Inspection Report Summary
The most recent inspection of Schowalter Villa on June 2, 2025, resulted in zero deficiencies. Earlier inspections showed a mixed record with several citations related primarily to resident care planning, medication management, and activity programming, particularly noted in a November 7, 2024 complaint investigation. Prior complaint investigations included substantiated issues with supervision and safety, including immediate jeopardy findings related to resident elopement in 2019 and 2021, but these were followed by corrective actions and subsequent compliance. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with recent inspections showing no deficiencies after addressing prior concerns.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
95 residents
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Deficiencies: 0
Jun 2, 2025
Visit Reason
The visit was a Re-Licensure survey for the Assisted Living Facility Schowalter Villa conducted on 05/29/25 and 06/02/25.
Findings
The survey resulted in zero deficiencies for the facility.
Inspection Report
Renewal
Deficiencies: 0
Jun 2, 2025
Visit Reason
The visit was conducted as a Re-Licensure survey for the Assisted Living Facility on 05/29/25 and 06/02/25.
Findings
The Re-Licensure survey resulted in zero deficiencies for the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 20, 2024
Visit Reason
An offsite revisit survey was conducted on 12/20/24 to verify correction of all previous deficiencies cited on 11/07/24.
Findings
All deficiencies have been corrected as of the compliance date of 12/02/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 6
Nov 7, 2024
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation involving multiple complaint numbers.
Findings
The facility was found deficient in multiple areas including failure to revise care plans to reflect resident behaviors, failure to provide weekend activities reflecting resident interests, failure to ensure pharmacist review and reporting of antipsychotic medications without CMS-approved indications, failure to ensure appropriate use and documentation of psychotropic medications, failure to ensure collaboration with hospice services, and failure to offer pneumococcal conjugate vaccine PCV20 to a resident.
Complaint Details
The inspection included complaint investigations KS00191102, KS00188575, and KS00188208.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to revise Resident 82's care plan to include identified behaviors toward male residents. | SS=D |
| Failure to provide activities on weekends reflecting residents' interests and preferences. | SS=E |
| Failure to ensure the Consultant Pharmacist identified and reported antipsychotic medication use without CMS-approved indication for Residents 31, 48, and 59. | SS=D |
| Failure to ensure appropriate indication or documented physician rationale and risk versus benefits for continued use of antipsychotic medications for Residents 31, 48, 12, and 59. | SS=E |
| Failure to ensure collaboration and communication between nursing home and hospice for Resident 59. | SS=D |
| Failure to offer and administer or obtain informed declination for Pneumococcal Conjugate Vaccine (PCV20) for Resident 31. | SS=D |
Report Facts
Census: 95
Residents reviewed for care plan revisions: 19
Residents reviewed for unnecessary medications: 5
BIMS score: 13
BIMS score: 7
BIMS score: 8
BIMS score: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements regarding antipsychotic medication indications and care plan updates. |
| Administrative Nurse D | Administrative Nurse | Discussed medication review processes and collaboration with pharmacy and physicians. |
| Certified Medication Aide R | Certified Medication Aide | Commented on care plan access and hospice equipment information. |
| Administrative Nurse E | Administrative Nurse | Discussed immunization policies and CDC guidelines. |
Inspection Report
Plan of Correction
Deficiencies: 6
Nov 7, 2024
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa Skilled Nursing in response to deficiencies cited during a survey concluded on November 7, 2024.
Findings
The Plan of Correction outlines corrective actions, prevention of recurrence, and monitoring plans for multiple deficiencies related to care plan timing and revision, activities meeting resident interests, drug regimen review, psychotropic medication use, hospice services, and immunizations.
Severity Breakdown
D: 4
E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Care Plan Timing and Revision | D |
| Activities Meet Interest/Needs Each Resident | E |
| Drug Regimen Review, Report Irregular, Act On | D |
| Free from Unnecessary Psychotropic Medications/PRN Use | E |
| Hospice Services | D |
| Influenza and Pneumococcal Immunizations | D |
Report Facts
Goal Date of Completion/Compliance: Dec 2, 2024
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 21, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-12-12.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2023-12-21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 30
Deficiencies: 1
Dec 11, 2023
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance with healthcare service plan requirements for residents at Schowalter Villa.
Findings
The facility failed to ensure that a licensed nurse developed healthcare service plans for falls to be included as part of the negotiated service agreements for three sampled residents. Documentation for fall-related services was missing in the healthcare service plans and negotiated service agreements for residents 1, 2, and 3.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop healthcare service plans for falls as part of the negotiated service agreement for residents 1, 2, and 3. | SS=E |
Report Facts
Census: 30
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN A | Licensed Nurse | Named in deficiency for failure to develop healthcare service plans for falls |
| LN B | Licensed Nurse | Interviewed regarding healthcare service plans for residents |
| Administrator C | Administrator | Interviewed regarding healthcare service plans for residents |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 11, 2023
Visit Reason
The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on 2023-12-11 at the facility.
Findings
The Plan of Correction addresses the citations identified during the licensure resurvey conducted on 2023-12-11. Specific deficiencies are not detailed in this document.
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 11, 2023
Visit Reason
The health survey was conducted as a regulatory inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 11, 2023
Visit Reason
The document is a Plan of Correction submitted in response to a health survey conducted at 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
Follow-Up
Deficiencies: 0
Jun 29, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-06-01.
Findings
All previously cited deficiencies have been corrected as of the compliance date 2022-06-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2022-06-01 and corrected by 2022-06-10
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 3
Jun 1, 2022
Visit Reason
The visit was a resurvey of the assisted living facility Schowalter Villa conducted on 05/31/22 - 06/01/22 to assess compliance with disaster preparedness, food preparation, infection control, and tuberculosis guidelines.
Findings
The facility failed to ensure quarterly reviews of the emergency management plan with residents, failed to serve food at proper temperatures as documented by incomplete food temperature logs, and failed to comply with tuberculosis guidelines by not completing a two-step TB skin test for a newly hired staff member.
Severity Breakdown
F: 1
E: 1
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure quarterly review of the facility's emergency management plan with residents. | F |
| Failed to ensure designated employees served food at the proper temperature; food temperatures were not logged 16 of 93 opportunities. | E |
| Failed to ensure compliance with tuberculosis guidelines; a newly hired Certified Medication Aide lacked a two-step TB skin test upon hire. | D |
Report Facts
Census: 37
Food temperature log missing entries: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager C | Certified Dietary Manager | Stated expectation that food temperatures be checked and documented for each meal |
| Certified Medication Aide B | Certified Medication Aide | Newly hired staff lacking two-step TB skin test upon hire |
| Operator A | Stated expectations regarding emergency preparedness plan reviews and TB skin testing |
Inspection Report
Plan of Correction
Deficiencies: 0
May 31, 2022
Visit Reason
This document represents the findings of a resurvey conducted for the Assisted Living facility between 05/31/22 and 06/01/22.
Findings
The document provides the provider's plan of correction related to the resurvey findings for the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 20, 2021
Visit Reason
The visit was conducted as a Health Survey and complaint investigation for complaint numbers #163249 and #162698 at the facility.
Findings
The investigation resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.
Complaint Details
Complaint investigation #163249 and #162698 resulted in no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 20, 2021
Visit Reason
The document is a plan of correction related to a health survey and complaint investigation #163249 and #162698 at the facility.
Findings
The health survey and complaint investigation 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.
Complaint Details
Complaint investigations #163249 and #162698 were conducted and resulted in no deficiencies.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Apr 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#161509) and a partial extended survey by the Kansas Department for Aging and Disability Services on behalf of CMS, triggered by concerns about failure to provide adequate supervision and perform 30 minute checks for a resident at risk for elopement.
Findings
The facility failed to provide adequate supervision of Resident 1, who was allowed unsupervised access to an unlocked courtyard and exited the facility, crossing a residential street. Staff failed to perform required 30 minute checks, placing the resident in immediate jeopardy. The facility subsequently locked the courtyard gate and provided staff education to address the issue.
Complaint Details
The investigation was based on complaint #161509. The immediate jeopardy status was identified due to failure to supervise a resident at risk for elopement. The immediate jeopardy was removed by 04/05/2021 after corrective actions were implemented.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision and perform 30 minute checks for a resident at risk for elopement, allowing the resident to exit the unlocked courtyard and cross a residential street. | J |
Report Facts
Resident census: 97
Residents at risk for elopement: 19
Missed 30 minute checks: 3
Time courtyard gate unlocked: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Informed of immediate jeopardy status and confirmed failure to perform 30 minute checks |
| Certified Medication Aide R | Certified Medication Aide | Described courtyard 30 minute checks process and staff responsibilities |
| Administrative Staff A | Administrative Staff | Reported on courtyard gate locking schedule and staff check procedures |
| Maintenance Staff U | Maintenance Staff | Responsible for locking/unlocking courtyard gate |
| Certified Nurse Aide M | Certified Nurse Aide | Admitted to forgetting resident was in courtyard and missing checks |
| Licensed Nurse G | Licensed Nurse | On duty during incident, unaware of resident missing and incomplete checks |
| Certified Nurse Aide N | Certified Nurse Aide | Reported shift details and staff responsibilities for 30 minute checks |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 27, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 7-27-2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 21, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 21, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a COVID-19 related survey conducted on 04/21/2020.
Findings
The facility was found to be deficiency free in the COVID survey conducted on 04/21/2020.
Deficiencies (1)
| Description |
|---|
| Deficiency free Covid survey |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 13, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 11/30/19.
Findings
All deficiencies have been corrected as of the compliance date of 12/13/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 5
Nov 13, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to allegations of abuse and other compliance issues at the facility.
Findings
The facility failed to timely report an allegation of abuse involving Resident 25, did not thoroughly investigate the allegation, and failed to separate the alleged perpetrator from resident care during the investigation. Additionally, the facility failed to implement fall prevention interventions for Resident 83 and did not secure hazardous chemicals from confused residents. The kitchen environment was also found to be unsanitary.
Complaint Details
The complaint investigation involved allegations of abuse where Resident 25 accused a staff member of hitting him. The facility failed to report the allegation timely and did not conduct a thorough investigation or separate the alleged perpetrator from resident care during the investigation.
Severity Breakdown
SS=D: 1
SS=E: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse to administrative staff and the state agency in a timely manner for Resident 25. | SS=D |
| Failure to thoroughly investigate the abuse allegation and prevent further potential abuse by not separating the alleged perpetrator from resident care. | SS=E |
| Failure to provide interventions to prevent repeated falls for Resident 83, including keeping the resident's door open for visual monitoring and keeping the wheelchair locked and beside the bed. | SS=E |
| Failure to secure hazardous chemicals from five confused, self-mobile residents on the 300/400 halls. | SS=E |
| Failure to maintain a clean and sanitary kitchen environment, including peeling paint on cabinets, grime buildup on outlets and floors. | SS=E |
Report Facts
Census: 98
Residents reviewed: 21
Residents reviewed for abuse: 2
Residents reviewed for falls: 5
Residents identified as confused and self-mobile: 5
Residents residing on 300-400 hall: 9
Fall Risk Assessment score: 23
Time delay in reporting abuse allegation: 3.37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Failed to report the abuse allegation to the State Agency and confirmed the alleged perpetrator continued working with residents. |
| Licensed Nurse G | Licensed Nurse | Notified Administrative Nurse D of the abuse allegation but did not receive further instruction and delayed notification. |
| Administrative Staff A | Administrative Staff | Failed to report the abuse allegation to the State Agency and verified lack of thorough investigation and failure to separate alleged perpetrator. |
| Certified Medication Aide Q | Certified Medication Aide | Alleged perpetrator accused by Resident 25 of hitting him. |
| Certified Nurse Aide LL | Certified Nurse Aide | Reported on wheelchair placement for Resident 83. |
| Administrative Nurse F | Administrative Nurse | Observed Resident 83 unattended with door closed. |
| Licensed Nurse H | Licensed Nurse | Reported on chemical storage concerns. |
| Licensed Nurse I | Licensed Nurse | Reported on fall prevention interventions for Resident 83. |
| Dietary Staff CC | Dietary Staff | Verified kitchen sanitation deficiencies. |
Inspection Report
Re-Inspection
Deficiencies: 5
Sep 25, 2019
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey conducted on 2019-07-25.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date 2019-09-25.
Deficiencies (5)
| Description |
|---|
| Deficiency identified under regulation 26-41-202 (a) |
| Deficiency identified under regulation 26-41-205 (d) (1-2) |
| Deficiency identified under regulation 26-41-205 (g) (4) |
| Deficiency identified under regulation 26-41-104 (a) |
| Deficiency identified under regulation 26-41-104 (d) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Renewal
Census: 34
Deficiencies: 5
Jul 25, 2019
Visit Reason
Licensure resurvey of an assisted living facility conducted over 7/23/19 to 7/25/19 to assess compliance with state regulations and facility policies.
Findings
The inspection identified multiple deficiencies including failure to ensure complete negotiated service agreements, improper medication administration practices, inadequate handling of sample/drug study medications, insufficient staffing during emergency evacuations, and lack of quarterly review of the emergency management plan.
Severity Breakdown
Level D: 1
Level E: 3
Level F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure the written negotiated service agreement for 1 of 4 residents included a description of services, identification of provider, and party responsible for payment for outside resources. | Level D |
| Failed to ensure licensed nurses and certified medication aides administered medications in accordance with medical orders and professional standards for 2 of 4 residents. | Level E |
| Failed to administer sample/drug study medications per facility policy including proper labeling, documentation, and informing resident/legal representative of risks for 1 of 4 residents. | Level E |
| Failed to conduct an emergency evacuation drill with sufficient staff to assist residents requiring help to a secure location. | Level F |
| Failed to conduct quarterly review of the facility's emergency management plan with staff and residents. | Level E |
Report Facts
Residents: 34
Residents with cognitive impairment: 4
Medication administration errors: 2
Sampled residents: 4
Xanax PRN administrations: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Licensed Nurse | Interviewed and observed regarding medication administration and emergency preparedness |
| Certified medication aide A | Certified Medication Aide | Observed administering medications and interviewed about medication procedures |
| Licensed nurse D | Licensed Nurse | Interviewed regarding medication order discrepancies and emergency plan awareness |
| Certified staff C | Certified Staff | Interviewed regarding emergency evacuation assistance and emergency plan review |
| Administrator/operator E | Administrator/Operator | Interviewed regarding emergency preparedness and inspection findings |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 10, 2019
Visit Reason
A revisit survey was conducted on 6/10/19 to verify correction of all previous deficiencies cited on 5/14/19.
Findings
All deficiencies cited in the previous inspection have been corrected as of 5/17/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
May 14, 2019
Visit Reason
Partial extended survey conducted due to a complaint investigation regarding a resident elopement incident.
Findings
The facility failed to ensure adequate supervision and a secure environment for a resident at risk of elopement, resulting in the resident leaving the facility unsupervised, sustaining injuries, and being missing for an extended period. Immediate jeopardy was identified but later abated after corrective actions were implemented.
Complaint Details
Complaint investigation # KS 00140792. The resident eloped from the facility, was missing for 58 minutes, and sustained a fracture and other injuries. The facility failed to maintain a secure environment and adequate supervision.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure one resident received adequate supervision to prevent elopement, resulting in the resident exiting the facility courtyard, crossing a residential street, and sustaining injuries. | Immediate Jeopardy |
Report Facts
Census: 90
Residents reviewed for elopement: 3
Elopement risk assessment scores: 15
Elopement risk assessment scores: 10
Time resident was out of staff sight: 58
Time resident was missing: 43
Minutes resident was outside facility: 45
Date of report revision: May 24, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided census roster and information about resident's history and elopement. | |
| Licensed Nurse B | Reported resident's status and involvement during elopement event. | |
| Licensed Nurse C | Supervised resident during courtyard incident and initiated Code Green. | |
| Direct Care Staff D | Responded to code alert, failed to supervise resident properly during elopement. | |
| Direct Care Staff E and F | Returned resident from Arboretum to facility. | |
| Direct Care Staff G | Reported resident's routine and monitoring. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 14, 2019
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 facility was found not to be in substantial compliance and the conditions constituted immediate jeopardy to resident health or safety related to F689, "J" CFR 483.25(d)(1). Enforcement remedies including denial of payment for new admissions were imposed.
Severity Breakdown
immediate jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F689, "J" CFR 483.25(d)(1) resulting in immediate jeopardy to resident health or safety | immediate jeopardy |
Report Facts
Denial of payment effective date: Jun 5, 2019
Recommended termination date: Nov 14, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Treva Greaser | Administrator | Facility administrator named in the report header |
| Caryl Gill | Complaint Coordinator | Author of the report letter |
Inspection Report
Plan of Correction
Deficiencies: 1
May 10, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies related to the security and safety of a resident with a wander-guard/code alert system in a healthcare facility.
Findings
The plan addresses security concerns involving door codes and entry points to prevent a highly mobile resident with dementia from leaving the facility unsupervised. Multiple corrective actions were implemented including door code changes, installation of code alert antennas, staff education, and care plan updates to promote resident safety.
Deficiencies (1)
| Description |
|---|
| Security and safety issues related to the wander-guard/code alert system for a highly mobile resident. |
Report Facts
Dates of corrective actions: May 10, 2019
Dates of corrective actions: May 17, 2019
Dates of corrective actions: May 3, 2019
Dates of corrective actions: Apr 25, 2019
Education completion deadline: May 13, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 13, 2018
Visit Reason
An offsite revisit survey was conducted on 12/13/2018 for all previous deficiencies cited on 10/23/2018.
Findings
All deficiencies have been corrected as of the compliance date of 11/22/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: Oct 23, 2018
Compliance date: Nov 22, 2018
Inspection Report
Plan of Correction
Deficiencies: 8
Oct 31, 2018
Visit Reason
This document is a Plan of Correction submitted in response to a prior deficiency report, outlining corrective actions and monitoring plans for various identified deficiencies in the facility.
Findings
The Plan of Correction addresses multiple deficiencies related to resident care, including bed hold notices during transfers, fall prevention and root cause analysis, wheelchair positioning, pressure ulcer interventions, food preparation and kitchen safety, dishwasher temperature monitoring, blood glucose monitoring techniques, and infection control measures. Each corrective action includes education, policy updates, and monitoring plans with oversight by the Director of Nursing and other responsible staff.
Severity Breakdown
D: 3
E: 3
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide bed hold notice to residents during transfer out | D |
| Inadequate fall prevention and root cause analysis processes | E |
| Wheelchair use policy lacking guidance on resident positioning for comfort and alignment | D |
| Insufficient education and monitoring of pressure ulcer interventions | D |
| Need for re-education on root cause analysis and fall intervention lists | E |
| Food preparation policies and training for pureed food not fully implemented | E |
| Dishwasher machine temperature policies and staff education incomplete | F |
| Blood glucose monitoring technique education and infection log tracking incomplete | F |
Report Facts
Completion date: Nov 22, 2018
Completion date: Nov 9, 2018
Completion date: Oct 31, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Tonya Keim | Executive Assistant | Submitted the Plan of Correction to KDADS |
| Director of Nursing | Responsible for oversight and completion of education and monitoring | |
| Director of Social Services | Responsible for verifying bed hold letter sending and reporting to QA committee | |
| Culinary General Manager | Responsible for monitoring food preparation and dishwasher temperature logs | |
| Volunteer Coordinator | Responsible for volunteer illness education and reporting |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 8
Oct 23, 2018
Visit Reason
Annual health resurvey of Schowalter Villa nursing facility to assess compliance with federal regulations including resident care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide written bed-hold policy notice, untimely care plan revisions for fall prevention, improper body positioning, inadequate pressure ulcer treatment, failure to prevent accidents and falls, failure to follow pureed food recipes, improper dishwasher sanitization temperature, and infection control lapses during blood sugar testing and infection tracking.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide resident and/or DPOA with written notice specifying duration of bed-hold policy upon transfer to hospital. | SS=D |
| Failure to timely review and revise care plans for 5 residents related to fall prevention interventions. | SS=E |
| Failure to ensure proper body alignment and positioning for a resident requiring staff assistance. | SS=D |
| Failure to provide adequate pressure relieving devices for a resident with pressure ulcers to promote healing and prevent further ulcers. | SS=D |
| Failure to find root cause analysis of falls and failure to provide appropriate interventions to prevent repeated falls for 5 residents. | SS=E |
| Failure to follow recipes for pureed foods served to 10 residents, compromising nutritional value and palatability. | — |
| Failure to ensure proper sanitizing water temperature in one of two dishwashers, risking spread of foodborne infection. | — |
| Failure to maintain infection prevention and control program including improper blood sugar testing technique and failure to track infections of staff, volunteers, and visitors. | SS=F |
Report Facts
Resident census: 85
Residents reviewed: 18
Falls experienced: 11
Dishwasher temperature: 133
Dishwasher temperature: 154
Dishwasher temperature: 174
Pressure ulcer size: 5
Pressure ulcer size: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Nursing Staff | Named in infection control deficiency related to improper blood sugar testing technique and fall interventions |
| Staff B | Administrative Nursing Staff | Confirmed failure to provide bed-hold notice and inappropriate fall interventions |
| Staff G | Administrative Nursing Staff | Oversaw infection control program and confirmed lack of infection tracking for staff and visitors |
| Staff U | Dietary Staff | Failed to follow pureed food recipes for nutritional value and palatability |
| Staff S | Dietary Staff | Observed dishwasher sanitizing temperature issues and notified maintenance |
| Staff C | Maintenance Staff | Checked dishwasher water temperature and explained maintenance procedures |
| Staff BB | Licensed Nursing Staff | Explained fall investigations and interventions but noted lack of training in root cause analysis |
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 23, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-11-22.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency at level "F", widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact and signatory related to enforcement and plan of correction acceptance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 18, 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 that the facility was not in substantial compliance with participation requirements and that conditions constituted Immediate Jeopardy and Past Non-Compliance to resident health or safety.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies related to F223, "J", CFR 483.12(a)(1); F225, "K", CFR 483.12(a)(3)(4)(c)(1)-(4); and F226, "F", CFR 483.12(b)(1)-(3), 483.95(c)(1)-(3). | Immediate Jeopardy |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter. |
Inspection Report
Plan of Correction
Deficiencies: 4
Aug 18, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Schowalter Villa.
Findings
The plan addresses past non-compliance issues linked to specific deficiency tags, with no new corrective actions required as the deficiencies were previously noted.
Complaint Details
This plan of correction is linked to a second revision complaint dated 08/18/2017 for Schowalter Villa.
Deficiencies (4)
| Description |
|---|
| Past non-compliance: no POC required |
| Past non-compliance: no POC required |
| Past non-compliance: no POC required |
| Past non-compliance: no POC required |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 3
Aug 18, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#119151) related to allegations of resident-to-resident sexual abuse and failure to protect residents from abuse.
Findings
The facility failed to ensure one resident (#1) was free from inappropriate physical contact by another resident (#2) who touched the opposite gender resident in a sexual manner. The facility also failed to timely report and investigate the incident and failed to protect seven opposite gender residents from potential sexual abuse. Staff education and corrective actions were implemented after the incident was identified.
Complaint Details
The complaint investigation (#119151) was triggered by allegations of resident-to-resident sexual abuse involving resident #2 touching resident #1 inappropriately and asking for sex. The facility failed to protect resident #1 and other opposite gender residents, and failed to timely report and investigate the incident.
Severity Breakdown
SS=D: 1
SS=K: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility failed to ensure that one resident (#1) remained free from inappropriate physical contact when resident #2 touched the opposite gender resident (#1) in an inappropriate manner and asked the resident for sex. | SS=D |
| The facility failed to timely and thoroughly investigate and report to the state agency an incident of resident to resident sexual abuse, and failed to protect 7 opposite gender residents from potential sexual abuse. | SS=K |
| The facility failed to implement policies and procedures to prevent abuse, neglect, and exploitation, and failed to ensure all staff were adequately trained on abuse reporting and handling inappropriate sexual behavior. | SS=F |
Report Facts
Census: 92
Residents in sample review: 3
Opposite gender residents at risk: 7
Duration of immediate jeopardy: 86.83
Medication dosage: 500
Medication duration: 5
Frequency of checks: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff B | Reported resident had been treated for UTI and confusion may be clearing | |
| Direct care staff A | Reported resident was independent prior to head injury but confused since then | |
| Direct care staff C | Reported resident made inappropriate comments and staff monitored closely | |
| Social service staff D | Reported awareness of incident and observed stop sign on resident's door | |
| Administrative staff E | Verified incident was not reported timely to administration | |
| Licensed nursing staff F | Reported resident #2 crawled into resident #1's bed and failed to report incident |
Inspection Report
Follow-Up
Deficiencies: 3
Aug 14, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiencies identified under regulations 483.10(i)(2), 483.60(i)(1)-(3), and 483.80(a)(1)(2)(4)(e)(f) were corrected as of 08/14/2017.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.10(i)(2) |
| Deficiency related to regulation 483.60(i)(1)-(3) |
| Deficiency related to regulation 483.80(a)(1)(2)(4)(e)(f) |
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 14, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report indicates that the previously cited deficiency with ID Prefix S3299 and regulation 26-41-206 (e)(1) was corrected and completed as of 08/14/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency previously reported under regulation 26-41-206 (e)(1) corrected |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 20, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a prior deficiency report for the facility, addressing multiple corrective actions and preventive monitoring measures to resolve identified deficiencies.
Findings
The plan outlines corrective actions including cleaning and maintenance tasks such as dryer filter cleaning, installation of metal kick plates on resident doors, hand rail repairs and resurfacing, floor drain replacement, and improvements in dining room cleanliness and food storage. It also includes staff education and monitoring plans to ensure sustained compliance.
Deficiencies (1)
| Description |
|---|
| Issues with cleanliness and maintenance in Health Care Neighborhoods including dryer filters, resident room doors, hand rails, floor drains, and dining room areas. |
Report Facts
Completion date: Aug 14, 2017
Completion date: Jul 26, 2017
Completion date: Jul 28, 2017
Completion date: Aug 4, 2017
Completion date: Jul 17, 2017
Completion date: Jul 20, 2017
Completion date: Jul 14, 2017
Completion date: Aug 14, 2017
Completion date: Aug 2, 2017
Completion date: Aug 14, 2017
Completion date: Aug 2, 2017
Completion date: Jul 27, 2017
Completion date: Aug 14, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Tonya Keim | Exec Admin Assistant | Submitted the Plan of Correction to KDADS |
| Director of Environmental Services | Responsible for oversight of repairs, preventive maintenance, and monitoring activities | |
| Dining Services Manager | Responsible for implementing and monitoring corrective measures in dining areas | |
| Director of Nursing | Responsible for oversight and completion of education and compliance monitoring for glucometer disinfecting |
Inspection Report
Plan of Correction
Deficiencies: 4
Jul 20, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in an assisted living facility inspection.
Findings
Deficiencies included visible soiling and staining on cabinet shelves in the dining room, improper food storage practices, and pans with build-up in the kitchen. The facility outlined corrective actions including updated cleaning schedules, staff education, equipment replacement, and ongoing monitoring.
Deficiencies (4)
| Description |
|---|
| Cabinet under the coffee station held a visible soiled and stained bottom shelf. |
| Shelf under the juice dispenser held dry/wet soiling. |
| Food storage policy needed updating regarding container use and dating items. |
| Pans with build-up were in use and needed replacement. |
Report Facts
Date of statement of deficiencies taken to QA Committee: Jul 20, 2017
Completion date for resurfacing cabinets: Aug 14, 2017
Completion date for food storage policy in-service: Aug 4, 2017
Completion date for replacement pans availability: Aug 14, 2017
Date soap dispenser installed: Jul 26, 2017
Completion date for pot/pan washing in-service: Aug 4, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Tonya Keim | Exec Admin Assistant | Submitted the Plan of Correction to KDADS |
| Irina Strakhova | Modified the Plan of Correction | |
| Director of Environmental Services | Oversees resurfacing and inspection of dining cabinets | |
| Dining Services Manager | Responsible for monitoring cleaning schedules, food storage practices, and pot/pan cleaning |
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 17, 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 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction effective August 14, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies were 'F' level, 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 letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 3
Jul 10, 2017
Visit Reason
The inspection was a health resurvey to assess compliance with housekeeping, maintenance, food safety, and infection control standards at the facility.
Findings
The facility failed to maintain sanitary and comfortable conditions in multiple areas including hallways, resident rooms, and the dietary department. Deficiencies included poor housekeeping, maintenance issues, unsanitary food storage and preparation, and inadequate infection control practices related to shared glucometers and ice handling.
Severity Breakdown
Level E: 1
Level F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services to maintain a sanitary and comfortable interior on 3 of 6 halls and failed to maintain necessary wheelchair condition for 1 resident. | Level E |
| Failed to maintain a clean and sanitary dietary department for storage, preparation, and service of food. | Level F |
| Failed to maintain proper infection control practices to prevent cross contamination during blood glucose testing and ice handling. | Level F |
Report Facts
Census: 92
Residents sharing glucometers: 18
Hair dryers in beauty shop: 5
Full sheet pans with debris: 8
Long loaf pans with debris: 5
Containers lacking labels/dates in walk-in cooler: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff C | Licensed Nursing Staff | Observed performing blood glucose testing and cleaning glucometer improperly |
| Licensed nursing staff B | Licensed Nursing Staff | Observed performing blood glucose testing and cleaning glucometer improperly |
| Administrative licensed staff A | Administrative Licensed Staff | Reported proper glucometer cleaning procedures and wet time |
| Maintenance staff F | Maintenance Staff | Confirmed housekeeping and maintenance deficiencies and lack of wheelchair repair knowledge |
| Direct care staff D | Direct Care Staff | Observed passing ice with improper infection control technique |
| Dietary staff E | Dietary Staff | Verified unsanitary conditions in kitchen and food storage areas |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 10
Jul 10, 2017
Visit Reason
The inspection was a health resurvey to assess the facility's compliance with food storage and sanitary conditions in the dietary department.
Findings
The facility failed to maintain a clean and sanitary dietary department, with multiple instances of unlabeled and undated food packages, soiled kitchen equipment, and accumulation of debris on pans and shelves, posing a risk for foodborne illness.
Severity Breakdown
SS=F: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Cabinet under the coffee station held a visible soiled and stained bottom shelf. | SS=F |
| Shelf under the juice dispenser held dry/wet soiling. | SS=F |
| Two packages of cooked ribs in walk-in freezer lacked a label with the date. | SS=F |
| One package of undated cooked meat lacked a label and date. | SS=F |
| One opened package of chicken nuggets lacked a label with the date. | SS=F |
| One opened package of bratwurst sausages lacked a label with the date. | SS=F |
| Fifteen containers with assorted foods for the salad bar lacked labels and dates. | SS=F |
| Eight full sheet pans held debris with an accumulated dark build-up over all corners inside the pans. | SS=F |
| Five long loaf pans held an accumulated dark build-up over all surfaces inside the pans. | SS=F |
| Shelf under the tilt skillet held a visible accumulation of dust and debris. | SS=F |
Report Facts
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff E verified areas of concern and reported items needed labeling and cleaning |
Inspection Report
Follow-Up
Deficiencies: 1
Oct 19, 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 the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 09/14/2016. No other deficiencies were noted.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID Prefix F0323 related to regulation 483.25(h) |
Report Facts
Deficiency correction date: Sep 14, 2016
Inspection Report
Life Safety
Deficiencies: 1
Oct 6, 2016
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 an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
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. | F |
Report Facts
Effective date for denial of payments: Jan 6, 2017
Provider agreement termination date: Apr 6, 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 regarding cited deficiencies. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 14, 2016
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & 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 that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety related to F323, "J", CFR 483.25(h). Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed effective October 6, 2016.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F323, "J", CFR 483.25(h) constituting immediate jeopardy to resident health or safety | Immediate Jeopardy |
Report Facts
Denial of payment effective date: Oct 6, 2016
Provider agreement termination recommendation date: Mar 14, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the signatory and complaint coordinator for the survey report |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 14, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation related to resident safety and wandering behaviors at Schowalter Villa.
Findings
The plan addresses deficiencies related to inadequate monitoring of a resident at risk of wandering, including falsification of documentation by a staff member and insufficient direct observation practices. Corrective actions include updated care plans, staff education, enhanced monitoring protocols, and termination of the involved CNA.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Schowalter Villa dated 09/14/2016.
Deficiencies (1)
| Description |
|---|
| Inadequate monitoring of resident at risk of wandering and falsification of documentation by a CNA. |
Report Facts
Date of corrective action completion: Oct 13, 2016
Date of plan submission: Sep 19, 2016
Date of plan addition: Sep 15, 2016
Date of plan modification: Nov 9, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Director of Nursing | Responsible for program effectiveness and updates as needed |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Sep 14, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#104972) and a partial extended survey to assess the facility's compliance with supervision and accident hazard prevention requirements.
Findings
The facility failed to provide adequate supervision for a severely cognitively impaired resident who remained unsupervised in the courtyard for over 2 hours in hot weather, resulting in the resident experiencing lethargy, diaphoresis, and a mild sunburn. The lack of supervision placed the resident in immediate jeopardy. The facility subsequently revised policies and conducted staff inservices to prevent recurrence.
Complaint Details
The complaint investigation #104972 found that the facility failed to supervise resident #1, who has severe cognitive impairments, resulting in the resident being left outside unsupervised for 2 hours and 24 minutes on a hot day, leading to immediate jeopardy conditions including lethargy and sunburn.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide adequate supervision for a cognitively impaired resident who remained unsupervised in the courtyard for over 2 hours, resulting in immediate jeopardy due to heat exposure and sunburn. | D |
Report Facts
Census: 91
Duration unsupervised: 144
Temperature: 87
Vital signs: 99.2
Vital signs: 92
Vital signs: 60
Vital signs: 112
Vital signs: 16
Vital signs: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Direct Care Staff | Last staff to check on the resident before leaving him/her outside unsupervised |
| Staff P | Direct Care Staff | Noticed resident was missing from room at beginning of shift |
| Staff M | Direct Care Staff | Reported staff realized resident was missing and searched for resident |
| Staff L | Licensed Nursing Staff | Documented 15 minute checks and stated floor staff checked resident before shift end |
| Staff I | Licensed Nursing Staff | Reported day shift nursing staff informed evening shift that resident was outside |
| Staff D | Administrative Nursing Staff | Notified of incident and reported last staff to check resident was Staff O |
| Staff B | Administrative Nursing Staff | Reported resident went outside after lunch and staff falsified documentation on checks |
| Consultant Staff GG | Notified of incident and stated expectation for regular checks on confused residents |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 22, 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 have been corrected.
Findings
The report confirms that the identified deficiencies have been corrected as of the revisit date, with corrections completed and documented.
Deficiencies (1)
| Description |
|---|
| Deficiency identified by ID Prefix F0323 related to regulation 483.25(h) was corrected. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jul 1, 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 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 was 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 |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Jul 1, 2016
Visit Reason
The inspection was conducted as a result of complaint investigations #101244 and #101341 concerning resident safety and supervision related to elopement risks.
Findings
The facility failed to ensure adequate supervision and assistive devices to prevent two cognitively impaired residents from leaving the facility without staff knowledge. Issues included failure of the pager alarm system to alert staff and staff reliance on pagers instead of hall monitors, resulting in residents exiting unnoticed for extended periods.
Complaint Details
The visit was complaint-related, investigating allegations that two cognitively impaired residents left the facility without staff knowledge. The complaints were substantiated by observations, interviews, and record reviews.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident environment free of accident hazards and adequate supervision to prevent elopement of cognitively impaired residents. | SS=D |
Report Facts
Resident census: 88
Residents at risk for elopement: 17
Residents in sample: 3
Alarm delay: 17
Brief Interview for Mental Status score: 3
Date of admission resident #1: Dec 15, 2014
Date of admission resident #2: Dec 29, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse D | Announced alert regarding resident triggering alarm and completed resident assessment. | |
| direct care staff C | Found resident outside on patio and escorted resident back to unit. | |
| direct care staff F | Reported procedures for locating residents who elope. | |
| direct care staff K | Reported on documentation of residents with wandering tendencies. | |
| direct care staff G | Reported monitoring and care of resident with wandering behaviors. | |
| licensed nursing staff H | Completed investigation of resident going outside with non-family members. | |
| licensed nursing staff I | Completed investigation of resident elopement on 5/27/16. | |
| direct care staff J | Reported resident's usual behavior prior to elopement. |
Inspection Report
Re-Inspection
Deficiencies: 2
Nov 25, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report confirms that the deficiencies previously cited under regulation numbers 26-41-203 (e) and 26-41-205 (l)(1) were corrected by 11/25/2015.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-203 (e) |
| Deficiency related to regulation 26-41-205 (l)(1) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 12, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of Schowalter Villa Assisted Living Facility.
Findings
The plan addresses deficiencies related to door surface conditions for better cleaning and medication management for residents taking medications with black box warnings, including review and documentation procedures.
Deficiencies (2)
| Description |
|---|
| Doors in hallways require resurfacing and repair to allow for better surface cleaning and improved appearance. |
| Medication reviews including black box warnings were not adequately documented or reviewed with residents. |
Report Facts
Complete Date: Nov 12, 2015
Complete Date: Nov 25, 2015
Date: Oct 27, 2015
Date: Dec 5, 2014
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 26, 2015
Visit Reason
The document is a Plan of Correction submitted in response to a Health Survey and complaint investigation #92770 for the facility.
Findings
The Health Survey and complaint investigation resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, Requirements for long term care facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 26, 2015
Visit Reason
The visit was a health survey and complaint investigation (#92770) conducted at the facility.
Findings
The investigation resulted in no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, Requirements for long term care facilities.
Complaint Details
Complaint investigation #92770 was conducted and found no deficiencies.
Inspection Report
Renewal
Census: 35
Deficiencies: 3
Oct 22, 2015
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with routine maintenance and medication regimen review requirements.
Findings
The facility failed to maintain the finish on 34 of 40 resident room doors and common areas, and failed to provide adequate housekeeping and maintenance services. Additionally, the facility failed to identify and monitor residents for medications with black box warnings and did not obtain a required yearly TSH lab for one resident.
Severity Breakdown
Level E: 1
Level D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services to maintain the finish on 34 of 40 resident room doors, common living area, and 2 resident rooms. | Level E |
| Failed to monitor 3 residents for lack of identification of medications with black box warnings and lack of care planning for these medications. | Level D |
| Failed to obtain a yearly TSH laboratory test related to synthroid medication usage for 1 resident as ordered by the physician. | Level D |
Report Facts
Resident census: 36
Resident census: 35
Number of resident room doors with finish issues: 34
Number of residents in medication sample: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Confirmed maintenance deficiencies and stated facility never placed black box warnings on care plans | |
| Licensed nursing staff B | Confirmed black box warnings were not on residents' care plans or MARs | |
| Consultant staff C | Reviewed residents' MARs every 3 months and did not address black box warnings as not appropriate for long term care | |
| Administrative nursing staff D | Unable to locate TSH lab for resident in October |
Inspection Report
Life Safety
Deficiencies: 1
Jul 31, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility found to have 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Oct 31, 2015
Provider agreement termination date: Jan 31, 2016
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
Aug 12, 2014
Visit Reason
This post-certification revisit was conducted to verify correction of previously cited deficiencies from the survey completed on 2014-07-14.
Findings
The revisit confirmed that the previously cited deficiency under regulation 483.35(i) was corrected as of 2014-08-12.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.35(i) |
Report Facts
Date of original survey: Jul 14, 2014
Inspection Report
Follow-Up
Deficiencies: 1
Aug 12, 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)(c) with ID prefix S1176 was corrected as of 2014-08-12.
Deficiencies (1)
| Description |
|---|
| Deficiency identified under regulation 26-40-303 (b)(c) with ID prefix S1176 |
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 4, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiency identified as Reg. # 28-39-158(g) with ID Prefix S0640 was corrected as of 08/04/2014. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency identified under regulation 28-39-158(g) previously reported was corrected. |
Report Facts
Deficiencies corrected: 1
Inspection Report
Enforcement
Deficiencies: 1
Jul 14, 2014
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 '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 August 12, 2014.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 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 |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey and certification. |
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 6
Jul 9, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with food procurement, storage, preparation, and serving sanitary requirements.
Findings
The facility failed to store and serve food in a sanitary manner, evidenced by brownish build-up and flaking on various kitchen pans and equipment, posing a risk for food borne illness among residents.
Deficiencies (6)
| Description |
|---|
| Sixteen large baking sheets contained a brownish build-up along the interior surfaces and sides. |
| Thirteen small baking sheets contained a brownish build-up along the interior surfaces and sides. |
| Eight meat loaf pans contained a brownish/black build-up on the interior surfaces of the top edges. |
| Ten cupcake pans contained a brownish build-up in the interior surfaces of the individual cups. |
| Two bunt pans had flaking or completely removed non-stick coating and brown build-up on interior surfaces. |
| Food warmer had flaking paint and brownish build-up on the inside door and rubber seal, breaking apart in five areas. |
Report Facts
Resident census: 83
Large baking sheets with build-up: 16
Small baking sheets with build-up: 13
Meat loaf pans with build-up: 8
Cupcake pans with build-up: 10
Bunt pans with coating issues: 2
Areas of flaking paint on food warmer: 5
Inspection Report
Renewal
Census: 34
Deficiencies: 5
Jul 9, 2014
Visit Reason
The inspection was a licensure resurvey of an Assisted Living/Residential Healthcare facility to assess compliance with sanitary conditions and other regulatory requirements.
Findings
The facility failed to store and serve food in a sanitary manner, as evidenced by brownish build-up and flaking on multiple baking and cooking pans, which posed a risk for food borne illness among residents.
Deficiencies (5)
| Description |
|---|
| Sixteen large baking sheets contained a brownish build-up along interior surfaces and sides. |
| Thirteen small baking sheets contained a brownish build-up along interior surfaces and sides. |
| Eight meat loaf pans contained a brownish/black build-up on interior surfaces of top edges. |
| Ten cupcake pans contained a brownish build-up in interior surfaces of individual cups. |
| Two bunt pans showed flaking and complete removal of non-stick coating with brown build-up on interior surfaces. |
Report Facts
Resident census: 34
Number of large baking sheets with build-up: 16
Number of small baking sheets with build-up: 13
Number of meat loaf pans with build-up: 8
Number of cupcake pans with build-up: 10
Number of bunt pans with flaking or coating removed: 2
Inspection Report
Life Safety
Deficiencies: 1
Nov 8, 2013
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.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'D' level, isolated, with no harm but potential for more than minimal harm that is not immediate jeopardy. | D |
Report Facts
Effective date for denial of payments: Feb 8, 2014
Provider agreement termination date: May 8, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Treva Greaser | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Follow-Up
Deficiencies: 1
Apr 19, 2013
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been accomplished.
Findings
The report confirms that the previously identified deficiency with regulation 26-40-305 (c)(1)(2) was corrected as of 04/19/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-305 (c)(1)(2) |
Report Facts
Deficiency correction date: Apr 19, 2013
Inspection Report
Follow-Up
Deficiencies: 1
Apr 19, 2013
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 have been corrected.
Findings
The report confirms that the previously cited deficiency under regulation 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(h) previously cited and corrected |
Report Facts
Deficiency correction date: Apr 19, 2013
Follow-up survey completion date: Mar 27, 2013
Inspection Report
Plan of Correction
Deficiencies: 3
Apr 4, 2013
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa in response to a statement of deficiencies identified during a prior inspection.
Findings
The plan addresses deficiencies related to hazardous chemical storage, housekeeping closet security, and ventilation system maintenance. Corrective actions include staff re-education, installation of keypad entry systems on trash closets, replacement of door handles with continuous locking mechanisms, and repair and maintenance of the ceiling exhaust ventilation motor.
Severity Breakdown
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Improper storage and handling of potentially hazardous chemicals affecting all residents cognitively impaired and independently mobile. | Level E |
| Housekeeping closet found unlocked and housekeeping storeroom door handle needing replacement with continuous locking mechanism. | — |
| Ceiling exhaust ventilation motor requiring repair and verification of ventilation system function. | — |
Report Facts
Corrective action completion date: Apr 19, 2013
Committee presentation date: Apr 3, 2013
Committee discussion date: Apr 16, 2013
Ventilation motor repair completion date: Apr 12, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 1
Mar 27, 2013
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with heating, ventilation, and air conditioning system requirements, specifically focusing on ventilation in the facility's beauty shop.
Findings
The facility failed to meet the minimum ventilation requirements for the negative pressure exhaust fans in the beauty shop. Observations and interviews revealed that the vents were not functioning properly, with maintenance staff reporting missing parts and no alternative measures in place to ensure proper ventilation.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to meet minimum ventilation requirements for the negative pressure exhaust fans in the facility's beauty shop. | SS=F |
Report Facts
Facility census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Staff C | Reported vents did not work and called contractor for motor repair | |
| Maintenance Staff F | Checked vents monthly and last checked roof vents in September 2012 | |
| Housekeeping Staff D | Reported housekeeping only swept floors and did not check vents | |
| Administrative Staff G | Reported no policy regarding beauty shop ventilation maintenance and monitoring |
Inspection Report
Plan of Correction
Deficiencies: 1
N040006 POC OWIX11
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa Assisted Living in response to deficiencies cited in a prior inspection.
Findings
The plan addresses deficiencies related to the condition and sanitation of pans used in food service, with actions including replacement of pans, staff education on washing pans to prevent buildup, and ongoing monitoring by the Dining Service Manager and QA committee.
Deficiencies (1)
| Description |
|---|
| Pans used in food service had buildup and required replacement and improved cleaning procedures. |
Report Facts
Completion date for pan replacement: Aug 4, 2014
Date of QA/Pharmacy Committee presentation: Jul 15, 2014
Date for staff education completion: Aug 1, 2014
Date for QA monitoring results presentation start: Aug 19, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 4
N040006 POC SS0V11
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa in response to deficiencies cited in a prior inspection report dated 11/13/19.
Findings
The Plan of Correction addresses deficiencies related to timely reporting and investigation of allegations of abuse, neglect, exploitation, or mistreatment; staff education on care plans and safe chemical storage; and cleaning and sanitation of dining and food service areas.
Severity Breakdown
D: 1
E: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to timely report allegations of abuse, neglect, exploitation, or mistreatment. | D |
| Failure to suspend alleged perpetrators and thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment. | E |
| Lack of staff knowledge regarding care plans and safe chemical storage. | E |
| Inadequate cleaning and sanitation of dining and food service areas. | E |
Report Facts
Deficiency completion dates: Dec 13, 2019
Policy update dates: Nov 7, 2019
Cleaning dates: Nov 6, 2019
Cleaning dates: Nov 19, 2019
Inspection Report
Plan of Correction
Deficiencies: 2
N040006 POC YLWO11
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa addressing deficiencies identified in a prior inspection, including issues related to food service equipment and safety measures on the 700 hall.
Findings
The plan outlines corrective actions such as replacing pans, acquiring new food warmer equipment, educating staff on cleaning procedures, and locking exit doors on the 700 hall to ensure resident safety and compliance.
Deficiencies (2)
| Description |
|---|
| Build-up on pans used for residents who eat food in Health Care and food warmer/holding cabinet condition in dining rooms. |
| Exit doors on the 700 hall not continuously locked without supervision. |
Report Facts
Residents affected: 12
Completion date: Jul 17, 2014
Completion date: Aug 18, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
N040006 POC BVHS11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation related to resident safety and elopement incidents on 5/27/16 and 5/30/16.
Findings
The facility identified issues with residents who have impaired decision-making ability being oblivious to their safety needs, particularly related to elopements. Multiple corrective actions were implemented including staff counseling, system changes to door alert notifications, re-education of staff on monitoring residents, and new assessment forms to identify at-risk residents.
Complaint Details
This Plan of Correction addresses deficiencies identified in complaint investigations #1341 and #1244 related to resident elopements and safety monitoring.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents with impaired decision-making ability are oblivious to their safety needs, leading to elopements. | D |
Report Facts
Elopement incidents: 2
Dates of corrective actions: 7
Frequency of elopement drills: 1
Staff monitoring interval: 30
Duration of daily staff verification: 90
Document
Deficiencies: 0
N040006 POC FMFK11
Visit Reason
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Findings
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