Inspection Reports for Smoky Hill Rehabilitation Center
1007 JOHNSTOWN AVENUE, SALINA, KS, 67401
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 6, 2022, found the facility in compliance with all regulations and no deficiencies were cited. Prior inspections showed a pattern of deficiencies primarily related to resident care, including medication management, supervision to prevent elopement, bathing and hygiene, nutritional services, and safe transfer techniques. Several complaint investigations were substantiated, including incidents involving medication errors that caused harm, failure to prevent resident elopement, and abuse or neglect concerns, some resulting in immediate jeopardy findings and enforcement actions such as denial of payment for new admissions. Enforcement remedies and fines were noted in earlier years, but no recent enforcement actions were listed in the available reports. The facility appears to have made improvements over time, with multiple revisit surveys confirming correction of prior deficiencies and the most recent inspections showing compliance.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
31.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
425% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
59 residents
Based on a June 2022 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 6, 2022
Visit Reason
A revisit survey was conducted on 07/06/22 to verify correction of all previous deficiencies cited on 06/09/22.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 06/09/22. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Date: Jun 9, 2022
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations related to the facility's failure to provide a safe environment and adequate supervision to prevent elopement of Resident 1 (R1), who was independently mobile and cognitively impaired.
Complaint Details
The complaint investigations #KS00172328 and KS00172172 found that Resident 1 eloped from the facility on 06/06/22, exposing him to immediate jeopardy. The facility was informed of the immediate jeopardy situation on 06/09/22 and took corrective actions including increased monitoring and securing exits.
Findings
The facility failed to prevent R1 from eloping through an unalarmed back door and an unsecured gate, resulting in Immediate Jeopardy. R1 was found three blocks away unharmed. The facility implemented 15-minute checks, changed exit codes, secured gates with alternative locks, and conducted an audit of all residents at risk for wandering. The scope and severity of the deficiency was rated as 'D'.
Deficiencies (1)
Failure to provide a safe environment and adequate supervision to prevent elopement for Resident 1, who exited the facility without staff knowledge through an unalarmed door and unsecured gate.
Report Facts
Census: 59
Residents at risk for elopement: 2
Distance walked by Resident 1: 3
Time Resident 1 was missing: 83
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Stated Resident 1 was a risk for wandering and elopement and had a Wander guard on his right ankle |
| Certified Medication Aide R | Certified Medication Aide | Found Resident 1 outside approximately three blocks away and reported Resident 1 was anxious and frequently asked if it was time to smoke |
| Licensed Nurse G | Licensed Nurse | Documented Resident 1's anxious behavior and coordinated search efforts when Resident 1 was missing |
| Certified Nurse's Aide M | Certified Nurse's Aide | Reported searching for Resident 1 after he was found missing and relayed information from other residents |
| Certified Nurse's Aide N | Certified Nurse's Aide | Discovered the baby lock missing from the gate and initiated search for Resident 1 |
| Administrative Staff A | Administrative Staff | Verified the facility did not provide a safe environment and expressed concern about replacement of padlocks with baby locks |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 9, 2022
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection related to resident elopement and safety.
Findings
The plan addresses the movement of Resident R1 to a secure locked unit, staff placement for monitoring, changes to exit door security, staff education on resident safety, and ongoing audits and reviews to ensure compliance and resident safety.
Deficiencies (1)
Resident R1 was moved to a secure locked unit due to elopement risk; exit codes were changed and combination locks placed on courtyard gates; staff educated on safety and supervision.
Report Facts
Completion Date: Jun 9, 2022
Audit period: 4
Staff monitoring period: 48
QAPI review period: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the plan of correction |
| Shirley Boltz | Contact for plan of correction assistance | |
| Felicia Majewski | Added and modified the plan of correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 12, 2022
Visit Reason
An offsite revisit survey was conducted on 05/12/22 for all previous deficiencies cited on 03/28/22 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of 04/22/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies correction date: Apr 22, 2022
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Apr 22, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies during a regulatory inspection.
Findings
The plan addresses multiple deficiencies related to resident care including pain assessment, medication self-administration, transfer assistance, behavior management, injury prevention, bathing, dental services, nutrition, and risk management. The facility outlines corrective actions such as in-services, audits, care plan updates, monitoring, and education to ensure compliance and improve resident care.
Deficiencies (13)
Resident was assessed for pain and skin breakdown; transfer to more comfortable chair offered; no areas of concern identified.
Resident assessed for hypertension and swelling; no latent effects from self-administering medications; self-administration assessments completed.
Resident assessed for pain and skin breakdown; no reported complaints of pain; no abnormal skin changes.
Resident R52 has passed; education provided on proper notification of Medicare non-coverage.
Resident evaluated for behaviors affecting self and others; care plans updated with interventions.
Resident assessed and assistive device modified to protect lower extremities; monitoring of care plans for injury prevention.
Head-to-toe assessment completed; residents offered shower/bath; no skin abnormalities found.
Residents R102 and R10 assessed; no injury findings; risk management and root cause analysis completed.
Resident R7 given medication for symptoms; review initiated for uncontrolled pain; care plans updated.
Resident assessed for injury; no injury noted; social services assessed for unmet needs and elopement risk.
Resident evaluated by physician and dentist; antibiotics ordered; dental services baseline established.
Dietary service manager educated on pureed diet recipes; audits planned for weight loss and nutritional needs.
Certified Dietary Manager and Registered Dietician oversee food and nutritional services; measures implemented to prevent recurrence of deficiencies.
Report Facts
Completion Date: Apr 22, 2022
Completion Date: Apr 29, 2022
Observation frequency: 2
Monitoring duration: 6
Weekly review frequency: 1
Inspection Report
Census: 55
Deficiencies: 1
Date: Mar 28, 2022
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to employ a full-time certified dietary manager to plan and supervise meal preparation for the 55 residents, placing them at risk for inadequate nutrition.
Deficiencies (1)
Failure to employ a full-time certified dietary manager to plan and supervise meal preparation.
Report Facts
Resident census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DS BB | Dietary Staff | Observed overseeing meal preparation and stated not certified as dietary manager |
| Administrative Staff A | Verified DS BB was not a certified dietary manager |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 11, 2022
Visit Reason
An offsite revisit survey was conducted on 03/11/22 for all previous deficiencies cited on 01/25/22 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 02/25/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 3
Date: Jan 25, 2022
Visit Reason
The inspection was conducted as a complaint investigation for allegations KS00168527 and KS00168525 regarding resident care and facility practices.
Complaint Details
The visit was triggered by complaint investigations KS00168527 and KS00168525.
Findings
The facility failed to assess residents for safe self-administration of medications and did not consistently provide bathing and linen changes as per care plans for multiple residents, placing them at risk for medication errors, impaired dignity, infection, and skin integrity issues.
Deficiencies (3)
Facility failed to assess residents R2 and R6 for ability to safely self-administer medications.
Facility failed to ensure consistent bed linen changes for residents R2, R3, R4, R5, and R6.
Facility failed to provide consistent bathing/showers for residents R1, R2, R3, R4, R5, and R6.
Report Facts
Census: 61
Bathing days documented: 85
Number of baths for R1: 0
Number of baths for R2: 12
Number of baths for R3: 1
Number of baths for R4: 9
Number of baths for R5: 4
Number of baths for R6: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified self-administration assessment requirements and acknowledged bathing issues after reviewing records. |
| Licensed Nurse G | Licensed Nurse | Confirmed resident R2 self-administered insulin without proper care plan. |
| Administrative Nurse G | Administrative Nurse | Stated no residents were known to self-administer insulin. |
| Certified Nurse Aid M | Certified Nurse Aid | Reported showers were not always completed but staff tried their best; bedding changed on shower days. |
| Certified Nurse Aid N | Certified Nurse Aid | Reported showers were not always completed but staff tried their best; bedding changed on bath days. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jan 25, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection conducted on 01/25/2022.
Findings
The plan addresses deficiencies related to residents' ability to self-administer medications, proper changing of bed linens, and bathing of residents. Corrective actions include staff in-service training, audits by nursing leadership, and ongoing review in the facility's Quality Assurance Performance Improvement (QAPI) meetings.
Deficiencies (3)
Residents R2 & R6 were assessed for ability to correctly and safely self-administration of medications.
Residents R1, R2, R3, R4, R5 & R6 had linens changed on beds.
Residents R1, R2, R3, R4, R5 & R6 bathing of residents.
Report Facts
Residents involved: 6
Completion date: Feb 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 30, 2021
Visit Reason
An offsite revisit survey was conducted on 09/30/21 to verify correction of all previous deficiencies cited on 09/08/21.
Findings
All deficiencies have been corrected as of the compliance date of 09/10/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 10, 2021
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified related to wound care treatments and documentation, specifically concerning residents with pressure ulcers.
Findings
An audit was performed to review the Treatment Admission Report (TAR) for missed treatments or documentation issues. The facility implemented education and monitoring measures to ensure compliance with wound care policies and procedures.
Deficiencies (1)
Deficiency related to missed treatment and/or documentation of wound care treatments for residents with pressure ulcers.
Report Facts
Plan of Correction completion date: Sep 10, 2021
Audit duration: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Sep 8, 2021
Visit Reason
The inspection was conducted as a result of complaint investigations #165311 and #165348 to assess compliance with care standards related to pressure ulcers.
Complaint Details
The findings represent the results of complaint investigations #165311 and #165348. The facility failed to comply with physician orders for wound care treatments for resident R1, substantiating the complaint.
Findings
The facility failed to provide necessary treatments and services to promote healing of pressure ulcers for one resident (R1) despite physician orders, resulting in prolonged wound healing and placing the resident at risk.
Deficiencies (1)
Failure to provide services and treatments to promote healing of pressure ulcers for one of four sampled residents, including incomplete treatment as ordered by physician.
Report Facts
Census: 63
Pressure ulcer treatment non-compliance days: 6
Undocumented dressing changes: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Facility Wound Nurse | Stated responsibility for dressing changes and confirmed lack of documentation for wound care treatments |
| Administrative Nurse D | Administrative Nurse | Verified lack of documentation for wound treatments and dressing changes as ordered |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Jul 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#164011) regarding medication errors at the facility.
Complaint Details
Complaint investigation #164011. The medication error was substantiated, placing the resident in immediate jeopardy.
Findings
The facility failed to correctly transcribe admission medication orders for one resident, resulting in the resident receiving Methotrexate daily instead of weekly as prescribed. This medication error caused the resident to develop a gastrointestinal bleed, be hospitalized, and subsequently die. The facility identified the error, conducted audits, and provided in-service education to nursing staff.
Deficiencies (1)
Failed to correctly transcribe admission medication orders, resulting in a resident receiving Methotrexate daily instead of weekly, causing harm and death.
Report Facts
Census: 60
Medication dosage error: 20
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician GG | Physician | Stated the resident received too much Methotrexate and passed away |
| Administrative Staff A | Administrative Staff | Reported facility awareness of medication error and investigation |
| Licensed Nurse G | Licensed Nurse | Administered medication to resident and observed adverse effects |
| Licensed Nurse I | Licensed Nurse | Entered admission medication orders into the computer |
| Licensed Nurse H | Licensed Nurse | Reviewed admission medications and did not detect the error |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 9, 2021
Visit Reason
This document is a Plan of Correction submitted in response to past noncompliance deficiencies identified in a prior inspection.
Findings
The Plan of Correction addresses past noncompliance issues identified under tags F0000 and F760-J, with corrective actions completed by 07/09/2021.
Deficiencies (2)
Past noncompliance under tag F0000
Past noncompliance under tag F760-J
Report Facts
Complete Date: Jul 9, 2021
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 5, 2021
Visit Reason
An offsite revisit survey was conducted on 05/05/21 for all previous deficiencies cited on 03/15/21 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 04/08/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Mar 15, 2021
Visit Reason
The inspection was conducted as a result of complaint investigations #160536 and #160726 regarding potential abuse and misappropriation of resident property.
Complaint Details
The visit was triggered by complaint investigations #160536 and #160726. The facility was found to have misappropriated narcotic medication, confirmed by missing Fentanyl patches and improper medication handling. The complaint was substantiated leading to staff suspension and termination.
Findings
The facility failed to ensure one resident was free from abuse when their pain medication, specifically Fentanyl patches, was misappropriated. The investigation revealed missing narcotic patches, improper logging and handling of controlled substances by staff, and subsequent police notification and staff termination.
Deficiencies (1)
Failure to ensure a resident was free from abuse due to misappropriation of pain medication (Fentanyl patches).
Report Facts
Residents in census: 56
Fentanyl patches delivered: 10
Fentanyl patches missing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Signed for Fentanyl patches delivery but did not log medication |
| LN H | Licensed Nurse | Suspended and terminated due to involvement in medication misappropriation |
| CMA M | Certified Medication Aide | Counted narcotic medications with LN H and provided observations about medication boxes |
| Administrative Nurse D | Administrative Nurse | Stated LN G should have followed facility policy to log and lock up Fentanyl patches |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 15, 2021
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection, specifically addressing medication management issues including a missing pain medication for Resident R2.
Findings
The facility identified a missing pain medication for Resident R2 and implemented a new tracking system, staff education, and revised controlled substance count procedures to prevent recurrence. The plan includes weekly audits and integration into the Quality Assurance Performance Improvement program.
Deficiencies (1)
Missing pain medication for Resident R2 and issues with controlled substance tracking and management
Report Facts
Completion date: Mar 18, 2021
Quality Assurance Performance Improvement Committee meeting date: Apr 8, 2021
Audit period: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren RN | Registered Nurse | Provided input on new controlled substance count sheets |
| Joseph Benter | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Feb 1, 2021
Visit Reason
A complaint survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS due to an episode of abuse involving Resident 1.
Complaint Details
The complaint involved an unauthorized video posted on social media by a staff member showing Resident 1 in a vulnerable state. The immediate jeopardy was determined to be past non-compliance after the facility suspended and terminated the staff involved and re-educated all staff on abuse, neglect, exploitation, and cell phone/media policy.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483.12 due to an immediate jeopardy situation involving abuse of Resident 1, which was determined to be past non-compliance after corrective actions were taken.
Deficiencies (3)
Immediate jeopardy for failing to prevent an episode of abuse to Resident 1.
Deficiency F600-J identified as past non-compliance.
Deficiency F609-D identified as past non-compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Notified of immediate jeopardy and provided copy of IJ Template. |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Feb 1, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#159814) related to allegations of abuse involving a resident at the facility.
Complaint Details
The complaint investigation revealed that CNA M posted a video of Resident 1 on social media showing the resident in a vulnerable state. CNA N saw the video but delayed reporting it to management. The facility failed to report the abuse allegation immediately as required by policy.
Findings
The facility failed to prevent an incident of abuse when a Certified Nurse Aide posted a video of a resident in a vulnerable state on social media, placing the resident at risk of humiliation. Additionally, the facility failed to ensure timely reporting of the abuse incident by staff. The facility terminated the responsible CNA and provided staff education on abuse and social media policies.
Deficiencies (2)
Failure to prevent abuse when a CNA posted a video of a resident on social media exposing the resident in only a brief and bare skin.
Failure to report an incident of abuse in a timely manner to facility management.
Report Facts
Census: 58
Brief Interview for Mental Status (BIMS) score: 13
Date of incident video posting: Jan 17, 2021
Date of termination: Jan 19, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Posted inappropriate video of resident on social media and was terminated. |
| CNA N | Certified Nurse Aide | Saw the video on social media, saved it, but delayed reporting to management. |
| Administrative Nurse D | Administrative Nurse | Suspended and terminated CNA M; gave verbal warning and education to CNA N. |
| Licensed Nurse G | Licensed Nurse | Interacted with Resident 1 during the incident; was unaware of video recording. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 22, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey and a COVID-19 Focused Emergency Preparedness Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) on 12/22/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and in compliance with 42 CFR §483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 22, 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 CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and with 42 CFR §483.73 related to emergency preparedness.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 11/23/20 to assess compliance with COVID-19 preparation and infection control practices.
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
Abbreviated Survey
Deficiencies: 0
Date: Nov 23, 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 CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 1, 2020
Visit Reason
An offsite revisit survey was conducted on 10/01/2020 for all previous deficiencies cited on 08/18/2020 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 09/10/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies compliance date: Sep 10, 2020
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Aug 20, 2020
Visit Reason
This document is a Plan of Correction submitted by Smoky Hill Health & Rehabilitation in response to deficiencies identified during a prior inspection.
Findings
The plan addresses multiple deficiencies related to resident care, including ensuring residents have designated representatives or DPOAs, proper transportation policies, updated advance directives, resident inventory sheets, individualized care plans and activities, nutritional interventions, blood sugar management, dietary services oversight, and safe water/ice provision. Corrective actions include audits, staff in-services, ongoing monitoring, and integration into the facility's Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (9)
Failure to ensure residents have designated representatives or medical DPOAs.
Deficient transportation policies for residents transferred to emergency departments.
Lack of updated advance directives for residents.
Incomplete or outdated resident inventory sheets.
Care plans and activity preferences not individualized or updated.
Inadequate nutritional supplements and interventions.
Physician orders for blood sugar parameters not established or reviewed timely.
Dietary services oversight and management deficiencies.
Improper location and management of ice dispensing machine affecting resident hydration.
Report Facts
Completion date: Aug 28, 2020
Audit initiation date: Aug 20, 2020
Review period: 60
Minimum care plans reviewed weekly: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Administrator responsible for monitoring corrective actions and submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Terry Riley | Person who added and modified the Plan of Correction. |
Inspection Report
Census: 66
Deficiencies: 10
Date: Aug 18, 2020
Visit Reason
The inspection was a Health Resurvey and complaint investigations covering multiple complaint numbers.
Complaint Details
The visit included complaint investigations #150773, #150846, #152051, #152166, and #154682.
Findings
The facility had multiple deficiencies including failure to provide resident rights representation, reasonable accommodations, advance directives, personal property documentation, individualized activities, nutritional interventions, social services, medication monitoring, qualified dietary staff, and infection prevention and control.
Deficiencies (10)
Failed to attempt to provide Resident 168 the right to designate a representative or Durable Power of Attorney before cognition declined.
Failed to provide Resident 166 transportation from the emergency room back to the facility.
Failed to offer Resident 168 the right to formulate an Advanced Directive before condition declined.
Failed to document Resident 168's personal property inventory on admission, yearly, and discharge; failed to track and locate missing diamond ring.
Failed to provide individualized activities for Residents 38, 20, and 40.
Failed to develop and implement effective nutritional interventions for Resident 8 with significant weight loss.
Failed to provide medically related social services to Resident 168 after DPOA passed away and cognition declined.
Failed to adequately monitor and assess blood sugars, recheck out of range values, and notify physician for Resident 52.
Failed to employ a full time Certified Dietary Manager to oversee food and nutrition services.
Failed to maintain a safe and sanitary environment to prevent development and transmission of infections; residents self-served ice and staff refilled used cups at ice machine.
Report Facts
Weight loss: 20.2
Resident census: 66
Blood sugar readings: 575
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Verified Resident 168 lacked DPOA and advanced directive; verified facility meeting to make healthcare decisions for Resident 168; verified dietary staff not certified. | |
| Administrative Nurse D | Verified Resident 168 lacked designated representative; verified blood sugar parameters missing for Resident 52; verified infection control issues. | |
| Dietary Staff BB | Dietary Staff | Not certified dietary manager but enrolled in program. |
| Activity Staff Z | Activity Staff | Reported lack of group activities and individualized activities. |
| Licensed Nurse G | Licensed Nurse | Unaware of blood sugar parameters for Resident 52. |
| Social Service Designee | Called state about court appointed guardian for Resident 168. | |
| Social Service Director SSD | Held Resident 168's diamond ring in safe. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 08/04/2020 to assess compliance with COVID-19 preparation practices.
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
Abbreviated Survey
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 13, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 07/13/20.
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.
Deficiencies (1)
No deficiencies noted; facility found in compliance with COVID-19 infection control practices.
Report Facts
Inspection date: Jul 13, 2020
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 13, 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 CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Jan 30, 2020
Visit Reason
A complaint survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS to investigate failure to administer a resident's physician ordered medications, which caused altered mental status and hospitalization.
Complaint Details
The complaint investigation found the facility was not in substantial compliance with 483.45 due to medication errors leading to immediate jeopardy for Resident 1. The immediate jeopardy began on 11/15/19 and was removed on 01/21/2020 after corrective actions including suspension of Licensed Nurse G and education of licensed nurses.
Findings
The facility failed to administer Resident 1's prescribed medications from 11/15/2019 through 01/19/2020, resulting in immediate jeopardy due to altered mental status, critical low thyroid levels, and hospitalization. The failure was linked to improper medication order documentation and verification during admission.
Deficiencies (1)
Failed to administer Resident 1's physician ordered Levothyroxine and other medications from 11/15/19 through 01/19/2020, causing altered mental status, critical low thyroid level, and hospitalization.
Report Facts
Census: 72
TSH level: 41.263
Potassium level: 2.7
Medication delivery date: Nov 16, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Suspended due to failure to properly document and administer admission medications for Resident 1 |
| Administrative Nurse D | Administrative Nurse | Entered Resident 1's admission medication orders into the computer but used incomplete admission orders |
| Administrative Nurse E | Assistant Director of Nursing | Did not verify admission medication orders against admission packet |
| Licensed Nurse H | Licensed Nurse | Verified medication card for Levothyroxine should not have been placed in overflow medication area |
| Consultant GG | Consultant Pharmacist | Explained clinical consequences of missed Levothyroxine and expected double checks of admission medications |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 21, 2020
Visit Reason
This document is a Plan of Correction submitted in response to past non-compliance deficiencies identified in a prior inspection.
Findings
The Plan of Correction addresses past non-compliance issues identified under tags F0000 and F760-J, with corrective actions completed by 01/21/2020.
Deficiencies (2)
Past non-compliance under tag F0000
Past non-compliance under tag F760-J
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 4, 2019
Visit Reason
An offsite revisit survey was conducted on 09/04/2019 for all previous deficiencies cited on 07/18/2019.
Findings
All deficiencies have been corrected as of the compliance date of 07/25/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies compliance date: Jul 25, 2019
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 24, 2019
Visit Reason
This document is a Plan of Correction submitted by Smoky Hill Health & Rehabilitation in response to deficiencies cited in a prior inspection, specifically addressing care plan meeting notifications.
Findings
The facility acknowledged that Resident #1 no longer resides there and that care plan meeting notices were not consistently sent. Measures including audits, staff education, and monitoring were implemented to prevent recurrence.
Deficiencies (1)
Failure to ensure care plan meeting notices were sent to residents' family members.
Report Facts
Frequency of care plan notice review: 2
Plan of correction review period: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Terry Riley | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Jul 18, 2019
Visit Reason
The inspection was conducted as a result of complaint investigations #139862 and #141736.
Complaint Details
The findings represent the results of complaint investigations #139862 and #141736. The facility failed to notify the representatives of residents #1 and #3 about care plan meetings, violating their rights to participate in care planning.
Findings
The facility failed to notify the representatives of two sampled residents (#1 and #3) about care plan meetings, denying them the right to participate in the planning process, which placed the residents at risk for inadequate care and unmet needs.
Deficiencies (1)
Failure to notify resident representatives of care plan meetings for 2 of 3 sampled residents, denying their right to participate in care planning.
Report Facts
Census: 80
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Responsible for sending notices of care plan meetings; verified failure to send notices to representatives of Residents #1 and #3. | |
| Licensed Nurse G | Verified failure to notify Administrative Staff A to send care plan meeting notices to representatives of Residents #1 and #3. | |
| Administrative Nurse E | Verified unawareness of failure to notify representatives of Residents #1 and #3 and confirmed they should have been notified. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 3, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-03-04.
Findings
All deficiencies have been corrected as of the compliance date of 2019-03-21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Mar 4, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report for Smoky Hill Health & Rehabilitation.
Findings
The plan addresses multiple deficiencies including baseline care plans, pressure ulcer prevention, nutritional supplements, medication disposal, and oversight of dietary services. Corrective actions include audits, staff education, monitoring, and ongoing quality assurance reviews.
Deficiencies (5)
Baseline care plans were not developed or entered timely for residents #289 and #1.
Pressure reducing devices were not adequately provided or monitored for residents, including Resident #1.
Nutritional supplements were not consistently provided according to updated care plans for residents #73 and #47.
Unused medications were not properly logged and returned or destroyed from medication storage.
Facility food and nutritional services oversight required improvement.
Report Facts
Completion date: Mar 6, 2019
Education date: Mar 5, 2019
QAPI review frequency: 2
Medication storage checks: 2
Monitoring frequency: 2
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 5
Date: Mar 4, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #136279 and #137846 at Smoky Hill Rehabilitation Center.
Complaint Details
The visit was triggered by complaint investigations #136279 and #137846.
Findings
The facility failed to develop baseline care plans with specific ADL directions for 2 sampled residents, failed to prevent and treat pressure ulcers for 1 resident, failed to provide nutritional support consistent with care plans for 2 residents, failed to maintain a system for returning unused medications, and failed to provide a certified dietary manager.
Deficiencies (5)
Failed to develop a baseline care plan for 2 of 19 sampled residents with directions to staff regarding Activities of Daily Living (ADLs).
Failed to prevent and treat pressure ulcers for 1 of 3 sampled residents, including lack of pressure relief devices and incomplete dressing changes.
Failed to provide nutritional support consistent with the comprehensive plan of care for 2 of 4 sampled residents, including failure to provide ordered nutritional supplements.
Failed to complete a system for returning and/or destroying unused medications; large amounts of unsecured discontinued medications found.
Failed to provide a certified dietary manager to carry out the functions of food and nutritional services for the facility.
Report Facts
Residents sampled: 19
Facility census: 85
Weight loss: 29.2
Medication boxes: 3
Course duration: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Verified large number of discontinued, unsecured medication cards not returned to pharmacy. |
| Administrative Nurse D | Administrative Nurse | Verified medications not logged and returned; directed placement of pressure relief cushion; stated nutritional supplement substitution. |
| Dietary Staff BB | Dietary Staff | Participated in meal oversight; enrolled in online Nutrition and Food Service Management certification course. |
| Registered Dietician GG | Registered Dietician | Managed nutritional guidelines and expected nursing staff to compare supplement labels for acceptable exchanges. |
| Licensed Nursing Staff H | Licensed Nursing Staff | Performed wound dressing changes; reported resident refusal to wear Prevalon boots. |
| Administrative Nurse E | Administrative Nursing Staff | Reported wound nurse only changed one dressing and resident refused Prevalon boots. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 17, 2018
Visit Reason
This document is a plan of correction submitted following a revisit inspection conducted on 1/17/2018 to address previously identified deficiencies.
Findings
The revisit inspection found that all previously cited deficiencies have been corrected and no new noncompliance was identified. The facility is in compliance with all regulations surveyed.
Deficiencies (1)
All deficiencies have been corrected and no new noncompliance was found.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 17, 2018
Visit Reason
A revisit survey was conducted on 1/17/18 for all previous deficiencies cited on 12/5/17 to verify correction of prior deficiencies.
Findings
All deficiencies cited on 12/5/17 have been corrected as of the compliance date of 12/15/17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Dec 5, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including proper notification of Medicare non-coverage, investigation and reporting of resident-to-resident altercations, updating care plans for nutritional supplements, medication administration errors, expired medications, food handling procedures, and proper disinfection of glucose meters. Corrective actions include staff education, monitoring, audits, and integration into the facility's Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (10)
Failure to provide Advance Beneficiary Notice forms to residents and/or responsible parties.
Failure to investigate and report resident-to-resident altercations according to facility policy.
Care plan for resident #29 not updated to reflect scheduled nutritional supplements.
Issues related to low albumin and protein supplements and monitoring of nutritional supplements.
Pharmacist's medication recommendations not reviewed timely for resident #44.
Appropriate diagnosis not obtained for resident #44's antidepressant medication.
Medication aide removed from medication cart due to errors; staff education and competency checks initiated.
Expired medication found and removed from medication carts and storage areas.
Staff member removed from food contact and food preparation duties due to improper food handling.
Alcohol pads replaced with appropriate disinfectant; proper cleaning of glucometers ensured.
Report Facts
Complete Date: Dec 15, 2017
Frequency of monitoring: 3
Frequency of monitoring: 4
Audit date: Nov 28, 2017
Date of pharmacist review: Dec 4, 2017
Date of diagnosis obtained: Dec 4, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Named as responsible party and submitter of the Plan of Correction |
Inspection Report
Census: 77
Deficiencies: 10
Date: Dec 5, 2017
Visit Reason
The inspection was a Health Resurvey and complaint investigations covering multiple complaint numbers.
Complaint Details
The inspection included complaint investigations for allegations including failure to provide ABN notices, failure to report resident-to-resident altercation, and medication errors.
Findings
The facility had multiple deficiencies including failure to provide Advance Beneficiary Notices for skilled services, failure to report and investigate a resident-to-resident altercation, failure to revise care plans for nutritional supplements, failure to maintain acceptable nutritional status for several residents, failure to act on pharmacist recommendations for medication adjustments, medication errors including administration of another resident's medications, failure to date insulin pens and store medications properly, improper food handling practices, and failure to properly disinfect glucometers.
Deficiencies (10)
Failed to provide Advance Beneficiary Notice (ABN) for skilled services to 3 sampled residents.
Failed to investigate and report a resident-to-resident altercation.
Failed to review and revise care plan to direct staff to provide and monitor nutritional supplements for 1 sampled resident.
Failed to maintain acceptable nutritional status for 3 sampled residents, including failure to monitor meal, snack, and supplement intake.
Failed to act on consultant pharmacist recommendations for diagnosis clarification and medication discontinuation for an antidepressant and antipsychotic medication.
Failed to obtain appropriate diagnosis for an antidepressant medication.
Failed to ensure residents were free of significant medication errors when a resident was administered another resident's medications causing adverse effects and hospital visits.
Failed to date insulin pens when opened and store unopened insulin pens requiring refrigeration properly.
Failed to follow proper food handling practices including bare hand contact with resident food.
Failed to sufficiently disinfect multi-resident use glucometers according to manufacturer's instructions.
Report Facts
Residents with ABN deficiency: 3
Residents sampled for complaint investigation: 18
Weight loss percentage: 12.75
Weight loss percentage: 11.3
Weight loss percentage: 8.93
Medication errors: 1
Residents affected by glucometer disinfection issue: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide P | Administered another resident's medications to Resident #273 causing adverse effects. | |
| Nurse J | Charge Nurse | Notified physician and monitored Resident #273 after medication error. |
| Nurse E | Licensed Nurse | Observed medication administration and verified physician was not responsive to pharmacist recommendations. |
| Administrative Nurse A | Verified failures to follow up on pharmacist recommendations and insulin pen storage. | |
| Dietary Staff D | Observed handling resident food with bare hands. | |
| Dietary Staff C | Reported staff training on food handling. | |
| Nurse F | Verified physician had not replied to pharmacist recommendation. | |
| Registered Dietician L | Registered Dietician | Provided recommendations for nutritional supplements and monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 31, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in the Smoky Hill complaint inspection dated 08/31/2017.
Complaint Details
This Plan of Correction is related to the Smoky Hill complaint investigation dated 08/31/2017.
Findings
The plan addresses discharge procedures for residents, including review of discharge documentation, notifications to appropriate agencies, staff in-service training, and audits of discharge plans to ensure compliance and resident safety.
Deficiencies (1)
Resident #1 has been discharged from the facility. Discharge procedures including documentation, notifications, and planning require improvement.
Report Facts
Dates for substantial compliance: Sep 15, 2017
Date of Quality Assurance meeting: Sep 21, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Administrator submitting the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Diana Melander | Person who modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 4
Date: Aug 31, 2017
Visit Reason
Complaint investigation #120132 regarding failure to comply with notice requirements before transfer/discharge and related discharge planning deficiencies.
Complaint Details
Complaint investigation #120132 focused on failure to comply with transfer/discharge notice requirements and discharge planning for Resident #1.
Findings
The facility failed to record reasons for discharge in the medical record, failed to notify the Office of the State Long-Term Care Ombudsman, failed to provide a 30-day discharge notice to a terminally ill resident receiving Hospice services, and failed to ensure the resident was discharged to a safe environment. The facility also failed to develop and implement an effective discharge plan and post-discharge plan of care for the resident.
Deficiencies (4)
Failed to record reasons for discharge in the medical record and notify the appropriate entity after discharge.
Failed to provide a 30 day discharge notice to a terminally ill resident receiving Hospice services and failed to ensure discharge to a safe environment.
Failed to provide sufficient preparation and orientation to ensure safe and orderly transfer or discharge.
Failed to develop and implement an effective discharge planning process and post-discharge plan of care.
Report Facts
Census: 75
Discharge notice period: 30
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Involved in discharge decision and notification process for Resident #1 |
| Social Service Staff B | Social Service Staff | Communicated with resident about discharge and contacted hospice |
| Hospice Nurse D | Hospice Nurse | Informed about discharge and resident's post-discharge status |
| Physician Assistant E | Physician Assistant | Commented on discharge planning and resident safety |
| Licensed Nurse G | Licensed Nurse | Completed discharge paperwork for Resident #1 |
| Licensed Nurse I | Licensed Nurse | Reported resident's alcohol and marijuana use incident |
| State Representative F | State Representative | Commented on lack of notification and discharge procedures |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 22, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the previously cited deficiency related to regulation 483.45(f)(1) was corrected as of 06/22/2017. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Deficiency related to regulation 483.45(f)(1) previously cited and corrected.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 22, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in the Smoky Hill complaint investigation dated 06/19/2017.
Complaint Details
This plan of correction is in response to the Smoky Hill complaint investigation dated 06/19/2017.
Findings
The plan addresses medication errors related to medication patches, noting that Resident #1 no longer resides in the facility and Resident #2 was assessed with no adverse reactions. Staff were educated on medication error definitions and administration protocols, and new monitoring procedures were implemented to ensure compliance.
Deficiencies (1)
Medication errors related to administration of medication patches affecting residents.
Report Facts
Plan of Correction completion date: Jun 22, 2017
Monitoring frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Administrator responsible for plan of correction and monitoring compliance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 19, 2017
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 which was accepted, resulting in a finding of substantial compliance effective June 22, 2017.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 2
Date: Jun 19, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#116607) related to medication error rates at the facility.
Complaint Details
The complaint investigation found substantiated medication errors involving improper management of Fentanyl patches leading to residents receiving twice the ordered narcotic dose.
Findings
The facility failed to ensure that medication error rates were below 5%, with two of three residents reviewed receiving medications incorrectly. Specifically, two residents had overlapping Fentanyl patches applied without removal of the previous patch, resulting in double dosing and risk of adverse effects.
Deficiencies (2)
Failure to remove Resident #1's previous Fentanyl patch before applying a new one, resulting in double dosing for approximately 20 hours.
Failure to remove Resident #2's previous Fentanyl patch before applying a new one, resulting in double dosing for approximately 41 hours.
Report Facts
Census: 79
Residents reviewed for medication errors: 3
Residents with medication errors: 2
Duration of double dosing for Resident #1: 20
Duration of double dosing for Resident #2: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Verified finding regarding Resident #1's Fentanyl patch placement and search procedures. |
| Administrative Nurse B | Administrative Nurse | Verified Nurse A's statements and confirmed incomplete search for Resident #1's patch. |
| Nurse C | Nurse | Involved in Resident #2's patch placement, failed to document and perform full body search. |
| Nurse D | Nurse | Applied Fentanyl patches to Resident #2 and removed overlapping patches. |
| Nurse Aide E | Nurse Aide | Verified finding regarding Resident #2's pain patch found in bed. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 9, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 and Plan of Correction.
Findings
The revisit report confirms that the previously cited deficiency with ID Prefix F0315 related to regulation 483.25(e)(1)-(3) was corrected as of 06/09/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency with ID Prefix F0315 related to regulation 483.25(e)(1)-(3)
Report Facts
Deficiencies corrected: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 30, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a "D" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 9, 2017.
Deficiencies (1)
Most serious deficiency found was a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 30, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a revised complaint inspection at Smoky Hill Health & Rehabilitation.
Complaint Details
This Plan of Correction is related to a revised complaint inspection identified as Smoky Hill revised complaint 05302017.
Findings
The facility acknowledged the need to provide timely toileting for Resident #1 and reviewed the bowel and bladder program for appropriateness. Staff education and monitoring plans were established to ensure compliance and corrective action effectiveness.
Deficiencies (1)
Failure to provide timely toileting and appropriate bowel and bladder program for Resident #1 and potentially all incontinent residents.
Report Facts
Number of incontinent residents monitored weekly: 3
Plan completion date: Jun 9, 2017
Quality Assurance meeting date: Jun 15, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: May 30, 2017
Visit Reason
The inspection was conducted as a result of complaint investigations #114840 and #115689 regarding the facility's care of residents with urinary and fecal incontinence.
Complaint Details
The findings represent the results of complaint investigations #114840 and #115689. The facility failed to provide appropriate continence care for Resident #1, who was frequently incontinent of urine and was not toileted as care planned, leading to wet clothing and potential health risks.
Findings
The facility failed to provide appropriate treatment and services for one of three residents reviewed for incontinence, specifically Resident #1, who was frequently incontinent of urine and was not toileted in a timely manner, resulting in wet clothing and increased risk of embarrassment, infections, and skin breakdown.
Deficiencies (1)
Failure to provide appropriate treatment and services for urinary and fecal incontinence for Resident #1, including timely toileting and continence care.
Report Facts
Census: 73
Residents reviewed for urinary incontinence: 3
Residents with incontinence deficiency: 1
Incontinence episodes recorded: 11
Incontinence episodes recorded: 23
Incontinence episodes recorded: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide B | Certified Nurse Aide | Assisted Resident #1 and provided statements regarding toileting and continence care. |
| Nurse Aide F | Nurse Aide | Assisted Resident #1 with toileting and continence care during observation. |
| Nurse Aide J | Nurse Aide | Provided statements about Resident #1's toileting needs and continence episodes. |
| Nurse G | Nurse | Provided information about Resident #1's toileting preferences. |
| Administrative Nurse E | Administrative Nurse | Provided statements regarding Resident #1's care and assessment documentation. |
| Administrative Staff K | Administrative Staff | Assisted Resident #1 outside to smoke during observation. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 26, 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 deficiencies identified in the prior survey were corrected as of 06/16/2016, with corrections documented for specific regulation numbers.
Deficiencies (2)
Deficiency related to regulation 483.10(b)(4)
Deficiency related to regulation 483.75(e)(8)
Report Facts
Deficiency correction date: Jun 16, 2016
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 16, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in the Smoky Hill complaint inspection dated 06/14/2016.
Complaint Details
This Plan of Correction is related to the Smoky Hill complaint investigation dated 06/14/2016.
Findings
The plan addresses deficiencies related to staff suspension pending investigation, staff education on responding to full code events, CPR and Basic Life Support policy training, and ensuring Certified Nursing Assistants receive required yearly education.
Deficiencies (2)
Licensed Nurses and C.N.A.’s involved were suspended pending investigation; staff educated about responding appropriately to a full code event.
Four identified CNA's will be given necessary education to meet required yearly education.
Report Facts
Number of identified CNA's: 4
Audit frequency: 5
Mock Code Drills frequency: 1
Required CNA education hours: 12
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 14, 2016
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety related to F155, CFR 483.10(b)(4). Enforcement remedies including denial of payment for new admissions were imposed.
Deficiencies (1)
Facility was not in substantial compliance with participation requirements, constituting immediate jeopardy to resident health or safety for F155, CFR 483.10(b)(4).
Report Facts
Denial of payment effective date: Jul 4, 2016
Recommended termination date: Dec 14, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Named as facility administrator |
| Caryl Gill | Complaint Coordinator | Signed letter and contact for questions |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 2
Date: Jun 14, 2016
Visit Reason
The inspection was conducted as a complaint investigation for Complaint Investigations #101533 and #101686.
Complaint Details
The complaint investigations revealed that staff failed to initiate CPR on Resident #1 who was a full code and found unresponsive without pulse or respirations, leading to immediate jeopardy. The facility also failed to provide required annual in-service education to some nurse aides.
Findings
The facility failed to initiate CPR for a full code resident who was found unresponsive and ultimately died, placing the resident in immediate jeopardy. Additionally, the facility failed to provide the required 12 hours of yearly education for 4 of the 34 nurse aides employed.
Deficiencies (2)
Failure to initiate CPR for a full code resident found unresponsive, resulting in resident death.
Failure to provide the required 12 hours of yearly education for 4 nurse aides.
Report Facts
Census: 74
Number of nurse aides employed: 34
Number of nurse aides lacking required education: 4
Number of residents sampled: 3
Number of residents identified as full code: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Reported checking resident's chart and code status; stated Nurse E was charge nurse and resident was deceased. |
| Nurse C | Nurse | Did not start CPR; stated resident was deceased. |
| Nurse E | Charge Nurse | Did not start CPR or call 911; stated resident was gone; lacked education on code status location. |
| Nurse Consultant F | Nurse Consultant | Stated nurses made a poor decision and a devastating error in judgment by failing to start CPR. |
| Administrative Nurse G | Administrative Nurse | Expected staff to initiate CPR on full code resident. |
| Administrative Staff H | Administrative Staff | Verified failure to provide required education hours to some CNAs and lack of tracking system. |
Inspection Report
Follow-Up
Deficiencies: 9
Date: Jun 7, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each correction completed and documented accordingly.
Deficiencies (9)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(c)(6)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 10
Date: May 24, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during the Smoky Hill Rehab inspection conducted on May 24, 2016.
Findings
The facility identified multiple deficiencies related to resident dignity and respect, housekeeping and maintenance, care planning for toileting, accident hazard prevention, medication labeling and storage, and infection control. Corrective actions include staff education, care plan updates, maintenance repairs, and ongoing monitoring integrated into the Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (10)
Failure to promote dignity and respect during dining room cleaning while residents are seated.
Failure to address grievances and recommendations timely; bedding not changed for some residents.
Housekeeping and maintenance deficiencies including gouged sheetrock areas needing repair and paint.
Care plans for toileting not comprehensive or accurate for resident #46.
Lack of individualized toileting and bowel/bladder programs for incontinent residents.
Inadequate monitoring and documentation of bowel movements for resident #18.
Urinary incontinence care plans not established or updated for all residents.
Unsafe environment due to unlocked treatment room and cart; improper chemical storage.
Inadequate labeling and destruction of outdated insulin vials; improper storage of drugs and biologicals.
Improper cleaning techniques for resident bathrooms by housekeeping staff.
Report Facts
Plan of Correction completion date: Jun 7, 2016
Number of insulin cart checks: 4
Frequency of housekeeping checks: 2
Number of care plans and Kardex to be reviewed: 5
Inspection Report
Deficiencies: 1
Date: May 24, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.
Deficiencies (1)
'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter accepting plan of correction and confirming substantial compliance. |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 10
Date: May 18, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations #100279, #99678 and #96776.
Complaint Details
The inspection included complaint investigations #100279, #99678 and #96776.
Findings
The facility failed to promote dignity and respect by removing dishes and cleaning dining tables while residents were still eating, failed to act on resident grievances about bedding changes, failed to maintain a sanitary and comfortable environment due to room damages, failed to develop comprehensive care plans for urinary incontinence, failed to assess bowel status and provide interventions, failed to provide appropriate urinary incontinence treatment, failed to maintain a safe environment by cleaning tables with disinfectant while residents were seated, failed to secure treatment carts and medication storage, failed to ensure proper labeling and storage of medications, and failed to maintain infection control by improper cleaning of resident bathrooms.
Deficiencies (10)
Failed to promote dignity and respect by removing dishes and cleaning dining tables while residents were still eating.
Failed to act on resident grievances about bedding changes on bath days.
Failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Failed to develop a comprehensive care plan for urinary incontinence for Resident #46.
Failed to assess bowel status and provide interventions for Resident #18 after no bowel movement for several days.
Failed to provide appropriate treatment and services to maintain as much normal urinary function as possible for Resident #46.
Failed to provide an environment free of accident hazards by cleaning dining room tables with spray disinfectant while residents were seated.
Failed to ensure treatment cart and treatment room were locked when unattended; multiple medications and supplies were unsecured.
Failed to ensure all drugs or biologicals were in a locked treatment cart and locked room; insulin vials undated and outdated insulin administered.
Failed to provide a sanitary environment to help prevent infection by improper cleaning of resident bathrooms, including contamination of disinfectant bottles and use of same toilet brush between rooms.
Report Facts
Residents in facility: 79
Residents in Special Care Unit: 16
Residents in SCU: 12
Residents in sample: 23
Residents reviewed for urinary incontinence: 3
Residents reviewed for unnecessary drugs: 5
Insulin vial outdated days: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide S | Observed removing dishes and cleaning tables while residents were seated | |
| Nurse Aide T | Observed cleaning tables with disinfectant while residents were seated | |
| Administrative Nurse F | Administrative Nurse | Verified improper cleaning procedures and lack of individualized toileting programs |
| Nurse Aide G | Stated aides strip residents' beds twice a week on bath days | |
| Nurse Aide L | Observed checking incontinent brief of Resident #46 | |
| Nurse Aide C | Observed providing peri care to Resident #46 | |
| Nurse Aide N | Stated Resident #46 is always incontinent and brief is checked every 2-3 hours | |
| Nurse H | Verified insulin administration and bowel protocol | |
| Nurse K | Verified outdated insulin should have been disposed | |
| Housekeeping Staff P | Observed improper cleaning of resident bathroom and contamination of disinfectant bottles | |
| Housekeeping Staff Q | Verified disinfectant wait time and risk of using same toilet brush between rooms | |
| Administrative Nurse J | Administrative Nurse | Stated staff document bowel movements incorrectly and cannot verify bowel movements |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 14, 2016
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 the most serious deficiencies at the facility to be at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found to be "F" level with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jul 14, 2016
Provider agreement termination date: Oct 14, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Feb 23, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were corrected as of 01/29/2016, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (8)
Deficiency with ID Prefix F0157 related to regulation 483.10(b)(11)
Deficiency with ID Prefix F0225 related to regulation 483.13(c)(1)(i)-(iii), (c)(2)-(4)
Deficiency with ID Prefix F0226 related to regulation 483.13(c)
Deficiency with ID Prefix F0280 related to regulations 483.20(d)(3), 483.10(k)(2)
Deficiency with ID Prefix F0315 related to regulation 483.25(d)
Deficiency with ID Prefix F0325 related to regulation 483.25(i)
Deficiency with ID Prefix F0441 related to regulation 483.65
Deficiency with ID Prefix F0520 related to regulation 483.75(o)(1)
Report Facts
Date deficiencies corrected: Jan 29, 2016
Date of follow-up survey completion: Jan 20, 2016
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jan 29, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in the Smokey Hill complaint investigation dated 01/20/2016.
Complaint Details
This Plan of Correction is in response to the Smokey Hill complaint dated 01/20/2016.
Findings
The plan addresses multiple deficiencies related to resident care, including notification of physician for changes in condition, abuse neglect exploitation policies, care plan updates for urinary status and weight loss, peri-care competency, infection control, and quality assurance monitoring. Substantial compliance was reported to be accomplished by January 29, 2016.
Deficiencies (8)
Failure to notify physician of changes in resident condition (F157-D)
Failure to properly handle allegations of abuse, neglect, exploitation (F225-D)
Failure to report allegations of abuse, neglect, exploitation properly (F226-D)
Failure to update care plans for residents with changes in urinary status (F280-D)
Failure to provide peri-care according to policy and lab monitoring system issues (F315-J)
Failure to address significant weight loss in residents (F325-D)
Failure to ensure competency in peri-care and infection control policy implementation (F441-F)
Failure to adequately monitor Quality Assurance and Performance Improvement Program (F520-F)
Report Facts
Staff in-service duration: 4
Staff sample size: 5
Date of substantial compliance: Jan 29, 2016
Date of bowel & bladder assessment: Jan 21, 2015
Number of CNAs observed per shift: 3
Observation duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Administrator who submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 20, 2016
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not to be in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety from December 4, 2015 through January 15, 2016 related to F315, CFR 483.25(d). Enforcement remedies including denial of payment for new admissions were imposed.
Deficiencies (1)
Noncompliance with F315, CFR 483.25(d) resulting in immediate jeopardy to resident health or safety
Report Facts
Denial of payment effective date: Feb 18, 2016
Termination recommendation date: Jul 20, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | LBSW, Complaint Coordinator | Signed the report and is contact for questions regarding the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 7
Date: Jan 20, 2016
Visit Reason
Complaint investigations #95076 and #95570 and partial extended survey were conducted to investigate allegations of failure to notify physician of resident decline, abuse reporting, care plan revisions, infection control, and nutritional status.
Complaint Details
The complaint investigations #95076 and #95570 included allegations of failure to notify physician of resident decline, abuse reporting failures, inadequate care plan revisions, infection control deficiencies, and nutritional neglect.
Findings
The facility failed to timely notify a physician of a resident's significant decline resulting in systemic infection and death, failed to promptly report and investigate an allegation of abuse, failed to revise care plans for urinary status and nutrition, failed to provide appropriate peri-care leading to UTIs, and failed to maintain an effective infection control program and quality assurance committee to monitor and address infection trends.
Deficiencies (7)
Failure to timely notify physician of significant physical and mental decline in Resident #1 who developed systemic infection and died.
Failure to promptly report and investigate an allegation of abuse for Resident #4 and protect residents during investigation.
Failure to implement abuse/neglect policies and report through chain of command for Resident #4.
Failure to review and revise care plans for urinary status for Residents #1 and #4 after decline and UTIs.
Failure to maintain acceptable nutritional status and implement interventions for Resident #1 with significant weight loss.
Failure to provide an effective infection control program to prevent infections and monitor infection trends for all residents.
Failure to maintain an effective Quality Assessment and Assurance committee to recognize, analyze, and intervene on infection trends.
Report Facts
Resident census: 74
Weight loss: 91
Weight loss percentage: 26
White blood cell count: 14.6
Blood pressure: 80
Blood pressure: 42
Urine culture bacteria count: 100000
Albumin level: 2.8
Albumin level: 3.2
Resident weight: 349
Resident weight: 250
Resident weight: 284
Resident weight loss: 64
Resident weight loss: 34
Residents with UTI: 15
Residents with UTI: 9
Residents with UTI: 11
Residents with UTI: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Nurse | Verified physician treated Resident #1 with antibiotics and expected peri care |
| Nurse Aide D | Nurse Aide | Reported Resident #1 decline and feeding difficulties |
| Administrative Nurse B | Administrative Nurse | Verified failure to notify physician timely, expected staff to notify physician, and verified infection control and peri care deficiencies |
| Physician N | Physician | Verified not timely informed of Resident #1 decline and sepsis |
| Physician P | Physician | Verified symptoms of infection and importance of timely UA collection |
| Nurse O | Nurse | Failed to report abuse allegation immediately |
| Nurse D | Nurse | Failed to report abuse allegation and investigate |
| Administrator A | Administrator | Verified expectation of immediate abuse reporting |
| Nurse Aide F | Nurse Aide | Observed failing to provide peri care after toileting |
| Nurse Aide H | Nurse Aide | Verified Resident #4 incontinence and peri care issues |
| Nurse I | Nurse | Monitors peri care, identified supply issues |
| Registered Dietician C | Registered Dietician | Verified delayed consult for weight loss |
| Administrative Staff A | Administrator | Verified unrecognized weight loss and infection control deficiencies |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 4, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiency with regulation 483.25(a)(3) was corrected as of 09/04/2015. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency related to regulation 483.25(a)(3)
Report Facts
Deficiencies corrected: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 19, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective September 4, 2015.
Deficiencies (1)
Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Date: Aug 19, 2015
Visit Reason
The inspection was conducted as a result of complaint investigations #89911, #89208, and #89864 to assess compliance with care standards related to dependent residents.
Complaint Details
The visit was complaint-related, involving investigations #89911, #89208, and #89864. The deficiency was substantiated as the facility failed to follow the resident's care plan for transfers.
Findings
The facility failed to provide one of three sampled residents, who was dependent on staff, with a safe and appropriate transfer method, creating a potential for injury. Staff transferred the resident by lifting under the arms instead of using the required gait belt or mechanical lift as per the care plan.
Deficiencies (1)
Failure to provide a safe, appropriate transfer for a dependent resident, contrary to the care plan instructions.
Report Facts
Census: 75
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Nurse | Verified staff were expected to use the gait belt during transfers. |
| Administrative Nurse A | Administrative Nurse | Verified improper transfer methods and lack of care plan updates. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 10, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency with regulation 28-39-158(a) was corrected as of 05/15/2015. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency related to regulation 28-39-158(a)
Report Facts
Deficiency correction date: May 15, 2015
Inspection Report
Follow-Up
Deficiencies: 18
Date: Jun 10, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected.
Findings
The report documents that all previously cited deficiencies were corrected by 05/15/2015, with no uncorrected deficiencies remaining at the time of the revisit.
Deficiencies (18)
Deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency identified under regulation 483.15(a)
Deficiency identified under regulation 483.15(f)(1)
Deficiency identified under regulation 483.15(g)(1)
Deficiency identified under regulation 483.15(h)(2)
Deficiency identified under regulation 483.20(g)-(j)
Deficiency identified under regulation 483.20(d), 483.20(k)(1)
Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2)
Deficiency identified under regulation 483.25
Deficiency identified under regulation 483.25(a)(3)
Deficiency identified under regulation 483.25(h)
Deficiency identified under regulation 483.25(j)
Deficiency identified under regulation 483.25(l)
Deficiency identified under regulation 483.35(d)(1)-(2)
Deficiency identified under regulation 483.55(b)
Deficiency identified under regulation 483.60(c)
Deficiency identified under regulation 483.65
Deficiency identified under regulation 483.70(h)
Report Facts
Correction completion date: May 15, 2015
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Apr 21, 2015
Visit Reason
This document is a Plan of Correction submitted by Smoky Hill Health & Rehabilitation in response to deficiencies cited during a regulatory inspection. It outlines corrective actions to address violations related to resident care, safety, and facility environment.
Findings
The plan addresses multiple deficiencies including investigation of alleged abuse and neglect, promotion of resident dignity and respect, activities programming, social services, housekeeping and maintenance, accurate resident assessments, medication monitoring, care plan revisions, pressure ulcer prevention, infection control, hydration monitoring, dental services, and environmental safety. The facility commits to staff training, monitoring, and integration of corrective actions into the Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (15)
Failure to thoroughly investigate and report alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property.
Failure to promote care that maintains or enhances resident dignity and respect.
Failure to provide an ongoing activities program meeting residents' interests and well-being.
Failure to provide medically-related social services to attain or maintain residents' highest practicable well-being.
Failure to maintain a sanitary, orderly, and comfortable facility environment.
Failure to accurately document resident assessments on MDS.
Failure to thoroughly monitor medications with black box warnings and develop care plans accordingly.
Failure to review and revise care plans appropriately.
Failure to provide necessary care and services to prevent pressure ulcers.
Failure to provide a safe, sanitary, and comfortable environment to prevent disease and infection.
Failure to ensure sufficient fluid intake monitoring to maintain proper hydration.
Failure to ensure licensed pharmacist reports irregularities during drug regimen reviews are acted upon.
Failure to provide food that is palatable and at proper temperature.
Failure to provide dental services to residents choosing to participate.
Failure to provide a safe environment, including repair/replacement of sidewalks.
Report Facts
Substantial compliance date: May 1, 2015
Substantial compliance date: May 15, 2015
Substantial compliance date: Jul 30, 2015
Staff in-service date: Apr 21, 2015
Staff in-service date: Apr 23, 2015
Certification test date: May 22, 2015
Random checks duration: 8
Palatability testing duration: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Named as responsible party for multiple corrective actions |
| Dietary Staff C | Named as staff completing education and testing for certification |
Inspection Report
Enforcement
Deficiencies: 1
Date: Apr 16, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services (KDADS) to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at 'F' level, resulting in enforcement remedies including a denial of payment for new Medicare admissions effective July 16, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Most serious deficiencies found at 'F' level
Report Facts
Denial of payment effective date: Jul 16, 2015
Compliance deadline: Oct 16, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the letter |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 15
Date: Apr 16, 2015
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to investigate allegations of abuse, neglect, mistreatment, and failure to report incidents.
Complaint Details
The visit was triggered by a complaint investigation #85797 related to abuse, neglect, mistreatment, and failure to report incidents.
Findings
The facility failed to thoroughly investigate and report falls with injury, maintain resident dignity and hygiene, provide individualized activities, ensure medically-related social services, maintain a sanitary environment, accurately assess residents, develop and revise care plans, provide necessary care and services, monitor medications with black box warnings, provide palatable food at proper temperatures, provide dental services, and maintain a safe environment.
Deficiencies (15)
Failed to thoroughly investigate and report a fall with injury to a state agency for 2 sampled residents.
Failed to provide care for residents in a manner that maintained or enhanced each resident's dignity for Residents #7, #16 and #71.
Failed to provide an ongoing program of activities designed to meet the interests and the physical, mental and psychosocial well-being for 5 residents reviewed for activities.
Failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents #7 and #63.
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment on the interior of the facility on 4 of 4 halls.
Failed to accurately assess a resident's status on the Minimum Data Set assessment for Resident #63.
Failed to review and revise a care plan for Resident #63 to include the physician's ordered splint.
Failed to provide the necessary care and services to maintain appropriate positioning when seated in the wheelchair for Resident #63.
Failed to provide the necessary care and services to maintain grooming and personal and oral hygiene for Residents #7, #71, and #16.
Failed to ensure the resident environment remains as free of accident hazards as possible for Resident #52 and 5 cognitively impaired residents.
Failed to ensure the provision and monitoring of sufficient fluid intake to maintain adequate hydration for Resident #55 who was on a physician ordered fluid restriction.
Failed to ensure that Resident #37's drug regimen was free of unnecessary drug use without adequate monitoring, including failure to monitor black box warnings.
Failed to provide or obtain routine and emergency dental services to meet the needs of Resident #82 who had carious/missing teeth and lacked dental care since admission.
Failed to establish and maintain an infection control program to provide a safe, sanitary and comfortable environment and to prevent transmission of disease and infection, including improper cleaning and lack of staff training.
Failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, including uneven sidewalks.
Report Facts
Resident census: 75
Deficiency count: 15
Fluid restriction: 1500
Medication dosages: 40
Medication dosages: 15
Medication dosages: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Verified failure to report fall, care plan inaccuracies, and monitoring of medications |
| Nurse Aide P | Nurse Aide | Observed and reported fall with injury and resident positioning |
| Nurse Aide J | Nurse Aide | Verified resident hygiene needs and clothing issues |
| Social Service staff I | Social Service Staff | Verified responsibility for resident clothing and dental services |
| Activity Staff M | Activity Staff | Verified lack of individualized activity program |
| Housekeeping Staff T | Housekeeping Staff | Observed improper cleaning and infection control practices |
| Maintenance staff B | Maintenance Staff | Verified environmental safety issues |
| Administrative Nurse F | Administrative Nurse | Verified splint use and care plan inaccuracies |
| Restorative Aide G | Restorative Aide | Reported splint use and care |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 12, 2015
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 the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jun 12, 2015
Effective date for provider agreement termination: Sep 12, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Named as facility administrator |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
| Joe Ewert | Commissioner | Mentioned in correspondence copy |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 12, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of 12/12/2014.
Deficiencies (1)
Deficiency under regulation 483.25(h) previously cited
Report Facts
Deficiencies corrected: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 12, 2014
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)
D level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Signed letter regarding survey findings and plan of correction acceptance |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 4, 2014
Visit Reason
The revisit was conducted on December 4, 2014, as a result of an Abbreviated survey on October 23, 2014, to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The revisit found the most serious deficiency in the facility to be a 'D' level deficiency. Based on the deficiencies cited, denial of payment for new Medicare/Medicaid admissions will be imposed effective January 23, 2015, and termination of the provider agreement is recommended for April 23, 2015.
Deficiencies (1)
Most serious deficiency found was a 'D' level deficiency.
Report Facts
Denial of Payment effective date: Jan 23, 2015
Provider agreement termination date: Apr 23, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Named as facility administrator |
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the letter |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 4, 2014
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The report documents that multiple deficiencies previously cited under regulations 483.10(b)(11), 483.25(a)(3), and 483.25(f)(2) were corrected as of 11/07/2014.
Deficiencies (3)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(f)(2)
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 4, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Smoky Hill Health & Rehabilitation.
Complaint Details
This Plan of Correction is linked to Complaint 120114, indicating the visit was complaint-related.
Findings
The plan addresses deficiencies related to improper resident transfer techniques involving resident #7, with corrective actions including staff training, use of a Broda chair, and ongoing monitoring of mechanical lift transfers.
Deficiencies (1)
Improper resident transfer techniques according to facility Mechanical Lift Policy related to resident #7.
Report Facts
Number of documented observations per week: 3
Date for substantial compliance completion: Dec 12, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Irina Strakhova | Added and modified the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: Dec 4, 2014
Visit Reason
The inspection was conducted as a Non-compliance Revisit and Complaint Investigation related to concerns about safe transfer techniques and resident safety.
Complaint Details
The investigation was triggered by complaints #80988, #81180, and #81104. The complaint was substantiated as the facility failed to safely transfer Resident #7, causing bruising.
Findings
The facility failed to provide safe transfer techniques for one resident using a mechanical lift, resulting in extensive bruising. Staff used an unsafe method by tilting the wheelchair backwards during transfer, contrary to facility policy and training.
Deficiencies (1)
Failed to provide safe transfer techniques for Resident #7 using a mechanical lift, resulting in bruising.
Report Facts
Resident census: 73
Bruise measurements: 10
Bruise measurements: 16
Bruise measurements: 4
Bruise measurements: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide B | Nurse Aide | Involved in unsafe transfer technique by tilting wheelchair |
| Nurse Aide C | Nurse Aide | Assisted in mechanical lift transfer |
| Nurse E | Nurse | Verified unsafe transfer technique and staff training |
| Nurse Aide D | Nurse Aide | Assisted resident back to bed and noted improper lift sheet placement |
| Administrative Nurse A | Administrative Nurse | Verified staff training and unsafe transfer practices |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 23, 2014
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be a 'G' level. As a result, enforcement remedies including denial of payment for new Medicare admissions effective January 23, 2015, were recommended due to failure to achieve substantial compliance.
Deficiencies (1)
Most serious deficiency found to be a 'G' level
Report Facts
Denial of payment effective date: Jan 23, 2015
Termination recommendation date: Apr 23, 2015
Civil Money Penalty threshold: 5000
IDR submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Named as facility administrator |
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions and IDR process |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 4
Date: Oct 23, 2014
Visit Reason
The inspection was conducted as a result of multiple complaint investigations regarding the facility's compliance with regulations.
Complaint Details
The inspection findings represent the results of complaint investigations #78773, #79053, #78239, #79461, #79458, #80044, #80245. The complaint involved failure to notify physician of significant resident changes, inadequate ADL care, and failure to evaluate psychosocial status.
Findings
The facility failed to promptly notify the physician of a significant change in Resident #4's psychosocial status prior to the resident leaving the facility. The facility also failed to provide adequate bathing services for dependent residents #2 and #6, and failed to evaluate Resident #4's behavior to maintain mental or psychosocial functioning.
Deficiencies (4)
Failed to promptly notify the physician when Resident #4 had a significant change in psychosocial status and prior to leaving the facility at 2:30 AM in the rain on 10/13/14.
Failed to provide adequate bathing services for dependent Resident #2 to maintain grooming and personal hygiene.
Failed to provide adequate bathing services for dependent Resident #6 to maintain grooming and personal hygiene.
Failed to evaluate Resident #4's behavior to maintain mental or psychosocial functioning.
Report Facts
Resident census: 74
Residents in sample: 8
Baths documented for Resident #2 in September 2014: 4
Baths documented for Resident #6 in August 2014: 2
Baths documented for Resident #6 in September 2014: 1
Ativan dose: 0.5
Time resident left facility: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Provided witness statement regarding Resident #4's behavior and facility policies. |
| Nurse F | Nurse | Witnessed Resident #4 leaving the facility and described events leading to resident's departure. |
| Administrative Nurse B | Administrative Nurse | Provided statements about facility policies and knowledge of Resident #4's leaving the facility. |
| Social Service Staff E | Social Service Staff | Provided statements regarding Resident #4's psychosocial status and conversations about insurance. |
| Physician C | Physician | Provided statement regarding expectations for notification and resident's ability to drive. |
| Nurse J | Nurse | Stated the facility did not have a sign out sheet for residents leaving the building. |
| Nurse Aide D | Nurse Aide | Provided statements about bathing assistance for residents #2 and #6. |
| Nurse I | Nurse | Stated the facility does not have a sign out sheet for residents leaving the building. |
| Nurse Aide G | Nurse Aide | Stated never seeing Resident #4 leave the facility and lack of sign out sheet. |
| Nurse Aide H | Nurse Aide | Stated never seeing Resident #4 leave the building. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 16, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Smoky Hill Rehabilitation Center were corrected.
Findings
The report confirms that the deficiency identified under regulation 26-40-301 (c)(3)(4)(5)(6) was corrected as of 04/16/2014.
Deficiencies (1)
Deficiency under regulation 26-40-301 (c)(3)(4)(5)(6)
Report Facts
Deficiencies corrected: 1
Inspection Report
Follow-Up
Deficiencies: 8
Date: Apr 16, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date.
Deficiencies (8)
Deficiency related to regulation 483.10(i)(1)
Deficiency related to regulation 483.13(a)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.15(c)(6)
Deficiency related to regulation 483.20(b)(1)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Apr 16, 2014
Visit Reason
This document is a Plan of Correction submitted by Smoky Hill Rehabilitation Center in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including resident rights related to mail delivery, use of restraints, reporting of abuse and neglect, grievance handling, completion of resident assessments, medication administration, food service sanitation, pharmacist reporting of drug regimen irregularities, and facility maintenance such as parking lot repairs.
Deficiencies (9)
Failure to protect residents' rights to send and promptly receive unopened mail.
Use of physical or chemical restraints for discipline or convenience rather than medical necessity.
Failure to immediately report alleged violations involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property.
Failure to listen and act upon grievances and recommendations of residents and families.
Incomplete comprehensive assessments for residents affecting care plan development.
Failure to follow physician orders and parameters for administration of diabetic medications.
Failure to store, prepare, distribute, and serve food under sanitary conditions.
Licensed pharmacist failing to report irregularities identified during drug regimen reviews to attending physician and Director of Nursing Services.
Facility parking lot has potholes and uneven rough surfaces needing repair.
Report Facts
Random resident assessment reviews: 5
Timeframe for substantial compliance: 2014
Parking lot repair completion deadline: 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Administrator named in plan of correction and responsible for oversight |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 1
Date: Mar 11, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation #71712 regarding facility conditions.
Complaint Details
The visit was complaint-related as indicated by the Health Resurvey and complaint investigation #71712. Resident council minutes from April and May 2013 and March 2014 documented complaints about the rough, uneven asphalt surface with numerous potholes. Activity Staff A and Administrative Staff E verified the findings.
Findings
The facility failed to maintain a safe entryway and parking lot free of potholes and uneven rough surfaces, posing safety risks to residents, staff, and visitors. Resident council minutes documented complaints about the rough asphalt surface, and staff verified these environmental concerns.
Deficiencies (1)
Failed to maintain a safe entryway/parking lot free of potholes and uneven rough surfaces.
Report Facts
Census: 77
Parking stalls: 14
Pothole depth: 6
Date of observation: Mar 11, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Staff A | Verified the findings of the rough parking lot on 3/13/2013. | |
| Administrative Staff E | Verified the environmental concerns on 3/13/2014. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 31, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h) were corrected by 12/06/2013.
Deficiencies (2)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Date: Nov 19, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#69073) regarding allegations of inadequate investigation and supervision related to resident falls and injuries.
Complaint Details
The complaint investigation (#69073) found the facility did not thoroughly investigate the resident's injury fall and failed to provide adequate supervision, resulting in two unattended falls with serious injuries.
Findings
The facility failed to thoroughly investigate an accident resulting in injury for one resident and failed to provide adequate supervision to prevent two unattended falls in the dementia unit dining room, resulting in serious injuries including a head laceration, hip fracture, and brain hemorrhages.
Deficiencies (2)
Failed to thoroughly investigate an accident resulting in injury for one resident.
Failed to provide adequate supervision to prevent accidents for one resident who had two unattended falls resulting in serious injuries.
Report Facts
Census: 76
Resident sample size: 3
Fall injury measurements: 6.5
Fall injury measurements: 3
Hematoma size: 2.1
Hematoma size: 5.1
Hematoma size: 4.3
Sutures count: 9
Staff count: 3
Staff count: 2
Staff count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Verified staffing issues and lack of witness statements related to resident falls. | |
| Nurse Aide D | Verified work shift and staffing on day of resident's fall. | |
| Nurse Aide B | Verified staffing and resident left unattended during fall incident. | |
| Nurse Aide A | Verified dementia care unit staffing levels. | |
| Nurse C | Verified lack of staff education after prior fall incident. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 6, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report shows that deficiencies identified under regulations 483.25(k) and 483.60(a),(b) were corrected as of 09/06/2013.
Deficiencies (2)
Deficiency related to regulation 483.25(k)
Deficiency related to regulation 483.60(a),(b)
Report Facts
Deficiencies corrected: 2
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 7, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that all previously reported deficiencies related to regulations 483.15(g)(1), 483.20(d), 483.20(k)(1), 483.25, 483.25(c), and 483.25(i) were corrected as of 07/18/2013.
Report Facts
Correction completion date: Jul 18, 2013
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 2
Date: Aug 7, 2013
Visit Reason
The inspection was conducted as a Non-Compliance Revisit and Complaint investigation related to the facility's failure to provide proper respiratory treatment and pharmaceutical services to residents.
Complaint Details
The visit was a Non-Compliance Revisit and Complaint investigation #67054, 66910, and 67090.
Findings
The facility failed to provide proper respiratory care for one resident when the oxygen tank was empty, causing labored breathing and anxiety. Additionally, the facility failed to administer physician-ordered medications to a newly admitted resident on the day of admission.
Deficiencies (2)
Failed to provide proper respiratory treatment and care for one resident including oxygen use when the oxygen tank was empty.
Failed to provide physician ordered pharmaceutical services for one resident, including failure to administer scheduled medications on admission day.
Report Facts
Resident sample size: 6
Residents reviewed for medication irregularities: 3
Oxygen saturation level: 77
Oxygen saturation level: 90
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Observed resident's respiratory distress, administered breathing treatment, and noted empty oxygen tank. | |
| Nurse Aide C | Pushed resident in wheelchair during respiratory distress and attempted to change oxygen tubing. | |
| Nurse Aide A | Stated resident was on oxygen at all times at 3L per minute and staff should check oxygen tank gauge. | |
| Administrative nurse D | Administrative nurse | Verified failure to administer medications to Resident #7 and described medication order process. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jun 18, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Smoky Hill Rehabilitation Center.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as Smoky Hill 061813 Complaint.
Findings
The plan addresses multiple deficiencies related to provision of medically related social services, comprehensive care plans, pain management, pressure ulcer prevention, and resident assessments. The facility outlines corrective actions including staff in-service, interdisciplinary team monitoring, policy reviews, and integration into the Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (5)
Failure to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Failure to develop comprehensive care plans based on comprehensive assessments including measurable objectives and time tables.
Failure to provide care and services necessary to attain or maintain the highest practicable physical, mental and psychosocial status in accordance with individual comprehensive assessment and plan of care.
Failure to prevent development of pressure sores/ulcers unless clinically unavoidable.
Failure to prevent development of pressure sores/ulcers unless clinically unavoidable.
Report Facts
Dates for corrective actions: Jul 18, 2013
Medication review date: Jun 13, 2013
Psychiatric evaluation date: Jun 24, 2013
Comfort care implementation date: Jun 21, 2013
Staff in-service dates: Jun 14, 2013
Staff in-service dates: Jun 25, 2013
Registered Dietician review date: Jun 20, 2013
Physician ulcer re-affirmation date: Dec 17, 2012
Physician ulcer re-affirmation verification date: Jun 26, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Administrator who submitted the Plan of Correction |
| Director of Social Services | Responsible for ensuring medically related social services and resident rounds | |
| Director of Nursing Services | Responsible for nursing protocols, care plans, staff in-service, and monitoring | |
| MDS Coordinator | Involved in reviewing facility protocols and care plans | |
| Director of Staff Development | Involved in reviewing nursing services and staff training needs | |
| Registered Dietician | Reviewed resident #2's chart and made nutritional recommendations |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 5
Date: Jun 18, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#66205) and partial extended survey to evaluate compliance with regulatory requirements related to resident care and facility operations.
Complaint Details
The visit was triggered by complaint investigation #66205. The complaint was substantiated as the facility failed in multiple areas of resident care for Resident #2.
Findings
The facility failed to provide medically-related social services, develop a comprehensive care plan for comfort care, provide effective pain management, promote aggressive wound management, and maintain acceptable nutritional status for Resident #2, who was on comfort care and had a stage 4 pressure ulcer and significant weight loss.
Deficiencies (5)
Failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for Resident #2 on comfort care.
Failed to develop a comprehensive care plan outlining comfort care for Resident #2.
Failed to provide effective pain management interventions for Resident #2, resulting in immediate jeopardy.
Failed to promote aggressive wound management for Resident #2 with a stage 4 pressure ulcer.
Failed to maintain acceptable nutritional status and implement registered dietician recommendations for Resident #2 with significant weight loss.
Report Facts
Census: 80
Sample size: 6
Pressure ulcer size: 6
Weight loss: 35
Medication administration dates: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician G | Physician | Verified resident's pain during dressing changes and expected facility to administer Xanax as ordered. |
| Nurse C | Nurse | Observed and changed dressing on resident's right foot, verified wound measurements and resident's pain response. |
| Nurse F | Nurse | Verified failure to administer pain medication and notify physician of dietician recommendations. |
| Nurse E | Nurse | Verified resident had not received as needed Xanax medication prior to dressing changes. |
| Nurse D | Nurse | Described monitoring effectiveness of pain medication for cognitively impaired resident. |
| Social Service Staff H | Social Service Staff | Verified no comfort care support was provided to resident or family since January. |
Inspection Report
Follow-Up
Deficiencies: 15
Date: Mar 6, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously reported deficiencies at Smoky Hill Rehabilitation Center.
Findings
All previously cited deficiencies listed on the CMS-2567 were corrected as of the revisit date, with corrections completed on 03/06/2013.
Deficiencies (15)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.13(c)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(g)-(j)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.30(e)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(a),(b)
Deficiency related to regulation 483.70(f)
Deficiency related to regulation 483.70(g)
Report Facts
Deficiencies corrected: 15
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Feb 6, 2013
Visit Reason
This document is a Plan of Correction submitted by Smoky Hill Rehabilitation Center in response to deficiencies identified in a prior inspection report.
Findings
The Plan of Correction outlines multiple deficiencies related to resident care, staff training, documentation, facility maintenance, and compliance with policies. Corrective actions include staff in-services, audits, monitoring protocols, and facility repairs with specified completion dates.
Deficiencies (15)
Failure to notify physicians and family members of changes in resident status.
Incomplete criminal background checks and license verification for staff.
Failure to promote resident dignity and respect, including discussing care in common areas.
Maintenance issues including repainting resident's wall and repair of front parking lot.
Inaccurate or incomplete assessments of residents' functional capacity.
Failure to include resident or responsible party in care planning and treatment changes.
Failure to provide necessary care and services to maintain residents' physical, mental, and psychosocial well-being.
Failure to provide necessary services for residents unable to carry out activities of daily living, including nutrition and hygiene.
Improper catheter care and failure to follow physician orders related to catheterization.
Failure to ensure residents' drug regimens are free from unnecessary drugs and proper pain medication assessment.
Failure to post nurse staffing data daily.
Dietary staff noncompliance with hair net use and facility cleanliness issues.
Medications administered without proper diagnosis documentation.
Call light system issues including nonfunctional call lights.
Furniture arrangement impeding resident traffic flow and failure to transfer residents appropriately during meals.
Report Facts
Completion date: Mar 6, 2013
Completion date: Feb 15, 2013
Completion date: Feb 20, 2013
Completion date: Jan 30, 2013
Completion date: Jun 30, 2013
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 15
Date: Feb 5, 2013
Visit Reason
Health resurvey inspection to evaluate compliance with federal regulations and previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to notify legal representatives of changes, inadequate employee background checks, dignity concerns, housekeeping and maintenance issues, inaccurate resident assessments, failure to revise care plans, inadequate care and services for residents, improper medication management, nurse staffing posting errors, unsanitary food preparation, missing medication diagnosis, malfunctioning nurse call systems, and insufficient dining space in the memory care unit.
Deficiencies (15)
Failure to notify legal representative of medication error and change in condition for Resident #85.
Failure to obtain timely criminal background checks and certification verification for employees.
Failure to promote dignity by referring to residents as 'feeder' in the special care unit.
Failure to maintain sanitary and orderly environment including unfinished painting, cracked parking lot, and dirty floors.
Failure to accurately complete comprehensive assessments regarding vision for residents #38 and #44.
Failure to review, revise, and follow care plan for Resident #44 regarding pressure ulcer care.
Failure to provide necessary care and services to maintain highest practicable well-being for Residents #84, #77, and #46.
Failure to provide necessary personal hygiene services to Resident #18.
Failure to provide proper urinary catheter care for Residents #38, #68, and #60.
Failure to ensure drug regimen free from unnecessary drugs and failure to assess and reassess pain medication effectiveness for Residents #82 and #31.
Failure to post nurse staffing data on the proper date.
Failure to prepare, store, distribute and serve food under sanitary conditions including staff not wearing hair nets and dirty kitchen environment.
Failure to identify diagnosis and side effects for medication Myrbetriq administered to Resident #31.
Failure to ensure nurse call system worked effectively and efficiently on 2 of 4 halls; missing call lights in resident bathrooms and rooms.
Failure to provide sufficient space for dining activities for 17 residents in the special care unit.
Report Facts
Resident census: 83
Sample size: 25
Days without bowel movement: 5
Days missing documentation: 11
Days missing showers: 6
Days staffing data not updated: 17
Residents in memory care unit: 17
Available dining spaces: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Nurse | Verified multiple deficiencies including failure to notify family, incomplete assessments, missing documentation, and catheter care |
| Nurse A | Nurse | Verified failure to notify family and proper catheter care |
| Nurse H | Nurse | Verified failure to notify family and catheter care |
| Nurse M | Nurse | Verified lack of bowel assessment documentation |
| Nurse N | Nurse | Verified missing documentation for dialysis fistula care |
| Nurse O | Nurse | Verified catheter care practices |
| Nurse U | Nurse | Verified lack of knowledge about medication purpose |
| Certified Medication Aide J | CMA | Administered pain medication and verified pain assessments |
| Certified Medication Aide V | CMA | Administered medication and verified pain assessments |
| Dietary Staff P | Dietary Staff | Observed not wearing hair net properly |
| Dietary Staff Q | Dietary Staff | Observed not wearing hair net properly |
| Dietary Staff R | Dietary Staff | Verified hair net policy and kitchen cleanliness issues |
| Maintenance Staff I | Maintenance Staff | Verified missing call lights and kitchen maintenance issues |
| Administrative Staff K | Administrator | Verified dining space availability |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N085006 POC 691V11
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at Smoky Hill Rehabilitation Center, addressing deficiencies related to mistreatment, neglect, abuse, and inadequate supervision of residents.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Smoky Hill 111913 Complaint.
Findings
The facility acknowledged deficiencies involving alleged mistreatment, neglect, abuse, injuries of unknown origin, misappropriation of resident property, and inadequate supervision to prevent accidents. The plan outlines corrective actions including policy review, staff training, resident assessments, and ongoing monitoring through the Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (2)
Alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property were not thoroughly investigated and steps to prevent further potential abuse were insufficient.
Residents did not receive adequate supervision to prevent accidents.
Report Facts
Substantial Compliance Date: Dec 6, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N085006 POC BZRU12
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Smoky Hill Rehabilitation Center.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Smoky Hill Rehabilitation Center.
Findings
The plan addresses deficiencies related to respiratory care and medication administration, including staff in-service training, monitoring, and quality assurance measures to ensure proper treatment and adequate medication supplies.
Deficiencies (2)
Deficiency related to respiratory care including oxygen policy and assessment techniques.
Deficiency related to routine and emergency drugs and biologicals availability and administration.
Report Facts
Completion Date: Sep 6, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N085006 POC IKH711
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Smoky Hill Health and Rehabilitation.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by the event ID IKH711 and deficiency report 2567.
Findings
The facility addressed deficiencies related to safe transfer techniques for residents requiring assistance, including reviewing and correcting care plans, educating staff, and implementing observation protocols to ensure compliance.
Deficiencies (1)
Failure to safely transfer residents who require assistance, specifically resident #2's care plan needing correction and staff education on transfer techniques.
Report Facts
Number of transfers observed per week: 5
Plan completion date: Sep 4, 2015
Quality Assurance meeting date: Sep 18, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N085006 POC VTRC11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Smoky Hill Rehabilitation Center.
Complaint Details
This Plan of Correction is linked to a complaint investigation at Smoky Hill Rehabilitation Center.
Findings
The plan addresses deficiencies related to notification of changes in resident status, bathing schedules for dependent residents, and identification and intervention for residents with depression or psychosocial issues. Corrective actions include staff in-service training, monitoring compliance, and integration into the Quality Assurance Performance Improvement program.
Deficiencies (3)
Failure to promptly notify physician and responsible party of changes in resident status.
Residents #2 and #6 did not have baths scheduled for 2 times weekly as required.
Inadequate identification and intervention for residents with signs and symptoms of depression, withdrawal, or isolation.
Report Facts
Plan of Correction completion date: Nov 7, 2014
Staff in-service date: Oct 27, 2014
QAPI review duration: 2
Sampling percentage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Benter | Administrator | Submitted the Plan of Correction |
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