly to ensure proper working order.
F463: A call light was installed in a new public restroom promptly; maintenance will ensure ongoing compliance and communication with contractors.
F490: An in-service will cover investigation and reporting of abuse, fall investigations, care plan revisions, and immunization documentation.
F497: A spreadsheet tracks in-service attendance; individual education will be provided for staff who do not attend required sessions.
F501: A contract with the Medical Director will be secured and maintained to ensure compliance.
F520: The Quality Assurance committee will review survey results and ensure plans of correction are followed, especially regarding abuse reports.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N078017 POC NXL811
Visit Reason
This document is a Plan of Correction submitted by Prairie Sunset Home in response to deficiencies cited during a prior survey.
Findings
The plan outlines corrective actions including obtaining physician orders for restraints, conducting quarterly MDS assessments, staff re-education on restraint and fall prevention policies, increasing staffing levels, and improving documentation and scheduling practices.
Deficiencies (6)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations and provide the deficiency list to the Quality Assurance Committee for review.
F221: A physician's order for the use of a merri-walker as a restraint has been obtained, including type, duration, and justification, with family consent and staff re-education completed.
F276: A new quarterly MDS assessment for restraints has been completed and will continue, with plans to move the resident to a special care unit for better monitoring.
F323: Sunflower Consultants will provide training on MDS assessments, fall prevention, and documentation to nursing staff to ensure proper fall management.
F353: Staffing concerns during a flu outbreak were addressed by hiring additional staff and agency agreements, achieving a staffing ratio of 3.79 to optimize resident care.
F354: The Director of Nursing filled in for a nurse but failed to clock in; she has been educated on proper time documentation and scheduling responsibilities.
Report Facts
Staffing ratio: 3.79
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078017 POC TWB711
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a corrective action plan reference.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078017 POC
Visit Reason
This document is a Plan of Correction related to a facility identified by State ID N078017 and ASPEN Event ID 2567.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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