Deficiencies (last 13 years)
Deficiencies (over 13 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
61% occupied
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
The visit was a Re-Licensure survey conducted for the Assisted Living Facility on 05/29/2025 and 06/02/2025.
Findings
The survey resulted in zero deficiencies for the facility.
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
The visit was a Re-Licensure survey for the Assisted Living Facility conducted on 05/29/2025 and 06/02/2025.
Findings
The survey resulted in zero deficiencies for the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 20, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-11-07.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2024-12-02, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Nov 7, 2024
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa Skilled Nursing to address deficiencies cited during the survey concluded on November 7, 2024.
Findings
The facility is implementing corrective actions and ongoing monitoring to ensure compliance with Kansas and Federal requirements related to care plan timing and revision, activities meeting resident needs, drug regimen review, psychotropic medication use, hospice services, and immunizations.
Deficiencies (6)
F Tag # 657: Care Plan Timing and Revision. New interventions were implemented for resident R82, with daily nursing management reviews and quarterly care plan audits to ensure resident-specific interventions.
F Tag # 679: Activities Meet Interest/Needs Each Resident. Planned activities with resident input are scheduled for all seven days weekly, with monthly calendar reviews to verify resident preferences.
F Tag # 756: Drug Regimen Review, Report Irregular, Act On. Pharmacist includes risk vs benefit statements and medication reviews with residents or DPOA, with monthly pharmacy reviews by the Director of Nursing.
F Tag # 758: Free from Unnecessary Psychotropic Meds/PRN Use. Pharmacist and medical director review medications with risk vs benefit statements, with weekly interdisciplinary review of antipsychotic medications.
F Tag # 849: Hospice Services. Care plans for hospice residents include needs, equipment, nurse visit frequency, and coordination, reviewed upon admission and quarterly.
F Tag # 883: Influenza and Pneumococcal Immunizations. All residents are reviewed for immunization eligibility, offered vaccines or declination forms, with ongoing monitoring and monthly audits.
Inspection Report
Annual Inspection
Census: 95
Deficiencies: 6
Date: Nov 7, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements including care planning, activities, medication management, hospice care, and immunizations.
Findings
The facility had multiple deficiencies including failure to revise care plans to address specific resident behaviors, inadequate weekend activities, failure to ensure appropriate medication indications and documentation, lack of collaboration with hospice services, and failure to offer pneumococcal vaccination to a resident.
Deficiencies (6)
F 0657: The facility failed to revise Resident 82's Care Plan to include her identified behaviors toward male residents, placing her at risk for impaired care due to uncommunicated care needs.
F 0679: The facility failed to provide weekend activities reflecting residents' interests and preferences, placing residents at risk for boredom, isolation, and decreased quality of life.
F 0756: The facility failed to ensure the Consultant Pharmacist identified and reported non-CMS-approved indications for antipsychotic medications for residents R31, R48, R59, and R12, placing residents at risk for adverse medication effects and unnecessary medications.
F 0758: The facility failed to implement gradual dose reductions and document physician rationale for extended use of psychotropic medications, including lack of approved indications and risk-benefit analysis, placing residents at risk for adverse effects.
F 0849: The facility failed to ensure collaboration and communication between the nursing home and hospice provider for Resident 59, placing the resident at risk for impaired end-of-life care.
F 0883: The facility failed to discuss and offer the Pneumococcal Conjugate Vaccine (PCV20) or obtain informed declination for Resident 31, placing the resident at increased risk for pneumonia complications.
Report Facts
Residents in census: 95
Residents reviewed: 19
Residents reviewed for unnecessary medications: 5
Residents reviewed for hospice services: 1
Residents reviewed for immunization status: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R | Certified Medication Aide (CMA) | Named in relation to care plan access and hospice communication |
| G | Licensed Nurse (LN) | Provided statements regarding care plans, medication indications, and hospice communication |
| D | Administrative Nurse | Provided statements regarding care plan reviews, medication oversight, and hospice collaboration |
| E | Administrative Nurse | Provided statements regarding immunization policies and procedures |
| Z | Activities Staff | Provided statements regarding weekend activities |
Inspection Report
Annual Inspection
Census: 95
Deficiencies: 6
Date: Nov 7, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements including care planning, activities, medication management, hospice care, and immunizations.
Findings
The facility had multiple deficiencies including failure to revise care plans to address resident-specific behaviors, inadequate weekend activities, failure to ensure appropriate medication indications and documentation, lack of collaboration with hospice services, and failure to offer pneumococcal vaccination to a resident.
Deficiencies (6)
F 0657: The facility failed to revise Resident 82's Care Plan to include her identified behaviors toward male residents, placing her at risk for impaired care due to uncommunicated care needs.
F 0679: The facility failed to provide weekend activities reflecting residents' interests and preferences, placing residents at risk for boredom, isolation, and decreased quality of life.
F 0756: The facility failed to ensure the Consultant Pharmacist identified and reported non-CMS-approved indications for antipsychotic medications for residents R31, R48, R59, and R12, placing them at risk for adverse medication effects and unnecessary medications.
F 0758: The facility failed to implement gradual dose reductions and document physician rationale for psychotropic medications, including extended use of as-needed lorazepam for R59, placing residents at risk for adverse effects and unnecessary medications.
F 0849: The facility failed to ensure collaboration and communication between the nursing home and hospice provider regarding Resident 59's care, placing the resident at risk for impaired end-of-life care.
F 0883: The facility failed to discuss and offer the Pneumococcal Conjugate Vaccine (PCV20) or obtain informed declination for Resident 31, placing the resident at increased risk for pneumonia complications.
Report Facts
Census: 95
Residents reviewed: 19
Residents reviewed for unnecessary medications: 5
Residents reviewed for hospice services: 1
Residents reviewed for immunization status: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements regarding care plans, medication indications, and hospice communication |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding care plan reviews, medication policies, and hospice communication |
| Certified Medication Aide R | Certified Medication Aide | Provided statements regarding access to care plans and hospice equipment |
| Administrative Nurse E | Administrative Nurse | Provided statements regarding immunization policies and procedures |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 6
Date: Nov 7, 2024
Visit Reason
The inspection was a health resurvey and complaint investigation involving multiple complaint case numbers.
Complaint Details
The inspection included complaint investigations KS00191102, KS00188575, and KS00188208.
Findings
The facility was found deficient in revising care plans to address resident-specific behaviors, providing weekend activities reflecting residents' interests, ensuring pharmacist review and reporting of antipsychotic medication indications, collaborating with hospice services, and offering pneumococcal vaccinations as required.
Deficiencies (6)
F 657 Care Plan Timing and Revision: The facility failed to revise Resident 82's care plan to include her identified behaviors toward male residents, risking impaired care due to uncommunicated needs.
F 679 Activities Meet Interest/Needs Each Resident: The facility failed to provide weekend activities reflecting residents' interests, placing residents at risk for boredom and isolation.
F 756 Drug Regimen Review, Report Irregular, Act On: The facility failed to ensure the consultant pharmacist identified and reported unapproved indications for antipsychotic medications for Residents 31, 48, and 59, risking adverse effects and unnecessary medications.
F 758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to ensure CMS-approved indications or documented physician rationale for continued antipsychotic use for Residents 31, 48, 12, and 59, and lacked rationale for extended as-needed lorazepam use for Resident 59.
F 849 Hospice Services: The facility failed to ensure collaboration and communication between the nursing home and hospice regarding Resident 59's care, risking impaired end-of-life care.
F 883 Influenza and Pneumococcal Immunizations: The facility failed to offer or obtain informed declination for the Pneumococcal Conjugate Vaccine (PCV20) for Resident 31, increasing risk for pneumonia complications.
Report Facts
Resident 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 physicians and pharmacists. |
| 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
Re-Inspection
Deficiencies: 0
Date: 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 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
Plan of Correction
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
This document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on 2023-12-11.
Findings
The Plan of Correction addresses the deficiencies identified during the licensure resurvey of the facility on 2023-12-11. The document confirms the facility's corrective actions and completion date.
Inspection Report
Renewal
Census: 30
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance with healthcare service plan requirements for residents.
Findings
The facility failed to ensure that a licensed nurse developed healthcare service plans for falls prevention 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 these residents.
Deficiencies (1)
K.A.R. 26-41-204 (b) Health Care Services: The facility failed to develop healthcare service plans for falls as part of the negotiated service agreements for three residents. Documentation of fall prevention services was missing in the residents' plans.
Report Facts
Census: 30
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 11, 2023
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
Annual Inspection
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
Annual inspection survey of Schowalter Villa nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 11, 2023
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 related to the applicable regulations for the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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 deficiencies cited in the prior inspection have been corrected as of the compliance date of 2022-06-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 3
Date: Jun 1, 2022
Visit Reason
This is a resurvey of an assisted living facility conducted to verify compliance with previously identified deficiencies related to disaster and emergency preparedness, food preparation, and infection control.
Findings
The facility failed to perform quarterly reviews of the emergency management plan with residents, failed to ensure food was served at proper temperatures, and did not comply with tuberculosis guidelines for adult care homes, including failure to complete required two-step TB skin tests for new employees.
Deficiencies (3)
KAR 26-41-104(d)(3) The facility failed to perform quarterly reviews of the emergency management plan with residents as required.
KAR 26-41-206(d) The operator failed to ensure designated employees served food at the proper temperature, with 16 of 93 food temperature checks not logged.
KAR 26-41-207(c) The facility failed to comply with tuberculosis guidelines by not completing a two-step TB skin test for a newly hired Certified Medication Aide upon hire.
Report Facts
Food temperature log omissions: 16
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide B | Certified Medication Aide | Named in tuberculosis skin test deficiency for lack of two-step TB test upon hire. |
| Operator A | Provided statements regarding expectations for emergency preparedness plan reviews and TB testing. | |
| Certified Dietary Manager C | Certified Dietary Manager | Stated expectation that food temperatures be checked and documented for each meal. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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 summarizes the provider's plan of correction following the resurvey findings. It does not detail specific deficiencies or findings within this text.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
The document is a plan of correction related to a health survey and complaint investigation for a long term care 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.
Inspection Report
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
The visit was a health survey and complaint investigation related to complaint numbers #163249 and #162698 for the long term care facility.
Complaint Details
Complaint investigation #163249 and #162698 resulted in no deficiency citations.
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.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Date: 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.
Complaint Details
The complaint investigation found that Resident 1, at risk for elopement, was left unsupervised in an unlocked courtyard and exited the facility without staff knowledge. The resident was found approximately a block away by an off-duty staff member. Immediate jeopardy was cited but later removed after corrective actions.
Findings
The facility failed to provide adequate supervision and perform required 30-minute checks for a resident at risk for elopement, resulting in the resident exiting the unlocked courtyard and crossing a residential street unsupervised. This placed the resident in immediate jeopardy, which was later removed after corrective actions.
Deficiencies (1)
CFR 483.25(d) The facility failed to provide adequate supervision and perform 30-minute checks for Resident 1, allowing her to exit the unlocked courtyard and walk unsupervised outside the facility, placing her in immediate jeopardy.
Report Facts
Resident census: 97
Residents at risk for elopement: 19
Missed 30-minute checks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Informed of immediate jeopardy status and confirmed failure of supervision and 30-minute checks. |
| Certified Medication Aide R | Certified Medication Aide | Described courtyard check procedures and lack of specific staff assignment. |
| Administrative Staff A | Administrative Staff | Reported courtyard gate locking times and check completion. |
| Maintenance Staff U | Maintenance Staff | Responsible for locking/unlocking courtyard gate. |
| Certified Nurse Aide M | Certified Nurse Aide | Admitted to forgetting Resident 1 was in courtyard during busy period. |
| Licensed Nurse G | Licensed Nurse | On duty during incident; unaware of Resident 1's absence and missed checks. |
| Certified Nurse Aide N | Certified Nurse Aide | Last saw Resident 1 before incident and described staff responsibility for checks. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 27, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/27/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 21, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a Covid survey inspection conducted on 04/21/2020.
Findings
The Covid survey was deficiency free, indicating no deficiencies were found during the inspection.
Deficiencies (1)
F0000 Deficiency free Covid survey conducted on 04/21/2020.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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 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
Re-Inspection
Deficiencies: 0
Date: Jan 13, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 11/30/2019.
Findings
All deficiencies have been corrected as of the compliance date of 12/13/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Nov 13, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the inspection of Schowalter Villa on 11/13/2019.
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 sanitation and maintenance issues in the kitchen.
Deficiencies (4)
F609-D: Education will be provided to Health Care staff regarding timely reporting of allegations of abuse, neglect, exploitation, or mistreatment. An updated investigation report form will be distributed to licensed nurses to ensure proper response to allegations.
F610-E: Education will be provided to Health Care staff on suspending alleged perpetrators and thoroughly investigating allegations of abuse, neglect, exploitation, or mistreatment. The updated investigation form will be distributed to licensed nurses.
F689-E: Education will be provided to Health Care staff on knowledge of care plans and safe chemical storage. Staff will be interviewed weekly to assess knowledge of fall prevention interventions, and safety committee members will monitor chemical storage quarterly.
F921-E: The policy for cleaning and sanitation of dining and food service areas has been updated. Kitchen areas were cleaned and sanitized in November 2019. The Culinary Manager will conduct monthly walk-throughs and weekly spot checks, reporting findings to the QA committee.
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 4
Date: Nov 13, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to allegations of abuse and other regulatory compliance issues at the facility.
Complaint Details
The complaint investigation involved allegations of abuse by a staff member against Resident 25. The allegation was substantiated as the facility failed to report the abuse timely and failed to conduct a thorough investigation or separate the alleged perpetrator from resident care.
Findings
The facility failed to report an allegation of abuse in a timely manner and failed to report it to the State Agency. The facility also failed to thoroughly investigate the abuse allegation and did not separate the alleged perpetrator from resident care. Additionally, the facility failed to implement fall prevention interventions for a resident and failed to secure hazardous chemicals from confused residents. The kitchen environment was found to be unsanitary.
Deficiencies (4)
F 609: Facility staff failed to report an allegation of abuse to administrative staff in a timely manner and failed to report the allegation to the State Agency for one resident who accused a staff member of hitting him.
F 610: Facility failed to have evidence of a thorough investigation and failed to prevent potential abuse by not separating the alleged perpetrator from resident care during the investigation.
F 689: Facility failed to provide interventions to prevent repeated falls for one resident by not keeping the resident's door open for visual monitoring and not keeping the wheelchair locked and beside the bed. Facility also failed to secure hazardous chemicals from five confused, self-mobile residents.
F 921: Facility failed to provide a clean and sanitary environment in the kitchen, including peeling paint on cabinets, grime buildup on an outlet and floor.
Report Facts
Resident census: 98
Residents reviewed: 21
Residents reviewed for abuse: 2
Residents reviewed for falls: 5
Residents confused and self-mobile: 5
Fall risk assessment score: 23
Time delay in reporting abuse: 202
Residents on 300-400 hall: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Failed to report abuse allegation to State Agency and confirmed alleged perpetrator continued working with residents. | |
| Licensed Nurse G | Notified Administrative Nurse D of abuse allegation but did not receive further instruction and delayed notification. | |
| Administrative Staff A | Verified failure to report abuse allegation to State Agency and lack of thorough investigation. | |
| Certified Medication Aide Q | Alleged perpetrator accused of hitting Resident 25. | |
| Certified Nurse Aide LL | Reported wheelchair placement and use related to Resident 83 fall prevention. | |
| Licensed Nurse I | Reported fall prevention interventions for Resident 83. | |
| Administrative Nurse F | Observed Resident 83 unattended with door closed. | |
| Licensed Nurse H | Reported that chemicals should not be stored in unlocked cabinets accessible to confused residents. | |
| Dietary Staff CC | Reported kitchen sanitation issues. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 25, 2019
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Inspection Report
Renewal
Census: 34
Deficiencies: 5
Date: Jul 25, 2019
Visit Reason
Licensure resurvey of the assisted living facility conducted on 7/23/19, 7/24/19, and 7/25/19.
Findings
The facility was found deficient in multiple areas including failure to ensure negotiated service agreements included all required information, improper medication administration practices, inadequate handling of sample/drug study medications, and deficiencies in disaster and emergency preparedness including insufficient staffing for evacuation and lack of quarterly emergency plan reviews.
Deficiencies (5)
26-41-202 (a) Negotiated Service Agreement: The facility failed to ensure the written negotiated service agreement for resident #699 included a description of services, identification of the provider, and party responsible for payment for outside resources.
26-41-205 (d) Facility Administration of Medications: Licensed nurses and medication aides did not administer medications according to medical orders and professional standards for residents #712 and #767, including improper handling of controlled substances and transcription errors.
26-41-205 (g) (4) Sample & Indigent Medication Program Meds: The facility failed to properly administer sample/drug study medications for resident #699, including lack of labeling, receipt documentation, and informing the resident or representative of risks.
26-41-104 (a) Disaster and Emergency Preparedness: The facility failed to conduct an emergency evacuation drill with sufficient staff to assist residents requiring help to a secure location.
26-41-104 (d) Disaster and Emergency Preparedness: The facility failed to conduct quarterly reviews of the emergency management plan with staff and residents as required.
Report Facts
Census: 34
Residents with cognitive impairment: 4
Medication administration errors: 2
Sample/drug study medication issues: 1
Evacuation drill times: 10
Evacuation drill times: 6
Evacuation drill times: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Interviewed regarding medication administration and emergency preparedness | |
| Certified medication aide A | Interviewed regarding medication administration | |
| Licensed nurse D | Interviewed regarding medication order discrepancies and emergency plan awareness | |
| Certified staff C | Interviewed regarding evacuation drill assistance and emergency plan knowledge | |
| Administrator/operator E | Interviewed regarding emergency preparedness and documentation |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 10, 2019
Visit Reason
A revisit survey was conducted on 2019-06-10 to verify correction of all previous deficiencies cited on 2019-05-14.
Findings
All deficiencies cited in the previous inspection have been corrected as of 2019-05-17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Date: May 14, 2019
Visit Reason
Partial extended survey conducted due to a complaint investigation regarding a resident elopement incident.
Complaint Details
Complaint investigation #KS 00140792. The resident eloped from the facility, was missing for 58 minutes, and sustained a fracture and other injuries. Immediate jeopardy was identified and later removed after corrective actions.
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 and sustaining injuries. The facility implemented corrective actions to address the security and supervision deficiencies.
Deficiencies (1)
CFR 483.25(d) Accidents. The facility failed to provide adequate supervision to prevent a resident at risk of elopement from exiting the facility unsupervised, resulting in injury and immediate jeopardy.
Report Facts
Resident census: 90
Elopement risk assessment scores: 15
Elopement risk assessment scores: 10
Time resident was out of staff sight: 58
Time resident was missing: 43
Immediate jeopardy removal date: May 13, 2019
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 10, 2019
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa in response to identified deficiencies related to the security and safety of residents with wander-guard/code alert systems.
Findings
The plan addresses security issues involving door codes and alert systems to prevent residents with dementia from leaving the facility unsupervised. Multiple corrective actions were implemented including door code changes, installation of alert antennas, staff education, and care plan updates for a highly mobile resident.
Deficiencies (1)
F689-J: Residents with wander-guard/code alert systems who are highly mobile require enhanced safety measures. The facility implemented door locking, code changes, alert antenna installation, and staff communication updates to promote resident safety.
Report Facts
Dates of corrective actions: Multiple dates from 2019-04-25 to 2019-05-17 related to implementation of safety measures
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-10-23.
Findings
All deficiencies have been corrected as of the compliance date of 2018-11-22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Nov 22, 2018
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa in response to previously identified deficiencies during a regulatory inspection.
Findings
The Plan of Correction outlines corrective actions and monitoring plans for multiple deficiencies related to resident care, including bed hold notices, fall prevention, wheelchair alignment, pressure ulcer interventions, food preparation, dishwasher temperature control, blood glucose monitoring, and infection control.
Deficiencies (8)
F625-D: The facility updated the Admission Order Document with EMS packets including bed hold notices and will provide nursing education on this by 11/22/18.
F657-E: Licensed Nurses received education on root cause analysis for falls and care plan updates, with new flowsheets and intervention lists to be implemented by 11/22/18.
F684-D: Wheelchair Use policy will be updated to address resident positioning for comfort and alignment, with staff education and monthly OT screenings completed by 11/22/18.
F686-D: Direct Care staff will be educated on pressure relieving interventions, with weekly and monthly reviews by wound specialists to ensure interventions are in place.
F689-E: Re-education on root cause analysis for falls will be completed by 11/22/18, with competency validation and intervention lists provided to Licensed Nurses.
F804-E: The kitchen has a policy for following recipes, with updates to pureed food recipes and staff education to be completed by 11/10/18, including skills validation and monthly spot checks.
F812-F: Dining services staff will be educated on dishwasher machine temperatures and policy compliance, with weekly spot checks and quarterly reporting.
F880-F: Licensed Nurses will be educated on proper blood glucose monitoring technique using alcohol wipes, with infection logs maintained and reviewed weekly by the Infection Preventionist.
Report Facts
Completion date: Nov 22, 2018
Completion date: Nov 10, 2018
Completion date: Nov 9, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for oversight and completion of education and monitoring for multiple deficiencies | |
| Director of Social Services | Responsible for verifying bed hold letters and reporting to QA committee | |
| Culinary General Manager | Responsible for monitoring pureed food preparation and dishwasher temperature compliance | |
| Volunteer Coordinator | Responsible for volunteer illness education and reporting |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: 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 Medicare and/or Medicaid programs.
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, resulting in a finding of substantial compliance effective 11/22/2018.
Deficiencies (1)
The facility had a level F deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Contact person for questions concerning the information in the letter. |
Inspection Report
Re-Inspection
Census: 85
Deficiencies: 8
Date: Oct 23, 2018
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide written notice of bed-hold policy, failure to timely review and revise care plans related to falls, improper body positioning, inadequate pressure ulcer prevention, failure to prevent accidents and falls, failure to follow food preparation recipes, improper dishwasher sanitizing temperatures, and failure to maintain an effective infection prevention and control program.
Deficiencies (8)
F625: The facility failed to provide the resident and/or durable power of attorney with a written notice specifying the duration of the bed-hold policy upon transfer to hospital.
F657: The facility failed to timely review and revise care plans for 5 residents to include appropriate interventions to prevent further falls and accidents.
F684: The facility failed to ensure proper body alignment and positioning for a resident requiring staff assistance, lacking pillows or positioning devices in wheelchair.
F686: The facility failed to ensure adequate pressure relieving devices for a resident with a pressure ulcer in all seating areas to promote healing and prevent further ulcers.
F689: The facility failed to conduct root cause analyses and implement appropriate interventions to prevent repeated falls for 5 residents with fall histories.
F804: The facility failed to follow recipes for pureed foods served to 10 residents, compromising nutritional value and palatability.
F812: The facility failed to maintain proper dishwasher sanitizing water temperature in one kitchen, risking foodborne infection.
F880: The facility failed to maintain an effective infection prevention and control program by reusing alcohol wipes during blood sugar testing and failing to track infections among staff, volunteers, and visitors.
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 blood sugar testing procedure |
| Staff B | Administrative Nursing Staff | Named in multiple deficiencies including bed-hold policy, fall interventions, and infection control oversight |
| Staff G | Administrative Nursing Staff | Oversaw infection control program and confirmed lack of infection tracking for staff and visitors |
| Staff U | Dietary Staff | Named in pureed food recipe and preparation deficiency |
| Staff S | Dietary Staff | Named in dishwasher temperature monitoring deficiency |
| Staff C | Maintenance Staff | Named in dishwasher temperature monitoring deficiency |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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.
Deficiencies (1)
Deficiencies were cited 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).
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Aug 18, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior complaint investigation at Schowalter Villa.
Findings
The plan addresses past non-compliance issues identified under tags F0000, F223-D, F225-K, and F226-F, all of which required no further plan of correction.
Deficiencies (4)
Tag F0000 indicates past non-compliance with no plan of correction required.
Tag F223-D indicates past non-compliance with no plan of correction required.
Tag F225-K indicates past non-compliance with no plan of correction required.
Tag F226-F indicates past non-compliance with no plan of correction required.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 3
Date: Aug 18, 2017
Visit Reason
Complaint investigation #119151 regarding allegations of resident to resident sexual abuse and failure to protect residents from abuse.
Complaint Details
Complaint investigation #119151 focused on resident to resident sexual abuse involving resident #1 and resident #2. The facility failed to protect residents and failed to report the incident timely to administration and the state agency.
Findings
The facility failed to ensure one resident was free from inappropriate physical contact by another resident and failed to protect multiple opposite gender residents from sexual abuse. The facility also failed to timely report and investigate the incident and failed to follow abuse prevention policies.
Deficiencies (3)
483.12(a)(1) The facility failed to ensure a resident remained free from inappropriate physical contact when another resident touched the resident in an inappropriate manner and asked for sex.
483.12(a)(3)(4) The facility failed to timely report and investigate an incident of resident to resident sexual abuse and failed to protect multiple opposite gender residents from potential sexual abuse.
483.12(b) The facility failed to implement policies and procedures to prevent abuse, ensure timely investigation and reporting, and provide adequate staff training on abuse prevention and reporting.
Report Facts
Resident census: 92
Residents selected for sample review: 3
Opposite gender residents at risk: 7
Duration of immediate jeopardy: 86.83
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 14, 2017
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency under regulation 26-41-206 (e)(1) was corrected as of the revisit date. No other deficiencies or issues were noted in this report.
Deficiencies (1)
Regulation 26-41-206 (e)(1) deficiency was corrected as of 2017-08-14.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 14, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously reported deficiencies identified by regulation numbers 483.10(i)(2), 483.60(i)(1)-(3), and 483.80(a)(1)(2)(4)(e)(f) have been corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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
The report identifies sanitation issues in the dining room, including soiled cabinet shelves and improper food storage practices. Corrective actions include updated cleaning schedules, staff education, equipment replacement, and ongoing monitoring.
Deficiencies (1)
S3299 The cabinet under the coffee station held a visible soiled and stained bottom shelf. The shelf under the juice dispenser held dry/wet soiling.
Report Facts
Plan of Correction completion date: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Tonya Keim | Exec Admin Assistant | Submitted the Plan of Correction |
| Irina Strakhova | Modified the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Jul 20, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection.
Findings
The plan addresses multiple deficiencies related to cleanliness, maintenance, and infection control in various areas including resident room doors, hand rails, floor drains, dining room, and glucometer disinfecting procedures. Corrective actions and preventive monitoring plans are outlined with completion dates.
Deficiencies (12)
F253-E: Housekeeping and salon staff will clean dryer filters and personal fans weekly to maintain cleanliness. Metal kick plates will be installed on resident room doors in specified neighborhoods by 8/14/17.
Hand rails in West Orchard will be repaired and those in South Coralberry resurfaced by 9/16/17 to maintain sanitary and comfortable interiors.
Floor drain in the 200 Spa Room will be replaced with a drain cover by 7/26/17 to maintain sanitary conditions.
Dirty items in the 300 Shower Room were removed on 7/14/17; housekeeper retraining and quarterly inspections will ensure ongoing cleanliness.
Floor seam in the West Orchard 300 hall restroom was temporarily repaired on 7/20/17; full floor replacement scheduled by 8/4/17.
Spa room wall heater casing and area around sink will be painted by 7/28/17 to maintain sanitary conditions.
Floor transition strip was removed, cleaned, and re-installed on 7/18/17 with quarterly inspections planned.
Harvest Dining Room cabinets had soiled shelves; cleaning schedules updated and cabinets will be resurfaced by 8/14/17 with quarterly inspections.
Food storage policy updated on 7/19/17 with mandatory in-service training and biweekly monitoring for compliance.
Pans with build-up removed; replacements ordered by 8/14/17; cleaning schedules updated with staff training and monitoring.
Ice delivery procedure changed to prevent contamination; staff education ongoing with completion by 8/2/17.
New germicidal bleach wipes ordered for glucometer disinfection; licensed nurses to be educated by 8/14/17 with ongoing compliance monitoring.
Report Facts
Completion date: Jul 20, 2017
Completion date: Aug 14, 2017
Completion date: Jul 26, 2017
Completion date: Jul 28, 2017
Completion date: Aug 2, 2017
Completion date: Aug 4, 2017
Completion date: Aug 14, 2017
Length of hand rail resurfacing: 320
Length of hand rail repair: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tonya Keim | Exec Admin Assistant | Submitted the Plan of Correction to KDADS |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 17, 2017
Visit Reason
The visit was a Health survey conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective August 14, 2017.
Deficiencies (1)
The survey found 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 3
Date: Jul 10, 2017
Visit Reason
The inspection was a health resurvey to assess compliance with housekeeping, maintenance, food safety, and infection control standards.
Findings
The facility failed to maintain sanitary and comfortable conditions in multiple areas including resident halls, dietary department, and shared equipment. Deficiencies included poor housekeeping, unsanitary food storage and preparation, and inadequate infection control practices during blood glucose testing and ice handling.
Deficiencies (3)
F 253 Housekeeping and maintenance services were inadequate, with dust buildup, scraped doors, missing flooring, worn handrails, and a damaged wheelchair seat posing safety risks.
F 371 The dietary department was unsanitary with soiled surfaces and multiple food items lacking proper labeling and dating, risking foodborne illness.
F 441 The infection control program failed to prevent cross contamination during blood glucose testing and ice distribution, with improper sanitization of glucometers and unsafe ice scoop handling.
Report Facts
Census: 92
Residents using shared glucometers: 18
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff C | Licensed Nursing Staff | Observed performing blood glucose testing with improper glucometer sanitization |
| Licensed nursing staff B | Licensed Nursing Staff | Observed performing blood glucose testing with inadequate glucometer sanitization |
| Administrative licensed staff A | Administrative Licensed Staff | Reported proper glucometer sanitization procedures and wet time requirements |
| Maintenance staff F | Maintenance Staff | Confirmed facility maintenance issues and wheelchair condition |
| Direct care staff D | Direct Care Staff | Observed passing ice with improper infection control technique |
| Dietary staff E | Dietary Staff | Verified unsanitary conditions and unlabeled food items in dietary department |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 2
Date: Jul 10, 2017
Visit Reason
The inspection was a health resurvey to assess 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 and accumulation of debris on kitchen equipment and surfaces.
Deficiencies (2)
26-41-206 (e) (1) Facility Food Storage: The facility failed to store food under safe and sanitary conditions, including unlabeled and undated cooked meats and other food items in the walk-in freezer and cooler.
The facility had visible soiling and debris on kitchen equipment, including stained shelves, dirty pans, and dust accumulation under cooking equipment.
Report Facts
Census: 35
Number of unlabeled food packages: 22
Number of pans with debris: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff E verified and reported multiple sanitation and labeling issues |
Inspection Report
Follow-Up
Deficiencies: 1
Date: 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 have been corrected.
Findings
The revisit confirmed that the deficiency identified under regulation 483.25(h) was corrected as of 09/14/2016. No uncorrected deficiencies were noted at the time of this revisit.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 09/14/2016.
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 6, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was found to have deficiencies at an "F" level in Life Safety Code compliance, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Jan 6, 2017
Effective date for provider agreement termination: Apr 6, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the survey report |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 14, 2016
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 in substantial compliance and the 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 admissions were imposed.
Deficiencies (1)
F323, "J", CFR 483.25(h) was cited for substandard quality of care constituting immediate jeopardy to resident health or safety.
Report Facts
Denial of payment effective date: Oct 6, 2016
Recommended provider agreement termination date: Mar 14, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter and contact for questions regarding the matter |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Sep 14, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#104972) and a partial extended survey related to resident safety and supervision.
Complaint Details
The complaint investigation #104972 substantiated that the facility failed to supervise a resident with severe cognitive impairment who eloped to the courtyard and remained there for 2 hours and 24 minutes without staff knowledge, resulting in immediate jeopardy.
Findings
The facility failed to provide adequate supervision for a severely cognitively impaired resident who remained outside in the courtyard for over 2 hours without staff knowledge, resulting in the resident experiencing lethargy, diaphoresis, and a mild sunburn. Staff falsified documentation regarding resident checks, and the lack of supervision placed the resident in immediate jeopardy.
Deficiencies (1)
483.25(h) The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision for a cognitively impaired resident who remained outside unsupervised for over 2 hours, resulting in lethargy and sunburn.
Report Facts
Census: 91
Duration resident unsupervised: 144
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Direct Care Staff | Last staff to check on resident before leaving shift; failed to report resident was outside |
| Staff P | Direct Care Staff | Noticed resident missing from room at 2:00 p.m. |
| Staff GG | Consultant Staff | Notified of incident and provided direction to monitor resident |
| Staff B | Administrative Nursing Staff | Reported falsification of documentation by staff O |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 14, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at Schowalter Villa related to resident safety and wandering.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Schowalter Villa dated 09/14/2016.
Findings
The plan addresses corrective actions for a resident at risk of wandering, including updated care plans, staff education, monitoring protocols, and termination of a CNA for falsifying documentation. Ongoing monitoring and reporting to the QA committee are established to ensure resident safety.
Deficiencies (2)
F0000 Statement of Deficiency will be taken to the QA Committee at the next meeting on 10/13/16.
F323-J The care plan for the resident affected has been updated to include 30 minute in-person checks and assistance with skin protection. Staff will notify the licensed nurse if the resident demonstrates discomfort and refuses to return from the courtyard.
Report Facts
Date of complaint: Sep 14, 2016
Plan of Correction completion date: Oct 13, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Director of Nursing | Responsible for program effectiveness and updates as needed |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 22, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the deficiencies previously cited have been corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected and the corrective action was completed by 07/22/2016.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Jul 1, 2016
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of residents eloping or leaving the facility without staff knowledge.
Complaint Details
The findings represent the results of complaint investigations #101244 and #101341 regarding resident elopement incidents.
Findings
The facility failed to ensure adequate supervision and assistive devices to prevent two cognitively impaired residents from exiting the facility without staff knowledge. The pager system failed to alert staff of a resident's exit, and staff did not monitor hall exit alarms properly.
Deficiencies (1)
483.25(h) The facility failed to ensure two cognitively impaired residents did not leave the facility without staff knowledge, resulting in elopement risks.
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
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 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.
Deficiencies (1)
The facility had a 'D' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Nov 25, 2015
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at the facility.
Findings
The report confirms that previously reported deficiencies identified by regulation numbers 26-41-203 (e) and 26-41-205 (l)(1) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-203 (e): Previously cited deficiency has been corrected as of 11/25/2015.
Regulation 26-41-205 (l)(1): Previously cited deficiency has been corrected as of 11/25/2015.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 5, 2015
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa Assisted Living Facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses deficiencies related to door surface repairs for improved cleaning and medication management for residents taking medications with black box warnings. It also clarifies that there was no deficient practice related to monitoring TSH levels for a resident.
Deficiencies (2)
S3145: Doors in the 100 and 150 hallways have damage affecting cleaning effectiveness. Repairs and coverings will be applied to improve surface cleaning and appearance.
S3226: Medication reviews including black box warnings were not consistently documented. A checkbox was added to the Plan of Care form and pharmacy reviews will verify compliance.
Report Facts
Plan of Correction completion date: Nov 25, 2015
QA Committee meeting date: Nov 12, 2015
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 26, 2015
Visit Reason
The inspection was conducted as a health survey and complaint investigation (#92770) for the facility.
Complaint Details
Complaint investigation #92770 was conducted and found no deficiencies.
Findings
The investigation resulted in no deficiency citations related to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 26, 2015
Visit Reason
The document is a Plan of Correction related to a health survey and complaint investigation #92770 for a long term care facility.
Findings
The health survey and complaint investigation resulted in no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B.
Inspection Report
Renewal
Census: 36
Deficiencies: 2
Date: 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 resident room doors and common areas, and failed to monitor residents for medications with black box warnings, including failure to obtain required lab tests.
Deficiencies (2)
S3145 Routine Maintenance. The facility 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, including worn paint and corrosion on sinks.
S3226 Medication Regimen Review. The facility failed to identify and monitor 3 residents for medications with black box warnings and failed to obtain a yearly TSH lab for one resident as ordered by the physician.
Report Facts
Resident census: 36
Resident census: 35
Number of resident room doors: 40
Number of resident room doors with issues: 34
Number of residents in medication sample: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Confirmed maintenance and medication regimen findings | |
| Licensed nursing staff B | Confirmed lack of black box warnings on care plans and MARs | |
| Consultant staff C | Reviewed MARS every 3 months and commented on black box warning appropriateness | |
| Administrative nursing staff D | Reported inability to locate TSH lab for resident |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 31, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not immediate jeopardy.
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 for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 12, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as reported on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the previously reported deficiency with regulation 483.35(i) was corrected as of the revisit date. No other deficiencies were noted in this report.
Deficiencies (1)
Regulation 483.35(i) deficiency was corrected by the revisit date of 08/12/2014.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 12, 2014
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies from the survey completed on 2014-07-14.
Findings
The report documents that the previously identified deficiency under regulation 26-40-303 (b)(c) was corrected as of 2014-08-12. No other deficiencies are noted.
Deficiencies (1)
Regulation 26-40-303 (b)(c) deficiency was corrected as of 2014-08-12.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 4, 2014
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at the facility.
Findings
The report documents that the deficiency identified by regulation 28-39-158(g) with ID prefix S0640 was corrected as of 08/04/2014.
Deficiencies (1)
Regulation 28-39-158(g) deficiency identified by prefix S0640 was corrected on 08/04/2014.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 15, 2014
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 issues related to pans used in food service, specifically the replacement of pans and staff education to prevent build-up and ensure sanitary conditions.
Deficiencies (1)
S0640-F: Pans used in food service had build-up. The facility plans to replace all pans and educate staff on proper washing techniques to prevent reoccurrence.
Report Facts
Complete Date for pan replacement: Aug 4, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 14, 2014
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 1
Date: 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 multiple kitchen pans and food service equipment, risking food borne illness among residents.
Deficiencies (1)
F 371: The facility failed to store and serve food under sanitary conditions. Multiple pans and food service equipment had brownish build-up and flaking, indicating inadequate cleaning.
Report Facts
Resident census: 83
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
Size of flaking paint on food warmer: 5
Number of areas with flaking paint on food warmer: 5
Inspection Report
Renewal
Census: 34
Deficiencies: 1
Date: 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 on multiple kitchen pans and inadequate cleaning practices, posing a risk for food borne illness among residents.
Deficiencies (1)
28-39-158(g) SANITARY CONDITIONS: The facility failed to maintain sanitary conditions in the kitchen, with multiple pans showing brownish or black build-up and flaking non-stick coatings, indicating inadequate cleaning.
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 coating issues: 2
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 8, 2013
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for isolated 'D' level deficiencies under the Life Safety Code with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Feb 8, 2014
Provider agreement termination date: May 8, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 19, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report confirms that the previously identified deficiency under regulation 26-40-305 (c)(1)(2) was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-305 (c)(1)(2) deficiency was corrected by the revisit date of 2013-04-19.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 19, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-03-27.
Findings
The report confirms that the previously cited deficiency under regulation 483.25(h) was corrected as of 2013-04-19. No other deficiencies are noted.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 2013-04-19.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 1
Date: Mar 27, 2013
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with heating, ventilation, and air conditioning system requirements.
Findings
The facility failed to meet the minimum ventilation requirements for the negative pressure exhaust fans in the beauty shop. Observations and interviews revealed the exhaust vents were not functioning properly and there was no policy for ventilation maintenance and monitoring.
Deficiencies (1)
26-40-305(c)(1)(2) P E - Heating, Ventilation and A.C. The facility failed to meet minimum ventilation requirements for the negative pressure exhaust fans in the beauty shop. The vents did not operate properly and no maintenance policy was in place.
Report Facts
Facility census: 87
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N040006 POC BVHS11
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation regarding resident elopements and safety concerns at the facility.
Complaint Details
This Plan of Correction is related to a complaint investigation concerning resident elopements and safety risks due to impaired decision-making ability.
Findings
The plan addresses deficiencies related to residents with impaired decision-making ability who are oblivious to their safety needs, including incidents of elopement on 5/27/16 and 5/30/16. It outlines corrective actions such as staff counseling, system changes to door alert notifications, re-education of staff, and implementation of new assessment forms and monitoring procedures.
Deficiencies (1)
F323-D: All residents with impaired decision-making ability are oblivious to their safety needs, leading to elopements on 5/27/16 and 5/30/16. Corrective actions include staff counseling, system changes to door alert notifications, and enhanced monitoring and assessment procedures.
Report Facts
Elopement incidents: 2
Date of staff counseling: Staff counseling occurred on 5/30/16.
Date of system changes: Door alert color change and call alarm reset discontinuation on 5/31/16; pager tone and vibration change on 6/7/16.
Date of code alert device placement: Code alert device placed on resident on 5/27/16.
Date of staff re-education: Staff re-education on monitoring residents on 6/6/16.
Date of new hire orientation changes: Orientation changes implemented on 6/6/16.
Date of new elopement assessment form implementation: Implemented on 7/6/16 with initial assessments by 7/22/16.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040006 POC M9I911
Visit Reason
This document is a Plan of Correction related to deficiencies identified in a prior inspection report for Schowalter Villa ALF COVID dated 7.27.2020.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a corrective action plan following a previous inspection.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N040006 POC SY6311
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa in response to a prior statement of deficiencies identified during an 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, and scheduled preventative maintenance.
Deficiencies (2)
F323 Level E deficiency involved improper storage of hazardous chemicals and unlocked housekeeping closets. Corrective actions include staff re-education and installation of keypad entry systems to secure these areas.
S1354-F deficiency involved malfunctioning ceiling exhaust ventilation motor in the beauty shop. The motor will be repaired and preventative maintenance will include ventilation system checks.
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
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N040006 POC YLWO11
Visit Reason
This document is a Plan of Correction submitted by Schowalter Villa addressing deficiencies identified in a prior inspection related to food service and safety.
Findings
The plan addresses issues with pans having build-up and the condition of food warmer/holding cabinets, as well as continuous locking of exit doors on the 700 hall to ensure resident safety.
Deficiencies (3)
F371-F: Pans used for residents who eat food in Health Care have build-up and require replacement and staff education on proper washing techniques. New pans are anticipated to be in place by 8/4/14.
F371-F: Food warmer/holding cabinets in the Meadowlark and Bluespruce Dining Rooms show wear and require replacement; new equipment is expected by 8/15/14 with interim maintenance to prevent debris contamination.
S1176-E: The two exit doors on the 700 hall will be locked continuously unless continuous visual supervision is present to ensure resident safety; compliance will be monitored daily.
Report Facts
Residents affected: 12
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040006 POC Z7RS11
Visit Reason
This document is a Plan of Correction related to a previous inspection or regulatory finding for the facility identified as State ID N040006 ASPEN Event ID Z7RS11.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040006 POC
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040006 POC 3LJ311
Visit Reason
This document serves as a plan of correction related to a prior deficiency report for the facility Schowalter Villa dated 7.25.19.
Findings
No specific findings or deficiencies are detailed in this document. It references a prior deficiency report but contains no records or corrective details.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040006 POC 3LJ312
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
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