Inspection Reports for Recover-Care Spring View Manor LLC
412 S 8TH STREET, KS, 67031
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 24, 2024, found the facility in full compliance with no deficiencies noted. Prior inspections showed a pattern of deficiencies related mainly to resident personal care, medication administration, staffing documentation, infection control, and vaccination education. Several complaint investigations were substantiated, including issues with medication safeguarding, care planning for respiratory equipment, and a medication error involving delayed Vitamin K administration; however, no fines or license actions were listed in the available reports. The facility submitted plans of correction addressing these issues and demonstrated correction of cited deficiencies in subsequent revisit surveys. This indicates an improving trend with the facility resolving prior deficiencies and maintaining compliance in the most recent inspection.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
34 residents
Based on a May 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 24, 2024
Visit Reason
An offsite revisit survey was conducted on 06/24/24 for all previous deficiencies cited on 05/02/24 to verify correction of cited deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 05/30/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 7
May 2, 2024
Visit Reason
The inspection was a Health Resurvey and complaint investigation #KS00187559 conducted to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide adequate personal grooming for a resident, lack of annual evaluations for certified staff, incomplete nurse staffing postings, failure to obtain and report laboratory values timely, medication administration errors, inaccurate payroll-based journal staffing submissions, infection prevention and control deficiencies, and failure to provide education and documentation for influenza, pneumococcal, and COVID-19 vaccinations.
Complaint Details
The inspection included a complaint investigation identified as #KS00187559.
Severity Breakdown
SS=D: 3
SS=F: 2
SS=C: 1
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide personal grooming for a resident dependent on staff for bathing and hygiene. | SS=D |
| Failure to ensure certified nurse aides and medication aides received annual performance evaluations. | SS=F |
| Failure to post actual hours worked by nursing staff on daily staff postings. | SS=C |
| Failure to obtain laboratory values timely and failure to administer medications according to physician orders. | SS=D |
| Failure to electronically submit complete and accurate direct care staffing information to CMS, including agency staff hours. | SS=F |
| Failure to ensure sanitary tube feeding technique and hand hygiene during insulin administration to prevent infections. | SS=D |
| Failure to provide education and documentation for informed decision making regarding influenza, pneumococcal, and COVID-19 vaccinations for several residents. | SS=E |
Report Facts
Census: 34
Residents reviewed: 12
Certified Nurse Aides lacking annual evaluation: 4
Medication administration errors: 2
PBJ quarters with inaccurate staffing data: 2
Residents reviewed for immunizations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in grooming deficiency for Resident 10. |
| CNA N | Certified Nurse Aide | Named in grooming deficiency for Resident 10 and lacking annual evaluation. |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding grooming, lab delays, medication administration, and infection control deficiencies. |
| Consultant GG | Consultant | Interviewed regarding annual evaluations. |
| Licensed Nurse G | Licensed Nurse | Observed failing to sanitize feeding tube equipment and hand hygiene during insulin administration. |
Inspection Report
Plan of Correction
Deficiencies: 7
May 2, 2024
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 5/2/24. It outlines corrective actions, system changes, and monitoring plans to address identified deficiencies.
Findings
The Plan of Correction addresses multiple deficiencies related to resident grooming, staff evaluations, staffing posting requirements, medication administration, PBJ reporting, PEG tube and insulin administration, and vaccination policies. The facility describes re-education efforts, audits, and ongoing monitoring to ensure compliance and improvement.
Severity Breakdown
D: 3
F: 2
C: 1
E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Residents requiring assistance with grooming facial hair were affected. | D |
| Staff evaluations were incomplete for employees employed at least one year. | F |
| Staffing posting requirements were not met. | C |
| Failure to follow physician ordered parameters for labs and medication administration. | D |
| PBJ reporting requirements were not followed. | F |
| Inappropriate PEG tube and insulin pen administration procedures. | D |
| Vaccination offers and declinations documentation issues. | E |
Report Facts
Audit frequency: 5
Audit frequency: 2
Audit frequency: 4
Date: May 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Re-educated on PEG tube and insulin pen administration procedures |
| Director of Nursing | Responsible for re-education, audits, and monitoring related to multiple deficiencies | |
| Regional Nurse Consultant | Provided re-education to Director of Nursing, HR Manager, and Infection Preventionist | |
| HR Manager | Involved in audits and re-education related to staff evaluations |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 27, 2022
Visit Reason
An offsite revisit survey was conducted on 12/27/2022 for all previous deficiencies cited on 11/09/2022.
Findings
All deficiencies have been corrected as of the compliance date of 12/13/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: Nov 9, 2022
Compliance date: Dec 13, 2022
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Nov 9, 2022
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #175583 to evaluate compliance with care plan development and respiratory care standards.
Findings
The facility failed to develop a comprehensive care plan for Resident 9 regarding CPAP/BiPAP use and failed to obtain physician orders for CPAP/BiPAP use and cleaning. Additionally, the facility did not change oxygen tubing weekly or clean the oxygen concentrator as required, increasing the risk of respiratory infection.
Complaint Details
The visit was triggered by a complaint investigation #175583. The findings were substantiated as the facility failed to meet regulatory requirements related to care planning and respiratory care for Resident 9.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for Resident 9's use of CPAP/BiPAP equipment. | SS=D |
| Failed to change oxygen tubing per physician order and failed to obtain physician order for use, settings, and care of Resident 9's CPAP/BiPAP equipment, increasing risk of respiratory infection. | SS=D |
Report Facts
Census: 28
Residents reviewed: 13
BIMS score: 15
Oxygen tubing date: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) M | Reported Resident 9 wore CPAP mask at night and described shift responsibilities for cleaning and tubing changes. | |
| Administrative Nurse E | Stated Resident 9 controlled CPAP and described care plan and cleaning expectations. | |
| Administrative Nurse D | Stated CPAP use should be on care plan and described tubing change and cleaning requirements. |
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 9, 2022
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection at Spring View Manor Health Care and Rehabilitation.
Findings
The Plan of Correction addresses deficiencies related to respiratory care, specifically the auditing and updating of care plans for residents using CPAP/BiPAP equipment and oxygen concentrators, including staff re-education and monitoring to ensure compliance with facility policies.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #9 respiratory items were audited and care plan updated to include use of CPAP and required care. | D |
| Resident #9 respiratory items including oxygen tubing and CPAP equipment were audited, cleaned, and orders reviewed for accuracy. | D |
Report Facts
Compliance Date: Dec 13, 2022
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nickolas Palenske | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction | |
| Evelyn Lacey | Modified Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 26, 2022
Visit Reason
An offsite revisit survey was conducted on 07/26/2022 for all previous deficiencies cited on 06/02/2022.
Findings
All deficiencies have been corrected as of the compliance date of 07/06/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Jun 2, 2022
Visit Reason
The inspection was conducted as a result of complaint investigations #170162 and #169323 regarding medication safeguarding and potential diversion.
Findings
The facility failed to ensure adequate safeguarding of controlled substance medications in the licensed nurses' cart, resulting in a suspected diversion of a resident's liquid morphine. A licensed nurse gave the keys to a non-licensed staff member, leading to an unexplained increase of 12.75 ml in the morphine bottle. The facility reported the incident to law enforcement.
Complaint Details
The visit was complaint-related, investigating allegations of medication diversion involving resident R3's liquid morphine. The complaint was substantiated by findings of a medication discrepancy and improper handling of narcotic keys.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate safeguarding of residents' controlled substance medications in the licensed nurses' cart, allowing potential diversion. | SS=E |
Report Facts
Resident census: 25
Morphine liquid increase: 12.75
Morphine expected amount: 22.25
Morphine actual amount: 35
Time nurse was away: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Handed keys to non-licensed staff member, involved in medication diversion incident |
| CMA R | Certified Medication Aide | Received licensed nurses' keys from LN G and was involved in the incident |
| Administrative Nurse D | Administrative Nurse | Received keys from CMA R and returned them to LN G; provided statements about the incident |
| LN I | Licensed Nurse | Discovered the morphine discrepancy during medication count |
| Administrative Staff A | Administrative Staff | Notified of morphine discrepancy and reported incident to law enforcement |
Inspection Report
Follow-Up
Deficiencies: 0
May 19, 2021
Visit Reason
An offsite revisit was conducted on 05/19/21 to verify correction of all previous deficiencies cited on 03/25/21.
Findings
All deficiencies have been corrected as of the compliance date of 04/15/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Mar 25, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to medication regimen review irregularities and failure to act timely on pharmacist recommendations for certain residents.
Findings
The facility failed to act timely upon consultant pharmacist recommendations for two residents regarding diabetic and gastrointestinal medications. The facility policy lacked a defined timeframe for physician responses to pharmacist recommendations, and physician responses were delayed beyond a timely manner.
Complaint Details
The visit was complaint-related as it included a complaint investigation (#KS00158536 and #KS00145279) focusing on medication regimen review irregularities and failure to act on pharmacist recommendations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to act timely upon consultant pharmacist recommendations for Resident 7's diabetic medications and Resident 27's gastrointestinal medications. | SS=D |
Report Facts
Census: 30
Residents reviewed: 12
Days delay for physician response: 34
Hemoglobin A1c result: 8.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Confirmed lack of timely physician response and was in charge of pharmacy reviews. |
| Administrative Staff B | Administrative Staff | Confirmed no physician response to pharmacist recommendation and discussed pharmacy review process. |
| Licensed Nurse G | Licensed Nurse | Revealed Administrative Nurse D was in charge of pharmacy reviews. |
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 25, 2021
Visit Reason
This document is a Plan of Correction submitted by Spring View Manor in response to deficiencies cited related to drug regimen review irregularities.
Findings
The facility was found deficient in timely review and action on pharmacy recommendations for residents' drug regimens, requiring corrective actions to ensure pharmacist recommendations are addressed promptly to protect residents.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Drug Regimen Review, Report Irregular, Act On | Level D |
Report Facts
Dates for corrective actions: Apr 15, 2021
Dates for corrective actions: Apr 9, 2021
Date of pharmacy recommendation sent: Mar 24, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Griffin | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 20, 2020
Visit Reason
An offsite revisit was conducted on 10/20/2020 for all previous deficiencies cited on 07/14/2020.
Findings
All deficiencies have been corrected as of the compliance date of 08/20/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Jul 14, 2020
Visit Reason
The inspection was conducted as a complaint investigation (#154099) related to medication errors at the facility.
Findings
The facility failed to prevent a significant medication error by not administering an injection of Vitamin K in a timely manner for one resident with a critically elevated INR, resulting in a risk of abnormal bleeding.
Complaint Details
The complaint investigation found a significant medication error involving delayed administration of Vitamin K injection for resident 3 with a critical INR of 5.6. The injectable Vitamin K was not stocked in the facility emergency kit or pharmacy, causing a delay of approximately 25 hours after the physician's order before administration.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to administer Vitamin K injection in a timely manner as ordered by the physician to counteract critically elevated INR. | SS=D |
Report Facts
Census: 32
INR value: 5.6
Delay in medication administration (hours): 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Charge nurse who administered Vitamin K injection and made calls to provider and pharmacy |
| Administrative Nurse D | Administrative Nurse | Confirmed facility did not stock injectable Vitamin K and commented on appropriate staff actions |
| Pharmacy consultant GG | Pharmacy Consultant | Confirmed pharmacy did not stock injectable Vitamin K and had to order it |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 13, 2020
Visit Reason
This plan of correction was submitted in response to a survey conducted on 07/13/2020-07/14/2020 to address alleged deficiencies related to medication errors at Spring View Manor.
Findings
Spring View Manor implemented several updates and policy changes to ensure resident safety, including creating an Anticoagulation Therapy Policy, changing how Coumadin is handled, in-servicing nurses and CMAs on order input procedures, and collaborating with the contracted pharmacy and medical director to update providers on guidelines related to INRs and medication use.
Deficiencies (1)
| Description |
|---|
| Significant medication errors related to anticoagulation therapy and order input procedures. |
Report Facts
Survey dates: Survey conducted on 07/13/2020-07/14/2020
Plan of correction completion date: All alleged deficiencies to be corrected by 08/20/2020
Monitoring period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara McCue | Medical Director | Collaborated to update providers on medication guidelines |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 27, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a COVID-19 related survey conducted on 04/27/2020.
Findings
The facility was found to be deficiency free in the COVID-19 survey conducted on 04/27/2020.
Deficiencies (1)
| Description |
|---|
| Deficiency free Covid survey |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 27, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 12, 2019
Visit Reason
An offsite revisit was conducted on 08/12/19 for all previous deficiencies cited on 06/12/19.
Findings
All deficiencies have been corrected as of the compliance date of 07/24/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 10
Jun 12, 2019
Visit Reason
This document is a Plan of Correction submitted by Spring View Manor in response to deficiencies cited during a regulatory inspection conducted on June 12, 2019.
Findings
The plan addresses multiple deficiencies including resident care conferences, mental health evaluations, resident preferences for daily routines, restorative nursing, medication reconciliation, nursing staffing documentation, infection control, and environmental maintenance. The facility outlines corrective actions, staff education, audits, and monitoring to ensure compliance and resident safety.
Severity Breakdown
D: 5
F: 4
C: 1
E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to properly address resident #7's mental health and legal guardianship issues. | D |
| Failure to incorporate residents' preferences for getting up in the morning into care plans and team sheets. | D |
| Failure to provide assessed activities based on resident preferences and maintain records of participation. | D |
| Failure to properly apply and document use of splints and devices for residents with range of motion limitations. | D |
| Nursing aides not receiving required in-service training and annual performance evaluations. | F |
| Inaccurate nursing staffing sheets not reflecting actual hours worked. | C |
| Unnecessary weekly vital signs taken without physician orders. | D |
| Failure to properly secure and reconcile narcotics awaiting destruction. | E |
| Infection control deficiencies including unclean handwashing sink, broken cabinet doors, and improper drying techniques. | F |
| Laundry processing deficiencies including improper sorting and storage of soiled and clean barrels. | F |
Report Facts
Resident balance owed: 3195
Additional resident liability owed: 1865
Residents affected by infection control deficiency: 31
Audit frequency: 2
Audit duration: 3
Required nurse aide in-service hours: 12
Retention period for nurse staffing data: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Haynes | Administrator | Administrator submitting the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Evelyn Lacey | Person who added the Plan of Correction | |
| Diana Melander | Person who modified the Plan of Correction |
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 11
Jun 12, 2019
Visit Reason
Annual health resurvey of Spring View Manor nursing facility to assess compliance with resident rights, self-determination, care planning, activities, medication management, staffing, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure resident rights and self-determination, inadequate documentation and honoring of resident preferences, failure to provide appropriate restorative care, lack of proper medication monitoring and pharmacist follow-up, failure to maintain safe storage of controlled substances, inadequate staffing performance reviews and in-service training, failure to post accurate nurse staffing data, unsanitary food service and laundry conditions, and ineffective infection prevention and control program.
Severity Breakdown
SS=D: 5
SS=E: 1
SS=F: 3
SS=C: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure resident #7's right of self-determination, communication, and access to persons and services outside the facility. | SS=D |
| Failure to provide identified choices and preference for 3 residents (#16, #4, #21) related to preferred time to get up in the morning. | SS=D |
| Failure to review and revise care plans for 3 residents (#4, #16, #21) to include resident choices/preferences related to time to get up in the morning. | SS=D |
| Failure to provide individualized ongoing activities program and monitor participation for 2 residents (#4, #22). | SS=D |
| Failure to provide appropriate restorative treatment and services to resident #1 with limited range of motion and contracture of right hand. | SS=D |
| Failure to ensure 5 direct care staff received annual performance reviews and required 12 hours of in-service training. | SS=F |
| Failure to post daily nurse staffing information including actual hours worked for residents and visitors. | SS=C |
| Failure to act on pharmacist recommendations to monitor vital signs for resident #5 receiving medications with hypotension risk. | SS=D |
| Failure to ensure safe storage and accountability of controlled narcotic medications to be destroyed, accessible by all nursing staff. | SS=E |
| Failure to store, prepare, distribute and serve food under sanitary conditions including soiled hand washing sink, loose cabinet doors, grime on silverware drawers, stained towels, rust and lime build-up in kitchen and dry storage areas. | SS=F |
| Failure to maintain an effective infection control program related to sanitary environment in laundry including cross contamination risks, water leaks, rust, peeling paint, unsanitizable shelves, stained ceilings and dust accumulation. | SS=F |
Report Facts
Deficiencies cited: 15
Resident census: 31
In-service training hours: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Social Service Staff | Involved in resident #7's care and guardianship discussions |
| Staff W | Medical Records/Business Staff | Involved in resident #7's guardianship and billing issues |
| Staff N | Activity Staff | Responsible for resident activities program |
| Staff D | Licensed Nursing Staff | Provided care and confirmed issues with resident preferences and restorative care |
| Staff L | Direct Care Staff | Reported on resident preferences and activity program |
| Staff A | Administrative Staff | Confirmed deficiencies and policies related to resident preferences and activities |
| Staff B | Administrative Nursing Staff | Confirmed restorative care and staffing deficiencies |
| Staff U | Direct Care Staff | Reported not documenting vital signs or behaviors |
| Staff V | Direct Care Staff | Reported resident refusal of splint and documentation practices |
| Staff T | Administrative Staff | Reported kitchen sanitation issues |
| Staff J | Laundry Staff | Reported laundry sanitation issues |
| Staff K | Laundry Staff | Reported laundry sanitation issues |
| Staff P | Laundry Staff | Reported laundry sanitation issues |
| Staff C | Administrative Staff | Reported narcotic medication key storage |
Inspection Report
Re-Inspection
Deficiencies: 0
May 6, 2019
Visit Reason
A revisit survey was conducted on 5/6/19 for all previous deficiencies cited on 3/14/19 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 4/18/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Census: 26
Deficiencies: 2
Apr 1, 2019
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies related to abuse, neglect, and exploitation identified at Spring View Manor. It outlines corrective actions following an incident involving verbal abuse by an agency staff RN.
Findings
The deficient practices had the potential to affect 26 residents, with one resident verbally affected. Corrective measures included staff education on abuse reporting and investigation, revisions to care plans, and suspension of the responsible agency RN.
Severity Breakdown
G: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Verbal abuse of a resident by an agency staff RN | G |
| Failure in timely reporting and proper investigation of abuse, neglect, or exploitation | F |
Report Facts
Residents potentially affected: 26
Residents verbally affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Davis | Director of Nursing | Educated staff on abuse reporting and investigation |
| Kayla Haynes | Administrator | Educated staff on abuse reporting and investigation; submitted plan of correction |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 2
Mar 14, 2019
Visit Reason
Partial extended survey conducted for complaint investigation #KS00139009 regarding alleged verbal abuse of a resident by a licensed staff member following a fall.
Findings
The facility failed to ensure one resident was treated in a dignified and non-threatening manner after a fall, as a licensed staff member verbally demeaned the resident and performed unnecessary neurochecks throughout the night. The resident experienced emotional harm and the facility failed to protect residents from potential abuse and to thoroughly investigate the allegation in a timely manner.
Complaint Details
Complaint investigation #KS00139009 involved allegations that a licensed staff member verbally abused resident #1 after a fall on 3/1/19. The resident reported being lectured and punished by being awakened every 15 minutes for neurochecks all night. The facility allowed the accused nurse to work a subsequent shift despite the allegation. The investigation was incomplete and delayed, lacking multiple required witness statements, resident interviews, and evidence of pre-employment screening for the alleged perpetrator. The report was not completed within 10 days as required.
Severity Breakdown
SS=G: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure resident was free from verbal abuse and neglect when a licensed staff member verbally demeaned the resident and performed unnecessary neurochecks as punishment following a fall. | SS=G |
| Facility failed to thoroughly investigate allegations of abuse and failed to prevent further potential abuse while investigation was in progress. | SS=F |
Report Facts
Census: 26
Residents reviewed for abuse: 3
Neurocheck frequency: 15
Investigation completion delay: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Agency Nurse (Alleged Perpetrator) | Licensed staff member who verbally demeaned resident and performed unnecessary neurochecks | |
| Staff C | Social Services Staff / Investigator | Received resident complaint, notified administration and agency, and conducted investigation |
| Staff B | Administrative Nursing Staff | Verified investigation actions and decisions regarding alleged perpetrator |
| Staff G | Direct Care Staff | Witnessed agency nurse's rude behavior and assisted resident after fall |
| Staff E | Agency Nurse | Alleged perpetrator who administered neurochecks and was subject of investigation |
| Staff D | Licensed Nursing Staff | Checked on resident after fall and provided witness statement |
| Staff H | Direct Care Staff | Reported resident's emotional state and verbal abuse concerns |
| Staff J | Licensed Nursing Staff | Reported verbal abuse allegation during shift report |
| Staff K | Direct Care Staff | Noted resident's subdued behavior after fall |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Mar 14, 2019
Visit Reason
An abbreviated survey was conducted on March 14, 2019, by the Kansas Department for Aging and Disability Services 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 to be F610, 'F', Substandard Quality of Care, and F600, 'G', 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 effective April 9, 2019.
Severity Breakdown
F: 1
G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| F610, 'F', CFR 483.12(c)(2)-(4) identified as Substandard Quality of Care | F |
| F600, 'G', CFR 483.12(a)(1) at a level of actual harm that is not immediate jeopardy | G |
Report Facts
Civil Money Penalty threshold: 10483
Denial of payment effective date: Apr 9, 2019
Substantial compliance deadline: Sep 14, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Haynes | Administrator | Facility administrator named in the report header |
| Caryl Gill | Complaint Coordinator | Named as contact for questions and instructions regarding the letter |
| Benton Williams | CMS Regional Office Contact | Contact person for questions regarding the matter |
| Patty Brown | Interim Commissioner | Recipient of written requests for Informal Dispute Resolution |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 3, 2018
Visit Reason
An offsite revisit survey was conducted on 10/03/2018 for all previous deficiencies cited on 08/20/2018.
Findings
All deficiencies have been corrected as of the compliance date of 09/05/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 20, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-09-05.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact and signatory related to enforcement and plan of correction acceptance. |
Inspection Report
Re-Inspection
Census: 33
Deficiencies: 2
Aug 20, 2018
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with regulatory requirements, including activities programming and food safety standards.
Findings
The facility failed to provide an ongoing activities program tailored to a cognitively impaired resident's preferences and failed to maintain sanitary food procurement, storage, preparation, and serving practices, including improper handling of food and unclean kitchen equipment.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide an ongoing activities program for a cognitively impaired resident based on their preferences. | SS=D |
| Failed to store, prepare, and serve food under sanitary conditions, including expired food items, unclean cookware, and improper handling of food during meal delivery. | SS=F |
Report Facts
Census: 33
Activities attendance: 2
Activities attendance: 4
Expired food items: 7
Unclean cookware: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary manager A | Dietary Manager | Reported awareness of food safety concerns and lack of kitchen cleaning policy |
| Dietary staff E | Dietary Staff | Reported leftover food items should be discarded after 3 days |
| Dietary staff A | Dietary Staff | Identified dried food substance as sausage and verified it was not cooked on 8/16/18 |
| Dietary cook D | Dietary Cook | Reported staff should not place hands over the top of glasses/bowls |
| Direct care staff G | Direct Care Staff | Observed placing hands over residents' bowls and glasses during meal service |
| Activity staff C | Activity Staff | Reported lack of effective individual activity schedule for resident #7 |
| Social services staff B | Social Services Staff | Reported assisting with activities on weekends but resident #7 did not attend |
| Direct care staff H | Direct Care Staff | Reported staff did not take resident #7 to activities and did not provide one-to-one engagement |
Inspection Report
Plan of Correction
Deficiencies: 11
Apr 20, 2017
Visit Reason
This document is a Plan of Correction submitted by Spring View Manor in response to deficiencies cited in a prior inspection report dated 03/24/2017. The plan outlines corrective actions to address the cited deficiencies and compliance with state and federal law.
Findings
The plan details corrective actions including cleaning and maintenance, staff training on MDS completion and care planning, updated policies on bathing, wound care, medication documentation, fall risk management, weight monitoring, medication appropriateness, staffing, and kitchen sanitation. Monitoring and review processes are established through QA/QI committee meetings and regular inspections.
Severity Breakdown
D: 7
E: 4
F: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Cleaning and maintenance issues including floor stains, broken tiles, and window cleanliness. | E |
| Inaccurate ADL documentation and MDS assessment errors. | D |
| Care plan inaccuracies and need for updates for residents at high risk for bruising and skin tears. | D |
| Mandatory staff in-service training on wound measurements, neurological checks, and fall risk management. | E |
| New policies on bathing and importance of charting baths after provided. | D |
| Proper storage of chemicals and use of assistive devices per care plans. | E |
| Monitoring resident weight loss and dietary interventions. | D |
| Ensuring appropriate diagnosis for medication orders and staff education. | D |
| Staffing practices to maintain resident safety and preferences. | F |
| Kitchen and dry storage sanitation and updated cleaning schedules. | F |
| Housekeeping staff training on chemical application and infection control. | D |
Report Facts
Date of Plan of Correction review meeting: Apr 20, 2017
Date of staff in-service training: Apr 6, 2017
Date of prior inspection report: Mar 24, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Frihart | VP of Operations | Submitted the Plan of Correction to KDADS |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 20, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each correction documented and completed on 04/20/2017.
Inspection Report
Re-Inspection
Deficiencies: 1
Mar 24, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction effective April 20, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced as contact for questions. |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 12
Mar 22, 2017
Visit Reason
Health resurvey inspection to evaluate compliance with housekeeping, maintenance, comprehensive assessments, care planning, medication management, staffing, food safety, infection control, and resident care.
Findings
The facility failed to maintain sanitary housekeeping and maintenance services in resident areas, complete timely and accurate assessments, develop comprehensive care plans, monitor bruising and skin tears, provide adequate bathing opportunities, ensure sufficient staffing, maintain food safety and sanitation, and properly handle linens to prevent infection.
Severity Breakdown
SS=E: 1
SS=D: 8
SS=F: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services in 2 resident rooms and 9 resident bathrooms. | SS=E |
| Failed to complete a significant change MDS for a resident with multiple changes in mental and physical ability. | SS=D |
| Failed to accurately complete the MDS for a resident's improvement in locomotion. | SS=D |
| Failed to develop comprehensive care plans for residents with bruising and skin tears. | SS=D |
| Failed to monitor bruising and skin tears and neurological status after unwitnessed falls. | SS=D |
| Failed to provide bathing opportunities as planned for a resident. | SS=D |
| Failed to provide necessary assistance for good personal hygiene for dependent residents. | SS=D |
| Failed to identify weight loss in a timely manner and notify physician for further direction. | SS=D |
| Failed to ensure medications administered included an indication for use to avoid unnecessary medications. | SS=D |
| Failed to provide sufficient nursing staff to ensure resident safety and highest well-being. | SS=F |
| Failed to store, prepare and distribute food under sanitary conditions; multiple sanitation and storage violations noted. | SS=F |
| Failed to properly handle linen to prevent cross contamination; resident's mattress and linen lay directly on the floor. | SS=D |
Report Facts
Resident census: 35
Residents reviewed: 17
Residents requiring 2 staff for transfers: 9
Residents requiring cueing or physical assistance with dining: 18
Days without bathing: 14
Days without bathing: 14
Weight loss: 9
Weight loss percent: 6.25
Falls: 6
Fall risk score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Direct Care Staff | Mentioned in relation to resident assistance and observations during dining and transfers |
| Staff D | Licensed Nursing Staff | Mentioned in relation to resident care, skin assessments, and fall monitoring |
| Staff A | Administrative Nursing Staff | Mentioned in relation to care plan development and staffing |
| Staff B | Licensed Nursing Staff | Mentioned in relation to skin assessments and resident care |
| Staff M | Direct Care Staff | Mentioned in relation to resident assistance during dining and transfers |
| Staff L | Direct Care Staff | Mentioned in relation to resident assistance and observations |
| Staff N | Direct Care Staff | Mentioned in relation to resident assistance during dining |
| Staff E | Administrative Direct Care Staff | Mentioned in relation to dining assistance and staffing |
| Staff Q | Direct Care Staff | Mentioned in relation to staffing and bathing |
| Staff P | Direct Care Staff | Mentioned in relation to staffing and bathing |
| Staff R | Direct Care Staff | Mentioned in relation to assisting staff and bathing |
| Staff K | Dietary Staff | Mentioned in relation to kitchen and food sanitation |
| Staff O | Activity Staff | Mentioned in relation to cleaning kitchenette |
| Staff C | Administrative Nursing Staff | Mentioned in relation to care plans and fall monitoring |
Inspection Report
Life Safety
Deficiencies: 1
Sep 15, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at 'F' level, indicating no harm with potential for more than minimal harm, but not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Dec 15, 2016
Provider agreement termination date: Mar 15, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and responsible for enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 18
Nov 12, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously cited in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all previously identified deficiencies were corrected as of 10/08/2015, with no uncorrected deficiencies noted.
Deficiencies (18)
| Description |
|---|
| Deficiency identified under regulation 483.10(k),(l) |
| Deficiency identified under regulation 483.15(a) |
| Deficiency identified under regulation 483.15(h)(2) |
| Deficiency identified under regulation 483.15(h)(7) |
| Deficiency identified under regulation 483.20(b)(1) |
| Deficiency identified under regulation 483.25(a)(3) |
| Deficiency identified under regulation 483.25(c) |
| Deficiency identified under regulation 483.25(g)(2) |
| Deficiency identified under regulation 483.25(h) |
| Deficiency identified under regulation 483.25(l) |
| Deficiency identified under regulation 483.25(m)(1) |
| Deficiency identified under regulation 483.25(m)(2) |
| Deficiency identified under regulation 483.35(c) |
| Deficiency identified under regulation 483.35(d)(4) |
| Deficiency identified under regulation 483.35(i) |
| Deficiency identified under regulation 483.60(c) |
| Deficiency identified under regulation 483.70(h) |
| Deficiency identified under regulation 483.75(o)(1) |
Report Facts
Correction completion date: Oct 8, 2015
Follow-up survey date: Sep 9, 2015
Inspection Report
Plan of Correction
Deficiencies: 18
Sep 11, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction details corrective actions taken for multiple deficiencies including communication notebook implementation, resident dress policy, maintenance repairs, alarm sound adjustments, comprehensive assessments, perineal care retraining, skin assessments and wound care, medication administration timing, dietary menu revisions, and environmental cleaning improvements.
Severity Breakdown
D: 8
E: 6
F: 2
G: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Communication notebook instituted for Social Service issues including lost resident items. | D |
| Policy enacted regarding appropriate dress for residents when in bed. | D |
| Maintenance issues fixed including wall gouges, floor stains, toilet seats, broken tiles, vents, and fall mats. | E |
| Sound level of alarms reviewed and muffled to reduce resident anxiety. | E |
| Individualized comprehensive assessments completed and staff trained on CAAs. | E |
| Proper perineal care procedures reviewed and staff retrained. | D |
| Resident skin assessments done and pressure sore healing; staff retrained on prevention and treatment. | G |
| Facility policy revised to include checking for tube placement. | D |
| Policy written to address hot items in resident rooms with monitoring procedures. | E |
| AIMS completed and staff retrained on notifying physicians about accucheck results. | D |
| Med aides retrained on timing of medication administration related to meals. | D |
| Medication order processing procedure updated and monitored. | D |
| Dietary menus revised and staff retrained on puree food preparation. | E |
| Facility working with dietician to provide approved food substitutes. | D |
| Dietary staff retrained on food storage and dating; kitchen cleaning and cabinet refinishing planned. | F |
| Consulting pharmacist to retrain nursing staff on blood sugar monitoring and reporting. | D |
| Floors and sinks cleaned; kitchen floor replacement planned. | E |
| Director of Nursing to attend Quality Assurance meetings and QAPI team instituted. | F |
Report Facts
Completion date: Sep 11, 2015
Completion date: Sep 25, 2015
Completion date: Sep 30, 2015
Completion date: Oct 8, 2015
Days to complete cabinet refinishing: 90
Days to replace kitchen flooring: 60
Inspection Report
Deficiencies: 1
Sep 9, 2015
Visit Reason
A health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be at a "G" level related to pressure ulcers (F314). As a result, a denial of payment for new Medicare and Medicaid admissions was imposed effective December 9, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314, Pressure Ulcers | G |
Report Facts
Denial of Payment Effective Date: Dec 9, 2015
Termination Recommendation Date: Mar 9, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 17
Sep 9, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements related to resident rights, dignity, housekeeping, safety, medication administration, and quality of care.
Findings
The facility was found deficient in multiple areas including failure to ensure resident rights to personal property and dignity, inadequate housekeeping and maintenance, failure to maintain comfortable sound levels, incomplete comprehensive assessments, inadequate personal hygiene care, failure to prevent pressure ulcers, improper gastrostomy tube care, unsafe environment hazards, medication errors, failure to monitor psychoactive medications, failure to provide proper menus and food substitutes, and lack of effective quality assessment and assurance committee.
Complaint Details
The inspection was triggered by a complaint investigation #79505.
Severity Breakdown
SS=D: 7
SS=E: 5
SS=F: 2
: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to ensure resident was able to retain and use personal possessions related to a missing bracelet. | SS=D |
| Failure to ensure 2 of 3 residents reviewed for dignity were dressed in a manner to maintain their dignity. | SS=E |
| Failure to provide housekeeping and maintenance services for residents in multiple rooms and areas including whirlpool and beauty shop. | SS=E |
| Failure to provide a sound level to promote a pleasant dining experience for 18 residents in the assisted dining room. | SS=E |
| Failure to complete individualized comprehensive care area assessments for 7 of 17 selected residents. | SS=E |
| Failure to provide adequate personal hygiene with perineal care for 2 of 3 sampled residents. | SS=D |
| Failure to implement effective interventions to prevent development of a facility acquired unstageable pressure ulcer for 1 resident. | SS=D |
| Failure to provide appropriate treatment and services to prevent aspiration pneumonia or metabolic abnormalities for 1 resident with gastrostomy tube feedings. | SS=E |
| Failure to ensure resident environment remained free from accident hazards of a hot coffee cup warmer for 9 confused and mobile residents. | SS=D |
| Failure to monitor residents for unnecessary medications for 3 of 5 selected residents including lack of AIMS for antipsychotic medication, lack of psychoactive medication assessment, and failure to notify physician of blood sugars outside parameters. | SS=D |
| Failure to maintain less than 5 percent medication error rate with 3 medication errors in 26 opportunities for 2 residents. | SS=D |
| Failure to ensure antipsychotic medication administration as ordered for 1 resident who experienced restlessness. | SS=E |
| Failure to follow planned menu for 6 residents requiring pureed diet; bread was omitted. | SS=D |
| Failure to provide substitutes of similar nutritive value to residents who refused food served. | SS=F |
| Failure to maintain a clean and sanitary kitchen and food preparation area including unlabeled food, dirty equipment, and uncovered food during transport. | SS=D |
| Failure to maintain a safe, functional, and sanitary environment for residents, staff and public including dirty floors, dead insects, and maintenance issues. | SS=F |
| Failure to maintain a quality assessment and assurance committee that developed and implemented appropriate plans of action and included the director of nursing at each quarterly meeting. | — |
Report Facts
Census: 35
Sample size: 17
Medication administration opportunities: 26
Medication errors: 3
Medication error rate: 11.53
Temperature: 215
Pressure ulcer size: 3
Pressure ulcer size: 2.5
Pressure ulcer size: 2
Blood sugar: 258
Blood sugar: 273
Blood sugar: 284
Blood sugar: 271
Blood sugar: 271
Blood sugar: 279
Blood sugar: 286
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Direct Care Staff | Named in personal hygiene perineal care finding for resident #1 |
| Staff N | Direct Care Staff | Named in personal hygiene perineal care finding for resident #1 |
| Staff G | Licensed Nursing Staff | Named in personal hygiene and pressure ulcer findings |
| Staff B | Administrative Nursing Staff | Named in pressure ulcer and QAA committee findings |
| Staff Q | Direct Care Staff | Named in missing bracelet and housekeeping findings |
| Staff D | Social Services Staff | Named in missing bracelet finding |
| Staff S | Direct Care Staff | Named in missing bracelet and personal hygiene findings |
| Staff U | Direct Care Staff | Named in pressure ulcer and dining sound level findings |
| Staff W | Direct Care Staff | Named in pressure ulcer and personal hygiene findings |
| Staff V | Direct Care Staff | Named in pressure ulcer findings |
| Staff Z | Direct Care Staff | Named in blood sugar monitoring finding |
| Staff BB | Direct Care Staff | Named in medication administration error findings |
| Staff O | Licensed Nursing Staff | Named in medication administration error findings |
| Staff Y | Consultant Staff | Named in medication monitoring and administration findings |
| Staff F | Consultant Staff | Named in nutritional and menu findings |
| Staff C | Dietary Staff | Named in menu and kitchen sanitation findings |
| Staff A | Administrative Staff | Named in QAA committee findings |
| Staff R | Administrative Nursing Staff | Named in comprehensive assessment findings |
| Staff AA | Administrative Nursing Staff | Named in comprehensive assessment findings |
| Staff X | Physician Assistant | Named in pressure ulcer treatment findings |
Inspection Report
Life Safety
Deficiencies: 1
Oct 22, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be an "F" level deficiency, widespread, with 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were an "F" level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jan 22, 2015
Provider agreement termination date: Apr 22, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Joe Ewert | Commissioner | Commissioner of KDADS, copied on the letter. |
Inspection Report
Follow-Up
Deficiencies: 2
Jun 30, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report shows that deficiencies previously reported under regulations 483.35(i) and 483.65 were corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 2
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 30, 2014
Visit Reason
This report documents a revisit conducted to verify that previously reported deficiencies have been corrected and to confirm the dates when corrective actions were completed.
Findings
The revisit confirmed that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 06/30/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited was corrected. |
Report Facts
Correction completion date: Jun 30, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 17, 2014
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 6
Jun 17, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with sanitary food handling and infection control standards in the facility.
Findings
The facility failed to maintain sanitary conditions in food storage, preparation, and serving areas, including unlabeled food items, food stored directly on the floor, and unclean kitchen equipment. Additionally, the facility failed to maintain proper laundry water temperatures to ensure sanitization of residents' linens and clothing, risking infection spread.
Severity Breakdown
SS=F: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Food items in the walk-in refrigerator lacked labels and dates. | SS=F |
| Food items stored directly on the floor in the walk-in freezer and dry storage areas. | SS=F |
| Kitchen equipment and utensils had food debris, wet surfaces, and soot residue. | SS=F |
| Ice machine drain lacked an air gap to prevent contaminated water backflow. | SS=F |
| Laundry water temperatures failed to consistently reach 160°F required for sanitization. | SS=F |
| Laundry detergent used did not have disinfectant properties. | SS=F |
Report Facts
Census: 38
Laundry wash temperature: 150.6
Laundry wash temperature: 153
Laundry temperature range: 141.3
Laundry temperature range: 156.2
Laundry temperature: 163.2
Date of inspection: Jun 9, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff F | Reported unlabeled food items and food storage issues | |
| Dietary staff E | Reported kitchen equipment cleanliness issues | |
| Laundry supervisor F | Reported laundry temperature issues and sanitization procedures | |
| Administrative nursing staff B | Reported unawareness of laundry temperature issues | |
| Maintenance staff H | Confirmed laundry temperature requirements and reported plumbing repairs |
Inspection Report
Plan of Correction
Deficiencies: 4
Jun 9, 2014
Visit Reason
This document is a Plan of Correction submitted by Springview Manor addressing deficiencies found during a prior inspection related to food storage, dishwashing procedures, and laundry water temperatures.
Findings
The plan details corrective actions including discarding improperly stored food items, re-washing and air drying kitchenware, staff in-service training on labeling and dishwashing procedures, and monitoring laundry water temperatures to ensure compliance.
Deficiencies (4)
| Description |
|---|
| Improper labeling and dating of food items leading to disposal of puddings and jellos. |
| Issues with dishwashing procedures including the need to re-wash and air dry dishes and pans. |
| Laundry water temperatures not consistently maintained at 160 degrees or higher. |
| Maintenance issue causing water backflow, which was repaired. |
Report Facts
Food items discarded: 8
Dates of corrective actions: Jun 30, 2014
Laundry temperature: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Responsible for in-service training and daily follow-up on food labeling and dishwashing. | |
| Registered Dietitian | Checks dietary supervisor's work during monthly visits and supervises dietary until CDM course completion. | |
| Director of Nursing | Monitors laundry water temperature logs. | |
| Maintenance Supervisor | Monitors laundry water temperature logs and addressed water backflow issue. |
Inspection Report
Life Safety
Deficiencies: 1
Jul 26, 2013
Visit Reason
A Life Safety Code survey was conducted on July 26, 2013, by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Oct 26, 2013
Provider agreement termination date: Jan 26, 2014
Plan of Correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Winter | Administrator | Facility administrator named in the report header. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
Inspection Report
Follow-Up
Deficiencies: 12
Apr 12, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, April 12, 2013.
Deficiencies (12)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(g) - (j) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(h)(1) |
| Deficiency related to regulation 483.75(m)(2) |
Report Facts
Deficiencies corrected: 12
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 12
Mar 20, 2013
Visit Reason
The inspection was a health resurvey to investigate allegations of neglect and compliance with regulatory requirements.
Findings
The facility failed to thoroughly investigate and report incidents of alleged neglect, failed to provide dignified care regarding residents' clothing, failed to complete comprehensive assessments and care plans, failed to ensure freedom from unnecessary medications, failed to maintain sanitary conditions in dietary and linen handling, failed to ensure infection control practices, failed to establish adequate emergency water procedures, and failed to train staff on emergency procedures for chemical spills and bomb threats.
Severity Breakdown
SS=D: 9
SS=E: 1
SS=C: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate and report 2 of 4 incidents of alleged neglect involving residents #41 and #8. | SS=D |
| Failed to provide care in a dignified manner for residents #23 and #11 related to clothing issues. | SS=D |
| Failed to complete comprehensive assessments using Care Area Assessments for residents #41, #42, and #10. | SS=D |
| Failed to complete accurate comprehensive assessment for resident #30 related to dental needs. | SS=D |
| Failed to develop a comprehensive care plan for resident #18 to monitor bowel elimination. | SS=D |
| Failed to ensure residents #18 and #41 were free from unnecessary drugs related to bowel movement monitoring and missed Vitamin B12 injections for resident #41. | SS=D |
| Failed to provide pharmaceutical services to ensure resident #41 received all medications ordered, specifically monthly Vitamin B12 injections. | SS=D |
| Failed to ensure drug regimen review identified irregularities related to bowel movement monitoring and missed medication administration for residents #18 and #41. | SS=E |
| Failed to maintain a clean and sanitary dietary department; food items unlabeled and pans with debris and water droplets observed. | SS=D |
| Failed to ensure infection control practices including uncovered linens during distribution, unsanitary handling of clothing protectors, and potential cross contamination during blood glucose monitoring. | SS=C |
| Failed to establish procedures to ensure water availability to essential areas during loss of normal water supply; emergency water policy incomplete. | SS=C |
| Failed to train all employees in emergency procedures for chemical spills and bomb threats upon employment. | SS=C |
Report Facts
Resident census: 38
Days without bowel movement: 9
Days without bowel movement: 4
Days without bowel movement: 4
Days without bowel movement: 4
Vitamin B12 injection frequency error: 30
Vitamin B12 injection last given: Apr 4, 2012
Serum B12 level: 192
Medication administration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff U | Direct Care Staff | Failed to place barrier between glucose testing tote and resident bed surface |
| Staff E | Dietary Staff | Verified unlabeled food items and pans with debris in kitchen |
| Staff B | Licensed Staff | Reported Vitamin B12 order error and lack of medication administration documentation |
| Staff L | Consultant Pharmacist | Acknowledged pharmacy order entry error and failure to identify medication irregularities |
| Staff A | Administrative Nursing Staff | Reported linens should be covered during distribution and noted lack of bowel monitoring policy |
Inspection Report
Plan of Correction
Deficiencies: 2
N096006 POC F9R911
Visit Reason
This document is a Plan of Correction submitted by Spring View Manor in response to deficiencies cited in a prior inspection report dated 08/20/2018.
Findings
The plan addresses two deficiencies: one related to care plans for cognitively impaired residents and another related to sanitation and food safety in the kitchen. Both deficiencies were corrected by early September 2018.
Severity Breakdown
D: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Care plan for resident #7 revised to address deficient practice affecting cognitively impaired residents. | D |
| Sanitation issues in kitchen including dated foods and buildup on kitchen implements addressed. | F |
Report Facts
Deficiency correction date: Sep 5, 2018
Deficiency correction date: Aug 29, 2018
Audit date: Aug 24, 2018
Plan of correction review date: Sep 20, 2018
Care plan review deadline: Sep 12, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Haynes | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
N096006 POC FCKL11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection related to drug storage and accountability.
Findings
The facility identified a discrepancy in narcotic drug storage and immediately began an investigation, completed audits, and re-educated staff on medication administration and accountability policies.
Deficiencies (1)
| Description |
|---|
| F761- Label/Store Drugs and Biologicals: Facility must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel access to keys. |
Report Facts
Audit frequency: 5
Audit duration: 4
Date discrepancy identified: Mar 8, 2022
Compliance date: Jul 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nickolas Palenske | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 12
N096006 POC TST711
Visit Reason
This document is a Plan of Correction submitted by Spring View Manor in response to deficiencies identified in a prior inspection report.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including investigation and reporting of alleged violations, monitoring resident clothing, comprehensive assessments for psychotropic drug use and dental needs, care planning for bowel elimination, cleaning and labeling of food pans, pharmaceutical services, infection control measures, water storage policies, and staff training on bomb threat and chemical spill procedures.
Severity Breakdown
D: 7
F: 1
E: 1
C: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Alleged violations will be investigated and reported to State; monitoring residents with confusion and falls/wounds | D |
| Staff will monitor for torn clothes and ill fitting clothes and not place on resident | D |
| Complete comprehensive assessments for psychotropic drug use and rehab needs | D |
| Complete accurate comprehensive assessments on residents with dental needs | D |
| Develop comprehensive care plans for monitoring bowel elimination for residents diagnosed with constipation | D |
| Monitor residents with diagnosis of constipation for adequate bowel elimination | D |
| Discarded pans with build-up of dark brown debris; implemented cleaning schedule | F |
| Provide adequate pharmaceutical services to ensure correct medications as ordered | D |
| Policy written on bowel elimination; monitor residents for adequate bowel elimination | D |
| Laundry carts with clean linens will be covered; infection control measures for Accu-check items | E |
| Policy updated to include storage and distribution of water and estimated amount needed | C |
| Chief of Police to do inservice and bomb threat drill for all staff; chemical spill inservice | C |
Report Facts
Complete Date: Apr 17, 2013
Complete Date: Mar 30, 2013
Complete Date: Apr 4, 2013
Complete Date: Mar 25, 2013
Complete Date: Apr 12, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Roths | Medical Records | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction | |
| Chief of Police | Will do inservice and bomb threat drill for staff | |
| Director of Nursing | Monitors multiple corrective actions including investigations, care plans, and policy updates | |
| Charge Nurses | Monitor investigations and medication administration | |
| MDS Coordinator | Monitors assessments and care plans | |
| Social Service Designee | Notified regarding resident clothing issues | |
| Laundry Supervisor | Monitors laundry carts and clothing | |
| Dietary Manager | Monitors cleaning and labeling of food pans | |
| Consultant Pharmacist | Reviews physician orders and attends Quality Assurance Meetings | |
| Infection Control Supervisor | Monitors infection control measures | |
| Safety Supervisor | Monitors bomb threat and chemical spill drills |
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