Inspection Reports for Reed’s Cove Health and Rehabilitation LLC

A revisit survey and complaint investigation was conducted on 06/03/2025 to verify correction of all previous deficiencies cited on 04/24/2025.

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.

The visit included a complaint investigation identified as KS00195280. No new noncompliance was found.

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.

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.

The inspection was conducted as a complaint survey based on multiple complaint investigations on 04/23/2025.

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.

The visit was triggered by multiple complaint investigations (KS00194708, KS00194618, KS00194523, KS00194485, KS00194510, KS194261, KS00193368, KS00192980).

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.

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.

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.

The document addresses the findings of multiple complaint investigations related to medication administration errors at the facility.

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.

The findings represent the results of complaint investigations KS00190990, KS00191172, KS00191178, KS00191191, KS00191337, KS00191650, KS00191707, and KS00191801.

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.

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.

The inspection was an annual health survey including complaint investigations and medication administration review.

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.

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.

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.

The inspection was conducted as a health recertification survey and complaint investigation.

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.

An offsite revisit survey was conducted on 04/29/2022 for all previous deficiencies cited on 03/16/2022.

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.

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.

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.

The inspection was conducted as a complaint investigation involving multiple complaint case numbers related to the facility.

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.

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.

An offsite revisit survey was conducted on 01/18/2022 for all previous deficiencies cited on 10/19/2021.

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.

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.

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.

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.

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.

The visit included complaint investigations #165701 and #1666273 as part of the facility investigation.

An offsite revisit survey was conducted on 09/17/2021 for all previous deficiencies cited on 08/10/2021.

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.

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.

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.

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.

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.

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.

An offsite revisit was conducted on 05/17/2021 for all previous deficiencies cited on 04/05/2021.

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.

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.

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.

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.

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.

The inspection included complaint investigations related to resident rights, quality of life, quality of care, medication management, food safety, and infection control.

An off-site revisit was conducted to verify correction of all previous deficiencies cited on 01/05/21.

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.

This document is a Plan of Correction submitted by Reeds Cove Health and Rehabilitation to address deficiencies cited during a prior survey.

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.

The inspection was conducted as a complaint investigation (#153427) to evaluate allegations related to resident care and safety.

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.

The investigation was triggered by complaint #153427. The findings substantiated failures in care related to oral hygiene, accident prevention, supervision, and safe transfers.

The document is a Plan of Correction submitted in response to a COVID and complaint investigation survey conducted on 11/05/2020.

The facility was found to be deficiency free in the COVID survey conducted on 11/05/2020.

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.

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.

Complaint #KS00157407 was investigated and found to be unsubstantiated with no noncompliance identified.

This document is a Plan of Correction submitted in response to a Covid-19 survey conducted on June 4, 2020.

The facility was found to be deficiency free in the Covid-19 survey conducted on June 4, 2020.

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.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

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.

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.

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.

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.

The inspection was a health resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.

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.

An offsite revisit survey was conducted on 09/05/2018 for all previous deficiencies cited on 07/19/2018.

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.

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.

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.

The inspection was conducted as a Health Resurvey and Complaint Investigations #127925, #127216, #122296 to evaluate compliance with regulatory requirements.

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.

The visit was complaint-related as it included investigations of complaints #127925, #127216, and #122296.

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.

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.

An off-site survey was conducted to address deficiencies cited on December 8, 2017.

The deficiencies cited in the prior inspection were corrected as of the compliance date of February 14, 2018.

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.

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.

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.

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.

The inspection was conducted as a complaint investigation based on complaint investigation numbers 122232 and 123771.

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.

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.

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.

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.

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.

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.

This Plan of Correction is related to an Avita complaint dated 02/07/2017.

The inspection was conducted as a result of complaint investigations #1100126 and #1100125 regarding the facility's care related to pressure ulcers.

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.

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.

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.

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.

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.

The revisit confirmed that the deficiencies identified in the prior survey were corrected as of the revisit date.

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.

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.

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.

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.

The inspection was triggered by complaints alleging inadequate care planning and supervision related to resident falls.

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.

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.

This Plan of Correction is in response to deficiencies cited from a complaint investigation at Avita Reeds Cove dated 01/04/2017.

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.

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.

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.

All previously cited deficiencies related to various regulatory requirements were corrected as of the revisit date, with completion dates documented for each.

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.

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.

The inspection was conducted as a Health Licensure Resurvey and complaint investigations # KS00094937, KS00092819, and KS00106316.

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.

The visit included complaint investigations # KS00094937, KS00092819, and KS00106316.

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.

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.

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.

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.

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.

All previously cited deficiencies were corrected as of 06/05/2015, with corrective actions completed for each identified regulation.

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.

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.

The inspection was a Health Resurvey and Complaint Investigation covering multiple complaint investigation numbers.

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.

The inspection included a complaint investigation with multiple complaint numbers referenced in the initial comments.

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.

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.

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.

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.

This is a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report documents that all previously cited deficiencies identified by regulation numbers F0223, F0225, F0242, and F0280 were corrected by 09/05/2014.

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.

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.

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.

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.

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).

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.

All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, March 17, 2014.

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.

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.

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.

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.

The inspection was conducted as a health resurvey, non-compliance revisit, and complaint investigation #71552.

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.

Complaint investigation #71552 was part of the visit. The findings confirmed non-compliance related to electrical safety of the hydroculator.

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.

The report shows that all previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date.

The inspection was a partially-extended complaint investigation related to complaint numbers #70699 and #69671.

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.

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.

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.

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.

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.

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.

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.

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.

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.

This Plan of Correction is related to deficiencies cited from a complaint investigation survey.