Inspection Reports for Sandstone Heights Nursing Home
440 STATE STREET, KS, 67457
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 27, 2018, resulted in no deficiency citations. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including fall assessments, pressure ulcer prevention and treatment, catheter care, and supervision to prevent accidents. Complaint investigations substantiated issues such as inadequate supervision leading to falls and elopement risks, as well as failures in timely reporting of resident falls and injuries. Enforcement actions included denial of payment for new Medicare and Medicaid admissions following findings related to pressure ulcers, but no license suspensions or fines were listed in the available reports. The facility’s record shows improvement over time, with the most recent inspection free of deficiencies after previous corrective actions were implemented.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
14.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
140% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
27 residents
Based on a May 2017 inspection.
Census over time
Inspection Report
Deficiencies: 0
Dec 27, 2018
Visit Reason
The health survey was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 27, 2018
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 2
Sep 13, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection visit conducted from 2018-09-13 to 2018-09-17.
Findings
The facility reviewed the deficiencies with their QA committee and implemented corrective actions including staff education on resident assessments after falls, updated procedures for resident transfers, and enhanced fall notification protocols. The plan includes ongoing monitoring through daily meetings, weekly risk meetings, and quarterly QAPI meetings.
Deficiencies (2)
| Description |
|---|
| Deficiency F0000: Reviewed by facility QA committee; specific deficiency to be reviewed at next QA meeting. |
| Deficiency F684-D: Licensed nursing staff educated on resident assessments after falls, triage policy, transportation in case of injury; CMA/CNA staff educated on accident prevention; updated procedures and documentation for falls and transfers. |
Report Facts
Deficiency ID: F0000 and F684-D referenced in plan of correction
Plan of Correction Completion Date: F0000 corrective action completion date 10/16/2018; F684-D corrective action completion date 10/10/2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Todd Schlosser | Administrator | Administrator who submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 29, 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 had been corrected.
Findings
All previously cited deficiencies identified by regulation numbers and prefix codes were corrected as of 06/02/2017, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiency correction dates: 6
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 7
May 24, 2017
Visit Reason
The inspection was a health resurvey to assess compliance with previously cited deficiencies related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to update and revise care plans for pressure ulcer prevention and treatment, failure to obtain valid medical justification for indwelling catheter use, unsafe environmental hazards such as unsecured chemicals, improper storage of food items, and expired medications in stock.
Severity Breakdown
SS=D: 2
SS=G: 1
SS=E: 3
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to update and revise the care plan for a resident regarding individualized interventions for prevention and treatment of pressure ulcers. | SS=D |
| Failure to provide care consistent with professional standards to prevent and treat pressure ulcers, resulting in a facility-acquired unstageable pressure ulcer. | SS=G |
| Failure to obtain a valid medical justification for use of an indwelling urinary catheter for a resident. | SS=D |
| Failure to ensure the resident environment remained free from accident hazards, including inadequate assessment and unsafe grab bar installation. | SS=E |
| Failure to store, prepare, distribute, and serve food under sanitary conditions, including unlabeled and undated food items in nourishment refrigerator. | SS=F |
| Failure to ensure stock medications and vaccine vials were not expired in medication carts and medication room. | SS=E |
| Failure to secure chemicals in the beauty shop, exposing cognitively impaired residents to potential harm. | SS=E |
Report Facts
Resident census: 27
Sample size: 12
Pressure ulcer size: 6
Pressure ulcer size: 4
Grab bar gap: 10.25
Grab bar distance from mattress: 3
Expired Vitamin A capsules: 250
Expired medication liquid volume: 16
Expired pneumococcal vaccine: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Verified development of pressure ulcer, lack of care plan updates, medication expiration, unsecured chemicals, and catheter justification | |
| Nurse Aide H | Reported resident did not have pressure relieving boots until after ulcer development | |
| Nurse J | Reported resident's pressure ulcer progression | |
| Dr. K | Physician | Verified resident condition and ordered pressure relieving boots |
| Dietary Staff D | Verified improper food storage in nourishment refrigerator | |
| Dietary Staff C | Reported responsibility for checking nourishment refrigerator | |
| Nurse G | Reported resident's use of grab bar | |
| Nurse Aide F | Reported resident's use of grab bar | |
| Administrative Staff A | Verified unsafe grab bar gap |
Inspection Report
Re-Inspection
Deficiencies: 0
May 24, 2017
Visit Reason
The visit was a resurvey of the Assisted Living/Residential Healthcare facility to verify compliance following a prior inspection.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 1
May 24, 2017
Visit Reason
This document is a Plan of Correction submitted in response to the deficiency report for Sandstone Heights Assisted Living dated 05/24/2017.
Findings
No deficiencies were cited during the inspection on 05/24/2017.
Deficiencies (1)
| Description |
|---|
| No deficiencies were cited |
Inspection Report
Plan of Correction
Deficiencies: 6
May 24, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report dated May 24, 2017.
Findings
The Plan of Correction outlines corrective actions taken to address multiple deficiencies including care plan updates for pressure ulcers, catheter diagnosis documentation, removal of unauthorized grab bars, food labeling, and medication management. The facility commits to substantial compliance by early June 2017.
Severity Breakdown
D: 2
G: 1
E: 2
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Care plan updated with interventions for pressure ulcers including pressure relieving boots, wound treatments, and nutritional supplements. | D |
| Nursing staff educated to inspect skin daily and care plans updated for residents at high risk of skin breakdown. | G |
| Appropriate diagnosis obtained for catheter use and nursing staff educated on CMS diagnosis requirements. | D |
| Unauthorized grab bar removed; staff educated on assistive device policy; security lock installed on beauty shop door. | E |
| Improperly labeled food items removed; dietary and nursing staff educated on nourishment refrigerator/freezer policies. | F |
| Outdated medications removed; pharmacy consultant disposed of expired meds; staff educated on medication inventory procedures. | E |
Report Facts
Deficiencies cited: 6
Compliance target date: Jun 2, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Enforcement
Deficiencies: 1
May 24, 2017
Visit Reason
A Health survey was conducted on May 24, 2017, 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 at a level of actual harm that is not immediate jeopardy, specifically related to pressure ulcers (F314). Due to these deficiencies, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Severity Breakdown
Level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314, Pressure Ulcers | Level of actual harm |
Report Facts
Denial of payment effective date: Jun 14, 2017
Compliance deadline: Nov 24, 2017
Civil Money Penalty threshold: 5000
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact for questions regarding instructions and enforcement actions |
| Lisa Hauptman | CMS Regional Office Contact | Contact for questions regarding the enforcement matter |
Inspection Report
Life Safety
Deficiencies: 1
Mar 17, 2017
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 at the facility to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jun 17, 2017
Provider agreement termination date: Sep 17, 2017
Plan of Correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and is identified as Licensure Certification & Enforcement Manager. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 14, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that all previously cited deficiencies, including those under regulations 483.25 and 483.25(h), were corrected as of 10/14/2016.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Sep 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint Investigation #101597 and #105410 regarding the facility's failure to provide necessary care and services to residents.
Findings
The facility failed to provide necessary care and services, including thorough assessment and pain management after a fall with injury for one resident. The facility also failed to ensure adequate supervision to prevent accidents, resulting in a resident fall and wrist fracture.
Complaint Details
The visit was triggered by complaints #101597 and #105410. The complaint investigation found substantiated deficiencies related to failure in care and supervision.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide necessary care and services, including thorough assessment and pain management after a fall with injury for Resident #1. | SS=D |
| Failure to ensure each resident received adequate supervision to prevent accidents, resulting in Resident #1 falling and sustaining a wrist fracture. | SS=D |
Report Facts
Census: 31
Sample size: 4
Residents reviewed for care and services: 3
Residents reviewed for accidents: 3
BIMS score: 3
Tylenol dosage: 325
Fall time: 3
Visual check interval: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide A | Nurse Aide | Found Resident #1 on the floor and reported resident's pain in left wrist. |
| Nurse B | Nurse | Stated staff should assess resident and check vital signs when condition changes. |
| Administrative Nurse C | Administrative Nurse | Verified staff failed to complete thorough assessment and pain management for Resident #1. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 28, 2016
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 'D' level deficiencies that constitute 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 the credible allegation of compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
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
Follow-Up
Deficiencies: 5
Feb 10, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.25(d), 483.25(l), 483.60(c), 483.65, and 483.75(o)(1) were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.75(o)(1) |
Inspection Report
Plan of Correction
Deficiencies: 6
Feb 10, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The facility outlines corrective actions for multiple deficiencies related to urinary catheter care, vital sign monitoring, medication regimen review, perineal care, and Quality Assurance and Assessment Committee attendance. The facility commits to substantial compliance by February 10, 2016.
Severity Breakdown
D: 3
F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility-wide system to assure compliance with regulations | — |
| Urinary catheter care including sanitary procedures and contamination prevention | D |
| Vital sign monitoring and frequency adherence | D |
| Medication regimen review and notification procedures | D |
| Perineal care and urinary catheter care retraining including sanitary procedures and contamination avoidance | F |
| Quality Assurance and Assessment Committee attendance by Medical Director | F |
Report Facts
Compliance date: Feb 10, 2016
QAA committee meeting date: Feb 16, 2016
Medical Director quarterly meetings attended: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 10, 2016
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report documents that previously cited deficiencies have been corrected as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency identified by regulation 26-41-202 (d) was corrected |
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 5
Feb 1, 2016
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements related to catheter care, urinary incontinence care, medication regimen monitoring, infection control, and quality assessment and assurance.
Findings
The facility failed to provide proper catheter and perineal care to prevent urinary tract infections for two residents, failed to obtain scheduled blood pressure monitoring for three residents, and the pharmacist failed to report these irregularities. Infection control practices were inadequate during catheter and incontinent care. The Quality Assessment and Assurance committee did not have required members attending meetings regularly, affecting the facility's ability to address quality deficiencies.
Severity Breakdown
SS=D: 3
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure proper treatment and services to prevent urinary tract infections due to inadequate catheter and perineal care for residents #6 and #10. | SS=D |
| Failed to obtain scheduled blood pressure checks as ordered by the physician for residents #11, #14, and #25. | SS=D |
| Pharmacist failed to identify and report lack of blood pressure monitoring to the director of nursing for residents #11, #14, and #25. | SS=D |
| Failed to maintain infection control practices during catheter and incontinent care for residents #6 and #10. | SS=F |
| Failed to ensure required Quality Assessment and Assurance committee members attended meetings to identify and correct quality deficiencies. | SS=F |
Report Facts
Census: 27
Sample size: 14
Residents reviewed for medications: 5
Blood pressure checks missed: 128
Blood pressure checks missed: 74
Blood pressure checks missed: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide E | Observed improperly emptying urinary drainage bag and failing to wash hands before exiting resident's room | |
| Nurse Aide G | Observed contaminating washcloths and sink counter during catheter care | |
| Nurse Aide I | Verified improper perineal care technique and use of disposable wipes | |
| Administrative Nurse A | Verified staff should perform catheter and perineal care per policy; acknowledged lack of blood pressure monitoring and pharmacist reporting | |
| Nurse B | Verified missing blood pressure documentation for Resident #14 | |
| Nurse C | Unaware of physician order for blood pressure checks for Resident #11 | |
| Nurse D | Stated nurse aides perform catheter care but did not observe or verify correct technique | |
| Administrative Staff K | Reported medical director attended only one QAA meeting in prior year | |
| Administrative Nurse B | Stated QAA committee meets monthly and reviews reports from disciplines |
Inspection Report
Re-Inspection
Census: 6
Deficiencies: 1
Feb 1, 2016
Visit Reason
This inspection was a licensure resurvey of an Assisted Living/Residential Healthcare facility to assess compliance with negotiated service agreement review requirements.
Findings
The facility failed to ensure the review and, if necessary, revision of the negotiated service agreements at least once every 365 days for three sampled residents (#1, #2, and #3). The agreements had not been reviewed or revised since their admission dates in 2014.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to review and revise negotiated service agreements at least once every 365 days for Residents #1, #2, and #3. | SS=D |
Report Facts
Census: 6
Sampled residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Stated staff had not completed annual review of negotiated service agreements |
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 1, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the letter regarding the survey findings and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 14, 2015
Visit Reason
This document is a Plan of Correction report completed by a qualified State surveyor to show deficiencies previously reported on the CMS-2567 and the dates such corrective actions were accomplished.
Findings
The report lists corrections for deficiencies identified by regulation or LSC provision numbers, with completion dates noted. The only specific correction date provided is 12/14/2015 for regulation 483.25(h).
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.25(h) |
Report Facts
Correction completion date: Dec 14, 2015
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Nov 19, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#93178) regarding the facility's failure to provide adequate supervision and accident prevention measures for a resident with a history of falls.
Findings
The facility failed to provide adequate supervision and timely interventions to prevent accidents for Resident #1, who had severe cognitive impairment and a history of falls, resulting in a third fall from an electric lift recliner causing a cervical fracture. The care plan lacked updated preventative measures after multiple falls, and staff did not evaluate the resident's safe use of the recliner until after the third fall.
Complaint Details
Complaint investigation #93178 focused on inadequate supervision and accident prevention for Resident #1, who sustained a cervical fracture after a third fall from an electric recliner. The investigation found the facility failed to update the care plan or evaluate the resident's safe use of the recliner in a timely manner.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remained free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents for Resident #1. | SS=G |
Report Facts
Resident census: 28
Resident sample size: 3
Fall risk assessment score: 20
Number of falls: 3
Days delay in care plan update: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide A | Nurse Aide | Reported resident was confused and played with recliner controls |
| Nurse Aide B | Nurse Aide | Stated he/she was never told to watch resident's use of recliner controls |
| Nurse C | Nurse | Noted resident's increased confusion and use of recliner controls |
| Administrative Nurse E | Administrative Nurse | Verified resident had fallen 3 times and staff had not evaluated safe use of recliner until after 3rd fall |
| Nurse D | Nurse | Reviewed care plan after fall but did not make changes; unaware if evaluation for recliner use was done |
| Physician F | Physician | Stated facility should evaluate resident for safe use of electric recliner after recurrent falls |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 19, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be a "G" level. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended until substantial compliance is achieved.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be a "G" level | G |
Report Facts
Denial of payment effective date: Feb 19, 2016
Denial of payment effective date: Feb 19, 2015
Termination recommendation date: May 19, 2016
IDR submission timeframe: 10
Compliance timeframe: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named in relation to instructions for Informal Dispute Resolution and contact for questions |
Inspection Report
Plan of Correction
Deficiencies: 2
Oct 23, 2015
Visit Reason
This plan of correction addresses deficiencies cited related to a complaint investigation involving a fall incident on 10/23/2015 and subsequent lift chair assessment.
Findings
The facility identified issues with resident safety related to lift chair use after a fall incident. The plan includes implementing a facility-wide system for compliance, conducting lift chair assessments for all residents using lift chairs, and training nursing staff on care plans.
Complaint Details
Complaint investigation related to a fall incident on 10/23/2015 involving Resident 1 and lift chair safety.
Severity Breakdown
G: 1
F0000: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure resident safety related to lift chair use after a fall incident. | G |
| Failure to develop and implement a facility-wide system to assure compliance with regulations. | F0000 |
Report Facts
Completion date for plan of correction: Dec 14, 2015
Fall date: Oct 23, 2015
Training module duration: 30
BIMS score threshold: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the plan of correction |
Inspection Report
Follow-Up
Deficiencies: 3
Oct 1, 2015
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 had been corrected.
Findings
The report documents that deficiencies identified under regulations 483.25, 483.25(d), and 483.25(h) were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 483.25 |
| Deficiency under regulation 483.25(d) |
| Deficiency under regulation 483.25(h) |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 24, 2015
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 'D' level deficiencies that constitute 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 the credible allegation of compliance and the submitted plan.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and complaint coordinator related to the survey findings. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 3
Sep 24, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#90779 and #91096) to assess the facility's compliance with care and safety regulations.
Findings
The facility failed to provide thorough, timely, and accurate assessments for residents, failed to prevent urinary tract infections related to catheter care, and did not ensure safe transfers with mechanical lifts, resulting in resident harm and safety concerns.
Complaint Details
The visit was triggered by complaint investigations #90779 and #91096, focusing on care quality, catheter use, and resident safety.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide a thorough, timely, and accurate assessment for Resident #3 during an episode of low blood sugar and after weight gain and swelling. | SS=D |
| Failed to provide appropriate treatment and services to prevent urinary tract infections for Residents #2 and #3 with indwelling urinary catheters. | SS=D |
| Failed to provide a safe transfer with a mechanical lift for Resident #2, resulting in falls and unsafe transfers. | SS=D |
Report Facts
Resident census: 29
Sample size: 7
Resident #3 weight gain: 12
Blood sugar readings: 227
Blood sugar readings: 173
Blood sugar readings: 58
Blood sugar readings: 52
Urinary catheter size: 20
Antibiotic dosage: 500
Antibiotic dosage: 100
Resident #2 BIMS score: 3
Resident #3 BIMS score: 9
Resident #2 BIMS score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide B | Reported notifying charge nurse of resident condition changes and weight monitoring | |
| Nurse C | Stated he/she would not administer insulin if resident status changed | |
| Administrative Nurse D | Administrative Nurse | Verified weight gain, lack of physician notification, insulin administration errors, and infection control concerns |
| Nurse F | Verified staff placing urinary catheter drainage bags in trash cans | |
| Nurse Aide E | Verified unsafe mechanical lift transfer without proper strap placement | |
| Restorative Aide | Evaluated resident safety for mechanical lift use after incident |
Inspection Report
Follow-Up
Deficiencies: 1
May 19, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously cited deficiency with regulation 483.25(h) was corrected as of 05/19/2015. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.25(h) previously cited and corrected. |
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
May 14, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#86207) regarding the facility's supervision and safety measures related to resident elopement risks.
Findings
The facility failed to adequately supervise a resident identified as an elopement risk who eloped from the unsecured courtyard for approximately 15 minutes. Observations and interviews confirmed the resident ambulated independently and exited through a gate secured only by a chain and clasp hook, not a lock.
Complaint Details
The complaint investigation #86207 substantiated that the facility failed to supervise a cognitively impaired resident with elopement risk, who exited the facility unsupervised and was found walking in the street four blocks away.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to adequately supervise Resident #1 who eloped from the facility's unsecured courtyard. | SS=D |
Report Facts
Census: 31
Elopement duration: 15
Date of admission: Jan 31, 2015
BIMS score: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Provided observations and statements regarding the resident's elopement and facility courtyard security | |
| Nurse B | Provided statements about the resident's elopement risk and behavior | |
| Administrative Staff C | Provided background information on the resident's prior living situation and facility entry/exit behavior |
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 14, 2015
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and plan of correction correspondence. |
Inspection Report
Plan of Correction
Deficiencies: 1
May 14, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Sandstone Heights.
Findings
The facility was cited for deficiencies related to supervision of residents who are elopement risks, specifically regarding their presence in the patio area and outside the facility. The plan includes staff inservice and monitoring compliance by the Director of Nursing and Administrator.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Sandstone Heights 051415 Complaint.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents who are elopement risks are supervised in the patio area and outside the facility. | D |
Report Facts
Complete Date for Plan of Correction: May 19, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction. |
Inspection Report
Follow-Up
Deficiencies: 1
Apr 13, 2015
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 had been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) with ID prefix F0225 was corrected as of 04/13/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) previously cited and corrected. |
Report Facts
Deficiency correction date: Apr 13, 2015
Inspection Report
Plan of Correction
Deficiencies: 2
Apr 13, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at the facility.
Findings
The facility was cited for deficiencies related to unwitnessed falls with injury and other falls with significant injury, requiring reporting to appropriate agencies within 5 working days and investigation by the Director of Nursing or designee.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation.
Severity Breakdown
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility-wide system to assure correction and continued compliance with regulations. | — |
| Unwitnessed falls with injury and all other falls with significant injury will be reported to appropriate agencies within 5 working days; investigation started by DON or designee. | D |
Report Facts
Complete Date for Correction: Apr 13, 2015
Reporting timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Added and modified the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Apr 9, 2015
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of failure to report resident falls and injuries to the state agency within the required timeframe.
Findings
The facility failed to report two falls involving Resident #1 to the state agency within 5 working days, including one fall resulting in lacerations and another resulting in rib fractures. The resident had severe cognitive impairment and was at high risk for falls. The facility did not comply with its own Abuse, Neglect and Exploitation policy regarding timely reporting and investigation.
Complaint Details
Complaint #84803. The facility failed to report two falls involving Resident #1 to the state agency within the required 5 working days. One fall resulted in lacerations requiring sutures, and the other resulted in fractures of the 9th and 10th ribs. The resident was cognitively impaired and at high risk for falls.
Deficiencies (2)
| Description |
|---|
| Failure to report a fall with injury to the state agency within 5 working days. |
| Failure to report a fall resulting in rib fractures to the state agency within 5 working days. |
Report Facts
Resident census: 32
Falls with injury: 2
BIMS score: 3
Laceration size: 3
Rib fractures: 2
Reporting delay: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Verified the falls and reporting delays for Resident #1. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 9, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and compliance communication. |
| Sue Hine | Regional Manager, RN | Copied on the letter. |
Inspection Report
Follow-Up
Deficiencies: 11
Nov 21, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date 11/21/2014.
Deficiencies (11)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.15(g)(1) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(k)(3)(ii) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.55(b) |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 11
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 11
Oct 30, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #80063 to investigate allegations of possible misappropriation of residents' property and other compliance issues.
Findings
The facility failed to thoroughly investigate and report allegations of misappropriation of resident property, provide dignity and privacy during insulin administration, provide medically-related social services including dental care, accurately assess dental issues, ensure qualified staff for feeding tube care, provide education on edema and safe footwear, prevent urinary catheter contamination, maintain a safe environment free of hazards including accessible closets and secure equipment, provide routine and emergency dental services, administer medications as ordered, and maintain infection control practices including hand hygiene and sanitary cleaning.
Complaint Details
The visit was complaint-related as it included a complaint investigation (#80063) regarding allegations of misappropriation of resident property and other compliance issues.
Severity Breakdown
SS=D: 9
SS=E: 1
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate and report allegations of possible misappropriation of residents' property for 1 of 15 sampled residents. | SS=D |
| Failed to provide care in a manner that enhanced and promoted dignity for 2 residents who received insulin injections within view of other residents. | SS=D |
| Failed to provide medically-related social services to attain or maintain the highest practicable well-being for 3 residents regarding dental services and clothing/shoes. | SS=D |
| Failed to conduct a comprehensive and accurate dental assessment for 1 resident. | SS=D |
| Failed to ensure qualified staff provided appropriate care of feeding tube and to immediately report abnormal findings for 1 resident. | SS=D |
| Failed to provide education and consequences regarding bilateral lower extremity edema and unsafe, loose fitting footwear for 1 resident. | SS=D |
| Failed to prevent urinary catheter bag and/or tubing from contacting the floor for 2 residents. | SS=D |
| Failed to keep residents' closets accessible, prevent entrapment or injury from transfer bars or side rails, and secure towel warmer in janitor closet for 3 residents. | SS=E |
| Failed to provide or obtain routine and emergency dental services for 2 residents. | SS=D |
| Failed to administer medication as directed by physician's orders for 1 resident. | SS=D |
| Failed to use appropriate hand hygiene when administering medications for 8 of 11 residents and failed to provide a sanitary environment to prevent disease and infection. | SS=F |
Report Facts
Residents sampled: 15
Residents census: 24
Severity D deficiencies: 9
Severity E deficiencies: 1
Severity F deficiencies: 1
Fall risk score: 10
Temperature of towel warmer: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide G | Named in medication error finding for administering incorrect aspirin type. | |
| Administrative Nurse A | Involved in multiple findings including medication error, feeding tube incident, and infection control. | |
| Housekeeping Staff P | Named in infection control finding for using non-disinfectant cleaner on resident sinks. | |
| Social Service Staff I | Mentioned in relation to dental care and resident interviews. | |
| Nurse D | Mentioned in relation to dental care and resident observations. | |
| Nurse Aide C | Mentioned in feeding tube incident. | |
| Nurse Aide B | Mentioned in feeding tube incident. | |
| Therapy Staff F | Mentioned in relation to resident gait and footwear concerns. | |
| Nurse Aide E | Mentioned in relation to resident ambulation and footwear. | |
| Nurse A | Mentioned in multiple findings including infection control and resident care. | |
| Administrative Staff J | Mentioned in relation to towel warmer safety. |
Inspection Report
Renewal
Deficiencies: 0
Oct 30, 2014
Visit Reason
The licensure resurvey of the facility was conducted to assess compliance for continued program participation.
Findings
The inspection resulted in a finding of no deficiency citation.
Inspection Report
Enforcement
Deficiencies: 1
Oct 30, 2014
Visit Reason
A health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency classified as an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective November 21, 2014.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency classified as an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines Jr. | Administrator | Named as facility administrator in the report header. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Sue Hine | Regional Manager | Copied on the letter. |
Inspection Report
Life Safety
Deficiencies: 1
Aug 21, 2014
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 deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Denial of payments effective date: Nov 21, 2014
Provider agreement termination date: Feb 21, 2015
IDR request timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines Jr. | Administrator | Named as facility administrator in the report header. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Joe Ewert | Commissioner | Mentioned in carbon copy (c:) section. |
Inspection Report
Follow-Up
Deficiencies: 1
Sep 16, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.60(b), (d), (e) with ID prefix F0431 was corrected as of 09/16/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.60(b), (d), (e) previously cited |
Report Facts
Deficiencies corrected: 1
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 1
Aug 28, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with medication storage and narcotic drug record requirements.
Findings
The facility failed to ensure that the oncoming and offgoing nurses signed the narcotic count sheets to verify the accuracy of narcotic counts on two medication carts, with multiple missing signatures documented over several shifts.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have the oncoming and offgoing nurses sign the narcotic count sheet ensuring the narcotic count was correct on 2 of 2 medication carts. | SS=E |
Report Facts
Census: 28
Sample size: 13
Missing signatures: 18
Missing signatures: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified missing signatures on narcotic drug audit sheets | |
| Administrative Nurse B | Provided information about facility policy on narcotic count discrepancies |
Inspection Report
Original Licensing
Deficiencies: 0
Aug 28, 2013
Visit Reason
The licensure survey was conducted to assess compliance for facility licensure.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 9
Sep 11, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by their regulation numbers were corrected as of 08/16/2012, with no uncorrected deficiencies remaining at the time of this revisit.
Deficiencies (9)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.15(g)(1) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.55(b) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 9
Aug 16, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey and to assure correction and continued compliance with regulations.
Findings
The plan outlines corrective actions for multiple deficiencies including incident notification, dental services, housekeeping and maintenance, care plan adjustments, accident hazard prevention, food sanitation, and infection control practices. The facility commits to substantial compliance by August 16, 2012.
Severity Breakdown
D: 6
E: 2
G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to notify physician when a resident has an accident resulting in injury and lack of proper incident documentation. | D |
| Failure to provide medically-related social services including scheduling dental appointments and transportation. | D |
| Failure to maintain a sanitary, orderly, and comfortable interior including damaged bathroom doors and loose caulking around toilet base. | E |
| Failure to follow residents' care plans, specifically related to toileting needs and documentation. | D |
| Failure to provide necessary services for activities of daily living including toileting assistance and documentation. | D |
| Failure to ensure resident environment is free of accident hazards and provide adequate supervision to prevent accidents. | G |
| Failure to distribute and serve food under sanitary conditions. | E |
| Failure to provide or obtain routine and emergency dental services to meet resident needs. | D |
| Failure to provide infection control practices to maintain a safe, sanitary environment and prevent disease transmission. | D |
Report Facts
Complete Date: Aug 16, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin Crupper | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 9
Jul 17, 2012
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation regarding concerns at the facility.
Findings
The facility failed to notify a resident's physician timely after an accident causing burns, failed to provide medically-related social services including dental care follow-up, failed to maintain sanitary and comfortable conditions in resident areas, failed to follow care plans for toileting and ADL assistance, failed to provide adequate supervision and assistive devices preventing accidents, failed to maintain sanitary food handling practices, and failed to maintain proper infection control practices.
Complaint Details
The complaint investigation included allegations of failure to notify physician of injury, failure to provide medically-related social services, failure to maintain sanitary conditions, failure to follow care plans, failure to prevent accidents, failure to maintain food sanitation, failure to provide dental services, and failure to maintain infection control.
Severity Breakdown
SS=D: 6
SS=E: 2
SS=G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to notify the physician of an accident with injury involving a resident who spilled hot coffee causing burns. | SS=D |
| Failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for a resident with dental pain and no follow-up on dental appointment. | SS=D |
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for resident halls. | SS=E |
| Failed to follow the care plan for toileting assistance for a resident. | SS=D |
| Failed to provide assistance for activities of daily living for a dependent resident, including toileting and incontinence care. | SS=D |
| Failed to provide supervision and assistive devices to prevent accidents resulting in burns from spilled hot coffee. | SS=G |
| Failed to store, prepare, distribute and serve food under sanitary conditions, including improper handling of glasses and food plates by dietary staff. | SS=E |
| Failed to provide or obtain routine and emergency dental services for a resident with dental pain and missing/broken teeth. | SS=D |
| Failed to establish and maintain an infection control program including proper storage of oxygen equipment and proper hand hygiene during incontinence care. | SS=D |
Report Facts
Census: 30
Sample size: 13
Burn wound size: 2
Burn wound size: 3
Coffee temperature: 158
Coffee temperature: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Administrative Nurse | Verified failures in notification, assessment, and care related to resident burns. |
| Physician T | Physician | Provided treatment orders and guidance for resident burn care. |
| Nurse H | Nurse | Verified care plan instructions and lack of knowledge about resident dental pain. |
| Social Service Staff J | Social Service Staff | Verified attempts to arrange dental care and contact with resident's family. |
| Dietary Staff A | Dietary Staff | Observed improperly handling glasses and food plates. |
| Dietary Staff B | Dietary Staff | Verified proper food handling procedures. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 8, 2011
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID NLCK11 and State ID N080002.
Findings
No specific deficiencies or findings are detailed in this document; it serves as a record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 2
N080002 POC 8M7111
Visit Reason
This document is a Plan of Correction submitted by Sandstone Heights Assisted Living Facility in response to deficiencies cited in a prior inspection report.
Findings
The facility plans to develop and implement a system to assure compliance with regulations and update Assisted Living Negotiated Service Agreements, with oversight by the Director of Nursing and Administrator. The facility aims to be in substantial compliance by February 10, 2016.
Severity Breakdown
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to have a facility-wide system to assure compliance with regulations. | — |
| Assisted Living Negotiated Service Agreements were not reviewed or updated as needed. | D |
Report Facts
Complete Date for corrective actions: Feb 10, 2016
Date of review of Assisted Living Negotiated Service Agreements: Jan 26, 2016
Date of Quality Assurance and Assessment Committee meeting: Feb 16, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
N080002 POC EED411
Visit Reason
This document serves as the facility's Plan of Correction in response to deficiencies cited related to resident fall assessments and accident prevention.
Findings
The facility has implemented corrective actions including staff education on fall assessments and accident prevention, updated procedures and documentation for resident transfers and falls, and established ongoing monitoring through meetings and QAPI sessions.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency related to thorough resident assessments after a fall, triage policy, and transportation expectations. | D |
Report Facts
Plan of Correction completion date: Oct 10, 2018
Inspection Report
Plan of Correction
Deficiencies: 3
N080002 POC EPPC11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a complaint investigation at Sandstone Heights.
Findings
The facility outlines corrective actions including re-orientation of nursing staff on policies related to change in condition and incident/accident occurrences, with monitoring by the Director of Nursing and Assistant Director of Nursing to ensure compliance.
Severity Breakdown
D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility-wide system to assure compliance with regulations | — |
| Nurses re-oriented on Change in Condition Policy | D |
| Nurses re-oriented on Incident/Accident Occurrence Policy | D |
Report Facts
Complete Date for corrective actions: Oct 14, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Plan of Correction
Deficiencies: 2
N080002 POC FIL811
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The facility plans to develop and implement a system to assure correction and continued compliance with regulations, including monitoring narcotic audits weekly and involving the pharmacy consultant in monthly reviews.
Severity Breakdown
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficiencies cited during the survey requiring a facility-wide system to assure correction and compliance. | — |
| Failure to properly monitor narcotic counts and signatures for accuracy. | E |
Report Facts
Complete Date for Correction: Sep 16, 2013
Inservice Date: Aug 29, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Sandy Kliewer | Office Manager | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 3
N080002 POC GFR511
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Sandstone Heights.
Findings
The plan outlines corrective actions including staff inservices on weight monitoring and lift use, installation of hooks for catheter bags, and policy changes to ensure compliance with regulations.
Complaint Details
This Plan of Correction addresses deficiencies identified during a complaint investigation at Sandstone Heights.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to comply with regulations requiring weight monitoring policy adherence and thorough assessments. | D |
| Inadequate maintenance related to catheter bag placement leading to potential sanitation issues. | D |
| Improper use and monitoring of mechanical lifts for resident safety. | D |
Report Facts
Complete Date: Oct 7, 2015
Complete Date: Oct 1, 2015
Complete Date: Sep 28, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 9
N080002 POC O2OC11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions and timelines to achieve substantial compliance.
Findings
The Plan of Correction details multiple corrective actions including staff inservices, monitoring of compliance by the DON and other supervisors, resident-specific interventions, and environmental safety improvements to address cited deficiencies.
Severity Breakdown
D: 7
E: 1
F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to report suspected misappropriation of resident property and abuse. | D |
| Privacy during medical and nursing treatments not assured. | D |
| Inadequate dental care follow-up and oral assessment documentation. | D |
| Incident involving removed PEG tube and failure to notify appropriate staff. | D |
| Unsafe resident practices related to footwear and ambulation. | D |
| Improper positioning and handling of catheter tubing and bags. | D |
| Unsafe use of assist/side rails and unsecured janitor closet door posing safety hazards. | E |
| Medication aide errors and failure to follow proper medication administration procedures. | D |
| Medication aide failed to wash hands before medication administration. | F |
Report Facts
Dates for substantial compliance: Nov 11, 2014
Dates for substantial compliance: Nov 21, 2014
Dates for substantial compliance: Nov 29, 2014
Date for substantial compliance: Nov 6, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide G | Medication Aide | Named in findings related to medication errors and failure to wash hands before medication administration |
| John Gaines | Administrator | Administrator monitoring investigations and compliance |
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