Inspection Reports for Sharon Lane Health and Rehabilitation
10315 JOHNSON DRIVE, KS, 66203-3065
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
80 residents
Based on a September 2013 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 6
Oct 2, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers F0279, F0329, F0371, F0428, F0441, and F0460 were corrected as of the revisit date.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(d)(1)(iv)-(v) |
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Oct 2, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, addressing compliance issues related to care plans, medication monitoring, infection control, food sanitation, privacy, and other regulatory requirements.
Findings
The plan outlines corrective actions including revising care plans, monitoring medication side effects, conducting staff in-services, performing audits, and improving infection control and privacy policies. The facility aims to achieve substantial compliance by October 2, 2013.
Severity Breakdown
D: 1
E: 4
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to develop comprehensive care plans with measurable objectives and timetables. | D |
| Drug regimens not free from unnecessary drugs and inadequate monitoring of medication side effects. | E |
| Failure to store, prepare, and distribute food under sanitary conditions. | F |
| Failure to ensure monthly pharmacist review of drug regimens and proper monitoring of side effects. | E |
| Inadequate Infection Control Program and failure to properly clean and store nebulizers. | E |
| Failure to ensure full visual privacy for each resident in bedrooms. | E |
Report Facts
Deficiencies cited: 6
Compliance deadline: Oct 2, 2013
In-service dates: Sep 17, 2013
In-service dates: Sep 20, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Moore | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 8
Sep 4, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #KS00068252 and #KS00066483 to assess compliance with regulatory requirements.
Findings
The facility failed to develop individualized comprehensive care plans for residents, failed to monitor and document medication side effects, failed to provide adequate bowel monitoring, failed to serve food in a sanitary manner, failed to properly store nebulizers, failed to handle linens properly to prevent infection spread, and failed to assure full visual privacy for residents on one hall.
Complaint Details
The visit was triggered by complaint investigations #KS00068252 and #KS00066483.
Severity Breakdown
SS=D: 1
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to develop individualized comprehensive care plans for residents #49 and #64, including measurable objectives and specific behavior monitoring related to medication use. | SS=D |
| Failed to ensure drug regimen was free from unnecessary drugs and failed to document side effects for medications for residents #45, #79, #64, #49, and #66. | SS=E |
| Failed to serve food in a sanitary manner; staff fed a resident without washing hands and served food after handling dirty dishes. | — |
| Failed to document side effects for each medication and failed to act on irregularities identified by pharmacist for residents reviewed. | SS=E |
| Failed to properly store a medication nebulizer for resident #131; nebulizer was stored uncovered. | — |
| Failed to adhere to appropriate hand washing techniques after handling contaminated items. | — |
| Failed to handle soiled linens properly; soiled towels placed on floor before disposal. | — |
| Failed to assure full visual privacy for residents on the 100 hall; no privacy curtains were present. | — |
Report Facts
Census: 80
Sample size: 14
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Nursing Staff | Reported Black Box warnings were on care plans but side effects were not care planned to monitor for |
| Staff L | Licensed Nursing Staff | Reported nursing staff initiated temporary care plans and updated electronic care plans; acknowledged lack of side effect documentation |
| Staff M | Licensed Nurse | Reported behavior monitoring sheet listed Lorazepam for anxiety but resident took it for sleep |
| Staff H | Licensed Nursing Staff | Acknowledged resident records lacked side effects for medications; used drug book for side effect lookup |
| Staff K | Licensed Nursing Staff | Stated Black Box warnings were listed on care plans with side effects; explained paranoia behavior monitoring |
| Staff JJ | Social Services Staff | Reported resident was not aware of paranoid behavior; resident became depressed in isolation |
| Staff S | Direct Care Staff | Reported resident was depressed in isolation but improved after; worried about staff during transfers |
| Staff R | Direct Care Staff | Reported resident had no behaviors since out of isolation |
| Staff V | Direct Care Staff | Reported resident had no paranoia behaviors and was social |
| Staff U | Direct Care Staff | Documented bowel movements and reported unusual resident conditions to nursing staff |
| Staff J | Licensed Nursing Staff | Reported alert box on computer for residents without bowel movements |
| Staff KK | Consultant Pharmacist | Reviewed nurse notes for medication side effects; failed to identify need for individualized behavior monitoring |
| Staff DD | Dietary Staff | Observed serving food without handwashing after handling dirty dishes |
| Staff T | Direct Care Staff | Observed picking up food from floor without handwashing afterward |
| Staff Y | Housekeeping Staff | Observed placing soiled towels on floor before disposal |
| Staff X | Housekeeping Staff | Reported soiled laundry should not be placed on floor |
Inspection Report
Follow-Up
Deficiencies: 5
Jun 6, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that all previously identified deficiencies were corrected by the revisit date of 06/06/2012, with corrections documented for multiple regulatory requirements.
Deficiencies (5)
| Description |
|---|
| Deficiency identified under regulation 483.25 (F0309) |
| Deficiency identified under regulation 483.25(h) (F0323) |
| Deficiency identified under regulation 483.25(l) (F0329) |
| Deficiency identified under regulation 483.60(b), (d), (e) (F0431) |
| Deficiency identified under regulation 483.70(f) (F0463) |
Inspection Report
Plan of Correction
Deficiencies: 5
Jun 6, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The facility outlines corrective actions for multiple deficiencies including skin care, accident hazard prevention, drug regimen monitoring, medication labeling, and call light system functionality, with all actions planned to achieve substantial compliance by June 6, 2012.
Severity Breakdown
D: 3
E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide necessary care and services to maintain residents' skin integrity. | D |
| Failure to ensure the residents' environment remains free of accident hazards and provide adequate supervision and assistance devices. | D |
| Failure to ensure residents' drug regimens are free from unnecessary drugs. | D |
| Failure to label drugs and biologicals in accordance with professional principles including accessory and cautionary instructions and expiration dates. | E |
| Failure to maintain a functioning call light system accessible to residents. | E |
Report Facts
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Moore | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 79
Deficiencies: 5
May 14, 2012
Visit Reason
The inspection was a health resurvey to assess compliance with care standards and regulatory requirements at Sharon Lane Health Services.
Findings
The facility was found deficient in multiple areas including failure to provide necessary care for residents at high risk for skin problems, failure to maintain a safe environment free of accident hazards, failure to monitor pain adequately, improper labeling and dating of multi-dose medication vials and insulin cartridges, and failure to maintain a functioning resident call light system.
Severity Breakdown
SS=D: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide necessary care for 1 of 3 residents sampled for skin problems, including failure to apply barrier cream and report skin condition. | SS=D |
| Failed to address an exposed bed frame with sharp edges on the locked dementia unit presenting a hazard for 7 cognitively impaired residents. | SS=D |
| Failed to monitor pain for 1 resident who required pain medication according to physician's orders. | SS=D |
| Failed to ensure multi-dose medication vials and insulin cartridges were labeled and dated on 2 of 3 units. | SS=E |
| Failed to maintain a functioning call light system for residents in their rooms and toilet/bathing areas. | SS=E |
Report Facts
Residents present: 79
Residents sampled: 15
Residents sampled for unnecessary medications: 10
Residents on secure dementia unit: 17
Resident pain medication PRN doses in February: 14
Resident pain medication PRN doses in March: 12
Resident pain medication PRN doses in April: 24
Resident pain medication PRN doses in May through 5/10/12: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff member A | Oversaw resident house moves and acknowledged housekeeping should place mattress on bed | |
| Direct care staff C | Assisted resident with perineal care | |
| Direct care staff D | Assisted resident with perineal care | |
| Direct care staff E | Reported resident's reddened genital area to licensed staff | |
| Licensed staff F | Assessed resident's reddened genital area and stated staff could apply barrier cream | |
| Administrative nursing staff B | Acknowledged protocol for barrier cream application and failure to report skin condition | |
| Administrative licensed nurse A | Acknowledged exposed bed frame was an accident hazard | |
| Administrative nursing staff G | Acknowledged failure to monitor resident pain every shift | |
| Licensed staff H | Stated insulin cartridges were expired and multi-dose vials good for 30 days | |
| Administrative staff A | Acknowledged short call light string and non-functioning call light |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 16, 2011
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID H0F111 and State ID N046011.
Findings
No specific deficiencies or findings are detailed in this document; it serves as a record for the Plan of Correction associated with the inspection event.
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