Inspection Reports for Rockpoint Care Center LLC
302 E IOWA STREET, HIAWATHA, KS, 66434
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 19, 2017, confirmed that all previously cited deficiencies were corrected. Earlier inspections showed a pattern of deficiencies related mainly to medication management, infection control, and resident care practices, including issues with lighting, food service hygiene, and abuse reporting. Complaint investigations substantiated failures in protecting residents from abuse and timely reporting, with enforcement actions including denial of payment for new Medicare admissions imposed in 2014 due to pressure ulcer treatment deficiencies. Fines or license suspensions were not listed in the available reports. The facility demonstrated improvement over time, with the most recent follow-up confirming correction of prior issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
23.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
297% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
54 residents
Based on a June 2017 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jul 19, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all cited deficiencies identified by their regulation numbers 483.10(i)(5), 483.60(i)(1)-(3), 483.45(b)(2)(3)(g)(h), and 483.80(a)(1)(2)(4)(e)(f) were corrected as of 07/19/2017.
Deficiencies (4)
Deficiency related to regulation 483.10(i)(5)
Deficiency related to regulation 483.60(i)(1)-(3)
Deficiency related to regulation 483.45(b)(2)(3)(g)(h)
Deficiency related to regulation 483.80(a)(1)(2)(4)(e)(f)
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 19, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
Most serious deficiencies found were 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to findings and compliance decision. |
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 4
Date: Jun 19, 2017
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements following a previous survey.
Findings
The facility was found deficient in multiple areas including inadequate lighting in a resident's room, failure to maintain sanitary food service practices, improper labeling and storage of medications, and failure to follow infection control procedures during incontinent care.
Deficiencies (4)
Failed to provide adequate and comfortable lighting levels for Resident #64 in his/her room.
Nursing staff on the secured unit failed to wear hairnets or hair coverings while serving food, risking contamination.
Failed to ensure drugs were labeled according to professional standards and stock medications were not expired, including undated insulin pens and expired nutritional supplements.
Failed to provide appropriate infection control during incontinent care for Resident #27, including failure to change gloves between tasks.
Report Facts
Residents present: 54
Sample residents reviewed: 17
Residents on secured unit: 14
Insulin dependent residents: 14
Expired Ensure bottles: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide C | Observed placing food on plates without hairnet on secured unit | |
| Nurse Aide D | Observed placing food on plates without hairnet on secured unit | |
| Registered Dietician B | Registered Dietician | Stated nursing staff did not have to wear hairnets when serving meals |
| Administrative Nurse A | Administrative Nurse | Confirmed dietary staff should wear hair coverings and discussed medication checks |
| Nurse J | Stated staff were to date insulin pens when initially opened | |
| Medication Aide E | Medication Aide | Checked medication rooms and insulin pens for expiration and dating |
| Nurse Aide F | Observed providing incontinent care without changing gloves between tasks | |
| Nurse Aide G | Observed providing incontinent care | |
| Nurse Aide H | Observed providing incontinent care | |
| Nurse Aide I | Observed providing incontinent care without changing gloves after pericare |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 19, 2017
Visit Reason
The visit was a licensure resurvey of the facility to assess compliance with regulatory requirements.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 19, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Maple Hts ALF dated 06/19/2017.
Findings
No deficiencies were cited in the referenced inspection report dated 06/19/2017.
Deficiencies (1)
No deficiencies cited
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jun 19, 2017
Visit Reason
This document is a Plan of Correction submitted by Maple Heights in response to deficiencies cited in a prior inspection report dated June 19, 2017.
Findings
The plan addresses multiple deficiencies including inadequate lighting, improper hair restraint during food serving, expired insulin and medication management, and improper peri-care procedures. The facility outlines corrective actions, staff education, monitoring, and auditing to ensure compliance.
Deficiencies (4)
Inadequate and uncomfortable lighting levels for residents
Staff not appropriately restraining hair during serving process
Expired insulin pens and other expired medications not removed from medication areas
Improper peri-care procedures by nursing staff
Report Facts
Audit frequency: 3
Audit duration: 4
Audit frequency: 1
Audit frequency: 1
Audit frequency: 1
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Wolney | Administrator | Submitted the Plan of Correction and responsible for monitoring compliance |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: May 17, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the facility was not in substantial compliance, with conditions constituting Immediate Jeopardy and Past Non-compliance to resident health or safety for specific regulatory citations. Enforcement remedies will be recommended without opportunity to correct deficiencies before imposition.
Deficiencies (2)
Deficiency related to F225, initially Immediate Jeopardy, later lowered to a 'D' after Independent Informal Dispute Resolution.
Deficiency related to F226, with severity 'F'.
Report Facts
Days to request IDR: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Signed letter and contact for questions regarding the instructions |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Date: May 17, 2017
Visit Reason
The inspection was conducted as a partially extended survey and complaint investigation related to allegations of abuse by a staff member at Maple Heights Nursing & Rehabilitation Center.
Complaint Details
The complaint investigation involved an allegation of abuse by licensed nursing staff J against resident #1. Direct care staff H reported the allegation via phone message but did not report it immediately to the administrator. The alleged abuser continued to provide care for approximately 7 hours and 20 minutes after the allegation was made. The facility delayed investigation and reporting, with administrative staff not becoming aware until approximately 25 hours after the initial allegation.
Findings
The facility failed to protect residents from potential abuse when a staff member reported an allegation of abuse by another staff member, who continued providing care for the remainder of the shift. The facility also failed to timely report the allegation and implement their abuse prevention policies, resulting in delayed administrative awareness and response.
Deficiencies (2)
Failure to protect residents from potential abuse when a staff member reported an allegation of abuse by another staff member who continued providing care for the remainder of the shift.
Failure to develop and implement policies and procedures to prohibit and prevent abuse, neglect, and exploitation, and failure to timely report allegations of abuse.
Report Facts
Census: 63
Sample size: 3
Time delay in reporting: 7.33
Time delay in administrative awareness: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff J | Licensed Nurse | Alleged perpetrator of abuse against resident #1. |
| Direct care staff H | Direct Care Staff | Reported the abuse allegation and provided witness statements. |
| Administrative licensed nurse E | Administrative Licensed Nurse | Received the abuse allegation message and was involved in the investigation. |
| Administrative licensed nurse D | Administrative Licensed Nurse | Not aware of the situation until approximately 25 hours after the allegation. |
| Administrative staff A | Administrator | Expected all staff to report abuse allegations directly and verbally. |
| Direct care staff I | Direct Care Staff | Assisted resident #1 and provided observations during the investigation. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: May 17, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a revised complaint inspection report dated 05/17/2017.
Complaint Details
This Plan of Correction is related to a revised complaint inspection dated 05/17/2017.
Findings
The Plan of Correction addresses past noncompliance issues identified in the complaint inspection, with no new plans of correction required for the cited deficiencies.
Deficiencies (3)
Past noncompliance: no plan of correction required.
Past non-compliance: no POC required
Past noncompliance: no plan of correction required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance and submitter of the Plan of Correction. | |
| Caryl Gill | Modified the Plan of Correction on 08/31/2017. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 14, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Feb 14, 2017
Provider agreement termination date: May 14, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Dec 2, 2015
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
The report confirms that all previously cited deficiencies identified by their regulation numbers were corrected by 12/02/2015.
Deficiencies (6)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(e)(2)
Deficiency related to regulation 483.25(l)
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Dec 2, 2015
Visit Reason
This document is a Plan of Correction submitted by Maple Heights Nursing and Rehab Center in response to deficiencies cited during a prior inspection, addressing compliance with state and federal regulations.
Findings
The plan outlines corrective actions including staff training on resident rights and abuse prevention, re-education on skin breakdown risk assessments, meal assistance documentation, restorative programs implementation, and blood pressure monitoring procedures. The facility commits to substantial compliance by December 2, 2015, with ongoing audits and monitoring by the Administrator, DON, and QA committees.
Deficiencies (6)
Failure to ensure treatment of residents by staff, volunteers, and contract staff in accordance with resident rights and abuse prevention policies.
Failure to honor resident bathing preferences and frequency.
Inadequate assessment and intervention for residents at risk for skin breakdown.
Lack of policy and documentation for meal assistance and refusals, especially for residents near death.
Inconsistent implementation and monitoring of restorative programs for residents.
Failure to properly monitor and document blood pressure parameters and notify physicians as required.
Report Facts
Residents interviewed weekly: 5
Audit frequency: 3
Monitoring frequency: 3
Monitoring duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Wolney | Administrator | Submitted the Plan of Correction and responsible for monitoring compliance |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 3, 2015
Visit Reason
The Health Licensure Resurvey of the facility was conducted to assess compliance with health licensure requirements.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 1
Date: Nov 2, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an "E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 2, 2015.
Deficiencies (1)
"E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy
Report Facts
Effective date of substantial compliance: Dec 2, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 6
Date: Nov 2, 2015
Visit Reason
The inspection was conducted as a Health Resurvey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including failure to immediately report and investigate allegations of abuse, failure to assess and provide resident bathing preferences, failure to prevent development of a pressure ulcer due to inadequate assessment and intervention, failure to provide assistance with eating, failure to provide restorative range of motion services as ordered, and failure to follow up on blood pressure readings outside physician-ordered parameters.
Deficiencies (6)
Failure to ensure all alleged violations involving mistreatment or abuse were reported immediately to the administrator.
Failure to assess and provide resident #24 with bathing preferences.
Failure to prevent development of a pressure ulcer for resident #60 due to inadequate assessment and intervention.
Failure to provide assistance with eating for resident #16.
Failure to provide restorative range of motion services as ordered for residents #18 and #25.
Failure to follow-up on blood pressures outside of physician-ordered parameters for residents #31 and #24.
Report Facts
Census: 53
Residents in sample: 17
Blood pressure readings above parameters: 12
Blood pressure readings above parameters: 11
Blood pressure readings above parameters: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse J | Licensed Nurse | Named in abuse reporting deficiency for failure to report resident to resident abuse |
| administrative nursing staff D | Administrative Nursing Staff | Involved in abuse investigation and staff training |
| direct care staff T | Direct Care Staff | Reported abuse incidents to administrative staff |
| licensed nurse H | Licensed Nurse | Interviewed regarding wound care and restorative services |
| administrative nursing staff E | Administrative Nursing Staff | Involved in wound care and restorative services |
| therapy consultant JJ | Therapy Consultant | Developed restorative care evaluation and program |
| direct care staff R | Direct Care Staff | Interviewed regarding resident bathing preferences and range of motion |
| direct care staff S | Direct Care Staff | Interviewed regarding resident bathing preferences and eating assistance |
| direct care staff Q | Direct Care Staff | Interviewed regarding blood pressure monitoring |
| administrative nursing staff D | Administrative Nursing Staff | Interviewed regarding blood pressure monitoring and physician notification |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 13, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'D' level, isolated, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found were 'D' level, isolated, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payments effective date: Oct 13, 2015
Provider agreement termination date: Jan 13, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 6, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiency identified under regulation 483.12(a)(2) with ID prefix F0201 was corrected as of 09/06/2014.
Deficiencies (1)
Deficiency under regulation 483.12(a)(2) previously cited and corrected.
Report Facts
Deficiency correction date: Sep 6, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 6, 2014
Visit Reason
This document is a Plan of Correction submitted by Maple Heights Nursing and Rehabilitation Center in response to deficiencies cited in a prior survey related to discharge notices and compliance with state and federal regulations.
Findings
The plan addresses a deficiency regarding improper verbal rescindment of a discharge letter without written confirmation and outlines corrective actions to ensure all discharge notices are approved by the administrator and comply with regulatory requirements.
Deficiencies (1)
Verbal rescindment of discharge letter given without written confirmation; future rescindments to be confirmed by certified mail and discharge notices to be approved by administrator.
Inspection Report
Enforcement
Deficiencies: 1
Date: Sep 5, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found a 'D' level deficiency, isolated, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective September 6, 2014.
Deficiencies (1)
Most serious deficiency found was a 'D' level deficiency, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey and certification. |
Inspection Report
Follow-Up
Deficiencies: 10
Date: Sep 5, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, indicating compliance with the required standards.
Deficiencies (10)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.30(a)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.70(h)
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 5, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency identified by regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) was corrected as of the revisit date.
Deficiencies (1)
Deficiency related to regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c)
Report Facts
Deficiencies corrected: 1
Inspection Report
Re-Inspection
Census: 50
Deficiencies: 1
Date: Sep 5, 2014
Visit Reason
The inspection was a non-compliance revisit to determine if the facility corrected a prior deficiency related to the involuntary discharge of a resident.
Findings
The facility failed to ensure that one resident (#15) was not involuntarily discharged unless necessary for the resident's welfare and needs. The resident was discharged despite the facility being able to meet the resident's needs, due to the facility's decision to stop providing transportation to dialysis.
Deficiencies (1)
Facility failed to permit resident #15 to remain in the facility and discharged the resident involuntarily without meeting regulatory requirements.
Report Facts
Census: 50
Resident sample: 1
Resident #15 discharge date: Aug 9, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Stated the facility did not retract the involuntary discharge notice and discharged the resident on 8/9/14 |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Aug 8, 2014
Visit Reason
This document is a Plan of Correction submitted by Maple Heights Nursing & Rehabilitation Center in response to deficiencies cited during a prior inspection, addressing corrective actions for multiple cited deficiencies.
Findings
The plan outlines corrective actions for various deficiencies including environmental issues, care plan updates for residents, fall prevention interventions, medication and dietary procedures, housekeeping protocols, staffing levels on the special care unit, and facility repairs. The facility intends to achieve substantial compliance by August 8, 2014.
Deficiencies (11)
Environmental issues including cleaning and maintenance of resident areas and equipment.
Care plan updates to specify repositioning frequency for residents.
Care plan updates for pressure sore risk and nutritional tracking.
Urinary assessment and individualized toileting program development.
Fall prevention interventions and staff training.
Documentation of supplement intake percentages on MAR.
Staffing levels on the special care unit and supervision of residents.
Dietary staff training on dishwashing and food serving procedures.
Housekeeping staff training on disinfectant use and cleaning procedures for infections.
Facility repairs including hallway exit cement, siding, furnace door hole, roof tiles, patio fence and furniture.
Installation of lock on employee restroom door.
Report Facts
Date for substantial compliance: Aug 8, 2014
Staffing on special care unit: 3
Staffing on special care unit: 2
Dishwashing machine monitoring frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Wolney | Administrator | Administrator submitting the Plan of Correction and monitoring compliance |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jul 9, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be a 'G' level related to noncompliance with F314, Pressure Ulcers. Enforcement remedies including denial of payment for new Medicare admissions effective October 9, 2014, were imposed due to failure to achieve substantial compliance.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers
Report Facts
Denial of payment effective date: Oct 9, 2014
Termination recommendation date: Jan 9, 2015
Civil Money Penalty threshold: 5000
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Wolney | Administrator | Facility Administrator named in the report header |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
| Joe Ewert | Commissioner | Recipient of Informal Dispute Resolution requests |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 10
Date: Jul 9, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for facility compliance with regulatory requirements.
Complaint Details
The visit included a complaint investigation as indicated by the report referencing complaint investigation numbers #KS00072253 and #KS00074891.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance services, comprehensive care planning, pressure ulcer treatment, urinary incontinence management, fall prevention, staffing sufficiency, food handling and sanitation, infection control, and external environment safety.
Deficiencies (10)
Failed to provide a clean and comfortable environment; multiple maintenance and housekeeping issues noted in hallways and bathrooms.
Failed to develop comprehensive care plans for repositioning and hospice care for sampled residents.
Failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident with a suspected deep tissue injury.
Failed to ensure appropriate treatment and services to restore bladder function and prevent urinary tract infections for residents with urinary incontinence.
Failed to place timely and effective fall prevention interventions and ensure chemicals/products were inaccessible to cognitively impaired residents.
Failed to monitor percentage of nutritional supplement intake for dependent residents with abnormal weight loss or low protein levels.
Failed to maintain sufficient nursing staff to meet residents' needs and promote their well-being on one unit.
Failed to handle food hygienically and sanitize dishware according to facility policy.
Failed to utilize proper infection control precautions and thoroughly sanitize a resident's room identified with MRSA infection.
Failed to maintain a safe and functional external environment for residents, including crumbled cement, missing siding, holes in walls, and broken furniture.
Report Facts
Deficiency count: 10
Resident census: 51
Sample size: 16
Pressure ulcer measurements: 4
Prealbumin level: 8.3
Dishwasher sanitizer concentration: 50
Bed alarm duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse H | Licensed Nurse | Responded to bed alarm, provided care, and interviewed regarding staffing and infection control. |
| housekeeping staff Z | Housekeeping Staff | Observed cleaning MRSA resident's room and interviewed about cleaning procedures. |
| dietary staff EE | Dietary Staff | Interviewed regarding food handling and supplement intake monitoring. |
| administrative nursing staff D | Administrative Nursing Staff | Interviewed regarding care plans, staffing, infection control, and supplement monitoring. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 9, 2014
Visit Reason
The Assisted Living/Residential Healthcare resurvey of the facility was conducted to verify compliance and check for any deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 19, 2013
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected at Maple Heights Nursing & Rehabilitation Center.
Findings
The revisit confirmed that the deficiency identified by regulation 28-39-160 with ID prefix S0740 was corrected as of 04/19/2013.
Deficiencies (1)
Deficiency identified under regulation 28-39-160 with ID prefix S0740
Report Facts
Deficiencies corrected: 1
Inspection Report
Follow-Up
Deficiencies: 14
Date: Apr 19, 2013
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date, April 19, 2013.
Deficiencies (14)
Deficiency with ID prefix F0156 related to regulations 483.10(b)(5)-(10), 483.10(b)(1)
Deficiency with ID prefix F0272 related to regulation 483.20(b)(1)
Deficiency with ID prefix F0278 related to regulation 483.20(g)-(i)
Deficiency with ID prefix F0279 related to regulations 483.20(d), 483.20(k)(1)
Deficiency with ID prefix F0280 related to regulations 483.20(d)(3), 483.10(k)(2)
Deficiency with ID prefix F0286 related to regulation 483.20(d)
Deficiency with ID prefix F0315 related to regulation 483.25(d)
Deficiency with ID prefix F0318 related to regulation 483.25(e)(2)
Deficiency with ID prefix F0323 related to regulation 483.25(h)
Deficiency with ID prefix F0329 related to regulation 483.25(l)
Deficiency with ID prefix F0371 related to regulation 483.35(i)
Deficiency with ID prefix F0411 related to regulation 483.55(a)
Deficiency with ID prefix F0428 related to regulation 483.60(c)
Deficiency with ID prefix F0441 related to regulation 483.65
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Apr 19, 2013
Visit Reason
This document is a Plan of Correction submitted by Maple Heights Nursing and Rehabilitation Center in response to deficiencies cited in a prior survey, addressing corrective actions for various care and compliance issues.
Findings
The plan outlines corrective actions for multiple deficiencies including documentation of Medicaid and Medicare information, care plan updates, MDS accuracy, urinary assessments, psychotropic medication monitoring, infection control, and staff in-service training. Substantial compliance will be monitored through audits and QA processes.
Deficiencies (12)
Medicaid and Medicare information posting and maintenance
Care Area Assessments (CAA) documentation and psychotropic drug use causative factors
Updating MDS to reflect diagnoses and prescriptions for residents
Care plan updates addressing urinary incontinence, falls, grooming, psychotropic medication use
Toileting program reassessment and urinary assessment
Licensed physical therapist review and restorative care plans
Bath mats purchase for shower rooms
Behavior monitoring sheets for psychotropic medication effectiveness
Dietary staff training on utensil use and cart cleaning; maintenance on ice machine air gap
Oral assessment and dental care follow-up
Blood glucose monitoring infection control and staff training
Memory Unit placement orders and staff training
Report Facts
Audit frequency: 3
Audit frequency: 2
Audit frequency: 1
Blood glucose checks: 3
Blood glucose checks: 2
Blood glucose checks: 2
Blood glucose checks: 1
Pharmacy Consultant start timeframe: 30
Pharmacy Consultant start timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Wolney | Administrator | Administrator submitting the Plan of Correction |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 13
Date: Mar 21, 2013
Visit Reason
Annual health resurvey of Maple Heights Nursing & Rehabilitation Center to assess compliance with federal regulations.
Findings
The facility had multiple deficiencies including failure to post required Medicare/Medicaid information, incomplete comprehensive assessments for several residents, inaccurate Minimum Data Set (MDS) documentation, failure to develop or update comprehensive care plans, inadequate infection control practices, unsanitary food handling, and failure to monitor medication effectiveness.
Deficiencies (13)
Failed to post Medicare/Medicaid information as required.
Failed to complete comprehensive assessments for multiple residents (#49, #59, #12).
Failed to accurately assess diagnoses and medication use for residents (#55, #42, #32, #14).
Failed to develop comprehensive care plans for residents (#32, #30, #72).
Failed to update care plan for behavior with medication changes for resident #30.
Failed to maintain 15 months of Minimum Data Set (MDS) assessments accessible to staff for residents (#14, #62, #59, #72).
Failed to complete assessments for bladder incontinence and voiding diaries for residents (#30, #68, #14).
Failed to provide range of motion and splint assistance for resident #32 with limited range of motion of left middle finger.
Failed to provide a safe environment in shower rooms; lacked bath mats or safety strips in two shower rooms.
Failed to serve and prepare food in a sanitary manner; staff served food with bare hands without changing gloves; unclean food carts; ice machine lacked proper air gap.
Failed to provide dental services for resident #38 with broken/missing teeth and bleeding gums; no referral to dentist or social services documented.
Failed to monitor medication effectiveness for residents (#23, #42, #72, #59, #5), including lack of individualized behavior monitoring and blood pressure monitoring.
Failed to provide infection control techniques during blood glucose monitoring; staff did not cleanse glucose monitor between residents and failed to wash hands between glove changes.
Report Facts
Deficiencies cited: 13
Resident sample size: 20
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff D | Interviewed regarding assessments, care plans, medication monitoring, and infection control. | |
| Administrative nursing staff E | Interviewed regarding behavior monitoring sheets, dental referrals, and infection control. | |
| Administrative nursing staff F | Interviewed regarding MDS printing, lab monitoring, and behavior monitoring. | |
| Direct care staff O | Interviewed regarding incontinence care and blood pressure monitoring. | |
| Direct care staff P | Observed assisting with incontinence care and resident transfers. | |
| Direct care staff Q | Interviewed regarding incontinence care. | |
| Direct care staff R | Observed assisting with incontinence care and resident transfers. | |
| Direct care staff T | Interviewed regarding resident pain and infection control practices. | |
| Licensed nurse I | Interviewed regarding resident care and behavior monitoring. | |
| Licensed nursing staff J | Interviewed regarding behavior monitoring sheets and lab testing. | |
| Licensed nursing staff H | Interviewed regarding blood pressure monitoring. | |
| Dietary staff DD | Observed serving food with improper glove use. | |
| Dietary staff EE | Interviewed regarding cleaning of food carts. | |
| Dietary staff FF | Interviewed regarding food service sanitation and ice machine air gap. | |
| Social service staff HH | Interviewed regarding dental appointment assistance. |
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