Inspection Reports for
Recover-Care Spring View Manor LLC
412 S 8TH STREET, CONWAY SPRINGS, KS, 67031
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
89% occupied
Based on a March 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 8
Date: Mar 17, 2026
Visit Reason
The inspection was conducted as a Health Recertification Survey and complaint survey regarding allegations in case 2723862.
Complaint Details
The inspection included a complaint survey regarding allegations in case 2723862.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare beneficiary notices, inadequate discharge process notifications, inaccurate nurse staffing postings, improper food temperature and preparation practices, unsanitary food storage and preparation conditions, infection prevention and control lapses, incomplete immunization documentation, and insufficient nurse aide in-service training.
Deficiencies (8)
F0582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide form CMS-10055 Advanced Beneficiary Notice of Non-Coverage to residents R6 and R25.
F0628 Discharge Process: The facility failed to provide resident R50 with written notification of transfer and failed to send a copy to the ombudsman.
F0732 Posted Nurse Staffing Information: The facility failed to post accurate and complete nurse staffing data including actual hours worked per shift.
F0804 Nutritive Value/Appear, Palatable/Prefer Temp: Staff served meals at unsafe temperatures and failed to follow the recipe for pureed green beans.
F0812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary conditions in food storage and preparation, including improper dishwasher temperatures and food packaging.
F0880 Infection Prevention & Control: The facility failed to ensure proper storage of nebulizer masks, use of PPE, and hand hygiene during resident care.
F0883 Influenza and Pneumococcal Immunizations: The facility failed to offer or document informed declination or consent for influenza vaccination for resident R28.
F0947 Required In-Service Training for Nurse Aides: The facility failed to provide required annual in-service training of at least 12 hours for two of five CNAs reviewed.
Report Facts
Resident census: 40
Deficiencies cited: 8
Temperature of pureed spaghetti: 127
Temperature of cooked spaghetti: 130
Temperature of Italian tossed salad: 52
Dishwasher water temperature: 103
Training hours for CNA P: 8
Training hours for CNA Q: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Infection Preventionist | Named in infection control and immunization deficiencies. |
| Licensed Nurse G | Named in infection control deficiencies related to PPE and hand hygiene. | |
| Social Service Staff X | Named in failure to provide Advanced Beneficiary Notice. | |
| Social Service Staff Y | Named in failure to provide transfer notification. |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Mar 16, 2026
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a regulatory inspection of Spring View Manor RS.
Findings
The plan addresses multiple deficiencies including issues with Advanced Beneficiary Notices, transfer and discharge notifications, staffing sheet accuracy, food temperature monitoring, food storage and dishwashing practices, infection control, influenza vaccination documentation, and nursing services staffing policies.
Deficiencies (8)
F582-D: Social Service Designees were re-educated on Advanced Beneficiary Notices Policy due to potential impact on residents receiving Medicare A services with remaining benefit days.
F628-D: Social Service Designees were re-educated on Transfer and Discharge policy after a resident discharged on 12/16/25 no longer resides at the facility.
F732-C: Staffing sheet was immediately updated to reflect actual hours; re-education provided to Executive Director, Director of Nursing, and Charge Nurses on Nurse Staffing Posting Information policy.
F804-D: Resident's meal tray was returned and reheated to appropriate temperatures; dietary staff re-educated on food temperature monitoring and pureed meal preparation.
F812-F: Food with ice crystals, unsealed meat, and opened cheese were discarded; dietary staff re-educated on dishwashing machine operation and food storage policies.
F880-D: Licensed Nurse G was re-educated on Enhanced Barrier Precautions policy; nursing staff re-educated on infection control and hand hygiene policies.
F883-D: Influenza declination received and uploaded; Infection Preventionist re-educated on Influenza Policy; Director of Nursing completed 100% influenza audit of residents.
F947-F: Director of Nursing re-educated on Nursing Services and Sufficient Staff policy; Human Resource Manager and Executive Director re-educated; audits planned for Certified Nurse Aides in-service hours.
Report Facts
Audit frequency: 5
Audit duration: 4
Influenza audit completion: 100
Infection Control Rounds: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in re-education on Enhanced Barrier Precautions policy |
| Director of Nursing | Director of Nursing | Named in multiple re-education and audit activities including influenza audit and nursing services staffing policy |
| Dietary Manager | Dietary Manager | Named in corrective actions related to food safety, temperature monitoring, and food storage |
| Infection Preventionist | Infection Preventionist | Named in influenza declination documentation and re-education |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 24, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-05-02.
Findings
All deficiencies have been corrected as of the compliance date of 2024-05-30, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 7
Date: May 2, 2024
Visit Reason
The inspection was a Health Resurvey and complaint investigation #KS00187559 conducted to assess compliance with regulatory requirements.
Complaint Details
This inspection included a complaint investigation identified as #KS00187559.
Findings
The facility was found deficient in multiple areas including failure to provide adequate personal grooming, incomplete annual evaluations for certified staff, inaccurate nurse staffing postings, delayed laboratory testing and medication administration errors, inaccurate payroll-based journal submissions, infection control lapses, and failure to provide education for influenza, pneumococcal, and COVID-19 vaccinations.
Deficiencies (7)
F 677 ADL Care Provided for Dependent Residents: The facility failed to provide personal grooming for Resident 10, who had severe cognitive impairment and was dependent on staff for bathing and hygiene, resulting in several days' worth of facial hair growth.
F 730 Nurse Aide Performance Review: Four out of five certified nurse aides employed over a year lacked annual performance evaluations as required by facility policy.
F 732 Posted Nurse Staffing Information: The facility failed to ensure daily staff postings included actual hours worked, lacking a policy for daily staff posting.
F 755 Pharmacy Services: The facility failed to obtain laboratory values timely for Resident 4 and failed to administer medications according to physician orders for Resident 29, including missed administration of Bumex and improper holding of Lisinopril based on blood pressure parameters.
F 851 Payroll Based Journal: The facility failed to accurately report weekend staffing for the second and fourth quarters of 2023, excluding agency staff hours, and lacked a policy for Payroll Based Journal submission.
F 880 Infection Prevention & Control: The facility failed to ensure sanitary medication administration through a PEG tube for Resident 1 and failed to perform hand hygiene between insulin administrations for Resident 9, risking infection transmission.
F 883 Influenza and Pneumococcal Immunizations: The facility failed to provide education for informed decision making regarding influenza, pneumococcal, and COVID-19 vaccinations for several residents, and lacked documentation of education and declinations.
Report Facts
Resident census: 34
Residents selected for review: 12
Certified Nurse Aides lacking annual evaluation: 4
Residents reviewed for immunizations: 5
Medication administration errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in personal grooming deficiency for Resident 10. |
| CNA N | Certified Nurse Aide | Named in personal grooming deficiency for Resident 10 and lacking annual evaluation. |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding grooming expectations, medication administration, and infection control deficiencies. |
| Consultant GG | Consultant | Interviewed regarding annual evaluations for certified staff. |
| Licensed Nurse G | Licensed Nurse | Observed administering insulin and medication via PEG tube with infection control lapses. |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 2, 2024
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies during an inspection.
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 outlines corrective actions, staff re-education, and monitoring plans for each deficiency.
Deficiencies (7)
F677-D: Resident R10 was shaved by an assigned CNA on 5/1/24. Staff will be re-educated on the facility grooming facial hair policy and monitored with audits.
F730-F: Regional Nurse Consultant re-educated Director of Nursing and HR Manager on evaluation process policy. Audits will identify employees lacking annual evaluations and monitor compliance.
F732-C: Director of Nursing was educated on staffing posting requirements. Nurse leadership will be re-educated and audits conducted to ensure required staffing information is posted.
F755-D: Resident R4’s labs were obtained and sent to hospital. CMA re-educated on following physician ordered parameters. Medication administration audits will be conducted.
F851-F: Director of Nursing re-educated on PBJ reporting requirements. Daily staffing hours are being reviewed and weekend staffing audits will be conducted.
F880-D: Licensed Nurse G re-educated on PEG tube and insulin pen procedures. Nursing staff will be re-educated and audits conducted on PEG tube feedings and insulin administration.
F883-E: Residents were offered pneumococcal, influenza, and COVID vaccinations; some declined. Infection Preventionist will be re-educated on vaccination policies and immunization audits will be conducted.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 27, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-11-09.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2022-12-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 9, 2022
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 addresses deficiencies related to the care and management of residents requiring CPAP/BiPAP and oxygen equipment, including auditing respiratory items, updating care plans, and staff re-education.
Deficiencies (2)
F656: Resident #9 respiratory items were audited and care plan updated to include CPAP use and required care. Staff will be re-educated on care plan policies and monitoring will occur via weekly order reports for 4 weeks.
F695: Resident #9 respiratory items including oxygen tubing and CPAP equipment were audited and cleaned. Staff will be re-educated on CPAP/BiPAP and oxygen concentrator policies with weekly audits for 4 weeks to ensure compliance.
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 2
Date: Nov 9, 2022
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to assess compliance with care plan and respiratory care requirements.
Complaint Details
This inspection included a complaint investigation identified as #175583.
Findings
The facility failed to develop a comprehensive care plan for Resident 9's use of CPAP/BiPAP equipment and failed to change oxygen tubing per physician orders, obtain physician orders for CPAP/BiPAP use and cleaning schedule, and properly clean the oxygen concentrator and CPAP equipment, increasing the risk of respiratory infection.
Deficiencies (2)
F 656: The facility failed to develop a comprehensive care plan for Resident 9 that included use of CPAP/BiPAP equipment and required care.
F 695: The facility failed to change oxygen tubing weekly, clean the oxygen concentrator, obtain physician orders for CPAP/BiPAP use and cleaning schedule, increasing risk of respiratory infection for Resident 9.
Report Facts
Census: 28
Residents selected for review: 13
BIMS score: 15
Oxygen tubing date: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | Certified Nurse Aide | Reported Resident 9 wore CPAP mask at night and described staff cleaning practices. |
| Administrative Nurse E | Administrative Nurse | Stated Resident 9 controlled CPAP and described care plan and cleaning expectations. |
| Administrative Nurse D | Administrative Nurse | Stated CPAP use should be on care plan and described cleaning and physician order requirements. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 26, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-06-02.
Findings
All deficiencies have been corrected as of the compliance date of 2022-07-06, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 2, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection related to medication storage and narcotics accountability.
Findings
The facility identified a discrepancy in narcotics storage and immediately began an investigation. No further discrepancies were found after an audit, and staff were re-educated on medication administration and accountability.
Deficiencies (1)
F761- Label/Store Drugs and Biologicals: The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and restrict access to authorized personnel only. A discrepancy was identified on 3/8/22 related to narcotics storage and accountability.
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Date: Jun 2, 2022
Visit Reason
The inspection was conducted as a result of complaint investigations #170162 and #169323 regarding medication safeguarding and diversion concerns.
Complaint Details
The visit was complaint-related, investigating allegations of medication diversion. The findings substantiated diversion of liquid morphine due to improper handling of cart keys and failure to count controlled substances as required.
Findings
The facility failed to ensure adequate safeguarding of controlled substance medications in the licensed nurses' cart, resulting in a diversion indicated by an unexplained increase of 12.75 milliliters in a resident's liquid morphine. The nurse handed the keys to the cart to a non-licensed staff member, violating facility policy.
Deficiencies (1)
F 761 Label/Store Drugs and Biologicals: The facility failed to safeguard controlled substance medications in the licensed nurses' cart, allowing a non-licensed staff member access and resulting in diversion of a resident's liquid morphine.
Report Facts
Resident census: 25
Increase in liquid morphine: 12.75
Expected liquid morphine amount: 22.25
Observed liquid morphine amount: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Handed keys to non-licensed staff member and involved in medication counts |
| CMA R | Certified Medication Aide | Received keys from LN G and reported the incident |
| Administrative Nurse D | Administrative Nurse | Received keys from CMA R and involved in investigation |
| LN I | Licensed Nurse | Noticed discrepancy in morphine count and reported it |
| Administrative Staff A | Administrative Staff | Notified of discrepancy and reported to law enforcement |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 19, 2021
Visit Reason
An offsite revisit was conducted 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.
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 1
Date: Mar 25, 2021
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation for Spring View Manor Healthcare and Rehabilitation.
Complaint Details
The visit was complaint-related as it included a complaint investigation #KS00158536 and #KS00145279.
Findings
The facility failed to act timely upon consultant pharmacist recommendations for two residents regarding diabetic and gastro-intestinal medications. The facility policy lacked a timeframe for physician responses to pharmacist recommendations, and physician responses were delayed beyond a timely manner.
Deficiencies (1)
F 756 Drug Regimen Review. The facility failed to act timely upon consultant pharmacist recommendations for Resident 7's diabetic medications and Resident 27's gastro-intestinal medications. The facility policy lacked a timeframe for physician responses to pharmacist recommendations.
Report Facts
Census: 30
Residents reviewed: 12
Residents sampled for unnecessary medications: 5
Days delay for physician response: 34
Hemoglobin A1c result: 8.2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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 and timely action on pharmacy recommendations.
Findings
The facility was found deficient in ensuring timely review and action on pharmacy recommendations for residents' drug regimens. The plan outlines corrective actions to improve communication and follow-up with physicians and medical directors.
Deficiencies (1)
F756 Drug Regimen Review. The facility failed to ensure that pharmacy recommendations were acted upon promptly to protect residents. Policies and procedures for timely review and response were not adequately followed.
Report Facts
Plan of Correction completion date: Apr 15, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steve Griffin | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 20, 2020
Visit Reason
An offsite revisit was conducted to verify correction of 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
Re-Inspection
Deficiencies: 0
Date: Oct 20, 2020
Visit Reason
An offsite revisit was conducted to verify correction of 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
Date: Jul 14, 2020
Visit Reason
The inspection was conducted as a complaint investigation (#154099) regarding medication errors at the facility.
Complaint Details
The visit was triggered by complaint investigation #154099. The medication error was substantiated as the facility failed to administer Vitamin K injection timely for a resident with a critical INR value.
Findings
The facility failed to prevent a significant medication error by not administering an injection of Vitamin K in a timely manner as ordered by the physician for one resident with a critically elevated INR. The injectable Vitamin K was not stocked in the facility emergency kit or readily available from the pharmacy, causing a delay of approximately 25 hours before administration.
Deficiencies (1)
F 760 Residents are free of significant medication errors. The facility failed to administer a physician-ordered Vitamin K injection timely to counteract a critically elevated INR in one resident, resulting in a significant medication error.
Report Facts
Resident census: 32
INR laboratory value: 5.6
Delay in medication administration (hours): 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Charge nurse on 07/08/20 who administered Vitamin K injection and attempted to contact physician and pharmacy. |
| Nurse D | Administrative Nurse | Confirmed facility emergency kit did not stock injectable Vitamin K and commented on staff responsibilities. |
| Pharmacy consultant GG | Pharmacy Consultant | Confirmed pharmacy did not stock injectable Vitamin K and had to order it from a supplier. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 13, 2020
Visit Reason
This document is a plan of correction submitted by Spring View Manor in response to a survey conducted on July 13-14, 2020, addressing alleged deficiencies related to medication safety.
Findings
The plan outlines corrective actions including policy updates, staff training, and collaboration with pharmacy and medical providers to prevent significant medication errors, specifically related to anticoagulation therapy.
Deficiencies (1)
F760-D: The facility had deficiencies related to medication errors, specifically in handling Coumadin and anticoagulation therapy. Corrective actions include new policies, staff in-service training, and provider education.
Report Facts
Survey dates: Survey conducted on 07/13/2020-07/14/2020
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 27, 2020
Visit Reason
This document is a plan of correction submitted in response to a COVID-19 related survey conducted on April 27, 2020.
Findings
The COVID-19 survey was deficiency free, indicating no deficiencies were found during the inspection.
Deficiencies (1)
F0000 Deficiency free Covid survey completed on 04/27/2020.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 27, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey 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
Re-Inspection
Deficiencies: 0
Date: Aug 12, 2019
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-06-12.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2019-07-24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 11
Date: Jun 12, 2019
Visit Reason
Health resurvey inspection to evaluate compliance with resident rights, self-determination, care planning, activities, medication management, staffing, infection control, and food safety.
Findings
The facility failed to ensure resident rights to self-determination and communication, failed to document and honor resident preferences for wake-up times, failed to revise care plans accordingly, failed to provide individualized activities and monitor participation, failed to provide restorative services for limited range of motion, failed to conduct annual nurse aide performance reviews and in-service training, failed to post accurate nurse staffing data, failed to act on pharmacist recommendations for medication monitoring, failed to secure narcotic medications properly, failed to maintain sanitary food service and laundry areas, and failed to maintain an effective infection control program.
Deficiencies (11)
F 550 Resident Rights: The facility failed to ensure 1 resident's right to self-determination, communication, and access to persons and services outside the facility.
F 561 Self-Determination: The facility failed to provide identified choices and preferences for 3 residents related to preferred wake-up times.
F 657 Care Plan Timing and Revision: The facility failed to review and revise care plans for 3 residents to include preferences related to wake-up times.
F 679 Activities: The facility failed to provide individualized ongoing activities and monitor participation for 2 residents.
F 688 Mobility: The facility failed to provide appropriate restorative treatment and services to prevent further decrease in range of motion for 1 resident with contracture.
F 730 Nurse Aide Performance Review: The facility failed to ensure 5 direct care staff received annual performance reviews and required 12 hours of in-service training.
F 732 Nurse Staffing Information: The facility failed to post daily nurse staffing data including actual hours worked for residents and visitors.
F 756 Drug Regimen Review: The facility failed to act on pharmacist recommendations to monitor vital signs for 1 resident on medications with hypotension risk.
F 761 Label/Store Drugs: The facility failed to ensure safe storage and accountability of controlled narcotic medications to be destroyed, accessible by all nurses.
F 812 Food Safety: The facility failed to store, prepare, and serve food under sanitary conditions, with multiple areas of grime, rust, peeling paint, and unclean utensils in the kitchen.
F 880 Infection Control: The facility failed to maintain an effective infection control program related to sanitary conditions in the laundry, including cross contamination risks and unsanitizable surfaces.
Report Facts
Resident census: 31
Direct care staff reviewed: 5
In-service training hours required: 12
Residents sampled: 15
Vital sign monitoring missing days: 20
Laundry ceiling stain size: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Administrator | Interviewed regarding staffing, training, and infection control |
| Administrative staff B | Nursing Administrator | Interviewed regarding staffing, medication monitoring, and narcotic storage |
| Administrative staff C | Nursing Administrator | Interviewed regarding narcotic medication storage |
| Administrative staff T | Food Service Manager | Interviewed regarding kitchen sanitation |
| Activity staff N | Activity Director | Interviewed regarding resident activities and documentation |
| Direct care staff D | Licensed Nurse | Interviewed regarding resident care and medication administration |
| Direct care staff G | Certified Nursing Assistant | Interviewed regarding resident activities and preferences |
| Direct care staff L | Certified Nursing Assistant | Interviewed regarding resident preferences and activities |
| Direct care staff U | Certified Nursing Assistant | Interviewed regarding documentation of vital signs and behaviors |
| Direct care staff V | Certified Nursing Assistant | Interviewed regarding resident splint use and documentation |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: 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, updating care plans to reflect resident preferences, activity assessments, restorative nursing programs, nursing staff training, staffing documentation, medication management, infection control, and environmental sanitation issues. Corrective actions and audits are planned or underway to ensure compliance.
Deficiencies (11)
F550-D: A care conference was held for Resident #7 to discuss requests and options. The resident was referred for neurological and mental health evaluations, but access issues delayed care. The resident's legal guardianship pursuit ceased, and financial liability remains unpaid.
F561-D: Residents #16, #4, and #21 were re-interviewed to determine morning preferences, which were incorporated into care plans and team sheets. Staff education and audits will ensure preferences are honored.
F657-D: Care plans for Residents #4, #16, and #21 were updated to reflect morning preferences. Staff education and audits will ensure care plans accurately reflect preferences.
F679-D: Activity assessments were completed for Residents #$ and #22 to determine preferred activities. Activity programs will be coordinated and monitored with regular audits.
F688-D: Resident #1 will be re-evaluated for splint use and restorative nursing schedule upon return from hospitalization. Audits will ensure devices are applied and refusals documented.
F730-F: Nursing aides will receive required in-service training and annual evaluations. Employee files will be audited to ensure compliance with training requirements.
F732-C: The daily nursing staffing sheet was revised to reflect projected and actual direct care hours. The administrator will reconcile staffing data daily and retain records for at least 18 months.
F756-D: Weekly vital signs were removed as a standard order unless medically indicated. Licensed nursing staff will be educated on monitoring and documentation requirements with audits planned.
F761-E: Discontinued narcotics awaiting destruction were reconciled and secured under double lock with restricted access. Staff were educated on medication reconciliation and audits will be conducted.
F812-F: Infection control deficiencies including cleaning and maintenance of handwashing sinks, cabinets, utensils, and dining room nutrition center were corrected and added to cleaning schedules.
F880-F: Laundry processing deficiencies were addressed by staff education and proper sorting and storage of soiled and clean barrels to prevent contamination.
Report Facts
Resident balance owed: 3195
Additional resident balance: 1865
Residents potentially affected: 31
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 6, 2019
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-03-14.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2019-04-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 1, 2019
Visit Reason
This document is a plan of correction submitted by Spring View Manor in response to deficiencies related to abuse, neglect, and exploitation identified during a prior inspection.
Findings
The deficiencies involved verbal abuse by an agency staff RN affecting one resident and potential impact on all 26 residents. Corrective actions included staff education on abuse reporting, investigation procedures, resident rights, confidentiality, and revisions to care plans and communication protocols.
Deficiencies (2)
F600-G: The deficient practice had the potential to affect 26 residents. One resident was verbally abused by an agency staff RN who is no longer allowed to return. Staff were educated on abuse reporting, investigation, resident rights, confidentiality, and neuro checks.
F610-F: The deficient practice had the potential to affect all 26 residents with no additional harm. Staff were educated on witness statements, investigation steps, abuse forms, resident rights, and confidentiality. Staff with allegations are suspended pending investigation.
Report Facts
Residents potentially affected: 26
Residents verbally affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Davis | Director of Nursing | Conducted staff education on abuse reporting and investigation |
| Kayla Haynes | Administrator | Conducted staff education on abuse reporting and investigation |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 2
Date: Mar 14, 2019
Visit Reason
Partial extended survey conducted due to a complaint investigation regarding alleged verbal abuse of a resident by a licensed staff member.
Complaint Details
The complaint investigation involved allegations that a licensed staff member verbally abused resident #1 after a fall on 3/1/19 by lecturing and punishing the resident with frequent neurochecks overnight. The resident reported emotional distress and feeling punished. The facility failed to protect the resident and did not conduct a thorough investigation in a timely manner.
Findings
The facility failed to ensure a resident was treated in a dignified and non-threatening manner after a fall, resulting in emotional harm. The facility also failed to thoroughly investigate the allegation of abuse and allowed the alleged perpetrator to continue working during the investigation.
Deficiencies (2)
CFR 483.12(a)(1) Freedom from Abuse: The facility failed to prevent verbal abuse when a licensed staff member verbally demeaned a resident following a fall, causing emotional harm.
CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate the allegation of abuse and allowed the alleged perpetrator to work during the investigation despite the resident's complaint.
Report Facts
Resident census: 26
Residents reviewed for abuse: 3
Neurocheck frequency: 15
Days to complete investigation: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency nurse (alleged perpetrator) | Named in verbal abuse finding and investigation. | |
| Social services staff C | Investigator who reported the abuse and coordinated the investigation. | |
| Administrative nursing staff B | Verified investigation actions and decisions regarding alleged perpetrator. | |
| Licensed nursing staff D | Witness who checked on resident after fall. | |
| Direct care staff G | Witness who assisted resident after fall and observed agency nurse behavior. | |
| Direct care staff H | Reported resident's concerns about verbal abuse. | |
| Direct care staff K | Reported resident's subdued behavior after fall. | |
| Licensed nursing staff J | Reported shift report and resident's verbal abuse allegation. |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Mar 14, 2019
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 to be Substandard Quality of Care related to F610, "F", CFR 483.12(c)(2)-(4) and F600, "G", CFR 483.12(a)(1) at a level of actual harm that is not immediate jeopardy. The facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.
Deficiencies (2)
F610, "F", CFR 483.12(c)(2)-(4) was cited for Substandard Quality of Care. The facility failed to meet federal requirements resulting in substandard care.
F600, "G", CFR 483.12(a)(1) was cited at a level of actual harm that is not immediate jeopardy. Corrections are required to address this deficiency.
Report Facts
Civil Money Penalty amount: 10483
Enforcement effective date: Apr 9, 2019
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 regarding the letter and instructions |
| Benton Williams | CMS Contact | Contact person for questions regarding the matter |
| Patty Brown | Interim Commissioner | Responsible for receiving written requests for Informal Dispute Resolution |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 3, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of 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.
Inspection Report
Re-Inspection
Census: 33
Deficiencies: 2
Date: Aug 20, 2018
Visit Reason
The inspection was a health resurvey to assess compliance with previously identified deficiencies.
Findings
The facility failed to provide an ongoing individualized activities program for a cognitively impaired resident and failed to maintain sanitary food procurement, storage, preparation, and serving practices.
Deficiencies (2)
F 679 Activities: The facility failed to provide an ongoing activities program for a cognitively impaired resident based on their preferences and needs.
F 812 Food safety: The facility failed to store and prepare food under sanitary conditions, including expired food items and unclean cookware, and failed to handle food service in a sanitary manner.
Report Facts
Resident census: 33
Expired food items: 7
Unclean cookware items: 15
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 20, 2018
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 a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm without 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.
Deficiencies (1)
The facility had a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm without immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 20, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report lists multiple regulatory citations with completed corrections.
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Apr 20, 2017
Visit Reason
This document is a Plan of Correction submitted by Spring View Manor to address deficiencies cited in a prior inspection report dated 03/24/2017.
Findings
The plan outlines corrective actions taken to address environmental cleanliness, resident assessments, care planning, staff training, medication documentation, fall risk management, dietary and kitchen sanitation, and housekeeping practices. Monitoring and ongoing quality assurance measures are described for each corrective action.
Deficiencies (14)
F253-E: All items listed on the CMS-2567 have been cleaned, including floor stains, broken tiles, and windows. Cleaning schedules and maintenance procedures have been reviewed with staff.
F274-D: Resident #37's significant change was not correctly assessed; a correction MDS was filed and staff received education on MDS completion and submission.
F278-D: MDS for resident #38 was completed by relief staff during RAI Coordinator's vacation; staff training on MDS policies was conducted.
F279-D: Care Plan for resident #26 was updated; licensed nursing staff will review and update care plans for residents at high risk for bruising and skin tears.
F280-D: Care Plan for resident #13 was updated; licensed nursing staff will review care plans for residents at high risk for skin tears.
F309-E: Nursing staff completed in-service on weekly wound measurements, notification protocols, and updated fall policy including neurological checks after falls.
F311-D: New bathing policy adopted; staff trained on importance of charting baths after provided care.
F312-D: New bathing policy adopted; staff trained on charting baths with monitoring by DON and ADM.
F323-E: Policy on chemical storage adopted; staff trained on locked cabinets; assistive devices usage and fall prevention care plans reviewed and staff reeducated.
F325-D: Policy on weight assessment and intervention adopted; weekly Skin and Weights meeting started to monitor residents with weight loss issues.
F329-D: Compliance ensured for unnecessary medications by requiring appropriate diagnosis documentation; staff trained on medication order policies.
F353-F: Staffing schedules adjusted to assure resident safety and care; bonuses and incentives offered to attract staff; leadership hours staggered for coverage.
F371-F: Kitchen and dry storage areas cleaned and sanitized; outdated food items discarded; new cleaning schedules implemented and monitored monthly by CDM.
F441-D: Housekeeping staff trained on chemical application to prevent infection spread; policy for mattress placement on floor updated with monitoring by nursing and housekeeping staff.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 24, 2017
Visit Reason
The visit was conducted to determine if the facility was 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 credible allegation of compliance and evidence of correction.
Deficiencies (1)
The survey found 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated acceptance of plan of correction. |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 14
Date: Mar 24, 2017
Visit Reason
Health resurvey inspection to evaluate compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in housekeeping and maintenance services, comprehensive assessments after significant changes, accuracy of assessments, development of comprehensive care plans, participation in care planning, quality of care including pain management, sufficient nursing staff, food procurement and sanitation, infection control, and medication management. Specific issues included failure to maintain sanitary conditions, incomplete assessments and care plans, inadequate monitoring of skin issues and falls, insufficient staffing during meals and bathing, unsafe storage of chemicals, and improper handling of linens.
Deficiencies (14)
F253 Housekeeping and maintenance services were inadequate, with dirty floors, broken tiles, and unclean windows in resident areas.
F274 The facility failed to complete a significant change MDS for a resident with multiple mental and physical changes.
F278 The facility failed to accurately complete the MDS for a resident, including incorrect coding of locomotion assistance.
F279 The facility failed to develop comprehensive care plans addressing bruising and skin tears for two residents.
F280 The facility failed to support resident participation in care planning and failed to revise care plans after significant changes for one resident.
F309 The facility failed to monitor bruising and skin tears for three residents and failed to monitor neurological status after unwitnessed falls for one resident.
F311 The facility failed to provide bathing opportunities as planned for one resident.
F312 The facility failed to provide necessary assistance for good personal hygiene to two dependent residents.
F323 The facility failed to secure hazardous chemicals in a locked cabinet and failed to implement effective fall prevention interventions for two residents.
F325 The facility failed to identify and address weight loss in a resident in a timely manner.
F329 The facility failed to ensure medications had appropriate diagnoses for justification and indications for use.
F353 The facility failed to provide sufficient nursing staff to meet residents' needs and ensure safe care.
F371 The facility failed to store, prepare, and distribute food under sanitary conditions, including unclean kitchen equipment and expired or improperly stored food items.
F441 The facility failed to prevent cross contamination by placing a resident's mattress and linens directly on the floor without a barrier.
Report Facts
Resident census: 35
Resident sample size: 17
Weight loss: 9
Weight loss percentage: 6.25
Falls: 6
Bathing days missed: 14
Bathing days missed: 14
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 15, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Report Facts
Effective date for denial of payments: Dec 15, 2016
Provider agreement termination date: Mar 15, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 18
Date: Nov 12, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All deficiencies previously cited in the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by 10/08/2015 as verified during this revisit.
Deficiencies (18)
Regulation 483.10(k),(l) deficiency was corrected on 10/08/2015.
Regulation 483.15(a) deficiency was corrected on 10/08/2015.
Regulation 483.15(h)(2) deficiency was corrected on 10/08/2015.
Regulation 483.15(h)(7) deficiency was corrected on 10/08/2015.
Regulation 483.20(b)(1) deficiency was corrected on 10/08/2015.
Regulation 483.25(a)(3) deficiency was corrected on 10/08/2015.
Regulation 483.25(c) deficiency was corrected on 10/08/2015.
Regulation 483.25(g)(2) deficiency was corrected on 10/08/2015.
Regulation 483.25(h) deficiency was corrected on 10/08/2015.
Regulation 483.25(l) deficiency was corrected on 10/08/2015.
Regulation 483.25(m)(1) deficiency was corrected on 10/08/2015.
Regulation 483.25(m)(2) deficiency was corrected on 10/08/2015.
Regulation 483.35(c) deficiency was corrected on 10/08/2015.
Regulation 483.35(d)(4) deficiency was corrected on 10/08/2015.
Regulation 483.35(i) deficiency was corrected on 10/08/2015.
Regulation 483.60(c) deficiency was corrected on 10/08/2015.
Regulation 483.70(h) deficiency was corrected on 10/08/2015.
Regulation 483.75(o)(1) deficiency was corrected on 10/08/2015.
Inspection Report
Plan of Correction
Deficiencies: 18
Date: Sep 11, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection report.
Findings
The facility implemented multiple corrective actions including communication notebooks for lost items, policies on resident dress, maintenance repairs, alarm sound adjustments, comprehensive resident assessments, staff retraining on care procedures, and dietary improvements. Monitoring and ongoing quality assurance measures were established to ensure compliance and improvement.
Deficiencies (18)
F174-D: The facility instituted a communication notebook for Social Service issues, including lost resident items, with monitoring by the SSD and administrator.
F241-D: A policy was enacted regarding appropriate dress for residents in bed, with preferences documented in care plans and monitored by nursing staff.
F253-E: Maintenance issues such as wall gouges, floor stains, and broken tiles were repaired and cleaning schedules reviewed with staff.
F258-E: Alarm sound levels were muffled in dining and common areas to reduce resident anxiety, with monitoring of resident behaviors.
F272-E: Individualized comprehensive assessments were completed and staff trained on proper CAA completion methods.
F312-D: Proper perineal care procedures were reviewed and aides retrained, with annual skills checkoffs planned.
F314-G: Resident skin assessments are now properly documented; pressure sore healing and repositioning programs were implemented with staff retraining.
F322-D: Facility policy was revised to include checking for tube placement, with monitoring by the Director of Nursing.
F323-E: A policy was written to address hot items in resident rooms, including assessments and monitoring by med aides.
F329-D: AIMS were completed and staff retrained on notifying physicians when accuchecks are outside defined parameters.
F332-D: Med aides were retrained on timing of medication administration related to meals, monitored by consulting pharmacist.
F333-D: Medication order processing procedures were updated and monitored via a log book reviewed by the Director of Nursing.
F363-E: Dietary menus were revised for correct puree items and staff retrained, with monitoring by registered dietician.
F366-D: Approved food substitutes were established with consulting dietician and monitored by dietician sign off.
F371-F: Dietary staff were retrained on food storage procedures; kitchen equipment cleaned; plans made to refinish/replace cabinets within 90 days.
F428-D: Consulting pharmacist will retrain nursing staff on blood sugar monitoring and increase scrutiny during reviews.
F465-E: Floors and sinks were cleaned; kitchen floor replacement planned within 60 days with bids being obtained.
F520-F: Director of Nursing will attend Quality Assurance meetings; QAPI team instituted to review skin assessments and repositioning programs.
Report Facts
Days to complete cabinet refinishing/replacement: 90
Days to replace kitchen flooring: 60
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 17
Date: Sep 9, 2015
Visit Reason
Health Resurvey and Complaint Investigation #79505 conducted to assess compliance with resident rights, dignity, housekeeping, medication administration, and other regulatory requirements.
Complaint Details
Complaint investigation #79505 included multiple resident rights, care, safety, and quality of life concerns.
Findings
The facility was found deficient in multiple areas including resident rights to personal property and dignity, housekeeping and maintenance, sound levels in dining areas, comprehensive assessments, ADL care, pressure ulcer prevention and treatment, gastrostomy tube care, accident hazards, medication monitoring and administration, menu compliance, food safety, and quality assurance committee effectiveness.
Deficiencies (17)
483.10(k),(l) The facility failed to ensure a resident was able to retain and use personal possessions related to a missing bracelet.
483.15(a) The facility failed to ensure 2 residents were dressed in a manner to maintain their dignity, including appropriate clothing when in bed.
483.15(h)(2) The facility failed to provide housekeeping and maintenance services for multiple resident rooms, bathrooms, whirlpool, and beauty shop, resulting in unsanitary conditions and maintenance issues.
483.15(h)(7) The facility failed to maintain comfortable sound levels in the assisted dining room, with a resident's personal alarm sounding repeatedly and disturbing other residents.
483.20(b)(1) The facility failed to complete individualized comprehensive care area assessments for 7 of 17 residents, lacking root cause analysis and development of care plans.
483.25(a)(3) The facility failed to provide adequate personal hygiene with perineal care for 2 of 3 sampled residents, omitting cleaning of the frontal genital region during incontinence care.
483.25(c) The facility failed to implement effective interventions to prevent development of a facility-acquired unstageable pressure ulcer for 1 resident, including failure to complete weekly skin assessments and inconsistent use of skin prep and repositioning.
483.25(g)(2) The facility failed to provide appropriate treatment and services to prevent aspiration pneumonia and metabolic abnormalities for 1 resident with gastrostomy tube feedings, including failure to check tube placement before feeding.
483.25(h) The facility failed to ensure the resident environment remained free from accident hazards, including a hot coffee cup warmer accessible to confused and mobile residents.
483.25(l) The facility failed to monitor residents for unnecessary medications, including lack of AIMS assessment for antipsychotic use, lack of psychoactive medication assessment, and failure to notify physician of blood sugars outside parameters.
483.25(m)(1) The facility failed to maintain medication error rates below 5%, with 3 medication errors in 26 opportunities for 2 residents, including administration of potassium and other medications not with food as ordered.
483.25(m)(2) The facility failed to ensure residents were free of significant medication errors, including failure to administer antipsychotic medication as ordered for 1 resident, resulting in restlessness.
483.35(c) The facility failed to follow the planned menu for 6 residents on a pureed diet by omitting pureed bread, putting residents at nutritional risk.
483.35(d)(4) The facility failed to provide substitutes of similar nutritive value to residents who refused food served.
483.35(i) The facility failed to maintain a clean and sanitary kitchen and food service area, including unlabeled food in the freezer, dirty kitchen equipment, and uncovered food during transport to dining areas.
483.70(h) The facility failed to provide a safe, functional, and sanitary environment for residents, staff, and the public, including dirty floors with pitting and food debris in the kitchen, and unsanitary linen and utility rooms.
483.75(o)(1) The facility failed 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
Resident census: 35
Medication administration opportunities: 26
Medication errors: 3
Medication error rate: 11.53
Pressure ulcer size: 3
Temperature of coffee cup warmer: 215
Blood sugar levels above ordered parameters: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Licensed Nursing Staff | Named in findings related to pressure ulcer care, medication administration, and monitoring |
| Staff B | Administrative Nursing Staff | Named in findings related to pressure ulcer care, medication monitoring, and QAA committee |
| Staff C | Dietary Staff | Named in findings related to food preparation and sanitation |
| Staff M | Direct Care Staff | Named in findings related to perineal care |
| Staff N | Direct Care Staff | Named in findings related to perineal care and pressure ulcer prevention |
| Staff Q | Direct Care Staff | Named in findings related to missing resident property |
| Staff S | Direct Care Staff | Named in findings related to perineal care and missing resident property |
| Staff W | Direct Care Staff | Named in findings related to perineal care and pressure ulcer prevention |
| Staff Z | Direct Care Staff | Named in findings related to blood sugar monitoring |
| Staff AA | Administrative Nursing Staff | Named in findings related to QAA committee |
| Staff U | Direct Care Staff | Named in findings related to pressure ulcer prevention |
| Staff V | Direct Care Staff | Named in findings related to pressure ulcer prevention |
| Staff BB | Direct Care Staff | Named in findings related to medication administration errors |
| Staff O | Licensed Nursing Staff | Named in findings related to medication administration |
| Staff Y | Consultant Staff | Named in findings related to medication administration monitoring |
| Staff F | Consultant Staff | Named in findings related to nutrition and menu |
| Staff X | Physician Assistant | Named in findings related to pressure ulcer treatment |
| Staff R | Administrative Nursing Staff | Named in findings related to comprehensive assessments and medication monitoring |
| Staff D | Social Services Staff | Named in findings related to missing resident property |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 9, 2015
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be at a 'G' level related to pressure ulcers. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended due to noncompliance.
Deficiencies (1)
F314 Pressure Ulcers: The facility was noncompliant in preventing avoidable pressure ulcers and ensuring appropriate care to prevent worsening of existing ulcers.
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
Life Safety
Deficiencies: 1
Date: Oct 22, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be an "F" level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with an "F" level deficiency that was widespread, indicating noncompliance with Life Safety Code requirements with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Jan 22, 2015
Provider agreement termination date: Apr 22, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 30, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the prior survey.
Findings
The report documents that deficiencies previously cited under regulations 483.35(i) and 483.65 were corrected as of the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 30, 2014
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
The report confirms that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected by the revisit date of 2014-06-30.
Deficiencies (1)
Regulation 28-39-158(a) deficiency identified by prefix S0600 was corrected as of 2014-06-30.
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 confirms that the deficiencies previously reported on the CMS-2567 have been corrected as of the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 30, 2014
Visit Reason
This is a revisit inspection to verify correction of previously cited deficiencies at Spring View Manor.
Findings
The report confirms that the previously reported deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by 06/30/2014.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 17, 2014
Visit Reason
The visit was conducted to determine if the facility was 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 submitted 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 that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 17, 2014
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 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 is found to be in substantial compliance based on the credible allegation of compliance and the submitted 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.
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 2
Date: Jun 17, 2014
Visit Reason
The inspection was a Health Resurvey to verify correction of previous deficiencies related to sanitary food handling and infection control.
Findings
The facility failed to maintain sanitary conditions in food storage, preparation, and serving areas, and failed to ensure proper sanitization of linens due to inadequate laundry water temperatures.
Deficiencies (2)
F 371: The facility failed to store, prepare, distribute, and serve food under sanitary conditions. Observations included unlabeled and undated food items, food stored directly on the floor, wet and soiled kitchen utensils and equipment, and improper drainage on the ice machine.
F 441: The facility failed to maintain laundry water temperatures at 160 degrees Fahrenheit to properly sanitize residents' linens and clothing, risking infection spread. Laundry detergent used did not have disinfectant properties and temperature logs showed frequent failure to reach required temperatures.
Report Facts
Resident census: 38
Laundry wash temperature: 150.6
Laundry wash temperature: 153
Laundry wash temperature range: 141.3
Laundry wash temperature range: 156.2
Laundry wash temperature: 163.2
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jun 9, 2014
Visit Reason
This document is a Plan of Correction submitted by Springview Manor addressing deficiencies identified during a prior inspection related to food storage, dishwashing procedures, and laundry water temperatures.
Findings
The facility had issues with improper labeling and dating of food items, inadequate cleaning and sanitizing of kitchen utensils and dishes, and laundry water temperatures not consistently meeting required standards. Corrective actions include staff in-service training, daily monitoring by supervisors, and monthly oversight by a registered dietitian.
Deficiencies (4)
F371-F Four chocolate puddings, two vanilla puddings, and two red jellos were thrown away due to improper labeling and dating on 6-9-14. Staff will be trained on labeling and dating food items with daily and monthly supervisory follow-up.
F371-F Multiple kitchen utensils and dishes were improperly cleaned or discarded, including plates, pans, scoops, pitchers, and glasses between 6-9-14 and 6-12-14. In-service training on dishwashing procedures and discarding damaged items will be conducted with daily and monthly follow-up.
F441-F Laundry water temperatures will be tested daily to ensure 160 degrees or higher and recorded in a log book. Monitoring will be conducted by the Director of Nursing and Maintenance Supervisor with quarterly quality assurance follow-up.
S0600-F Registered dietitian visits monthly to supervise dietary supervisor until CDM class completion. Dietary supervisor is enrolled in CDM course with completion expected by 12-25-15. Staffing is sufficient for nutritional care planning and supervision.
Report Facts
Food items discarded: 8
Plan of Correction completion dates: Jun 30, 2014
CDM course completion date: Dec 25, 2015
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 26, 2013
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not immediate jeopardy.
Report Facts
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. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 26, 2013
Visit Reason
A Life Safety Code survey was conducted 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 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 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
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. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 12, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-03-20.
Findings
All previously cited deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 12, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-03-20.
Findings
All previously cited deficiencies listed on the CMS-2567 were corrected as of the revisit date 2013-04-12. The report documents completion of corrective actions for multiple regulatory requirements.
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 12
Date: Mar 20, 2013
Visit Reason
The inspection was a health resurvey to evaluate compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate and report incidents of neglect, failure to provide dignified care, incomplete comprehensive assessments, inaccurate assessments, failure to develop comprehensive care plans, failure to ensure freedom from unnecessary drugs, unsanitary food storage and preparation, inadequate pharmaceutical services, failure to identify and act on drug irregularities, poor infection control practices, lack of emergency water supply procedures, and inadequate staff training on emergency procedures.
Deficiencies (12)
F225: The facility failed to thoroughly investigate and report to the state agency 2 of 4 incidents of alleged neglect involving residents who sustained falls and injuries.
F241: The facility failed to provide care in a dignified manner for 2 residents, including dressing residents in misfit or torn clothing.
F272: The facility failed to complete comprehensive assessments using Care Area Assessments to identify causes of triggered concerns for 3 residents, including psychotropic drug use and rehabilitation needs.
F278: The facility failed to complete an accurate comprehensive assessment for 1 resident related to dental needs, missing documentation of oral/dental status.
F279: The facility failed to develop a comprehensive care plan for 1 resident to monitor bowel elimination despite diagnosis of constipation and documented bowel movement irregularities.
F329: The facility failed to ensure 2 residents' drug regimens were free from unnecessary medications by failing to monitor bowel movements and omitting administration of ordered Vitamin B12 injections.
F371: The facility failed to maintain a clean and sanitary dietary department, with unlabeled food items and pans with food debris and water droplets.
F425: The facility failed to provide pharmaceutical services ensuring a resident received monthly Vitamin B12 injections as ordered due to a pharmacy order entry error.
F428: The facility's consultant pharmacist failed to identify and report drug irregularities including missed Vitamin B12 injections and failure to monitor bowel movements for 2 residents.
F441: The facility failed to ensure infection control by not covering linens during distribution, unsanitary handling of clothing protectors, and lack of sanitary procedures for blood glucose monitoring supplies.
F466: The facility failed to establish complete procedures to ensure availability of water to essential areas during loss of normal water supply, lacking provisions for storage, distribution, and volume estimation.
F518: The facility failed to train all employees in emergency procedures for chemical spills and bomb threats upon employment.
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 serum level: 192
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Staff | Reported Vitamin B12 order error and lack of administration documentation |
| Staff L | Consultant Pharmacist | Reported pharmacy order entry error and failure to identify drug irregularities |
| Staff E | Dietary Staff | Verified unlabeled food items and pans with debris in kitchen |
| Staff U | Direct Care Staff | Observed failing to use barrier during blood glucose monitoring |
| Staff J | Direct Care Staff | Reported lack of training on chemical spills and bomb threats |
| Staff M | Direct Care Staff | Reported bomb threat procedure as 'go with policy' |
| Staff O | Direct Care Staff | Reported chemical spill and bomb threat procedures |
| Staff H | Direct Care Staff | Reported chemical spill and bomb threat procedures |
| Staff V | Housekeeping Staff | Observed unsanitary handling of clothing protectors |
| Staff A | Administrative Nursing Staff | Reported linens should be covered during distribution and lack of bomb threat training |
| Staff D | Maintenance Staff | Reported chemical spill and bomb threat procedures |
| Staff H | Social Service Staff | Reported bomb threat and chemical spill procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096006 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility with State ID N096006.
Findings
No deficiencies or findings are detailed in this document. It serves as a placeholder or record for Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: 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 revising care plans for cognitively impaired residents to include individualized activities, and another related to kitchen sanitation and food dating procedures. Both deficiencies were corrected by early September 2018.
Deficiencies (2)
F 679-D The care plan for resident #7 was revised to address deficient practices affecting cognitively impaired residents. Care plans will be reviewed quarterly or upon significant change and audited weekly by nursing leadership.
F 812-F The facility corrected deficient practices related to food dating and kitchen sanitation, including discarding past dated foods and cleaning or replacing kitchen equipment. Monthly sanitation audits will be conducted for three months.
Report Facts
Deficiency correction date: Sep 5, 2018
Deficiency correction date: Aug 29, 2018
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096006 POC FO2111
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as FO2111 for facility State ID N096006 ASPEN.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction with no records found.
Inspection Report
Plan of Correction
Deficiencies: 13
Date: N096006 POC TST711
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies during an inspection.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including investigation of alleged violations, monitoring resident care issues such as clothing and bowel elimination, ensuring pharmaceutical services accuracy, infection control measures, and safety drills.
Deficiencies (13)
F0000 Statement of deficiencies has been or will be taken to the facility's Quality Assurance Assessment Committee.
F225 Alleged violations will be investigated and reported to State. The facility will monitor residents with confusion and investigate falls/wounds.
F241 Staff will monitor for torn and ill-fitting clothes and not place them on residents. Families will be notified if needed.
F272 The MDS Coordinator will complete assessments for psychotropic drug use and rehab needs to assist in care plan development.
F278 The facility will complete accurate comprehensive assessments on residents with dental needs and review MDS for accuracy.
F279 The facility will develop comprehensive care plans for monitoring bowel elimination for residents diagnosed with constipation.
F329 Staff will monitor residents with constipation for adequate bowel elimination on all three shifts and document accordingly.
F371 Discarded pans with build-up and replaced with new ones. Implemented daily cleaning schedule and labeled food containers.
F425 The facility will provide adequate pharmaceutical services to ensure residents receive correct medications as ordered.
F428 A policy was written on bowel elimination and plans of care updated. Consultant Pharmacist will monitor orders monthly.
F441 All laundry carts with clean linens will be covered and barriers placed between Accu-check items and residents' beds.
F466 Policy updated to include storage and distribution of water and estimated amount needed. Policy reviewed annually.
F518 Chief of Police will conduct inservice and bomb threat drill for all staff with quarterly follow-up drills and chemical spill training.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Roths | Medical Records | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
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