Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 2
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess the facility's pharmaceutical services, specifically the management, documentation, and reconciliation of controlled drugs for residents.
Findings
The facility failed to maintain accurate and timely documentation of controlled drug administration and narcotic reconciliation for 5 residents, resulting in discrepancies between documented narcotic counts and actual medication counts on medication carts. This posed risks of medication overdose, under-dose, and ineffective therapeutic outcomes.
Deficiencies (2)
Failure to provide pharmaceutical services that ensure drug records are in order and controlled drugs are periodically reconciled for 5 residents.
Failure to accurately and timely complete documentation of controlled drug administration and monitoring of controlled medications stored on medication carts.
Report Facts
Residents reviewed for pharmacy services: 65
Residents with deficiencies: 5
Narcotic count discrepancies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Reported failure to sign out narcotic sheets immediately and described facility policy on narcotic documentation |
| LVN B | Licensed Vocational Nurse | Reported failure to sign out narcotic sheets due to moving on to other medications and described risks of overmedication |
| ADON A | Assistant Director of Nursing | Present during medication cart audit and described facility policy on narcotic signing and counting |
| DON | Director of Nursing | Reported facility policy on narcotic documentation and stated minimal risk due to single person on medication cart |
| Regional Nurse | Reported facility policy on narcotic documentation alongside DON |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 1, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with nursing competencies, pharmaceutical services, medication administration, and clinical record maintenance.
Findings
The facility failed to ensure licensed nurses had appropriate competencies and supervision as per Texas Board of Nursing orders, failed to maintain accurate controlled substance records with required signatures, and failed to document medication administration accurately in residents' medical records.
Deficiencies (3)
Licensed nurse (LVN A) was not supervised as per Texas Board of Nursing agreed order, placing residents at risk.
Facility failed to have a system to account for disposition and accurate accounting of controlled substances for 4 residents; missing second signatures on medication waste sheets.
Facility failed to maintain complete and accurate clinical records for 2 residents, including failure to document medication administration on MAR.
Report Facts
Residents reviewed for pharmacy records: 12
Residents affected by pharmaceutical deficiencies: 4
Residents affected by clinical record deficiencies: 2
Dates of medication waste missing second signature: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in findings related to nursing competency and medication waste |
| DON | Director of Nursing | Responsible for supervising LVN A and medication administration oversight |
| BOM | Board of Nursing Monitor | Interviewed regarding LVN A's stipulations and employment verification |
| ADON | Assistant Director of Nursing | Interviewed regarding medication waste sheet review and facility expectations |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning and food service safety at Senior Care Health & Rehabilitation Center - Wichita.
Findings
The facility failed to develop comprehensive care plans within 7 days after significant change assessments for two residents, and care plan meetings were not conducted or invitations extended to residents. Additionally, the facility failed to maintain cleanliness in the Rehab Dining Area and Rehab Kitchen, with soiled cabinet drawers, sticky floors, and dirty countertops, posing a risk for food-borne illness.
Deficiencies (2)
Failed to develop a comprehensive care plan within 7 days after significant change assessments for 2 of 4 residents, and care plan meetings were not conducted or residents invited.
Failed to store, prepare, distribute, and serve food in accordance with professional standards; countertops, floors, and cabinet drawers in Rehab Dining and Kitchen areas were unclean.
Report Facts
Residents affected: 2
Cabinet drawers soiled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Responsible for scheduling care plan meetings and sending invitations; acknowledged system failure causing missed care plan meetings | |
| Director of Nursing (DON) | Stated expectation for quarterly care plan meetings and inclusion of residents or representatives | |
| Corporate Dietary Manager | Acknowledged unclean conditions in Rehab Dining and Kitchen areas and potential for attracting pests | |
| Dietary Manager | Observed unclean cabinet drawers and kitchen area | |
| Administrator | Expressed expectation for cleanliness and noted plans for remodeling |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 14, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Senior Care Health & Rehabilitation Center - Wichi, summarizing the findings of a regulatory survey completed on 11/14/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the Senior Care Health & Rehabilitation Center - Wichi to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 4
Date: Nov 23, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, nursing staff competency, pharmaceutical services, and infection prevention and control.
Findings
The facility failed to ensure accurate resident assessments, specifically for Resident #77's range of motion; failed to ensure nurse aides demonstrated competency, as Medication Aide C did not report an elevated pulse for Resident #59; failed to provide pharmaceutical services properly, as LVN F left medication for Resident #121 to take later without observation; and failed to maintain an infection prevention and control program, with staff and visitors not properly donning PPE for residents on transmission-based precautions.
Deficiencies (4)
Failed to ensure assessments accurately reflected Resident #77's range of motion in upper and lower extremities.
Failed to ensure Medication Aide C reported an elevated pulse rate of 154 for Resident #59.
Failed to ensure LVN F administered medications to Resident #121 according to physician's orders and did not leave medication at bedside for later self-administration.
Failed to establish and maintain an infection prevention and control program; staff and visitors did not don required PPE for residents on transmission-based precautions.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Pulse rate: 154
Medication dosage: 0.5
Medication dosage: 25
Medication dosage: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide C | Failed to report elevated pulse of Resident #59 | |
| LVN F | Licensed Vocational Nurse | Failed to administer medication properly to Resident #121 |
| DON | Director of Nursing | Provided statements regarding assessment and medication administration failures |
| ADON | Assistant Director of Nursing | Observed Resident #77's contractures and commented on documentation responsibility |
| Occupational Therapist E | Occupational Therapist | Failed to don full PPE when providing therapy to Resident #276 |
| Maintenance Director | Entered Resident #276's room without donning PPE | |
| LVN D | Licensed Vocational Nurse | Assessed Resident #59 and commented on medication aide reporting expectations |
| Director or Rehabilitation | Commented on PPE compliance of Occupational Therapist E |
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