Inspection Reports for Reed’s Cove Health and Rehabilitation LLC
2114 N 127TH CT EAST, WICHITA, KS, 67206-3003
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 3, 2025, found no deficiencies and confirmed the facility was in compliance with all regulations surveyed. Prior inspections showed a pattern of deficiencies primarily related to pressure ulcer prevention and wound care, medication administration errors including one immediate jeopardy event involving a medication error by a Certified Medication Aide, and various issues with resident care planning, infection control, and safety. Complaint investigations were often substantiated, notably a case involving failure to prevent pressure ulcers that led to hospitalization and an immediate jeopardy medication error; most other complaints were addressed with corrective actions and staff education. Enforcement actions included denial of payment for new Medicare admissions in 2015 due to serious deficiencies but no fines or license suspensions were listed in the available reports. The trend shows improvement over time, with recent inspections demonstrating correction of prior deficiencies and compliance with regulatory requirements.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
66 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
A revisit survey and complaint investigation was conducted on 06/03/2025 to verify correction of all previous deficiencies cited on 04/24/2025.
Complaint Details
The visit included a complaint investigation identified as KS00195280. No new noncompliance was found.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 05/02/2025, 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: 1
Date: Apr 24, 2025
Visit Reason
The document is a Plan of Correction submitted by the facility in response to deficiencies related to the failure to prevent the development of facility-acquired pressure ulcers.
Findings
The facility failed to prevent the development of facility-acquired pressure ulcers as identified through observation, interview, and record review. The Plan of Correction outlines corrective actions including education, monitoring, and systematic changes to improve wound care and prevention.
Deficiencies (1)
Failure to prevent the development of facility-acquired pressure ulcers.
Report Facts
Date of performance improvement project submission: Mar 28, 2025
Date of wound log implementation: Mar 31, 2025
Date of wound surveillance education: Mar 31, 2025
Date of full house record review: Mar 30, 2025
Date of training for CNA’s and licensed nurses: May 2, 2025
Duration of monitoring summary submission: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Twyss Tamarawyss | Submitted and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Apr 23, 2025
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint investigations on 04/23/2025.
Complaint Details
The visit was triggered by multiple complaint investigations (KS00194708, KS00194618, KS00194523, KS00194485, KS00194510, KS194261, KS00193368, KS00192980).
Findings
The facility failed to prevent the development of facility-acquired pressure ulcers on Resident 1 due to inadequate wound monitoring, delayed repositioning, and lack of timely interventions such as nutritional support and use of pressure-reducing mattresses. The resident developed Stage 3 pressure injuries that worsened, leading to hospitalization for possible sepsis.
Deficiencies (1)
Failure to prevent development of facility-acquired pressure ulcers and inadequate wound care for Resident 1.
Report Facts
Resident census: 66
Residents sampled: 10
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 0.1
Pressure ulcer area: 11.25
Pressure ulcer volume: 1.125
Pressure ulcer measurements: 9.25
Pressure ulcer measurements: 6.5
Pressure ulcer measurements: 0.1
Pressure ulcer area: 59.8
Pressure ulcer volume: 5.98
Pressure ulcer measurements: 8.5
Pressure ulcer measurements: 3.5
Pressure ulcer area: 29.75
Pressure ulcer volume: 2.975
Pressure ulcer measurements: 13
Pressure ulcer measurements: 6
Pressure ulcer area: 78
Pressure ulcer volume: 7.8
Resident fever: 102.3
Protein supplement dosage: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nurse Aide | Reported notifying nurse of new skin issues and treatment application |
| CNA G | Certified Nurse Aide | Reported documentation of turn and reposition schedule in EHR |
| Licensed Nurse E | Licensed Nurse | Reported nurse responsibilities for skin assessments and wound measurements |
| Administrative Nurse D | Administrative Nurse | Reported staff reporting skin concerns and wound measurement responsibilities |
| Administrative Nurse C | Administrative Nurse | Reported gaps in wound assessments and training deficiencies |
| Administrative Nurse B | Administrative Nurse | Reported expectations for wound communication and documentation |
| Physician Assistant H | Physician Assistant | Reported expectations for wound documentation and preventative measures |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaint investigations (KS00190990, KS00191172, KS00191178, KS00191191, KS00191337, KS00191650, KS00191707, and KS00191801) focusing on medication errors and resident safety.
Complaint Details
The investigation was triggered by multiple complaints. The medication error was substantiated and placed Resident 1 in immediate jeopardy starting 10/11/24 at 09:00 AM. The facility was notified of the immediate jeopardy and corrective actions were verified completed prior to the onsite survey on 11/14/24.
Findings
The facility failed to prevent a significant medication error when a Certified Medication Aide (CMA R) administered Resident 2's medications orally to Resident 1, who was cognitively impaired and required medications via a jejunostomy tube. This error placed Resident 1 in immediate jeopardy. The facility took corrective actions including education, medication administration checkoffs, and placing the CMA on a do-not-return list. The deficiency was cited at a 'J' scope and severity level.
Deficiencies (1)
Failed to prevent significant medication error where CMA administered wrong resident's medications orally to a resident with a jejunostomy tube.
Report Facts
Census: 29
Medication error date: Oct 11, 2024
Vital signs monitoring timeframe: 72
Antibiotic treatment duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Certified Medication Aide | Administered wrong medications to Resident 1, placed on do not return list |
| LN G | Licensed Nurse | Reported medication error, educated CMA R, notified physician |
| Administrative Staff A | Reported CMA R's error and actions taken | |
| Licensed Nurse H | Licensed Nurse | Informed about medication error |
| Consultant GG | Consultant | Ordered chest x-ray and monitoring after medication error |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 11, 2024
Visit Reason
The document addresses the findings of multiple complaint investigations related to medication administration errors at the facility.
Complaint Details
The findings represent the results of complaint investigations KS00190990, KS00191172, KS00191178, KS00191191, KS00191337, KS00191650, KS00191707, and KS00191801.
Findings
An immediate jeopardy was identified on 2024-10-11 when a Certified Medication Aide (CMA) incorrectly administered medications orally to a resident who was NPO. Corrective actions were implemented prior to the onsite survey on 2024-11-14, including removal of the CMA, staff education, and competency checks.
Deficiencies (1)
Incorrect oral administration of medications to an NPO resident by a Certified Medication Aide.
Report Facts
Number of complaint investigations referenced: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felicia Majewski | RN Regional Manager | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 8, 2024
Visit Reason
An offsite revisit survey was conducted on 10/08/24 for all previous deficiencies cited on 08/19/24 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 09/16/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 20
Date: Aug 19, 2024
Visit Reason
The inspection was an annual health survey including complaint investigations and medication administration review.
Findings
The facility had multiple deficiencies including failure to protect resident dignity, incomplete care planning, medication administration errors, unsafe medication storage, infection control lapses, unsafe environment hazards, and inadequate documentation.
Deficiencies (20)
Staff labeled residents dependent on feeding assistance as 'feeders', violating resident dignity.
Resident 21 was excluded from care plan meetings, risking impaired care and uncommunicated needs.
Facility failed to verify advanced directives for Resident 8 and obtain proper DNR authorization for Resident 3.
Facility failed to provide written bed-hold notices to residents transferred to hospital, risking loss of bed reservation.
Baseline care plan for Resident 153 was incomplete and unsigned, lacking essential care instructions.
Comprehensive care plan for Resident 30 lacked documentation of oxygen and nebulized medication use.
Care plans for Residents 22 and 9 were not revised after falls, risking uncommunicated care needs.
Medication administration to Resident 6 was unsanitary; medications dropped on floor were administered without replacement.
Dependent residents 19 and 40 did not receive adequate personal care for facial hair removal and oral hygiene.
Resident 103's pressure ulcer wound care was provided without proper infection control practices, including failure to change gloves after cleaning bowel movement.
Facility failed to secure maintenance shop door containing hazardous chemicals and failed to maintain functional alarm on unsecured exit door.
Resident 9's room had a tripping hazard due to an electric cord placed on the floor where resident 'furniture surfed'.
Resident 103's urinary catheter collection bag was held above bladder level during emptying, risking urinary tract infection.
Resident 1 lacked physician order for oxygen administration and had contaminated cannula not replaced timely.
Resident 30's nebulizer equipment was not properly cleaned or dated after use.
Licensed Nurse I failed to administer medications as ordered for 15 of 20 residents during one shift.
Medication error rate for Resident 6 was 48% due to multiple administration errors and unsanitary practices.
Facility failed to store medications properly and lacked self-administration assessments for Residents 8, 22, and 153 who had medications in their rooms.
Facility failed to maintain complete, accurate, and accessible medical records for seven residents due to undocumented medications and assessments by Licensed Nurse I.
Facility failed to maintain an effective infection control program related to medication administration, including hand hygiene and glove use.
Report Facts
Residents sampled: 17
Medication opportunities observed: 25
Medication errors: 12
Medication error rate: 48
Residents with medication errors: 15
Residents reviewed for pressure ulcers: 5
Residents with urinary catheters sampled: 3
Residents with impaired cognition independently mobile: 5
Residents with medications left in room: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA II | Certified Medication Aide | Administered medications unsanitarily to Resident 6 |
| LN I | Licensed Nurse | Failed to administer medications to multiple residents during 07/21-07/22 shift |
| Administrative Nurse D | Administrative Nurse | Confirmed medication and infection control deficiencies |
| CNA AA | Certified Nurse Aide | Unaware of medication storage policies |
| LN R | Licensed Nurse | Reported medication storage and administration concerns |
| Maintenance Staff O | Maintenance Staff | Responsible for maintenance shop door and alarm system |
| Therapy Director T | Therapy Director | Reported therapy communication and care plan update issues |
| CNA F | Certified Nurse Aide | Reported lamp cord hazard and oral care concerns |
| Administrative Staff CC | Administrative Staff | Responsible for bed hold notices and process |
| Licensed Nurse K | Licensed Nurse | Reported medication and care plan concerns |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 21, 2023
Visit Reason
A revisit survey was conducted on 02/21/23-02/22/23 for all previous deficiencies cited on 11/30/22 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 01/01/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 15
Date: Nov 30, 2022
Visit Reason
The inspection was conducted as a health recertification survey and complaint investigation.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations, failure to notify resident representatives of changes, inconsistent bathing care, inadequate wound care and pressure ulcer prevention, unsafe environment hazards, improper medication management, insufficient RN coverage, failure to retain nurse staffing data, unsanitary food storage and preparation, and infection control deficiencies.
Deficiencies (15)
Failed to ensure foot pedals were available and utilized for Resident 11's wheelchair to prevent her feet from dragging on the floor.
Failed to notify Resident 43's representative of a change in condition.
Failed to provide consistent bathing opportunities for Resident 196.
Failed to ensure physician's orders were in place for Resident 197's Wound-Vac care.
Failed to prevent redevelopment of pressure related injury for Resident 33 and failed to ensure pressure reducing measures for Resident 9.
Failed to secure 21 pressurized oxygen tanks and failed to use gait belt for safe transfers for Resident 6.
Failed to implement individualized bowel and bladder toileting program for Resident 196 and failed to provide sanitary Foley catheter care for Resident 197.
Failed to ensure supplemental oxygen tubing was stored appropriately for Resident 12.
Failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week.
Failed to retain daily posted nursing staffing data for 18 months as required.
Failed to properly store and secure medications on two of three nursing units.
Failed to ensure timely physician response to Consultant Pharmacist recommendations for PRN Ativan orders lacking 14-day stop dates for Residents 2, 10, and 32.
Failed to administer Resident 12's antihypertensive medication metoprolol within physician ordered parameters.
Failed to store, prepare, and serve food under sanitary conditions including improper labeling, expired or unlabeled food items, and improper food storage temperatures.
Failed to follow infection control standards including proper hand hygiene, sanitary storage of oxygen tubing, proper urinary catheter care, and proper use of face masks.
Report Facts
Residents present: 49
Residents reviewed: 15
Pressurized oxygen tanks unsecured: 21
Days lacking posted nurse staffing data: 69
Partially used pharmacy bubble cards: 90
Metoprolol doses given outside parameters: 7
PRN Ativan orders lacking 14-day stop date: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple interviews regarding facility policies, deficiencies, and expectations |
| Licensed Nurse I | Licensed Nurse | Interviewed regarding medication administration and oxygen tubing storage |
| Certified Nurse Aide P | Certified Nurse Aide | Interviewed regarding foot pedal use and wheelchair cushions |
| Licensed Nurse H | Licensed Nurse | Interviewed regarding oxygen tank storage and foot pedal use |
| Certified Nurse Aide M | Certified Nurse Aide | Observed transferring Resident 6 without gait belt |
| Dietary Staff BB | Dietary Staff | Interviewed regarding food storage and preparation practices |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 29, 2022
Visit Reason
An offsite revisit survey was conducted on 04/29/2022 for all previous deficiencies cited on 03/16/2022.
Findings
All deficiencies have been corrected as of the compliance date of 03/21/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 21, 2022
Visit Reason
This document is a Plan of Correction submitted by Reeds Cove Health & Rehabilitation in response to deficiencies cited related to air mattress settings and resident safety.
Findings
The facility identified a deficiency involving improper air mattress settings for residents at risk of falls due to weakness and general debility. Corrective actions included revising care plans, staff training on air mattress settings, audits of all residents using air mattresses, and ongoing monitoring through weekly and monthly reviews.
Deficiencies (1)
Improper air mattress settings for residents at risk of falls due to weakness and general debility
Report Facts
Number of residents using air mattresses audited: 7
Date corrective action completed: Mar 21, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shay Cieschiermeyer | Administrator | Submitted the Plan of Correction to KDADS. |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Mar 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation involving multiple complaint case numbers related to the facility.
Complaint Details
The investigation involved multiple complaint case numbers (#KS00167025, KS00167630, KS00168056, KS00168207, KS00168764, KS00168735, KS00169129, KS00169816, and KS00170222). The complaint was substantiated as the facility failed to provide appropriate air mattress settings for Resident 3, contributing to a fall and injury.
Findings
The facility failed to ensure one resident remained free from accident hazards when staff did not provide appropriate air mattress settings according to the resident's weight, which contributed to an unwitnessed fall resulting in injury.
Deficiencies (1)
Failed to ensure appropriate air mattress settings according to resident's weight, causing over inflation and contributing to a fall.
Report Facts
Census: 57
Resident weight: 191
Air mattress setting weight: 400
Fall date: Jan 15, 2022
BIMS score: 10
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Responded to Resident 3's fall and provided care |
| PA GG | Physician Assistant | Notified about Resident 3's fall and injury |
| LN H | Licensed Nurse | Documented transport of Resident 3 to hospital after fall |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding air mattress settings and staff responsibilities |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 18, 2022
Visit Reason
An offsite revisit survey was conducted on 01/18/2022 for all previous deficiencies cited on 10/19/2021.
Findings
All deficiencies have been corrected as of the compliance date of 10/25/2021, 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: 1
Date: Oct 25, 2021
Visit Reason
This Plan of Correction document addresses deficiencies cited in a prior inspection related to staff compliance with mask-wearing protocols during the COVID-19 pandemic.
Findings
The facility reported no specific residents were directly affected by the deficient practice, but all residents had the potential to be affected. The plan includes staff education on mask use, daily audits for compliance, and ongoing monitoring through QAPI to ensure corrective actions are sustained.
Deficiencies (1)
Failure to ensure all staff properly wore masks except when eating or drinking, with non-compliance subject to disciplinary action.
Report Facts
Audit duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shay Cieschiermeyer | Administrator | Submitted the Plan of Correction |
| Evelyn Lacey | Added and modified the Plan of Correction | |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Date: Oct 19, 2021
Visit Reason
The inspection was a Targeted Infection Control Survey/COVID-19 Focused Survey conducted by the Kansas Department for Aging and Disability Services on behalf of CMS on 10/18/21 and 10/19/21. The facility investigation also included complaint investigations #165701 and #1666273.
Complaint Details
The visit included complaint investigations #165701 and #1666273 as part of the facility investigation.
Findings
The facility failed to follow CMS and CDC recommended practices to prevent COVID-19 transmission by not ensuring all staff wore masks appropriately in resident care areas on 2 of 3 nursing units, increasing the risk of virus spread to vulnerable residents.
Deficiencies (1)
Failure to ensure all staff had a mask in place while in resident care areas on 2 of 3 nursing units, increasing risk of COVID-19 transmission.
Report Facts
Census: 75
Residents in First and Second Nursing Units: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant Staff GG | Observed sitting at a table with mask pulled down under chin in the First House unit dining room. | |
| Certified Medication Aide R | Observed entering dining room with mask pulled down under chin and then going outside to administer medication. | |
| Licensed Nurse G | Licensed Nurse | Observed with mask below nose in dining room, removed mask to talk to nursing student. |
| Dietary Staff BB | Observed in kitchenette with mask pulled down under chin in Second House unit. | |
| Dietary Staff CC | Observed in kitchenette with mask pulled down under chin in First House unit. | |
| Administrative Staff A | Interviewed and stated staff were expected to wear masks appropriately at all times in resident care areas. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 17, 2021
Visit Reason
An offsite revisit survey was conducted on 09/17/2021 for all previous deficiencies cited on 08/10/2021.
Findings
All deficiencies have been corrected as of the compliance date of 08/13/2021, 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: 1
Date: Aug 13, 2021
Visit Reason
This document is a Plan of Correction submitted by Reeds Cove Health and Rehabilitation to address deficiencies cited during a prior survey related to oxygen and aerosol therapy care.
Findings
The facility identified deficiencies in the care and management of residents using oxygen and aerosol therapy, including issues with supplies and care plans. Corrective actions include audits, staff education, and ongoing monitoring to ensure compliance.
Deficiencies (1)
Deficient practice related to oxygen and aerosol therapy supplies and care plans.
Report Facts
Audit frequency: 2
Audit duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaycie Schiermeyer | Administrator | Submitted the Plan of Correction |
| Teresa Edwards | Added the Plan of Correction | |
| Evelyn Lacey | Modified the Plan of Correction | |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Director of Nursing | Director of Nursing | Performed staff education and audits related to oxygen therapy |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Date: Aug 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation (investigation number 164224) and included a Targeted Infection Control Survey/COVID-19 Focused Survey to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Complaint Details
The visit was triggered by complaint investigation number 164224. The facility was found non-compliant in respiratory care related to oxygen and nebulizer equipment maintenance and documentation.
Findings
The facility failed to provide necessary respiratory care for three residents related to oxygen cannula tubing, oxygen humidifier bottle, and nebulizer mask, tubing, and storage container. Specifically, the facility did not ensure weekly changing and proper documentation of oxygen and nebulizer equipment, increasing risk of respiratory infection.
Deficiencies (3)
Failure to change oxygen tubing and humidifier bottle weekly and document changes in the resident's Electronic Medical Records (EMR) for Resident 4.
Failure to date and document nebulizer mask, tubing, and storage container weekly for Resident 5, lacking guidance in care plan and documentation.
Failure to date and document nebulizer masks and tubing weekly for Resident 6, with lack of care plan guidance and documentation.
Report Facts
Resident census: 40
Residents sampled: 5
Residents reviewed for respiratory care: 3
Oxygen liters ordered: 10
Oxygen liters ordered for activity: 15
Nebulizer medication dose: 3
Nebulizer medication frequency: 2
Nebulizer medication dose: 3
Nebulizer medication frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Advised on facility policy for changing oxygen and nebulizer equipment weekly and documentation requirements | |
| Administrative Nurse E | Advised staff on changing oxygen tubing, humidifier bottles, and nebulizer equipment weekly and documentation in EMR |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 17, 2021
Visit Reason
An offsite revisit was conducted on 05/17/2021 for all previous deficiencies cited on 04/05/2021.
Findings
All deficiencies have been corrected as of the compliance date of 04/30/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Apr 30, 2021
Visit Reason
This document is a Plan of Correction submitted by Reeds Cove Health and Rehabilitation in response to deficiencies cited during a prior survey. It outlines corrective actions to address the alleged deficient practices identified in the facility.
Findings
The plan addresses multiple deficiencies related to resident dining assistance, wheelchair positioning, bathing schedules, medication storage and administration, physician order compliance, and infection control practices. Staff education and ongoing audits are planned to ensure compliance and resident safety.
Deficiencies (12)
Residents not assisted timely in dining
Inadequate wheelchair positioning assessments and treatments
Failure to offer showers according to resident preference
Dependent residents not bathed according to schedule
Improper wheelchair positioning leading to risk of falls and skin breakdown
Improper storage of chemicals and medication administration
Failure to follow physician standing orders for diabetic residents
Insulin pens not dated when opened
Failure to warm food for residents eating slowly
Lack of adaptive utensils for residents needing them
Improper serving of meals including food handling and hygiene
Inadequate hand hygiene and cleaning of glucometers
Report Facts
Audit frequency: 2
Audit frequency: 1
Date of staff education: Apr 12, 2021
Inspection Report
Health Resurvey And Complaint Investigation
Census: 47
Deficiencies: 12
Date: Apr 5, 2021
Visit Reason
Health Resurvey and Complaint Investigations were conducted to assess compliance with resident rights, quality of life, activities of daily living, quality of care, medication management, food safety, infection control, and other regulatory requirements.
Complaint Details
The inspection included complaint investigations related to resident rights, quality of life, quality of care, medication management, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meals, inadequate wheelchair positioning and bathing care, failure to monitor and manage blood sugars, improper medication labeling and storage, unsafe food handling practices, and inadequate infection control measures including improper disinfection of glucometers and hand hygiene.
Deficiencies (12)
Failure to promote dignity when Resident 37 was served meals after other residents had finished, in full view.
Failure to provide necessary assessments and care to maintain appropriate wheelchair positioning for Resident 24.
Failure to provide necessary bathing services for multiple residents including Residents 4, 17, 19, 24, 92, and 16.
Failure to provide necessary assessments, treatments and care to maintain appropriate chair and wheelchair positioning for Residents 24 and 19, and ensure treatment and care in accordance with professional standards for Resident 30.
Failure to follow medication administration policy allowing unqualified staff to apply discontinued medicated powder to Resident 30.
Failure to properly secure medications prepared in advance and failure to provide an environment free of chemical and medication accident hazards for cognitively impaired, independently mobile residents.
Failure to label insulin pens with the date opened for Residents 36, 20, and 28.
Failure to provide palatable, attractive food at an appetizing temperature for Resident 24.
Failure to provide built-up utensils to maintain the ability to eat independently for Resident 24.
Failure to prepare, store, distribute, and serve food under sanitary conditions including failure to cover food and drinks when delivered to resident rooms and failure to change gloves and wash hands during food preparation.
Failure to maintain an infection prevention and control program including failure to perform hand hygiene during incontinent care, failure to properly disinfect glucometer between residents, and failure to store oxygen tubing appropriately.
Failure to adequately monitor blood sugars above physician ordered parameters for Residents 4 and 28.
Report Facts
Census: 47
Blood sugar readings: 450
Blood sugar readings: 311
Bathing days missed: 4
Bathing days missed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | CNA | Named in findings related to failure to provide dignity to Resident 37, wheelchair positioning for Resident 24, and hand hygiene during incontinent care for Resident 30 |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding multiple deficiencies including dignity, bathing, blood sugar monitoring, medication administration, food handling, and infection control |
| Therapy Staff GG | Therapy Staff | Provided statements regarding wheelchair positioning for Residents 24 and 19 |
| Licensed Nurse H | Licensed Nurse | Provided statements regarding wheelchair positioning and blood sugar monitoring |
| Certified Medication Aide S | CMA | Named in medication application and glucometer disinfection findings |
| Licensed Nurse G | Licensed Nurse | Named in glucometer disinfection and blood sugar monitoring findings |
| Dietary Staff CC | Dietary Staff | Named in food temperature and food handling findings |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
An off-site revisit was conducted to verify correction of all previous deficiencies cited on 01/05/21.
Findings
All deficiencies have been corrected as of the compliance date of 01/19/21 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 19, 2021
Visit Reason
This document is a Plan of Correction submitted by Reeds Cove Health and Rehabilitation to address deficiencies cited during a prior survey.
Findings
The facility developed and implemented corrective actions including staff education on hygiene, oral care, fall prevention, and transfer procedures. Monitoring plans include audits and reviews by the Quality Assurance committee to ensure sustained compliance.
Deficiencies (2)
Deficiency related to hygiene and oral care policies not being followed.
Deficiency related to fall risk management, neurological checks, and proper resident transfers.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 4
Date: Jan 5, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#153427) to evaluate allegations related to resident care and safety.
Complaint Details
The investigation was triggered by complaint #153427. The findings substantiated failures in care related to oral hygiene, accident prevention, supervision, and safe transfers.
Findings
The facility failed to provide timely oral care, bathing, and appropriate hygiene for a dependent resident, failed to ensure adequate supervision and accident prevention for multiple residents including failure to monitor neurological status after a fall, and failed to provide safe transfer techniques for a dependent resident. Additionally, the facility did not implement immediate interventions following multiple falls for another resident.
Deficiencies (4)
Failure to ensure timely oral care, bathing, and appropriate hygiene needs related to shaving for Resident 5.
Failure to ensure adequate assistance and supervision to prevent accidents for three residents, including failure to monitor neurological status after an unwitnessed fall for Resident 6.
Failure to provide safe transfer for Resident 5 who required extensive assistance and was unable to bear weight during transfers.
Failure to implement immediate interventions following multiple falls for Resident 2, placing the resident at risk for reoccurring falls.
Report Facts
Census: 47
Residents reviewed: 7
Residents reviewed for ADLs: 3
Residents reviewed for accidents: 4
BIMS score: 4
BIMS score: 2
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in findings related to failure to provide oral care and safe transfers. |
| CNA N | Certified Nurse Aide | Named in findings related to failure to provide oral care and safe transfers. |
| CNA O | Certified Nurse Aide | Named in findings related to failure to provide safe transfers. |
| CNA P | Certified Nurse Aide | Named in findings related to failure to provide oral care. |
| Licensed Nurse H | Licensed Nurse | Named in findings related to oral care, shaving, and safe transfers. |
| Licensed Nurse G | Licensed Nurse | Named in findings related to failure to perform neurological assessments after a fall. |
| Administrative Nurse D | Administrative Nurse | Named in findings related to oral care, shaving, safe transfers, and failure to implement fall interventions. |
| Licensed Nurse J | Licensed Nurse | Named in findings related to failure to perform neurological assessments after a fall. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 5, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a COVID and complaint investigation survey conducted on 11/05/2020.
Findings
The facility was found to be deficiency free in the COVID survey conducted on 11/05/2020.
Deficiencies (1)
Deficiency Free Covid Survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 5, 2020
Visit Reason
A complaint survey was conducted on 11/05/2020 for complaint #KS00157407. Additionally, a Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess compliance with COVID-19 related practices.
Complaint Details
Complaint #KS00157407 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaint were not substantiated and no noncompliance was found. The facility was found to be in compliance with all regulations surveyed, including no deficiency citations related to COVID-19 infection control.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 4, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a Covid-19 survey conducted on June 4, 2020.
Findings
The facility was found to be deficiency free in the Covid-19 survey conducted on June 4, 2020.
Deficiencies (1)
Deficiency Free Covid-19 Survey
Inspection Report
Routine
Census: 56
Deficiencies: 0
Date: Jun 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) 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
Follow-Up
Deficiencies: 5
Date: May 17, 2019
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of 05/10/2019, with no uncorrected deficiencies noted at the time of the revisit.
Deficiencies (5)
Deficiency related to regulation 483.21(a)(1)-(3)
Deficiency related to regulation 483.21(c)(2)(i)-(iv)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(e)(1)-(3)
Deficiency related to regulation 483.80(a)(1)(2)(4)(e)(f)
Report Facts
Date of revisit: May 17, 2019
Correction completion date: May 10, 2019
Inspection Report
Plan of Correction
Deficiencies: 5
Date: May 10, 2019
Visit Reason
This document is a Plan of Correction submitted by Reed Cove Health & Rehab to address deficiencies cited during a prior survey. The plan outlines corrective actions to ensure compliance with state and federal regulations.
Findings
The facility identified multiple deficiencies related to baseline care plans, discharge summaries, dressing changes, sanitary catheter care, and infection control. The plan includes staff in-services, audits, monitoring, and ongoing compliance oversight through the Quality Assurance Committee.
Deficiencies (5)
Failure to develop baseline care plans within 24 hours of admission
Incomplete discharge summaries lacking diagnosis, vital signs, functional status, medical status, and medication
Improper dressing changes risking infection spread
Unsanitary catheter care with catheter touching the floor
Inadequate infection control program and hand hygiene practices
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Bragg | Executive Director | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 5
Date: May 1, 2019
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility failed to complete baseline care plans within 48 hours of admission, failed to complete discharge summaries, did not provide sanitary wound dressing changes, failed to ensure proper wheelchair positioning, failed to provide sanitary catheter care, and failed to maintain effective infection control practices including proper hand hygiene.
Deficiencies (5)
Failure to complete a baseline care plan within 48 hours following admission for resident #105.
Failure to complete a discharge summary for resident #51 discharged to the community.
Failure to provide sanitary wound dressing change and proper wheelchair positioning for residents #100 and #28 respectively.
Failure to ensure sanitary catheter care for resident #34 to prevent urinary infections.
Failure to maintain an effective infection control program including failure to ensure hand hygiene between medication administrations and during care for residents #4 and #17.
Report Facts
Census: 58
Residents selected for review: 17
Residents reviewed for wounds: 3
Residents reviewed for wheelchair positioning: 1
Residents reviewed for discharge: 1
Residents reviewed for urinary catheter: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Nursing Staff | Named in infection control deficiency for failure to change gloves and perform hand hygiene between medication administrations |
| Staff D | Licensed Nursing Staff | Named in wound care deficiency for failure to perform hand hygiene and sanitary dressing change |
| Staff N | Licensed Nursing Staff | Named in infection control deficiency for failure to change gloves between soiled and clean care |
| Staff I | Direct Care Staff | Named in catheter care deficiency for catheter bag placement |
| Staff P | Direct Care Staff | Named in wheelchair positioning deficiency for lack of foot pedals |
| Staff M | Direct Care Staff | Named in wheelchair positioning deficiency for foot pedal adjustment |
| Staff C | Administrative Nursing Staff | Named in baseline care plan deficiency for responsibility of care plan initiation |
| Staff A | Licensed Administrative Staff | Named in discharge summary deficiency for responsibility of completion |
| Staff B | Administrative Staff | Named in infection control deficiency for hand hygiene education oversight |
| Staff H | Administrative Staff | Named in discharge planning interview |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 5, 2018
Visit Reason
An offsite revisit survey was conducted on 09/05/2018 for all previous deficiencies cited on 07/19/2018.
Findings
All deficiencies have been corrected as of the compliance date of 08/10/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Aug 10, 2018
Visit Reason
This document is a Plan of Correction submitted by Avita Health & Rehab Reeds Cove in response to deficiencies cited in a prior inspection report dated 07/19/2018. The plan outlines corrective actions to address identified deficiencies related to care plans, medication administration, staff education, sanitization, and infection control.
Findings
The facility has implemented corrective actions including updating diabetic care plans, ensuring proper medication administration, conducting staff in-services, monitoring sanitizing solution levels, and maintaining an effective infection control program. Ongoing compliance will be monitored and reviewed monthly by the QAPI team.
Deficiencies (6)
Care plan for resident #5 regarding blood sugar parameters was corrected and audited for all diabetic residents.
Certified Nursing Assistants and Certified Medication Assistants will receive a minimum of 12 hours of in-service education annually.
Proper administration of Promethazine and Zofran anti-nausea medications ensured; duplicate medications avoided for resident #5.
All residents on antipsychotic medications will have Abnormal Involuntary Movement Scale (AIMS) assessments completed at least every 3 months.
Sanitizing solution in kitchens maintained at effective levels; replaced cutting boards and frying pans to ensure sanitizable surfaces.
Effective infection control program maintained to prevent spread of infection; proper cleaning and sanitizing procedures reinforced.
Report Facts
Date of Plan of Correction review: Aug 28, 2018
Number of cutting boards replaced: 12
Number of frying pans replaced: 3
Minimum in-service hours per year: 12
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 7
Date: Jul 19, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #127925, #127216, #122296 to evaluate compliance with regulatory requirements.
Complaint Details
The visit was complaint-related as it included investigations of complaints #127925, #127216, and #122296.
Findings
The facility was found deficient in multiple areas including failure to revise care plans timely, inadequate nurse aide in-service education documentation, failure to prevent duplicate antinausea medications, lack of AIMS assessments for residents on psychotropic drugs, improper food safety practices including sanitizing solution and cutting board conditions, and ineffective infection prevention and control practices related to linen and equipment handling.
Deficiencies (7)
Failure to review and revise the care plan for a resident regarding blood sugar parameters.
Failure to ensure certified direct care staff received 12 hours of education per year with proper documentation.
Consulting pharmacist failed to ensure residents remained free of duplicate antinausea medication and failed to clarify medication administration timing.
Failure to ensure residents' drug regimens were free from unnecessary drugs including duplicate antinausea medications.
Failure to complete AIMS assessment for a resident on antipsychotic medication and lack of facility policy for AIMS assessments.
Failure to ensure sanitizing solution contained effective sanitizing level and cutting boards maintained sanitizable surfaces.
Failure to maintain an effective infection prevention and control program including improper handling of soiled and clean linens and storage of soiled equipment.
Report Facts
Census: 53
Residents sampled: 14
Certified employees reviewed: 5
Residents reviewed for unnecessary medications: 5
Cutting boards with issues: 12
Sanitizing solution ppm: 0
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 19, 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 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-08-10.
Deficiencies (1)
'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact and signatory related to enforcement and survey findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 14, 2018
Visit Reason
An off-site survey was conducted to address deficiencies cited on December 8, 2017.
Findings
The deficiencies cited in the prior inspection were corrected as of the compliance date of February 14, 2018.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jan 5, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior complaint investigation report (2567) related to care plan revisions, gait belt usage, and monitoring of alarms.
Findings
The facility corrected cited deficiencies by educating staff on timely care plan revisions, ensuring gait belts are available and used, monitoring bed alarm functions, conducting full facility audits, and holding mandatory staff in-services. The Director of Nursing Services will monitor compliance.
Deficiencies (3)
Failure to ensure timely care plan revisions for residents #102 and #108
Failure to monitor the function of the bed alarm for resident #108
Failure to use a gait belt for residents #102 and #107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Bragg | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Caryl Gill | Modified the Plan of Correction document |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 8, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective January 5, 2018.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Date: Dec 8, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers 122232 and 123771.
Complaint Details
The inspection was triggered by complaint investigations #122232 and #123771. The facility was found deficient in care plan timing and revision, and in ensuring residents were free of accident hazards and received adequate supervision and assistance devices.
Findings
The facility failed to timely update care plans for residents #102 and #108 regarding gait belt usage and bed alarm monitoring. The facility also failed to ensure the use of gait belts during transfers for residents #102, #107, and #108, resulting in falls and injuries. Additionally, the facility failed to monitor the function and placement of bed alarms, contributing to a resident fall.
Deficiencies (2)
Failed to timely update care plans for residents regarding gait belt usage and bed alarm monitoring.
Failed to ensure residents received adequate supervision and assistance devices to prevent accidents, including failure to use gait belts during transfers and failure to monitor bed alarm function.
Report Facts
Residents selected for sample review: 5
Resident census: 48
Fall risk assessment scores: 5
Fall risk assessment scores: 9
Fall risk assessment scores: 8
Fall risk assessment scores: 10
Fall risk assessment scores: 8
Fall risk assessment scores: 10
Fall risk assessment scores: 12
Fall risk assessment scores: 12
Number of fractures: 3
Fall date: 2017
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 14, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiency with ID Prefix F0314 related to regulation 483.25(b)(1) was corrected as of 02/14/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency with ID Prefix F0314 related to regulation 483.25(b)(1)
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 14, 2017
Visit Reason
This document is a Plan of Correction submitted by Avita Health and Rehab at Reeds Cove in response to deficiencies cited during a health facility resurvey related to an Avita complaint dated 02/07/2017.
Complaint Details
This Plan of Correction is related to an Avita complaint dated 02/07/2017.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations. Resident #3's record was updated to clarify wound healing status and weekly wound assessments were replaced by weekly skin assessments. Policies for pressure ulcer and excoriation prevention were updated accordingly.
Deficiencies (2)
Deficiencies cited regarding findings of the health facility resurvey.
Resident #3's wound record was not updated to reflect healed status and wound assessments were not properly conducted.
Report Facts
Complete Date: Feb 14, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Feb 7, 2017
Visit Reason
The inspection was conducted as a result of complaint investigations #1100126 and #1100125 regarding the facility's care related to pressure ulcers.
Complaint Details
The visit was triggered by complaint investigations #1100126 and #1100125. The facility was found to have failed in adequately assessing and treating pressure ulcers for a resident, with incomplete wound monitoring and documentation.
Findings
The facility failed to ensure that one resident with pressure ulcers received adequate and timely skin assessments and appropriate treatment. The resident's wounds were not properly monitored or documented, and wound assessments were incomplete or missing for several weeks. Staff were unaware of the resident's current open wounds, and the facility failed to follow its own pressure ulcer prevention and care policies.
Deficiencies (1)
Failure to ensure timely and adequate skin assessments and treatment for a resident with pressure ulcers.
Report Facts
Census: 71
Residents reviewed for pressure ulcers: 4
Pressure ulcers stage: 2
Wound assessments missing: 4
Wound assessments documented: 4
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 7, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a "D" level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective February 14, 2017.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named in relation to the survey and complaint coordination |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 3, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiencies identified in the prior survey were corrected as of the revisit date.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 4, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective February 3, 2017.
Deficiencies (1)
Most serious deficiency found was an "E" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as Complaint Coordinator and contact person regarding the survey findings. |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 3
Date: Jan 4, 2017
Visit Reason
The inspection was conducted based on complaint investigations #108969, 108984, 109841, and 109829 to assess compliance with care planning and supervision requirements related to resident falls and safety.
Complaint Details
The inspection was triggered by complaints alleging inadequate care planning and supervision related to resident falls.
Findings
The facility failed to review and revise care plans for 5 of 6 sampled residents with repeated falls to include preventative interventions. The facility also failed to ensure adequate supervision and assistive devices to prevent repeated falls, and did not conduct thorough investigations with root cause analysis for each fall. Several residents experienced multiple falls without appropriate interventions or communication to staff and family.
Deficiencies (3)
Failure to review and revise plans of care for residents with repeated falls to include preventative interventions.
Failure to ensure adequate supervision and assistive devices to prevent repeated falls for residents.
Failure to conduct thorough investigations and root cause analysis for each fall to ensure interventions remain functional.
Report Facts
Census: 73
Residents sampled: 6
Fall risk scores: 12
Fall risk scores: 15
Fall risk scores: 14
Fall risk scores: 18
Fall risk scores: 18
Fall risk scores: 17
Fall risk scores: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Nursing Staff | Reported on duty when resident was found on floor and described supervision and care provided post-fall |
| Staff B | Administrative Nursing Staff | Reported facility identified resident left in wheelchair after supper and staff failed to assist resident to bed; verified lack of communication and staff consistency |
| Staff C | Administrative Staff | Completed fall investigations and root cause analyses for resident falls |
| Staff D | Licensed Nursing Staff | Reported on fall assessment procedures and resident agitation |
| Staff G | Direct Care Staff | Assisted resident with arising cares and transfers; reported resident fear of falling |
| Staff H | Direct Care Staff | Assisted resident with arising cares and transfers; reported resident fear of falling |
| Staff J | Direct Care Staff | Reported lack of communication about resident falls and interventions during work shifts |
| Staff K | Direct Care Staff | Reported staffing shortages and busy conditions on evening resident fell |
| Staff M | Direct Care Staff | Reported resident safety precautions and transfer assistance requirements |
| Staff O | Licensed Nursing Staff | Reported resident falls and described circumstances of falls |
| Staff P | Direct Care Staff | Reported receiving new task sheets with fall information and resident fall history |
| Staff V | Licensed Nursing Staff | Reported resident fall during shift and improper assistance by new staff |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 4, 2017
Visit Reason
This document is a Plan of Correction submitted by Avita Health and Rehab at Reeds Cove in response to deficiencies cited during a health facility resurvey related to a complaint dated 01/04/2017.
Complaint Details
This Plan of Correction is in response to deficiencies cited from a complaint investigation at Avita Reeds Cove dated 01/04/2017.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, focusing on reviewing and revising resident care plans to include preventative interventions for residents at risk of falls, ensuring staff are trained on care plans and accident response, and establishing a weekly interdisciplinary Fall Reduction Committee to investigate and analyze falls and accidents.
Deficiencies (2)
Failure to review and revise resident care plans to include preventative interventions for residents identified at risk of falls.
Failure to ensure residents receive adequate supervision and assistive devices to prevent avoidable accidents.
Report Facts
Plan of Correction completion date: Feb 3, 2017
Residents referenced: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Added Plan of Correction and contact for assistance | |
| Irina Strakhova | Modified Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Nov 18, 2016
Visit Reason
This document is a Plan of Correction submitted by Avita Health and Rehab at Reeds Cove in response to deficiencies cited during a health facility resurvey inspection.
Findings
The facility identified multiple deficiencies related to resident dignity during meal assistance, honoring resident choices, staffing sufficiency and posting, food storage sanitation, accurate pharmaceutical administration, medication labeling and expiration, and call light system pager usage. The Plan of Correction outlines corrective actions including staff in-service training, monitoring, and routine audits to ensure compliance.
Deficiencies (8)
Failure to provide meal assistance in an individualized and dignified manner
Failure to honor residents' rights to make choices about their care, including bathing preferences
Insufficient staff to provide necessary care and services
Incorrect daily staffing information posted for residents and the public
Food not stored under sanitary conditions
Inaccurate administration of pharmaceutical services
Medications not properly labeled with date opened and discarded per manufacturer's recommendations
Staff not wearing pagers designated for the call light system
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 18, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies related to various regulatory requirements were corrected as of the revisit date, with completion dates documented for each.
Report Facts
Deficiencies corrected: 8
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 18, 2016
Visit Reason
This report documents a revisit conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The revisit confirmed that the previously identified deficiency under regulation 26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) was corrected as of 11/18/2016. No other deficiencies were noted in this report.
Deficiencies (1)
Deficiency under regulation 26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) previously reported
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Nov 7, 2016
Visit Reason
The inspection was conducted as a Health Licensure Resurvey and complaint investigations # KS00094937, KS00092819, and KS00106316.
Complaint Details
The visit included complaint investigations # KS00094937, KS00092819, and KS00106316.
Findings
The facility failed to ensure staff wore portable electronic devices (pagers) that produced an audible tone or vibration upon activation of the call light system in 3 of 4 houses, compromising staff responsiveness to resident needs and safety.
Deficiencies (1)
Failure to ensure staff wore portable electronic devices (pagers) that produced audible or vibration signals upon activation of the call light system in 3 of 4 houses.
Report Facts
Facility census: 72
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 7, 2016
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.
Deficiencies (1)
Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding acceptance of plan of correction and substantial compliance. |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 13, 2016
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 at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
Deficiencies found at "F" level severity related to Life Safety Code compliance
Report Facts
Effective date for denial of payments: Aug 13, 2016
Provider agreement termination date: Nov 13, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and responsible for licensure certification and enforcement |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 20, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were corrected as of 06/05/2015, with corrective actions completed for each identified regulation.
Report Facts
Deficiency correction completion date: Jun 5, 2015
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jun 5, 2015
Visit Reason
This document is a Plan of Correction submitted by Avita Health and Rehab at Reeds Cove in response to deficiencies cited during a health facility resurvey.
Findings
The facility addressed multiple deficiencies including care plan updates for residents with special dietary needs, staff education on mobility and medication protocols, environmental safety improvements, medication error investigations, nutritional status monitoring, sanitary food preparation, and infection control procedures. Corrective actions included staff in-service training, policy revisions, audits, and disciplinary actions.
Deficiencies (6)
Failure to provide necessary care and services to maintain residents' well-being, including dietary and dialysis care.
Failure to maintain a safe environment and provide adequate supervision to prevent accidents.
Failure to ensure residents are free of significant medication errors.
Failure to maintain acceptable nutritional status and provide therapeutic diets as needed.
Failure to store, prepare, distribute, and serve food under sanitary conditions.
Failure to maintain an effective Infection Control Program to prevent disease transmission.
Report Facts
Date of Plan of Correction review: Jun 4, 2015
Date of staff in-service on Root Cause Analysis: Jun 2, 2015
Date of dietary cookware cleaning: May 13, 2015
Date of medication error investigation initiation: Nov 18, 2014
Date of staff suspension and termination: Dec 1, 2014
Date of Unit Manager demotion: Dec 1, 2014
Date of MAR audit: Nov 19, 2014
Inspection Report
Census: 69
Deficiencies: 6
Date: May 21, 2015
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation covering multiple complaint investigation numbers.
Complaint Details
The inspection included a complaint investigation with multiple complaint numbers referenced in the initial comments.
Findings
The facility was found deficient in multiple areas including failure to provide necessary care and services for a resident on dialysis, failure to prevent falls resulting in injury, failure to provide nutritional supplements leading to severe weight loss, failure to prevent significant medication errors, failure to maintain sanitary food preparation and storage, and failure to maintain infection control procedures in an isolation room.
Deficiencies (6)
Failure to ensure staff provided necessary care and services for a resident on dialysis including therapeutic diet, fluid restriction, and monitoring of dialysis access site.
Failure to ensure staff followed care plan to prevent a fall resulting in fractured pelvis for a resident.
Failure to provide nutritional supplements as ordered for a resident who experienced severe weight loss.
Failure to ensure resident remained free of significant medication errors; resident missed multiple medications including Lasix leading to hospitalization for acute congestive heart failure.
Failure to store food properly, prepare food in a sanitary manner, and maintain clean equipment in multiple kitchens.
Failure to maintain infection control in an isolation room for C-Difficile including failure to use disinfectant when mopping floors and failure to clean bed positioning bars and vacuum room.
Report Facts
Residents sampled: 27
Residents reviewed for accidents: 5
Residents reviewed for nutrition: 4
Residents reviewed for unnecessary medications: 6
Weight loss: 25.8
Weight loss percentage: 20.4
Weight loss percentage: 18.7
Weight loss percentage: 15.4
Weight loss percentage: 14
Weight loss percentage: 13.35
Weight loss percentage: 12.9
Weight loss percentage: 11.2
Weight loss percentage: 10.7
Medication days missed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner C | Nurse Practitioner | Monitored resident #182 and provided medical orders |
| Staff F | Dietary Staff | Observed preparing food and handling thermometer unsanitarily |
| Staff M | Dietary Staff | Reported on food storage and cleaning practices |
| Staff O | Housekeeping Staff | Observed cleaning isolation room without proper disinfectant use |
| Staff Q | Direct Care Staff | Administered medications and supplements to resident #107 |
| Staff U | Certified Medication Aide | Failed to report medication unavailability for resident #182 |
| Staff W | Certified Medication Aide | Failed to report medication unavailability for resident #182 |
| Nurse Y | Licensed Nurse | Described medication shortage procedures and verified E-kit availability |
| Administrative Nurse B | Administrative Nurse | Confirmed medication errors and investigation |
Inspection Report
Enforcement
Deficiencies: 0
Date: May 21, 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 serious deficiencies at a level of actual harm but not immediate jeopardy, with a history of noncompliance from a prior abbreviated survey. As a result, enforcement remedies including denial of payment for all new Medicare admissions effective June 10, 2015, were imposed without opportunity to correct.
Report Facts
Denial of payment effective date: Jun 10, 2015
Noncompliance follow-up deadline: Nov 21, 2015
Civil Money Penalty threshold: 5000
Hearing request deadline: 60
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator for Kansas Department for Aging & Disability Services |
| Gregg Brandush | Branch Manager | Authorized the letter as Branch Manager, Division of Survey & Certification, Centers for Medicare & Medicaid Services |
| Jane Weiler | Contact person at CMS for questions regarding the matter | |
| Joe Ewert | Commissioner | Commissioner of Kansas Department for Aging and Disability Services, recipient of IDR requests |
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 5, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payments effective date: May 5, 2015
Provider agreement termination date: Aug 5, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Facility administrator named in the report header. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Joe Ewert | Commissioner | Mentioned in carbon copy (c:). |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 14, 2014
Visit Reason
This is a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that all previously cited deficiencies identified by regulation numbers F0223, F0225, F0242, and F0280 were corrected by 09/05/2014.
Deficiencies (4)
Deficiency related to regulation 483.13(b), 483.13(c)(1)(i)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Report Facts
Deficiencies corrected: 4
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 4
Date: Aug 14, 2014
Visit Reason
The inspection was conducted as a complaint investigation #77825 and Partial Extended Health Resurvey related to allegations of abuse and failure to protect a resident from abuse and mental anguish.
Complaint Details
The complaint investigation involved allegations that a non-Caucasian staff member of the opposite gender sexually abused and inappropriately touched resident #3. The resident reported fear and mental anguish, and the facility failed to report the allegation timely, investigate thoroughly, and protect residents during the investigation.
Findings
The facility failed to protect resident #3 from abuse and mental anguish by a non-Caucasian staff member of the opposite gender, failed to immediately report the allegation to the State survey agency, failed to thoroughly investigate the allegation, and failed to protect all residents during the investigation. Resident #3 also expressed preference to have caregivers of the same gender, which was not honored consistently and not properly reflected in the care plan.
Deficiencies (4)
Facility failed to protect resident #3 from abuse and mental anguish by a staff member of the opposite gender.
Facility failed to immediately report an allegation of employee to resident sexual abuse and/or inappropriate touching to the State survey and certification agency, failed to thoroughly investigate the allegation, failed to submit the results of the investigation within 5 working days, and failed to protect all residents from potential abuse during the investigation.
Facility failed to honor resident #3's preference to not have caregivers of the opposite gender.
Facility failed to review/revise resident #3's care plan to include the resident's preference to have same gender caregivers.
Report Facts
Facility census: 66
Resident sample size: 3
Direct care staff E night shifts: 31
Direct care staff E day shifts: 5
Opposite gender nurse shifts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Direct Care Staff | Named as alleged perpetrator of abuse and opposite gender staff member working multiple shifts in resident #3's house |
| Staff A | Administrative Staff | Received abuse allegation report, failed to report timely, investigate thoroughly, or protect residents during investigation |
| Staff B | Social Services Staff | Received resident's preference for same gender caregivers and reported to charge nurse |
| Staff D | Therapy Staff | Received resident's abuse allegation and reported verbally and in writing to administrative staff |
| Staff C | Therapy Staff | Accompanied Staff D to report resident's abuse allegation to administrative staff |
| Staff F | Licensed Nurse | Spoke with resident's family member about abuse allegation |
| Staff G | Direct Care Staff | Interviewed regarding resident's condition and care |
| Staff I | Direct Care Staff | Interviewed regarding resident's condition and care |
| Staff J | Licensed Nurse | Interviewed regarding resident's preference for same gender caregivers |
| Staff K | Consultant Staff | Reported on facility's review of surveillance and investigation |
| Staff M | Direct Care Staff | Interviewed regarding resident's care |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 14, 2014
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 that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from July 23, 2014 through August 5, 2014, specifically related to F225, CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4).
Deficiencies (1)
Noncompliance with F225, CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) resulting in immediate jeopardy and substandard quality of care.
Report Facts
Denial of payment effective date: Nov 14, 2014
Provider agreement termination date: Feb 14, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Facility administrator named in the report header. |
| Mary Jane Kennedy | Complaint Coordinator | Author of the report and contact person for questions. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 17, 2014
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 with their regulation numbers were corrected as of the revisit date, March 17, 2014.
Report Facts
Deficiencies corrected: 12
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 17, 2014
Visit Reason
This report is a follow-up visit conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiency identified by regulation number 26-40-305 (3) with ID prefix S1364 was corrected as of 03/17/2014. No other deficiencies or findings are noted.
Deficiencies (1)
Deficiency identified under regulation 26-40-305 (3) with ID prefix S1364
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Feb 21, 2014
Visit Reason
This document is a Plan of Correction submitted by Avita Health and Rehab at Reeds Cove in response to deficiencies cited during a health facility resurvey.
Findings
The facility has developed and implemented corrective actions addressing multiple deficiencies related to residents' rights, care planning, assessments, medication management, safety, and environmental conditions. Staff training and ongoing monitoring plans are included to ensure continued compliance.
Deficiencies (13)
Failure to provide written notice of residents' rights and ensure understanding during Resident Council meetings.
Failure to inform resident, physician, and family of significant changes in resident status and document resident weights properly.
Failure to keep a clearly labeled copy of the most recent survey results accessible to residents.
Failure to respect residents' rights to make choices about their daily lives, including bathing preferences.
Failure to complete timely, comprehensive, and accurate assessments of residents' functional capacity and nutritional status.
Failure to develop comprehensive care plans with measurable objectives for residents, including those receiving dialysis and psychotropic medications.
Failure to coordinate care with hospice services and ensure staff understanding of roles.
Failure to maintain a safe resident environment, including fall prevention, medication storage, water temperature safety, and chemical storage.
Failure to store, prepare, distribute, and serve food under sanitary conditions.
Failure to assist residents in obtaining routine and emergency dental care and complete oral health assessments.
Failure to review drug regimens monthly and act on irregularities, including proper lab monitoring and physician communication.
Failure to properly label medications with date opened and discard expired medications per manufacturer recommendations.
Failure to ensure hydrotherapy units are plugged into outlets with ground-fault circuit interrupters (GFCI).
Report Facts
Date of discharge: Jan 29, 2014
Date of discharge: Feb 1, 2014
Date of kitchen door replacement: Feb 1, 2014
Date of hydrocollator outlet change: Jan 23, 2014
Date of TSH lab draw: Jan 27, 2014
Date of Plan of Correction review by Quality Assurance/Performance Improvement committee: Feb 12, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Jan 28, 2014
Visit Reason
The inspection was conducted as a health resurvey, non-compliance revisit, and complaint investigation #71552.
Complaint Details
Complaint investigation #71552 was part of the visit. The findings confirmed non-compliance related to electrical safety of the hydroculator.
Findings
The facility failed to maintain the hydroculator on a ground-fault circuit interrupter (GFCI) outlet as required. Observations and interviews confirmed the hydroculator was not plugged into a GFCI outlet, and the facility lacked a policy regarding the hydroculator.
Deficiencies (1)
Failed to maintain the hydroculator on a ground-fault circuit interrupter (GFCI) outlet.
Report Facts
Facility census: 58
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 28, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that all previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4)
Deficiency related to regulation 483.20(j) - (i)
Deficiency related to regulation 483.20(k)(3)(i)
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 5
Date: Dec 19, 2013
Visit Reason
The inspection was a partially-extended complaint investigation related to complaint numbers #70699 and #69671.
Complaint Details
The inspection was triggered by complaints #70699 and #69671. The facility failed to report an injury and failed to investigate multiple falls and update care plans accordingly.
Findings
The facility failed to immediately report an incident involving fractured ribs, failed to accurately assess residents' fall histories, failed to develop comprehensive care plans addressing falls and ADL needs for multiple residents, and failed to investigate falls to determine causes and update care plans accordingly. Several residents experienced falls resulting in injuries including fractures.
Deficiencies (5)
Failed to immediately report an incident involving fractured ribs to the State survey and certification agency.
Failed to accurately assess the resident's fall history for 1 of 7 sampled residents.
Failed to have a comprehensive care plan for 5 of 7 sampled residents regarding falls and ADLs.
Failed to have an accurate, timely care plan on admission for 2 of 7 sampled residents.
Failed to ensure resident environment remained free of accident hazards and provide adequate supervision and assistance devices to prevent falls, including failure to investigate falls and update care plans, resulting in fractures for 4 residents.
Report Facts
Facility census: 52
Sample size: 7
Falls with injury: 2
Fall risk score: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant C | Reported lack of investigation and inadequate fall prevention interventions | |
| Physician H | Reported expectation for staff to investigate falls and follow care plans | |
| Direct Care staff J | Reported resident fall risk and need for supervision | |
| Administrative nursing staff B | Reported no evidence of fall investigation | |
| Licensed Nursing staff G | Reported resident fall risk and supervision needs |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Nov 1, 2013
Visit Reason
This document is a Plan of Correction submitted by Avita Health and Rehab at Reeds Cove in response to deficiencies cited in a complaint investigation related to fall incidents and abuse, neglect, and exploitation policies.
Complaint Details
This Plan of Correction addresses deficiencies cited in a revised complaint investigation involving Resident #3 and other targeted residents related to fall incidents and potential abuse, neglect, and exploitation.
Findings
The facility identified multiple deficiencies related to fall investigations, post-fall documentation, care planning, and staff training on abuse, neglect, and exploitation. The plan outlines corrective actions including staff in-services, policy revisions, comprehensive care plan updates, and enhanced incident reporting procedures.
Deficiencies (4)
Failure to properly investigate and document falls and incidents involving potential abuse, neglect, or exploitation.
Inaccurate or incomplete Minimum Data Set (MDS) assessments and care plans for residents at risk of falls.
Failure to develop and implement individualized, comprehensive care plans with measurable objectives related to fall risk and ADL needs.
Failure to maintain a safe environment and provide adequate supervision to prevent accidents.
Report Facts
Date of staffing schedule reviewed: Nov 1, 2013
Date of Quality Assurance/Performance Improvement Committee meeting: Dec 30, 2013
Date of policy approval: Nov 27, 2013
Date of staff in-service trainings: Dec 6, 2013
Audit completion date: Dec 31, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Roby | Interim Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087076 POC 70C811
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report for Avita Health and Rehab Reeds Cove.
Findings
The document indicates that the Plan of Correction is currently a Work In Progress (WIP) status, but does not provide details on specific findings or deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N087076 POC L14611
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a health facility resurvey related to a complaint investigation.
Complaint Details
This Plan of Correction is related to deficiencies cited from a complaint investigation survey.
Findings
The facility identified deficiencies related to abuse prevention, investigation and reporting of alleged violations, resident rights to choose activities and care preferences, and care plan revisions to reflect resident preferences. Corrective actions include staff in-service training, revised staffing schedules, monitoring by leadership, and ongoing Quality Assurance/Performance Improvement reviews.
Deficiencies (4)
Failure to ensure residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
Failure to report and investigate all alleged violations involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property.
Failure to ensure residents have the right to choose activities, schedules, and health care consistent with their interests and plans of care.
Failure to review and revise residents' care plans to reflect their care preferences.
Report Facts
Percentage of residents interviewed monthly: 20
Working days for investigation reporting: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Added and modified the Plan of Correction. |
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