Inspection Reports for
Reed’s Cove Health and Rehabilitation LLC
2114 N 127TH CT EAST, WICHITA, KS, 67206-3003
Back to Facility ProfileDeficiencies (last 14 years)
Deficiencies (over 14 years)
13.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
127% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
92% occupied
Based on a May 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 5
Date: May 7, 2026
Visit Reason
A recertification survey with complaint investigation was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Multiple complaint reference numbers were investigated.
Complaint Details
The survey included complaint investigations for multiple complaint reference numbers. Specific complaints included failure to address a grievance filed by Resident 18 regarding inadequate assistance to another resident and failure to notify Resident 18 of grievance resolution.
Findings
Deficiencies were identified related to food safety and sanitation, infection prevention and control including hand hygiene and linen transport, grievance resolution, chemical restraint use and monitoring, and feeding tube management.
Deficiencies (5)
Food safety requirements were not met as the facility failed to prepare and serve food under sanitary conditions, including unlabeled and undated food items and incomplete temperature logs.
The facility failed to ensure adequate hand hygiene during dressing change and medication administration for Resident 48 and failed to properly transport clean personal linens.
The facility failed to address and resolve a grievance for Resident 18 and failed to notify the resident of any actions or the status of the grievance.
The facility failed to obtain a 14-day stop date or a specified duration with physician rationale for an as-needed lorazepam order for Resident 66 and failed to monitor antipsychotic medication for Resident 18.
The facility failed to ensure Resident 48's feeding tube was monitored for placement prior to administration of medications and enteral nutrition.
Report Facts
Facility census: 70
Sample size: 18
PRN order duration: 14
Lorazepam dose: 0.5
Abilify dose: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in grievance resolution and medication monitoring findings |
| Licensed Nurse G | Licensed Nurse | Named in hand hygiene and feeding tube management findings |
| Licensed Nurse H | Licensed Nurse | Named in medication order and monitoring findings |
| Administrative Staff A | Administrative Staff | Named in food safety and grievance findings |
| Certified Nurse Aide M | Certified Nurse Aide | Named in linen transport findings |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
A revisit survey and complaint investigation was conducted to verify correction of all previous deficiencies cited on 2025-04-24.
Complaint Details
The visit included a complaint investigation; all previous deficiencies were corrected and no new noncompliance was found.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2025-05-02. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
A revisit survey and complaint investigation was conducted to verify correction of all previous deficiencies cited on 2025-04-24.
Complaint Details
The visit included a complaint investigation; all deficiencies from the complaint were corrected and no new issues were found.
Findings
All previously cited deficiencies have been corrected as of 2025-05-02, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified related to pressure ulcer prevention and treatment.
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)
F 686 Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to prevent the development of facility-acquired pressure ulcers as identified by observation, interview, and record review.
Report Facts
Plan of Correction completion date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Twyss Tamaraw | Submitted and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Apr 23, 2025
Visit Reason
Complaint investigations were conducted on multiple complaint cases during a complaint survey on 04/23/2025.
Complaint Details
The survey was conducted based on multiple complaint investigations (KS00194708, KS00194618, KS00194523, KS00194485, KS00194510, KS194261, KS00193368, and KS00192980).
Findings
The facility failed to prevent the development of facility-acquired pressure ulcers on Resident 1 due to inadequate wound monitoring, delayed implementation of repositioning and pressure-relieving interventions, and lack of timely nutritional support. The resident developed Stage 3 pressure injuries and was hospitalized for possible sepsis secondary to wound infection.
Deficiencies (1)
F686: The facility failed to prevent pressure ulcers and provide necessary treatment, resulting in a facility-acquired Stage 3 pressure injury on Resident 1's buttocks. Wound assessments, measurements, and treatments were inconsistently documented and implemented, and repositioning and nutritional interventions were delayed.
Report Facts
Resident census: 66
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 temperature: 102.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant H | Physician Assistant | Reported assessing Resident 1's wounds near the end of stay and expected weekly wound documentation. |
| Administrative Nurse C | Administrative Nurse | Reported gaps in wound assessments and training; responsible for wound measurements. |
| Administrative Nurse D | Administrative Nurse | Reported staff reporting skin concerns and wound measurement expectations. |
| Administrative Nurse B | Administrative Nurse | Reviewed skin data collection tools and expected communication and wound measurement. |
| Licensed Nurse E | Licensed Nurse | Reported nurse responsibilities for skin assessments and wound documentation. |
| CNA F | Certified Nurse Aide | Reported notifying nurses of new skin issues and treatment implementation. |
| CNA G | Certified Nurse Aide | Reported documentation of turn and reposition schedules in EHR. |
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, KS00191801) focusing on medication errors and resident safety.
Complaint Details
The visit was triggered by multiple complaints alleging medication errors. The medication error was substantiated, and the facility was found to have placed the resident in immediate jeopardy on 10/11/24 at 09:00 AM due to the medication administration error.
Findings
The facility failed to prevent a significant medication error where a cognitively impaired resident (R1) was administered another resident's (R2) medications orally despite having a jejunostomy tube and being NPO. The error placed the resident in immediate jeopardy, but corrective actions were implemented prior to the survey.
Deficiencies (1)
F760: The facility failed to prevent a significant medication error when CMA R administered R2's medications orally to R1, who had a jejunostomy tube and was NPO. This error placed R1 at risk for aspiration pneumonia and other complications.
Report Facts
Census: 29
Medication error date: Oct 11, 2024
Vital signs monitoring duration: 72
Antibiotic treatment duration: 10
Number of residents reviewed for medications: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Reported and assessed the medication error, educated CMA R, and notified the physician |
| CMA R | Certified Medication Aide | Administered the wrong medications to resident R1 |
| Administrative Staff A | Reported the medication error and facility expectations | |
| Consultant GG | Ordered chest x-ray and vital signs monitoring after medication error |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 15, 2024
Visit Reason
The document addresses findings from a complaint investigation involving multiple complaint IDs related to medication administration errors.
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) 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)
F760-J: Immediate jeopardy was determined on 2024-10-11 when a CMA incorrectly administered medications orally to an NPO resident. Corrective actions included removal of the CMA, staff education, and competency checks completed before the onsite survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 8, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-08-19.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2024-09-16. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 19
Date: Aug 19, 2024
Visit Reason
Complaint investigation and health survey conducted due to multiple complaints and concerns regarding resident care, medication administration, infection control, and facility safety.
Complaint Details
The investigation was triggered by multiple complaints regarding resident care, medication errors, infection control, and facility safety. The licensed nurse from an agency was found to have failed to administer medications as ordered and failed to document treatments and assessments, resulting in multiple medication errors and incomplete medical records.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, care planning, medication administration, infection control, food safety, environmental safety, and medical record documentation. Significant medication errors were identified, improper infection control practices during medication administration, unsafe storage of medications in resident rooms, and failure to maintain a secure environment free of hazards.
Deficiencies (19)
F550 Resident Rights: Facility staff labeled residents dependent on feeding assistance as "feeders," violating resident dignity and privacy.
F553 Right to Participate in Planning Care: Resident 21 was not included in care plan meetings, risking impaired care and uncommunicated needs.
F578 Request/Refuse Treatment; Advance Directives: Facility failed to verify Resident 8's advanced directives and improperly accepted guardian consent for Resident 3's DNR order.
F625 Notice of Bed Hold Policy: Facility failed to provide written bed-hold notices to residents and/or representatives at time of hospital transfer, risking loss of bed reservation.
F655 Baseline Care Plan: Facility failed to develop a complete baseline care plan for Resident 153 within 48 hours of admission.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to develop a comprehensive care plan for Resident 30 regarding oxygen and nebulized medication use.
F657 Care Plan Timing and Revision: Facility failed to revise care plans for Residents 22 and 9 after falls, risking uncommunicated care needs.
F658 Services Provided Meet Professional Standards: Medication administration to Resident 6 was unsanitary and error-prone, including administering pills dropped on floor and cart.
F677 ADL Care Provided for Dependent Residents: Facility failed to provide facial hair removal and adequate oral care for Residents 19 and 40, risking psychosocial harm.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: Facility failed to use proper infection control during wound care for Resident 103 with pressure ulcer.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to secure maintenance shop door with hazardous chemicals and failed to maintain functional alarm on exit door; also failed to remove tripping hazard cord in Resident 9's room.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to keep urinary catheter collection bag below bladder level for Resident 103, risking urinary tract infection.
F695 Respiratory/Tracheostomy Care and Suctioning: Facility failed to properly clean and store nebulizer for Resident 30 and failed to obtain physician order for oxygen administration and replace contaminated cannula for Resident 1.
F755 Pharmacy Services/Procedures/Pharmacist/Records: Licensed Nurse I failed to administer medications as ordered to 15 of 20 residents during 07/21/24-07/22/24 shift, resulting in multiple medication errors and documentation failures.
F759 Free of Medication Error Rates 5 Percent or More: Resident 6 had 12 medication errors out of 25 opportunities during observed medication pass, resulting in a 48% error rate.
F761 Label/Store Drugs and Biologicals: Facility failed to properly store medications in resident rooms for Residents 8, 22, and 153 and failed to complete self-administration assessments.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to store, prepare, and serve food under sanitary conditions in multiple kitchen and storage areas, risking food-borne illness.
F842 Resident Records - Identifiable Information: Facility failed to maintain complete, accurate, and accessible medical records for seven residents due to medication and treatment documentation omissions by Licensed Nurse I.
F880 Infection Prevention & Control: Facility failed to maintain infection control during medication administration to Resident 6, including failure to perform hand hygiene and use gloves, risking infection transmission.
Report Facts
Resident census: 57
Residents sampled: 17
Medication opportunities observed: 25
Medication errors observed: 12
Medication error rate: 48
Residents with medication errors: 15
Residents with improper medication storage: 3
Residents with incomplete medical records: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN I | Licensed Nurse | Failed to administer medications as ordered and document treatments during 07/21/24-07/22/24 shift |
| CMA II | Certified Medication Aide | Administered medications unsanitarily to Resident 6, including picking up pills dropped on floor |
| Administrative Nurse D | Administrative Nurse | Confirmed medication and infection control deficiencies and expectations |
| Licensed Nurse K | Licensed Nurse | Reported medication errors and attempted to give report to LN I |
| Certified Nurse Aide AA | Certified Nurse Aide | Reported lack of knowledge about medication storage in resident rooms and oral care |
| Therapy Director T | Therapy Director | Reported therapy communication forms not updated in care plans |
| Maintenance Staff O | Maintenance Staff | Reported maintenance door alarm non-functional and chemicals unsecured |
| Dietary Staff EE | Dietary Staff | Observed food storage and sanitation deficiencies in kitchen |
| Administrative Staff CC | Administrative Staff | Responsible for bed hold process and verbal consents |
| Administrative Staff L | Administrative Staff | Reported background check on agency nurse and no red flags found |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 21, 2023
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 11/30/22.
Findings
All deficiencies have been corrected as of the compliance date of 1/1/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 16
Date: Nov 30, 2022
Visit Reason
The inspection was a health recertification survey and complaint investigation.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, failure to notify resident representatives of changes, inconsistent bathing care, inadequate wound care and pressure ulcer prevention, unsafe storage of oxygen tanks, improper transfer techniques, inadequate bowel and bladder management, medication management issues including failure to respond timely to pharmacist recommendations, improper medication storage, food safety violations, and infection control breaches.
Deficiencies (16)
F 558 Reasonable Accommodations Needs/Preferences: The facility failed to ensure foot pedals were available and utilized for Resident 11's wheelchair to prevent her feet from dragging on the floor while staff propelled her, placing her at risk for preventable injuries.
F 580 Notify of Changes (Injury/Decline/Room, etc.): The facility failed to notify Resident 43's representative of a significant change in condition, placing the resident at risk for delayed treatment decisions and decreased psychosocial well-being.
F 677 ADL Care Provided for Dependent Residents: The facility failed to provide consistent bathing opportunities for Resident 196, placing her at risk for preventable infections and decreased psychosocial well-being.
F 684 Quality of Care: The facility failed to ensure physician's orders were in place for Resident 197's wound-vac care, placing him at risk for complications related to ineffective wound care.
F 686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: The facility failed to prevent redevelopment of a pressure injury for Resident 33 and failed to ensure pressure reducing measures were in place for Resident 9, placing both at increased risk of pressure related injuries.
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to secure 21 pressurized oxygen tanks in a locked area and failed to use a gait belt for safe transfers for Resident 6, placing residents at risk for preventable accidents and injuries.
F 690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to implement an individualized bowel and bladder toileting program for Resident 196 and failed to provide sanitary Foley catheter care for Resident 197, placing them at risk for urinary tract infections.
F 695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure Resident 12's supplemental oxygen tubing was stored appropriately when not in use, placing the resident at risk for respiratory complications and infection.
F 727 RN 8 Hrs/7 days/Wk, Full Time DON: The facility failed to provide Registered Nurse coverage for eight consecutive hours a day, seven days a week, placing residents at risk of lack of assessment and inappropriate care.
F 732 Posted Nurse Staffing Information: The facility failed to retain daily posted nursing staffing data for the required 18 months.
F 755 Pharmacy Srvcs/Procedures/Pharmacist/Records: The facility failed to properly store and secure medications on two of three nursing units, placing residents at risk for unnecessary medication administration.
F 756 Drug Regimen Review, Report Irregular, Act On: The facility failed to ensure timely physician response to Consultant Pharmacist recommendations for prescribed PRN Ativan lacking a 14-day stop date for Residents 2, 10, and 32, and failed to ensure nursing staff administered Resident 12's metoprolol within ordered parameters, placing residents at risk for unnecessary medication administration and adverse side effects.
F 757 Drug Regimen is Free from Unnecessary Drugs: The facility failed to ensure nursing staff administered Resident 12's antihypertensive medication metoprolol within physician ordered parameters, placing the resident at risk for unnecessary medication administration and possible adverse side effects.
F 758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to ensure a 14-day stop date or appropriate rationale for continued use and duration for PRN Ativan for Residents 2, 10, and 32, placing them at risk for unnecessary medication administration and possible adverse side effects.
F 812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to store, prepare, and serve food under sanitary conditions including failure to label opened foods with dates, improper food storage temperatures, uncovered thawing foods, and inadequate air gaps in drains, placing residents at risk for food-borne illness.
F 880 Infection Prevention & Control: The facility failed to practice proper hand hygiene, failed to keep a urinary catheter bag off the floor, failed to ensure sanitary storage of oxygen tubing, and failed to ensure face masks covered nose and mouth, placing residents at risk for increased infection and transmission of communicable disease.
Report Facts
Deficiencies cited: 21
Deficiencies cited: 90
Deficiencies cited: 63
Deficiencies cited: 6
Deficiencies cited: 3
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple interviews regarding oxygen storage, catheter care, medication management, and infection control |
| Licensed Nurse I | Licensed Nurse | Provided multiple interviews regarding oxygen tubing storage, medication administration, and pharmacist recommendations |
| Certified Nurse Aide P | Certified Nurse Aide | Interviewed regarding foot pedal use, pressure ulcer care, wheelchair cushion use, and reporting skin issues |
| Licensed Nurse O | Licensed Nurse | Observed providing wound care and catheter care for Resident 197 |
| Licensed Nurse H | Licensed Nurse | Interviewed regarding oxygen tank storage and medication cart security |
| Certified Nurse Aide M | Certified Nurse Aide | Observed transferring Resident 6 without gait belt and interviewed about transfer practices |
| Dietary Staff BB | Dietary Staff | Interviewed regarding food storage and sanitation practices |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 29, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-03-16.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2022-03-21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 16, 2022
Visit Reason
This document is a Plan of Correction submitted by Reeds Cove Health & Rehabilitation in response to deficiencies cited in a prior inspection related to air mattress settings and resident safety.
Findings
The facility identified a deficient practice 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, and ongoing monitoring through audits and reviews.
Deficiencies (1)
F689 - The facility failed to ensure air mattress settings were appropriate for residents' weight, posing a risk for falls. Staff were trained on proper air mattress use and settings, and audits confirmed compliance for all residents using air mattresses.
Report Facts
Number of residents using air mattresses: 7
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Mar 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint cases identified by their investigation numbers.
Complaint Details
The findings represent the results of complaint investigation #KS00167025, KS00167630, KS00168056, KS00168207, KS00168764, KS00168735, KS00169129, KS00169816, and KS00170222.
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, contributing to an unwitnessed fall and injury.
Deficiencies (1)
F 689: The facility failed to ensure appropriate air mattress settings for Resident 3, whose mattress was set for 400 lbs while the resident weighed 191 lbs, causing over inflation and contributing to a fall with injury.
Report Facts
Resident census: 57
Resident weight: 191
Air mattress setting weight: 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Responded to Resident 3's fall and provided witness statement. |
| LN H | Licensed Nurse | Documented emergency transport of Resident 3 after fall. |
| PA GG | Physician Assistant | Notified about Resident 3's injury. |
| 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 to verify correction of all previous deficiencies cited on 2021-10-19.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2021-10-25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 25, 2021
Visit Reason
This document is a Plan of Correction submitted by Reeds Cove Health & Rehabilitation in response to deficiencies cited in a prior inspection report dated 10/18/21.
Findings
The Plan of Correction addresses staff non-compliance with proper mask-wearing protocols. The facility implemented staff education, daily audits, and ongoing monitoring to ensure compliance and prevent recurrence.
Deficiencies (1)
F880-E: Staff were not properly wearing masks as required, posing a potential risk to all residents facility-wide. Corrective actions include staff education, daily compliance audits, and ongoing monitoring through QAPI.
Report Facts
Audit duration: 30
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, which also included complaint investigations #165701 and #1666273.
Complaint Details
The visit included complaint investigations #165701 and #1666273 as part of the targeted infection control survey.
Findings
The facility failed to ensure that all staff wore masks appropriately in resident care areas on two of three nursing units, increasing the risk of COVID-19 transmission to vulnerable residents. Multiple staff members were observed with masks pulled down or removed in resident care areas, contrary to facility policy and CDC/CMS guidance.
Deficiencies (1)
F 880 Infection Prevention & Control: The facility failed to ensure all staff had masks appropriately in place while in resident care areas on two nursing units, increasing the risk of COVID-19 transmission.
Report Facts
Resident census: 75
Residents in First and Second Nursing Units: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant Staff GG | Observed with mask pulled down under chin in dining room | |
| Certified Medication Aide R | Observed with mask pulled down under chin in dining room | |
| Licensed Nurse G | Licensed Nurse | Observed with mask below nose and later removed mask in dining room |
| Dietary Staff BB | Observed with mask pulled down under chin in kitchenette | |
| Dietary Staff CC | Observed with mask pulled down under chin in kitchenette | |
| Administrative Staff A | Interviewed regarding mask policy and expectations |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 17, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of 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.
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 nebulizer therapy care.
Findings
The facility identified deficiencies in the care and management of oxygen and aerosol therapy supplies and care plans. Corrective actions include audits, staff education, replacement of supplies, and ongoing monitoring to ensure compliance.
Deficiencies (1)
F695D: Deficient practice related to oxygen and aerosol therapy supplies and care plans was identified. Audits and staff education were implemented to ensure proper care and replacement of supplies.
Report Facts
Audit frequency: 2
Audit duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Performed staff education and audits related to oxygen therapy care |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Date: Aug 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation (complaint investigation 164224) including a Targeted Infection Control Survey/COVID-19 Focused Survey and a COVID-19 Focused Emergency Preparedness Survey.
Complaint Details
The complaint investigation 164224 triggered the survey. The facility was found compliant with COVID-19 related practices but deficient in respiratory care for three residents.
Findings
The facility failed to provide necessary respiratory care for three residents related to undated or improperly maintained oxygen cannula tubing, oxygen humidifier bottles, nebulizer masks, tubing, and storage containers. The facility did not ensure weekly changing and documentation of these respiratory care supplies as required by their policy.
Deficiencies (3)
F 695 Respiratory care: The facility failed to ensure weekly changing and documentation of oxygen cannula tubing and humidifier bottles for Resident 4, risking respiratory infection.
F 695 The facility failed to ensure nebulizer mask, tubing, and storage container were dated and documented weekly for Resident 5, lacking care plan guidance and risking respiratory infection.
F 695 The facility failed to ensure nebulizer masks and tubing were dated and documented weekly for Resident 6, with absent care plan guidance and documentation, risking respiratory infection.
Report Facts
Resident census: 40
Residents sampled: 5
Nebulizer medication dosage: 3
Oxygen liters: 10
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 17, 2021
Visit Reason
An offsite revisit was conducted to verify correction of 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 to address deficiencies cited during a prior survey and to ensure compliance with state and federal regulations.
Findings
The facility identified multiple deficiencies related to resident care including dining assistance, wheelchair positioning, bathing schedules, medication storage, and adherence to physician orders. Staff education and ongoing audits were implemented to correct these issues.
Deficiencies (12)
F550: Residents needing assistance in dining were not consistently brought to the dining room or assisted in a timely manner. Staff were educated and audits scheduled to ensure dignified dining experiences.
F675: Residents with trunk control issues were not consistently assessed or treated for proper wheelchair positioning. Therapy evaluations and staff education were implemented with audits planned.
F676: Residents were not always offered showers according to their preferred schedule. Staff education and audits were initiated to ensure adherence to shower schedules.
F677: Dependent residents were not consistently bathed according to schedule. Education and audits were planned to improve compliance.
F684: Residents had assessments and treatments for proper wheelchair positioning, with interventions to prevent falls. Staff were educated and audits scheduled.
F689: Chemicals and medications were not always stored securely, risking access by confused residents. Staff education and audits were implemented to ensure proper storage.
F757: Staff did not consistently follow physician standing orders for diabetic residents. Education and audits were conducted to ensure physician notifications.
F761: Insulin pens were not always dated when opened. Staff education and audits were implemented to monitor compliance.
F804: Residents eating slowly were not consistently offered warmed food after 30 minutes. Staff were educated and audits planned.
F810: Adaptive utensils were not always provided as per care plans. Staff education and audits were conducted to ensure availability.
F812: Staff were not consistently following proper meal serving protocols including covering food and using tongs. Education and audits were implemented.
F880: Staff were not consistently practicing hand hygiene, glove changes, and proper glucometer cleaning. Education and audits were conducted to improve infection control.
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 12
Date: Apr 5, 2021
Visit Reason
Health Resurvey and Complaint Investigations to assess compliance with resident rights, quality of life, activities of daily living, quality of care, medication management, food service, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meals, inadequate wheelchair positioning and bathing care, improper medication management, unsafe food handling, and infection control practices.
Deficiencies (12)
F550 Resident Rights. The facility failed to maintain dignity when staff served other residents meals in full view of Resident 37 before serving her meal, delaying her meal by up to 66 minutes.
F675 Quality of Life. The facility failed to provide necessary assessments and care to maintain appropriate wheelchair positioning for Resident 24, placing him at risk for weight loss.
F676 Activities of Daily Living. The facility failed to provide routine bathing and personal hygiene care for five sampled residents, including Residents 4, 17, 19, 24, and 92, placing them at risk for poor hygiene.
F677 ADL Care Provided. The facility failed to provide routine bathing services for Resident 16 as scheduled, placing the resident at risk for poor hygiene.
F684 Quality of Care. The facility failed to provide necessary assessments, treatments, and care to maintain appropriate wheelchair positioning for Residents 24 and 19, and failed to follow medication administration policies for Resident 30.
F689 Free of Accident Hazards. The facility failed to secure medications prepared in advance and failed to store hazardous chemicals in locked areas, placing cognitively impaired residents at risk for accidents and chemical injuries.
F757 Drug Regimen. The facility failed to adequately monitor and respond to blood glucose levels outside physician ordered parameters for Residents 4 and 28, placing them at risk for complications.
F761 Label/Store Drugs. The facility failed to label insulin pens with the date opened for Residents 36, 20, and 28, risking use of ineffective medications.
F804 Nutritive Value. The facility failed to provide palatable, attractive food at an appetizing temperature for Resident 24, placing the resident at risk for weight loss.
F810 Assistive Devices. The facility failed to provide built-up utensils to maintain Resident 24's ability to eat independently.
F812 Food Procurement and Handling. The facility failed to maintain sanitary food handling practices including failure to cover food and drinks during transport and failure to change gloves and wash hands during food preparation.
F880 Infection Prevention and Control. The facility failed to perform proper hand hygiene during incontinence care for Resident 30, failed to disinfect blood glucose meters with approved disinfectants between residents, and failed to store oxygen tubing in a sanitary manner for Resident 4.
Report Facts
Resident census: 47
Blood sugar readings above 300 mg/dl: 21
Days without scheduled bathing: 18
Days without scheduled bathing: 16
Days without scheduled bathing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in findings for failure to provide timely meal to Resident 37 and improper hand hygiene during incontinence care for Resident 30 |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding facility policies and deficiencies in multiple areas including dignity, bathing, medication administration, infection control |
| Therapy Staff GG | Therapy Staff | Assessed wheelchair positioning for Resident 24 and communicated need for positioning devices |
| CMA S | Certified Medication Aide | Named in findings for improper application of discontinued medicated powder and glucometer disinfection |
| LN H | Licensed Nurse | Named in findings for wheelchair positioning and medication administration |
| LN G | Licensed Nurse | Named in findings for blood glucose monitoring and insulin pen labeling |
| Dietary Staff CC | Dietary Staff | Named in findings for food temperature and food handling violations |
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 2021-01-05.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2021-01-19. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
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.
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)
F677-D: Staff were re-educated on hygiene and oral care policies after deficiencies were found. Resident #5 received oral care and shaving with oversight by the Unit Manager.
F689-D: Neurological checks were initiated for Resident #6 and transfer evaluations conducted for Resident #5. Staff were re-educated on fall prevention and proper transfers.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 2
Date: Jan 5, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#153427) regarding concerns about care and safety at the facility.
Complaint Details
The complaint investigation #153427 focused on care deficiencies including oral hygiene, accident prevention, and safe transfers. The findings substantiated failures in these areas.
Findings
The facility failed to provide timely oral care, appropriate hygiene including shaving, adequate supervision to prevent accidents, and safe transfer techniques for dependent residents. There were failures in monitoring after falls and implementing immediate interventions to prevent further incidents.
Deficiencies (2)
F 677: The facility failed to ensure timely oral care, bathing, and shaving for a dependent resident with severe cognitive impairment requiring extensive assistance.
F 689: The facility failed to provide adequate supervision and assistance to prevent accidents for three residents, including failure to monitor neurological status after a fall, implement fall interventions promptly, and provide safe transfers.
Report Facts
Resident 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 oral care and shaving deficiencies |
| CNA N | Certified Nurse Aide | Named in oral care and shaving deficiencies and transfer issues |
| CNA O | Certified Nurse Aide | Named in transfer deficiencies |
| CNA P | Certified Nurse Aide | Named in oral care deficiency |
| Licensed Nurse H | Licensed Nurse | Named in oral care, shaving, and transfer deficiencies |
| Licensed Nurse G | Licensed Nurse | Named in failure to perform neurological assessments after fall |
| Licensed Nurse J | Licensed Nurse | Named in failure to perform neurological assessments after fall |
| Administrative Nurse D | Administrative Nurse | Named in oral care, shaving, transfer, and fall intervention deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 5, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a COVID and complaint investigation survey conducted on 11/05/2020.
Findings
The survey was deficiency free regarding COVID compliance.
Deficiencies (1)
F0000 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 on the same date.
Complaint Details
Complaint #KS00157407 was investigated and found to be unsubstantiated with no deficiencies cited.
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)
F0000 Deficiency Free Covid-19 Survey conducted on 06/04/2020.
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 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 identified deficiencies at Avita Health and Rehab at Reeds Cove were corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies related to regulations 483.21(a)(1)-(3), 483.21(c)(2)(i)-(iv), 483.25, 483.25(e)(1)-(3), and 483.80(a)(1)(2)(4)(e)(f) were corrected as of 05/10/2019.
Deficiencies (5)
Regulation 483.21(a)(1)-(3) deficiency was corrected by 05/10/2019.
Regulation 483.21(c)(2)(i)-(iv) deficiency was corrected by 05/10/2019.
Regulation 483.25 deficiency was corrected by 05/10/2019.
Regulation 483.25(e)(1)-(3) deficiency was corrected by 05/10/2019.
Regulation 483.80(a)(1)(2)(4)(e)(f) deficiency was corrected by 05/10/2019.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: May 10, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey and to ensure future 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 practices. Corrective actions include staff in-services, audits, policy development, and ongoing monitoring by leadership.
Deficiencies (5)
F655-D: The facility failed to develop baseline care plans within 24 hours of admission. Corrective actions include staff training and monthly audits to ensure compliance.
F661-D: The facility did not complete discharge summaries including diagnosis, vital signs, and medication for discharged residents. A policy was developed and staff were trained to ensure completion.
F684-D: Dressing changes were not performed in a sanitary manner. The facility conducted audits, staff training, and implemented ongoing monitoring to prevent infection spread.
F690-D: Sanitary catheter care was inadequate, risking catheter contamination. Interventions and staff training were implemented with daily compliance monitoring.
F880-D: The infection control program was insufficient, including hand hygiene between medication routes and care from soiled to clean areas. Staff were trained and ongoing monitoring established.
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
This was a health resurvey inspection to evaluate compliance with previously cited deficiencies and overall care quality at Avita Health and Rehab at Reeds Cove.
Findings
The facility failed to complete baseline care plans within 48 hours of admission, failed to complete discharge summaries, did not provide sanitary wound care, failed to ensure proper wheelchair positioning, did not maintain sanitary catheter care, and failed to maintain effective infection control practices including proper hand hygiene.
Deficiencies (5)
F655: The facility failed to complete a baseline care plan within 48 hours of admission for resident #105, delaying care planning and communication of care needs.
F661: The facility failed to complete a discharge summary for resident #51, omitting functional status, medical status, and medication reconciliation.
F684: The facility failed to provide sanitary wound dressing changes for resident #100 and failed to provide proper wheelchair footrest positioning for resident #28.
F690: The facility failed to ensure sanitary catheter care for resident #34, with the catheter bag placed on the floor risking infection.
F880: The facility failed to maintain effective infection control, including failure to perform hand hygiene between medication administrations for resident #4 and between soiled to clean care for resident #17.
Report Facts
Census: 58
Residents selected for review: 17
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 5, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-07-19.
Findings
All deficiencies have been corrected as of the compliance date of 2018-08-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Aug 10, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility to address and correct deficiencies identified in a prior inspection report dated 07/19/2018.
Findings
The facility outlines corrective actions for multiple deficiencies including care plan updates for diabetic residents, staff in-service training, medication administration improvements, sanitizing procedures in kitchens, and infection control measures. Ongoing monitoring and audits are planned to ensure compliance.
Deficiencies (7)
F657-D: The facility corrected the care plan for resident #5 regarding blood sugar parameters and audited all diabetic residents' care plans. Nursing staff received in-service training on diabetic care plan updates.
F730-F: The facility ensured all Certified Nursing Assistants and Certified Medication Assistants receive a minimum of 12 hours of in-service education annually, using a sister facility's education program for compliance.
F756-D: The facility ensured Promethazine and Zofran are administered as ordered and prevented duplicate anti-nausea medications for resident #5. Nursing staff were in-serviced on proper medication timing.
F757-D: The facility ensured proper administration of anti-nausea medications and monitored for duplicates, with ongoing staff education and pharmacist oversight.
F758-D: The facility ensured all residents on antipsychotic medications have Abnormal Involuntary Movement Scale (AIMS) assessments at least every 3 months, with audits and new policy implementation.
F812-F: The facility ensured sanitizing solutions in kitchens are effective, replaced worn kitchen equipment, and conducted staff in-service on sanitizing procedures and food preparation monitoring.
F880-F: The facility maintained an effective infection control program, including wound monitoring, cleaning of wheelchairs, proper linen transport, and staff in-service on infection control practices.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 19, 2018
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 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 reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-08-10.
Deficiencies (1)
The facility had a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm without immediate jeopardy.
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 7
Date: Jul 19, 2018
Visit Reason
The inspection was a Health Resurvey and Complaint Investigations related to regulatory compliance and quality of care at the facility.
Complaint Details
The inspection included complaint investigations #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 training documentation, failure to prevent duplicate antinausea medication administration, lack of psychotropic medication assessments, improper food safety practices, and ineffective infection prevention and control procedures.
Deficiencies (7)
Care Plan Timing and Revision: The facility failed to review and revise the care plan for a resident regarding updated blood sugar parameters.
Nurse Aide Performance Review: The facility failed to ensure certified direct care staff received 12 hours of in-service education per year with proper documentation.
Drug Regimen Review: The consulting pharmacist failed to identify and act on duplicate antinausea medications for two residents, risking adverse drug interactions.
Drug Regimen Free from Unnecessary Drugs: The facility failed to ensure two residents remained free of duplicate antinausea medication.
Psychotropic Medication Use: The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident on antipsychotic medication.
Food Safety: The facility failed to maintain effective sanitizing solution levels in one kitchen and had multiple cutting boards with deep scratches limiting proper sanitization.
Infection Prevention and Control: The facility failed to properly handle soiled and clean linens during transport, store soiled equipment correctly, and maintain hand hygiene during dressing changes, risking infection spread.
Report Facts
Census: 53
Residents sampled: 14
Certified employees reviewed: 5
Residents reviewed for unnecessary medications: 5
Cutting boards with deep scratches: 12
Antipsychotic medication days: 6
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, with corrections completed by February 14, 2018.
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 by the facility in response to deficiencies cited in a prior complaint investigation.
Findings
The facility had deficiencies related to timely revision of care plans, failure to monitor bed alarm functions, and failure to use gait belts for certain residents. The facility implemented corrective actions including policy updates, staff education, audits, and monitoring to address these issues.
Deficiencies (3)
F657-D: The facility failed to ensure timely care plan revisions for residents #102 and #108. Staff were educated on updating care plans and reviewing them at daily clinical meetings.
F689-D: The facility failed to monitor the function of the bed alarm for resident #108. A nurse order was added to check and monitor alarms with ongoing documentation and staff education.
F689-D: The facility failed to use gait belts for residents #102 and #107. Gait belts were made available, added to care plans, and staff were educated on protocol compliance.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Date: Dec 8, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of failure to update care plans and ensure resident safety during transfers and use of assistive devices.
Complaint Details
The complaint investigation #122232 and #123771 focused on allegations that the facility failed to update care plans and ensure proper use of assistive devices to prevent falls. The investigation substantiated these issues.
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 staff used gait belts during transfers, resulting in falls and injuries, and failed to monitor the function of bed alarms, contributing to resident falls.
Deficiencies (2)
Care Plan Timing and Revision: The facility failed to timely update care plans for residents #102 and #108 to include gait belt usage and monitoring of bed alarm function after falls.
Free of Accident Hazards/Supervision/Devices: The facility failed to ensure staff used gait belts during transfers for residents #102, #107, and #108, resulting in falls and injuries including fractures. The facility also failed to monitor bed alarm function, contributing to a fall with major injury.
Report Facts
Resident census: 48
Residents selected for sample review: 5
Fall risk assessment scores: 5
Fall risk assessment scores: 9
Fall risk assessment scores: 8
Fall risk assessment scores: 10
Fractures: 3
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 8, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility complies 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 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)
The facility had a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 14, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected as noted on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously cited deficiency under regulation 483.25(b)(1) was corrected by the revisit date of 2017-02-14. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(b)(1) deficiency was corrected as of 2017-02-14.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 14, 2017
Visit Reason
This document is a Plan of Correction submitted 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 an Avita complaint investigation 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 and weekly wound assessments were replaced by weekly skin assessments for ongoing monitoring.
Deficiencies (2)
F0000: The facility implemented a system to assure correction and continued compliance with regulations following deficiencies cited in the health facility resurvey.
F314-D: Resident #3's record was updated to clarify the wound was healed and weekly wound assessments were replaced by weekly skin assessments for continued monitoring of skin integrity.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance and involved in submission. | |
| Irina Strakhova | Modified the Plan of Correction document. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 7, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency related to pressure ulcers, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible evidence of correction.
Deficiencies (1)
F314 Pressure Ulcers: The facility was noncompliant with requirements to prevent avoidable pressure ulcers and to provide appropriate care to prevent worsening of existing ulcers.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory of the report letter. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Feb 7, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to pressure ulcer care and treatment at the facility.
Complaint Details
The findings represent the results of complaint investigations #1100126 and #1100125 regarding pressure ulcer care.
Findings
The facility failed to ensure timely and adequate skin assessments for a resident with pressure ulcers, resulting in inadequate monitoring and treatment of wounds. Documentation gaps and failure to complete weekly wound assessments were noted, along with staff unawareness of the resident's current open wounds.
Deficiencies (1)
483.25(b)(1) The facility failed to provide timely and adequate skin assessments and treatment for a resident with pressure ulcers, resulting in inadequate monitoring and delayed wound healing.
Report Facts
Resident census: 71
Residents reviewed for pressure ulcers: 4
Residents in sample: 5
Braden Risk Assessment score: 16
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 3, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously reported deficiencies identified on the CMS-2567 have been corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
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.
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. The facility also implemented a weekly Interdisciplinary Fall Reduction Committee and inserviced staff on care plan access and accident response.
Deficiencies (3)
F0000: The facility has developed and implemented a system to assure correction and continued compliance with regulations following the health facility resurvey findings. This plan does not constitute an admission of the alleged deficiencies.
F280-E: The facility will continue to review and revise resident care plans to include preventative interventions for residents identified at risk of falls. Staff will be inserviced on accessing and following care plans, and a weekly Fall Reduction Committee will monitor interventions.
F323-E: The facility will ensure residents receive adequate supervision and assistive devices to prevent avoidable accidents. Accident investigations will identify root causes and interventions will be reviewed and revised as necessary, with oversight by the Director of Nursing.
Report Facts
Complete Date: Feb 3, 2017
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Date: Jan 4, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint investigations numbered 108969, 108984, 109841, and 109829.
Complaint Details
The inspection findings are based on complaint investigations #108969, 108984, 109841, and 109829. The complaints involved failure to update care plans and prevent repeated falls among residents.
Findings
The facility failed to review and revise care plans for 5 of 6 sampled residents to include preventative interventions for repeated falls. The facility also failed to ensure adequate supervision and assistive devices to prevent repeated falls and did not conduct thorough root cause analyses following falls.
Deficiencies (2)
F 280: The facility failed to review and revise plans of care for 5 sampled residents to include fall prevention interventions after repeated falls.
F 323: The facility failed to ensure adequate supervision and assistive devices to prevent repeated falls for 5 sampled residents and failed to conduct thorough fall investigations with root cause analyses.
Report Facts
Resident census: 73
Fall risk assessment scores: 12
Fall risk assessment scores: 15
Fall risk assessment scores: 14
Fall risk assessment scores: 18
Fall risk assessment scores: 18
Fall risk assessment scores: 17
Fall risk assessment scores: 5
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 deficiencies to be an "E" level deficiency 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, resulting in a finding of substantial compliance effective February 3, 2017.
Deficiencies (1)
The facility had an "E" level deficiency indicating 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 contact and signatory related to the survey findings and 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.
Findings
The facility was found deficient in multiple areas including resident dignity during meal assistance, honoring resident choice for bathing frequency, staffing sufficiency and posting, food storage sanitation, accurate pharmaceutical services, medication labeling and expiration, and call light system pager usage. The Plan of Correction outlines corrective actions and ongoing monitoring to ensure compliance.
Deficiencies (8)
F241-D: The facility failed to provide meal assistance in a manner that maintains or enhances resident dignity. Nursing staff will be in-serviced to provide individualized and dignified meal assistance.
F242-D: The facility failed to honor each resident's right to make choices about significant aspects of their lives, including bathing frequency. Staff will be trained to respect resident preferences and offer alternate bathing opportunities.
F353-F: The facility failed to ensure sufficient staff were available to meet resident needs. Staffing schedules and assignments will be reviewed and adjusted based on resident acuity.
F356-B: The facility failed to post correct daily staffing information for residents and the public. The Director of Nursing will monitor staff posting sheets regularly.
F371-F: The facility failed to store food under sanitary conditions. Dietary staff will be educated on proper food storage and refrigerator temperature monitoring.
F425-D: The facility failed to ensure accurate administration of pharmaceutical services. Licensed staff will be in-serviced on accurate order entry and order clarification.
F431-E: The facility failed to properly label medications with the date opened and discard expired medications and dressings. Staff will be trained on medication labeling and expiration procedures.
S1164-F: The facility failed to ensure staff wore pagers designated for the call light system. Nursing staff will be in-serviced on pager usage and functionality reporting.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 18, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
All previously reported deficiencies listed on the CMS-2567 were corrected as of the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 18, 2016
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) deficiency was corrected by the revisit date of 11/18/2016.
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 in 3 of 4 houses. Staff interviews and observations confirmed that pagers were not consistently carried or functional, compromising the call system.
Deficiencies (1)
26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) Nursing facility support system. The facility failed to ensure staff wore and used portable electronic devices that produced audible or visual signals upon call light activation in 3 of 4 houses.
Report Facts
Facility census: 72
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 7, 2016
Visit Reason
The visit was conducted to determine if the facility complies 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.
Deficiencies (1)
The survey identified 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the letter accepting the plan of correction and confirming substantial compliance. |
Inspection Report
Life Safety
Deficiencies: 0
Date: May 13, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at the 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Inspection Report
Life Safety
Deficiencies: 0
Date: May 13, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at 'F' level, indicating no harm but with potential for more than minimal harm, and no immediate jeopardy was identified.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 20, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.25, 483.25(h), 483.25(i), 483.25(m)(2), 483.35(i), and 483.65 were corrected as of 06/05/2015.
Inspection Report
Plan of Correction
Deficiencies: 7
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.
Deficiencies (7)
F0000: The facility developed and implemented a system to assure correction and continued compliance with regulations following the health facility resurvey findings.
F309-D: The facility updated care plans and in-serviced staff regarding residents receiving dialysis and fluid restrictions to ensure proper care and monitoring.
F323-G: The facility conducted a self-investigation after a resident fall, provided staff education on mobility assistance, and implemented ongoing audits to prevent accidents.
F325-G: The facility investigated a medication error, took disciplinary actions against staff, audited medication records, and reinforced medication protocols to prevent errors.
F333-G: The facility ensured residents maintain acceptable nutritional status and therapeutic diets, updated care plans, and in-serviced staff on nutritional interventions.
F371-F: The facility improved sanitary conditions in food preparation areas by cleaning and replacing cookware and revising cleaning schedules and policies.
F441-F: The facility maintained an Infection Control Program, revised cleaning procedures for isolation rooms, and conducted staff in-service and audits to ensure compliance.
Report Facts
Date of Plan of Correction completion: Jun 5, 2015
Number of residents referenced: 3
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 compliance with Federal participation requirements for nursing homes in Medicare and Medicaid programs.
Findings
The survey found deficiencies at a level of actual harm but not immediate jeopardy. Due to prior noncompliance on an August 14, 2014 abbreviated survey, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare admissions effective June 10, 2015.
Report Facts
Denial of payment effective date: Jun 10, 2015
Noncompliance follow-up deadline: Nov 21, 2015
Civil Money Penalty minimum amount: 5000
Hearing request deadline days: 60
Informal Dispute Resolution request deadline days: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator |
| Gregg Brandush | Branch Manager | Authorized the letter as Branch Manager, Division of Survey & Certification |
| Jane Weiler | Contact person at CMS for questions regarding the matter | |
| Joe Ewert | Commissioner | Recipient of written requests for Informal Dispute Resolution |
Inspection Report
Census: 69
Deficiencies: 6
Date: May 21, 2015
Visit Reason
Health Resurvey and Complaint Investigation with multiple complaint numbers cited.
Complaint Details
The inspection included a complaint investigation with multiple complaint numbers cited (#75206, #75819, #76106, #77685, #81079, #81551, and #86315).
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 maintain nutrition status for a resident with severe weight loss, failure to prevent significant medication errors, failure to maintain sanitary food preparation and storage, and failure to maintain infection control practices in an isolation room.
Deficiencies (6)
F309: The facility failed to provide necessary care and services including therapeutic diet, fluid restriction, and monitoring of dialysis access site for resident #97.
F323: The facility failed to follow the care plan to prevent a fall for resident #22 which resulted in a fractured pelvis.
F325: The facility failed to provide nutritional supplements as ordered for resident #107 who experienced severe weight loss.
F333: The facility failed to ensure resident #182 remained free from significant medication errors, omitting multiple medications including Lasix for 8 days leading to hospitalization.
F371: The facility failed to store and prepare food in a sanitary manner and maintain clean equipment in multiple kitchens, risking contamination of food served to residents.
F441: The facility failed to maintain infection control in an isolation room for C-Difficile by not using proper disinfectants on all surfaces and failing to vacuum or disinfect floors.
Report Facts
Facility census: 69
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: 19.9
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
Medication days missed: 8
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 compliance with Federal participation requirements for nursing homes in Medicare and Medicaid programs.
Findings
The survey found deficiencies at a level of actual harm that is not immediate jeopardy, with a history of noncompliance from a prior abbreviated survey. Enforcement remedies including denial of payment for new Medicare admissions were imposed effective June 10, 2015.
Report Facts
Denial of payment effective date: Jun 10, 2015
Noncompliance follow-up deadline: Nov 21, 2015
Civil Money Penalty minimum amount: 5000
IDR request deadline days: 10
Hearing request deadline days: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as contact for questions regarding the enforcement action |
| Jane Weiler | Contact person at CMS for questions and hearing requests | |
| Gregg Brandush | Branch Manager | Authorized the enforcement letter |
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 5, 2015
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: May 5, 2015
Provider agreement termination date: Aug 5, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter. |
| Joe Ewert | Commissioner | Copied on enforcement letter. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 5, 2015
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: May 5, 2015
Provider agreement termination date: Aug 5, 2015
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter. |
| Joe Ewert | Commissioner | Copied on enforcement letter. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 14, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all cited deficiencies, identified by their regulation numbers and prefix codes, were corrected by 09/05/2014. No uncorrected deficiencies remain.
Report Facts
Deficiency correction dates: 5
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 4
Date: Aug 14, 2014
Visit Reason
Complaint investigation triggered by allegations of abuse and a partial extended health resurvey.
Complaint Details
Resident #3 alleged inappropriate touching and abuse by a non-Caucasian staff member of the opposite gender who had access to all facility houses. The resident was fearful and reported the incidents to therapy and social services staff. The facility delayed reporting to the State agency, failed to conduct a thorough investigation, and did not protect residents during the investigation. The alleged perpetrator was eventually suspended and removed after the investigation.
Findings
The facility failed to protect resident #3 from abuse and mental anguish related to inappropriate touching by a staff member of the opposite gender. The facility also failed to immediately report the allegation, thoroughly investigate it, protect residents during the investigation, honor the resident's preference for same gender caregivers, and update the care plan accordingly.
Deficiencies (4)
F 223: The facility failed to protect resident #3 from abuse and mental anguish after an allegation of inappropriate touching by a non-Caucasian staff member of the opposite gender.
F 225: The facility failed to immediately report, thoroughly investigate, and protect residents during an allegation of employee to resident sexual abuse and/or inappropriate touching involving resident #3.
F 242: The facility failed to honor resident #3's preference to not have caregivers of the opposite gender.
F 280: The facility failed to review and revise resident #3's care plan to include the resident's preference to have same gender caregivers.
Report Facts
Facility census: 66
BIMS score: 11
Staff E night shifts: 31
Staff E day shifts: 5
Opposite gender nurse shifts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Facility administrator involved in investigation and reporting of abuse allegations. | |
| Therapy staff D | Received resident #3's abuse report and provided written statement to administration. | |
| Therapy staff C | Accompanied therapy staff D to report resident #3's abuse allegation to administration. | |
| Social services staff B | Received resident #3's preference for same gender caregivers and reported to charge nurse. | |
| Licensed nursing staff J | Reported resident #3 did not like nursing staff of the opposite gender. | |
| Direct care staff E | Non-Caucasian staff member of opposite gender alleged to have abused resident #3. | |
| Consultant staff K | Reviewed surveillance and bed alarm logs during investigation. |
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 documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies identified by regulation numbers and prefix codes were corrected as of the revisit date 03/17/2014.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 17, 2014
Visit Reason
This is a follow-up visit to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously cited deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-305 (3) deficiency identified by prefix S1364 was corrected on 2014-03-17.
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 documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies were corrected as of the revisit date. The report lists multiple regulatory citations with correction completion dates of 03/17/2014.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 17, 2014
Visit Reason
This is a follow-up revisit to verify correction of previously reported deficiencies at Avita Health and Rehab at Reeds Cove.
Findings
The report documents that previously cited deficiencies, specifically Reg. # 26-40-305 (3) with ID Prefix S1364, were corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-305 (3) deficiency identified by code S1364 was corrected by the revisit date of 2014-03-17.
Inspection Report
Plan of Correction
Deficiencies: 15
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 developed and implemented corrective actions addressing multiple deficiencies including residents' rights, notification of significant changes, care planning, assessment accuracy, medication management, accident prevention, sanitary conditions, and coordination with hospice services. Staff training and ongoing compliance monitoring are emphasized throughout.
Deficiencies (15)
F0000: The facility developed a system to assure correction and continued compliance with regulations following the health facility resurvey findings.
F156-E: The facility will provide written notice of residents' rights upon admission and periodically, ensuring staff are trained and residents understand their rights.
F157-D: The facility will notify residents, physicians, and representatives of significant changes in physical, mental, or psychosocial status and revised policies on resident weight documentation.
F167-C: The facility will maintain clearly labeled copies of the most recent survey in accessible areas and train staff on residents' rights to examine survey results.
F242-D: The facility will respect residents' rights to make choices about daily living aspects, updating care plans to reflect preferences and training staff accordingly.
F272-E: The facility will complete timely, accurate assessments of residents' functional capacity and monitor weight changes with appropriate interventions.
F279-D: The facility will develop comprehensive care plans with measurable objectives for residents, including those receiving dialysis, ensuring staff are trained and plans are regularly reviewed.
F279DX1: The facility will complete behavior/intervention assessments for residents on psychotropic medications and incorporate findings into care plans with ongoing review.
F309-D: The facility will coordinate care with hospice services, ensuring care plans reflect responsibilities and preferences, and train staff on these roles.
F323-E: The facility will maintain a safe environment to prevent accidents, implement fall risk interventions, and ensure medication storage policies are followed.
F371-F: The facility will store, prepare, and serve food under sanitary conditions, revising policies and training dietary staff accordingly.
F411-D: The facility will assist residents in obtaining routine and emergency dental care, implementing an oral health assessment tool and training staff.
F428-D: A licensed pharmacist will review drug regimens monthly, with revised policies ensuring appropriate lab monitoring and physician follow-up.
F431-E: The facility will ensure medications are properly labeled with date opened and discarded per manufacturer recommendations, with staff training and monitoring.
S1364-D: The facility will maintain an electrical system ensuring safety, including use of ground-fault circuit interrupters for hydrotherapy units.
Report Facts
Date of resident discharge: Jan 29, 2014
Date of resident discharge: Feb 1, 2014
Date of hydrocollator outlet change: Jan 23, 2014
Date of kitchen door replacement: Feb 1, 2014
Date of TSH lab draw: Jan 27, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Administrator who submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Irina Strakhova | Person who added and modified 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
The visit included a complaint investigation #71552 as well as a health resurvey and non-compliance revisit.
Findings
The facility failed to maintain the hydroculator on a ground-fault circuit interrupter (GFCI) outlet as required by electrical safety regulations. Interviews confirmed staff awareness of the requirement, but the hydroculator was not plugged into a GFCI outlet and no policy was provided regarding its use.
Deficiencies (1)
26-40-305 (3) P E - Electrical requirements: The facility failed to maintain the hydroculator on a ground-fault circuit interrupter (GFCI) outlet as required. Observations and staff interviews confirmed the hydroculator was not plugged into a GFCI outlet.
Report Facts
Facility census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff FF and administrative nursing staff A were interviewed regarding the hydroculator but no full names were provided. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 28, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as of the revisit date.
Findings
The report confirms that all previously reported deficiencies identified on the CMS-2567 were corrected by the revisit date of 2014-01-28.
Deficiencies (3)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected by 01/28/2014.
Regulation 483.20(q)-(j) deficiency was corrected by 01/28/2014.
Regulation 483.20(k)(3)(i) deficiency was corrected by 01/28/2014.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 5
Date: Dec 19, 2013
Visit Reason
The inspection was a partially-extended complaint investigation triggered by complaint numbers #70699 and #69671.
Complaint Details
The inspection was triggered by complaints #70699 and #69671 and involved investigation of alleged violations related to abuse, neglect, and failure to report injuries.
Findings
The facility failed to immediately report an injury of unknown origin, failed to accurately assess residents' fall histories, failed to develop comprehensive care plans addressing falls and ADL needs, failed to provide timely admission care plans, and failed to investigate falls to determine causes and update care plans accordingly. Multiple residents experienced falls, some resulting in fractures, without adequate supervision or effective interventions.
Deficiencies (5)
F225: The facility failed to immediately report an incident involving fractured ribs to the State survey and certification agency for 1 of 7 sampled residents.
F278: The facility failed to accurately assess the resident's fall history for 1 of 7 sampled residents.
F279: The facility failed to develop comprehensive care plans for 5 of 7 sampled residents regarding falls and activities of daily living.
F281: The facility failed to have accurate, timely admission care plans for 2 of 7 sampled residents.
F323: The facility failed to ensure the resident environment remained free of accident hazards and failed to provide adequate supervision and assistance devices to prevent falls, resulting in multiple residents sustaining fractures after falls.
Report Facts
Residents in sample: 7
Facility census: 52
Deficiency counts: 5
Fall incidents: 4
Inspection Report
Plan of Correction
Deficiencies: 5
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 a revised complaint inspection report, detailing corrective actions to address alleged deficiencies related to fall investigations, care planning, and abuse/neglect reporting.
Findings
The facility implemented multiple corrective actions including staff in-service training on fall investigation and abuse/neglect policies, comprehensive review and revision of care plans for residents at risk of falls, and improved incident reporting procedures to ensure compliance with state and federal regulations.
Deficiencies (5)
F225: The staffing schedule for 11/1/2013 was reviewed and all staff were in-serviced on fall investigation, post-fall documentation, and follow-up procedures. The facility implemented policies to ensure thorough investigation and reporting of incidents involving potential abuse, neglect, or exploitation.
F278: On 12-23-13, the MDS nurse completed a comprehensive MDS for Resident #1 and reviewed care plans for all targeted residents to ensure individualized fall risk prevention interventions were in place and accurate.
F279: The clinical records for Residents #1, #5, and #6 were re-assessed for fall risk and ADL needs, with individualized care plans developed and staff trained accordingly. New admissions are comprehensively assessed with timely interventions implemented.
F281: Admission assessments and temporary care plans are completed for all newly admitted elders, with ongoing review and revisions by nursing management to ensure appropriate fall prevention and care interventions.
F323: The facility ensures the environment is free of accident hazards and provides adequate supervision and assistive devices. Fall tracking logs are reviewed monthly to ensure incidents are investigated and care plans updated accordingly.
Report Facts
Date of staffing schedule reviewed: Nov 1, 2013
Date of Quality Assurance/Performance Improvement Committee meeting: Nov 27, 2013
Date of MDS comprehensive assessment: Dec 23, 2013
Date of staff in-service training: Dec 6, 2013
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087076 POC 230B7DH1
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection of Avita Health and Rehab.
Findings
The document does not contain specific findings but indicates that the facility is addressing previously identified deficiencies as part of the correction process.
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 does not contain specific findings but serves as a corrective action plan addressing previously cited deficiencies.
Document
Deficiencies: 0
Date: N087076 POC IYDG11
Visit Reason
The document could not be accessed or rendered, so the purpose is unknown.
Findings
No findings or content are available due to the rendering error.
Inspection Report
Plan of Correction
Deficiencies: 5
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.
Findings
The facility identified deficiencies related to resident abuse prevention, investigation and reporting of alleged violations, resident rights to choose activities and care preferences, and care plan revisions to reflect resident preferences.
Deficiencies (5)
F0000: The facility developed and implemented a system to assure correction and continued compliance with regulations following the health facility resurvey findings.
F223-G: The facility will ensure residents are free from abuse and will investigate and report all allegations of abuse in accordance with state law.
F225-L: The facility will report and investigate all alleged violations involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property promptly and thoroughly.
F242-D: The facility will ensure residents have the right to choose activities, schedules, and health care consistent with their interests and plans of care.
F280-D: The facility will review and revise residents' care plans to reflect their care preferences, including caregiver gender preferences.
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