Inspection Reports for Tanglewood Nursing and Rehabilitation
5015 SW 28TH STREET, KS, 66614-2319
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 18, 2017, found no deficiencies, confirming that previously cited issues had been corrected. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including pressure ulcer prevention and treatment, medication management, infection control, food sanitation, and safety hazards such as fall prevention and environmental maintenance. Several complaint investigations substantiated failures in these areas, including a notable case involving a resident who developed a severe pressure ulcer resulting in hospitalization with sepsis and gangrene. Enforcement actions were imposed at various times, including denial of payment for new admissions due to noncompliance with pressure ulcer care and Life Safety Code deficiencies, but no fines or license suspensions were listed in the available reports. The trend indicates improvement over time, with recent revisits confirming correction of prior deficiencies and no new citations noted in the latest inspections.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
59.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
887% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
44 residents
Based on a February 2017 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 8
Apr 18, 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 had been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were marked as corrected and completed as of 02/24/2017.
Deficiencies (8)
| Description |
|---|
| Deficiency with regulation 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18) |
| Deficiency with regulation 483.10(f)(10)(i)-(iv) |
| Deficiency with regulation 483.10(f)(10)(v) |
| Deficiency with regulation 483.20(b)(1) |
| Deficiency with regulation 483.20(g)-(j) |
| Deficiency with regulation 483.24, 483.25(k)(l) |
| Deficiency with regulation 483.60(i)(1)-(3) |
| Deficiency with regulation 483.80(a)(1)(2)(4)(e)(f) |
Report Facts
Deficiencies corrected: 8
Inspection Report
Re-Inspection
Deficiencies: 1
Apr 18, 2017
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies at Tanglewood Nursing & Rehabilitation have been corrected.
Findings
The revisit inspection confirmed that the previously cited deficiency related to regulation 26-40-305 (c)(1)(2) was corrected as of 02/24/2017.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-305 (c)(1)(2) |
Report Facts
Date correction completed: Feb 24, 2017
Inspection Report
Plan of Correction
Deficiencies: 9
Feb 24, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey. It outlines corrective actions taken and measures to prevent recurrence of cited deficiencies.
Findings
The plan addresses multiple deficiencies including notice of rights, management of personal funds, conveyance of personal funds upon death, comprehensive assessments, assessment accuracy, care for residents on dialysis, food sanitation, infection control, and facility maintenance such as HVAC. Corrective actions and monitoring plans are described for each deficiency.
Severity Breakdown
D: 5
E: 2
F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Notice of Rights, Rules, Services, and Charges | D |
| Facility Management of Personal Funds | E |
| Conveyance of Personal Funds Upon Death | D |
| Comprehensive Assessments | D |
| Assessment Accuracy/Coordination/Certified | D |
| Provide Care/Services for Highest Well Being | D |
| Food Procure, Store/Prepare/Serve – Sanitary | F |
| Infection Control Prevent Spread, Linens | F |
| Heating, Ventilation and A.C. | E |
Report Facts
Audit frequency: 4
Audit reporting period: 3
Resident trust fund shortfall: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Patterson | Administrator | Administrator submitting the Plan of Correction |
| Vice President of Clinical Services | Educated Director of Nursing on MDS completion | |
| Director of Nursing | Responsible for audits and education related to assessments and medication administration | |
| Business Office Manager | Educated residents and staff on personal funds management and conveyance | |
| Dietary Manager | Educated dietary staff and conducted food safety audits | |
| Housekeeping Supervisor | Completed room cleaning competencies | |
| Healthcare Services Group District Manager | In serviced housekeeping staff on cleaning techniques |
Inspection Report
Enforcement
Deficiencies: 0
Feb 23, 2017
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at a level of no harm with the potential for more than minimal harm, not immediate jeopardy. Due to deficiencies cited and a history of noncompliance on a prior Life Safety Code survey, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.
Complaint Details
The enforcement action was based on deficiencies found on the current survey and a complaint survey, but no specific substantiation status or details were provided.
Report Facts
Denial of payment effective date: Mar 5, 2017
Non-compliance correction deadline: Aug 13, 2017
Civil Money Penalty threshold: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Named in relation to enforcement and survey findings |
Inspection Report
Life Safety
Deficiencies: 1
Feb 13, 2017
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited during the Life Safety Code survey at 'F' level severity. | F |
Report Facts
Effective date for discretionary denial of payments: Mar 5, 2017
Provider agreement termination date: Aug 13, 2017
Plan of correction submission timeframe: 10
Hearing request timeframe: 60
Informal Dispute Resolution request timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Patterson | Administrator | Named as facility administrator. |
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report as Licensure Certification & Enforcement Manager. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution requests. |
| Lisa Hauptman | CMS Contact | Contact person for questions regarding the matter. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Feb 13, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to ventilation and air conditioning system deficiencies.
Findings
The facility failed to maintain an exhaust fan in the beauty shop to eliminate fumes, and did not provide a policy regarding the exhaust fan. The beauty shop lacked a functioning exhaust fan despite being located at the junction of three hallways.
Complaint Details
The visit was triggered by complaints #105627, 104565, and 106096 as part of a Health Resurvey and Complaint Investigation.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain an exhaust fan in the beauty shop to eliminate fumes. | SS=E |
Report Facts
Census: 44
Inspection Report
Life Safety
Deficiencies: 1
Oct 31, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey identified the most serious deficiencies as 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level severity | F |
Report Facts
Days to submit plan of correction: 10
Effective date of denial of payments: Jan 31, 2017
Recommended termination date: May 1, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution |
Inspection Report
Follow-Up
Deficiencies: 6
Oct 6, 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 found to be corrected as of 08/18/2016, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 7
Aug 18, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey inspection, outlining corrective actions to address the cited deficiencies.
Findings
The plan addresses multiple deficiencies including employee background checks, replacement and evaluation of assist bars, medication regimen issues related to blood pressure monitoring and drug storage, and sanitary food preparation practices. The facility implemented audits, staff education, and monitoring systems to ensure compliance and prevent recurrence.
Severity Breakdown
C: 1
D: 2
E: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to complete background checks on employees | C |
| Failure to ensure assist bars met FDA requirements and proper evaluation of physical restraints | E |
| Drug regimen not free from unnecessary drugs | D |
| Failure to notify physician timely of blood pressure results outside ordered parameters | E |
| Unsanitary food procurement, storage, preparation, and serving practices | E |
| Failure to properly review, report, and act on irregular drug regimen findings | D |
| Failure to properly label and store drugs and biologicals | E |
Report Facts
Residents affected: 5
Medication carts audited: 2
Audit frequency: 3
Weekly kitchen inspections: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Subject of background check completed on 08/02/16 | |
| WILLIAMPATTERSON | Administrator | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Aug 9, 2016
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at 'E' level, resulting in enforcement remedies including a denial of payment for new Medicare and Medicaid admissions effective November 9, 2016, until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'E' level severity | E |
Report Facts
Denial of Payment Effective Date: Nov 9, 2016
Termination Recommendation Date: Feb 9, 2017
Civil Money Penalty Threshold: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed letter and contact for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 6
Aug 9, 2016
Visit Reason
Health Resurvey and Complaint Investigation #100667 and #98363 conducted to assess compliance with regulatory requirements.
Findings
The facility failed to complete a criminal background check timely for a licensed nurse, failed to ensure residents were free from accident hazards related to bed rails with unsafe gap measurements, failed to identify and notify physician of abnormal blood pressure readings for a resident, failed to maintain sanitary food preparation and serving conditions, failed to ensure consultant pharmacist reported medication irregularities, and failed to properly identify expired medications in medication carts.
Complaint Details
The inspection was triggered by complaints #100667 and #98363, focusing on background checks, resident safety, medication management, and food sanitation.
Severity Breakdown
Level C: 1
Level D: 2
Level E: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to complete a criminal background check for one licensed nurse prior to or within two days of hire. | Level C |
| Failed to ensure 5 residents were free from accident hazards such as bed rails with gaps exceeding FDA recommended measurements, risking entrapment. | Level E |
| Failed to identify and notify physician of resident #58's abnormal blood pressure levels as ordered. | Level D |
| Failed to prepare and serve food in a sanitary manner; dietary staff had hair exposed and flies were present on food prep surfaces. | Level E |
| Consultant pharmacist failed to identify and report lack of physician notification for resident #58's abnormal blood pressure levels. | Level D |
| Failed to ensure outdated and expired medications were identified and removed from medication carts affecting 7 residents. | Level E |
Report Facts
Census: 36
Sample size: 14
Days late for background check: 37
Bed rail gap measurements: 6.5
Blood pressure readings above threshold: 14
Expired eye medications: 8
Residents affected by expired medications: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Failed background check completed timely; involved in bed rail assessment |
| Administrative Staff C | Acknowledged background check delay for Licensed Nurse H | |
| Direct Care Staff O | Provided observations on resident transfers and bed rail use | |
| Direct Care Staff P | Reported blood pressure monitoring and resident care | |
| Licensed Nursing Staff H | Licensed Nurse | Assessed bed rail risks and blood pressure monitoring |
| Maintenance Staff X | Installed bed rails and discussed measurement policies | |
| Administrative Nursing Staff D | Confirmed bed rail gap risks and blood pressure notification requirements | |
| Dietary Staff DD | Observed with hair exposed and reported fly issue in kitchen | |
| Dietary Staff EE | Dietary Manager | Discussed hairnet policy and staff training |
| Pharmacist Consultant KK | Consultant Pharmacist | Failed to identify and report lack of physician notification for abnormal blood pressure |
Inspection Report
Follow-Up
Deficiencies: 6
Jul 11, 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
All previously cited deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.25(c), 483.25(h), 483.25(l), 483.60(c), and 483.60(b), (d), (e) were corrected as of the revisit dates.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
Inspection Report
Follow-Up
Deficiencies: 2
Jul 11, 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 facility corrected the deficiencies previously cited under regulations 483.25(c) and 483.75(o)(1), with corrective actions completed as of 07/11/2016.
Deficiencies (2)
| Description |
|---|
| Deficiency under regulation 483.25(c) |
| Deficiency under regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 15, 2016
Visit Reason
The revisit was conducted on June 15, 2016, as a result of the March 22, 2016 Health survey 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 deficiencies in the facility to be 'E' level deficiencies. Due to noncompliance with F314 related to Pressure Ulcers, a denial of payment for new Medicare and Medicaid admissions was imposed effective June 8, 2016, and termination of the provider agreement was recommended.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314, Pressure Ulcers | E |
Report Facts
Denial of Payment Effective Date: Jun 8, 2016
Recommended Termination Date: Sep 22, 2016
Civil Money Penalty Minimum Amount: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Author of the report and contact for questions concerning the instructions contained in the letter |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 15, 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
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.
Report Facts
Deficiencies corrected: 12
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 6
Jun 15, 2016
Visit Reason
This inspection was a Non-Compliance Revisit to verify correction of previously cited deficiencies related to care plans, treatment of pressure sores, fall prevention, medication regimen, and drug storage.
Findings
The facility failed to develop comprehensive care plans to prevent falls for a resident with repeated falls, failed to provide appropriate repositioning and off-loading interventions for a resident with pressure ulcers, failed to assess root causes and provide interventions to prevent falls, failed to notify physicians of abnormal blood sugar levels as ordered, and failed to properly label and store medications including insulin pens and inhalers.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to develop a care plan to prevent falls for a resident with repeated falls. | SS=D |
| Failed to provide appropriate repositioning and off-loading interventions for a resident with pressure ulcers. | SS=D |
| Failed to provide appropriate interventions to prevent falls for a resident with history of falls. | SS=D |
| Failed to identify and report lack of physician notification for abnormal blood sugar levels for a resident with diabetes. | SS=D |
| Consultant pharmacist failed to identify and report abnormal blood sugar levels for a resident with diabetes. | SS=E |
| Failed to properly label and store insulin pens, multi-dose vials, and medication inhalers according to manufacturer recommendations. | — |
Report Facts
Resident census: 42
Residents in sample: 12
Fall risk score: 18
Blood sugar readings above 250 mg/dL: 12
Blood sugar reading below 70 mg/dL: 1
Days opened: 47
Days opened: 30
Days opened: 48
Days opened: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Nursing Staff | Named in findings related to fall interventions and blood sugar monitoring |
| Staff E | Administrative Licensed Nursing Staff | Named in findings related to fall interventions and resident transfers |
| Staff D | Administrative Nursing Staff | Named in findings related to care plan updates and blood sugar monitoring |
| Staff P | Direct Care Staff | Named in resident transfer and gait belt adjustment |
| Consultant Pharmacist KK | Consultant Pharmacist | Failed to identify and report abnormal blood sugar levels |
| Nurse Practitioner JJ | Nurse Practitioner | Confirmed expectation for nurses to notify physician of abnormal blood sugar levels |
| Consultant Therapy Staff HH | Physical Therapy Assistant | Involved in resident transfer and therapy |
Inspection Report
Plan of Correction
Deficiencies: 6
Jun 15, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the Tanglewood revisit inspection conducted on 06/15/2016.
Findings
The plan addresses multiple deficiencies including fall risk assessments and interventions, pressure sore prevention and treatment, drug regimen reviews, and medication storage and labeling. The facility implemented corrective actions such as audits, staff in-services, and ongoing monitoring to ensure compliance and prevent recurrence.
Severity Breakdown
D: 5
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Develop Comprehensive Care Plans related to fall risk and interventions for Resident #22. | D |
| Treatment/Services to Prevent/Heal Pressure Sores for Resident #9's left heel wound. | D |
| Free of Accident/Hazards/Supervision/Devices related to fall prevention for Resident #22. | D |
| Drug Regimen is Free from Unnecessary Drugs with monitoring of blood glucose results for Resident #47. | D |
| Drug Regimen Review including communication with consulting pharmacy provider regarding blood glucose results. | D |
| Drug Records, Label/Store Drugs & Biologicals including proper storage, opening, and dating of medications. | E |
Report Facts
Deficiencies cited: 6
Audit frequency: 3
Audit duration: 4
Rounds frequency: 3
Rounds duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Patterson | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Added the Plan of Correction on 06/24/2016. | |
| Irina Strakhova | Modified the Plan of Correction on 07/13/2016. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 18, 2016
Visit Reason
An Abbreviated Survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not in substantial compliance, with conditions constituting immediate jeopardy to resident health or safety from May 3 through May 13, 2016, related to pressure ulcers (F314). Enforcement remedies including denial of payment for new admissions were imposed.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314, Pressure Ulcers, resulting in immediate jeopardy to resident health or safety. | Immediate Jeopardy |
Report Facts
Denial of payment effective date: Jun 8, 2016
Recommended termination date: Sep 22, 2016
Immediate jeopardy period start: May 3, 2016
Immediate jeopardy period end: May 13, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Patterson | Administrator | Named as facility administrator. |
| Caryl Gill | Complaint Coordinator | Signed letter and contact for questions regarding the survey. |
| Lisa Hauptman | CMS Contact | Contact person for CMS regarding the matter. |
| Codi Thurness | Commissioner | Commissioner of Kansas Department for Aging & Disability Services. |
Inspection Report
Plan of Correction
Deficiencies: 2
May 18, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey conducted on 05/18/2016.
Findings
The facility developed and implemented a facility-wide system to assure correction and continued compliance with regulations related to skin integrity and wound care. The plan includes staff education, monitoring, and ongoing audits to ensure compliance and quality improvement.
Complaint Details
This Plan of Correction is related to deficiencies cited during a complaint investigation survey conducted on 05/18/2016.
Severity Breakdown
J: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to properly assess and treat skin integrity issues and wounds. | J |
| Failure to maintain an effective Quality Assurance/Performance Improvement Committee to address skin management system issues. | F |
Report Facts
Date of resident transfer: May 3, 2016
Date of Plan of Correction completion: Jun 10, 2016
Date of QA Committee review: Apr 25, 2016
Date of staff training completion: May 13, 2016
Date of QA/PI Committee meeting: May 19, 2016
Date of education to QA/PI Committee: May 20, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Patterson | Administrator | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
May 18, 2016
Visit Reason
The inspection was a partial extended complaint survey investigation triggered by complaints #100347 and #100454 regarding pressure ulcer prevention and care.
Findings
The facility failed to develop and implement effective interventions to prevent the development of an avoidable pressure ulcer for resident #1, which resulted in hospitalization due to sepsis and gangrene requiring multiple surgical debridements and colostomy placement. The facility also failed to maintain an effective Quality Assurance and Assessment (QAA) committee to monitor and correct quality deficiencies related to pressure ulcer prevention.
Complaint Details
The complaint investigation revealed that resident #1 developed a severe pressure ulcer without facility knowledge, leading to hospitalization with sepsis and gangrene. The ulcer required multiple surgical interventions and colostomy placement.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement effective interventions to prevent an avoidable pressure ulcer resulting in hospitalization for sepsis and gangrene. | Immediate Jeopardy |
| Failure to maintain an effective Quality Assurance and Assessment committee to monitor and implement corrective actions for pressure ulcer prevention. | — |
Report Facts
Resident census: 41
Braden scale scores: 16
Braden scale score: 17
Pressure ulcer wound size: 25
Pressure ulcer wound size: 15
Pressure ulcer wound size: 13
Pressure ulcer wound size: 9
Pressure ulcer wound depth: 1.5
Date of immediate jeopardy abatement: May 13, 2016
Inspection Report
Life Safety
Deficiencies: 1
Apr 20, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies 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. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jul 20, 2016
Provider agreement termination date: Oct 20, 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 person for Informal Dispute Resolution process. |
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 22, 2016
Visit Reason
A health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at 'F' level, indicating significant noncompliance. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level severity | F |
Report Facts
Denial of Payment effective date: Jun 22, 2016
Termination recommendation date: Sep 22, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Smith | Administrator | Facility administrator named in the report header |
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the Plan of Correction and enforcement letter |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 16
Mar 22, 2016
Visit Reason
Health Resurvey and Complaint Investigation #96582 conducted to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to assess and accommodate resident bathing preferences, failure to provide clean linens, incomplete significant change assessments, inadequate individualized care plans, insufficient assistance with activities of daily living, failure to promote healing of pressure ulcers, inadequate incontinence care, insufficient nursing staff, improper medication monitoring, unsanitary food storage and preparation, expired medications in medication carts, improper infection control practices, and inadequate dining room space.
Complaint Details
Complaint Investigation #96582 triggered the survey.
Severity Breakdown
SS=D: 8
SS=E: 5
SS=F: 2
SS=C: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to assess and accommodate resident bathing preferences for multiple residents. | SS=D |
| Failed to ensure residents had clean towels and washcloths readily available. | SS=E |
| Failed to complete significant change assessments when indicated for sampled residents. | SS=D |
| Failed to develop individualized care plans for cognition, hospice, and urinary incontinence. | SS=D |
| Failed to perform and document assessments after dialysis and coordinate hospice services. | SS=D |
| Failed to provide assistance required for bathing for cognitively impaired residents. | SS=D |
| Failed to provide necessary treatment and services to promote healing of pressure ulcers. | SS=D |
| Failed to provide incontinence care and toileting for dependent incontinent resident. | SS=D |
| Failed to ensure resident environment was free of accident hazards and provide adequate supervision to prevent falls. | SS=D |
| Failed to ensure residents were free from unnecessary drugs and failed to monitor for side effects and effectiveness of medications. | SS=E |
| Failed to post daily nurse staffing information with required details in a publicly accessible location and maintain records for 18 months. | SS=C |
| Failed to provide sufficient dietary staff to serve meals to residents in a timely manner. | SS=E |
| Failed to store, serve, and prepare food in a sanitary manner including improper food storage temperatures and uncovered hair. | SS=F |
| Failed to dispose of expired medications in medication carts. | SS=E |
| Failed to follow infection control practices including proper glove use, resulting in contamination of commonly used items with feces and urine. | SS=D |
| Failed to provide a dining area with sufficient space to safely accommodate residents during dining. | SS=E |
Report Facts
Residents present: 47
Residents sampled: 21
Bathing frequency: 2
Blood sugar readings above 351 mg/dl: 38
Blood pressure readings below 105 mmHg: 3
Medication carts with expired meds: 2
Daily staffing sheets incomplete: 18
Meal service delay: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Nursing Staff | Provided multiple interviews regarding care plan expectations, staffing, and infection control |
| Staff H | Licensed Nursing Staff | Interviewed about care plan expectations, medication monitoring, and bathing assistance |
| Staff O | Direct Care Staff | Interviewed about bathing assistance, medication reporting, and staffing shortages |
| Staff QQ | Direct Care Staff | Administered medication and discussed blood pressure monitoring |
| Staff I | Licensed Nursing Staff | Interviewed about medication monitoring and refrigerator temperature monitoring |
| Staff DD | Dietary Staff | Interviewed about meal service delays and refrigerator maintenance |
| Staff R | Direct Care Staff | Observed and interviewed regarding infection control glove use and bathing assistance |
| Staff PP | Direct Care Staff | Observed and interviewed regarding infection control glove use |
| Staff T | Direct Care Staff | Interviewed about meal service and staffing |
| Staff S | Direct Care Staff | Observed serving meals and interviewed about meal service delays |
| Staff U | Direct Care Staff | Interviewed about hospice services and bathing assistance |
| Staff V | Direct Care Staff | Observed assisting with incontinent care |
| Staff EE | Dietary Staff | Interviewed about hair covering and refrigerator responsibility |
| Staff GG | Dietary Staff | Interviewed about refrigerator responsibility |
| Staff X | Maintenance Staff | Interviewed about refrigerator thermometer replacement |
| Consultant KK | Pharmacy Consultant | Interviewed about medication monitoring and black box warnings |
Inspection Report
Plan of Correction
Deficiencies: 19
Mar 22, 2016
Visit Reason
This document is a Plan of Correction submitted by Tanglewood Nursing and Rehab in response to deficiencies cited during a survey conducted on 03/22/2016.
Findings
The plan addresses multiple deficiencies related to resident care, including bathing choices, linen availability, comprehensive assessments, care planning, pressure ulcer prevention, incontinent care, accident hazards, medication management, staffing, dietary services, sanitation, infection control, and dining room requirements. Corrective actions include reassessments, staff education, audits, monitoring, and reporting to the Quality Assurance and Assessment (QAA) committee.
Severity Breakdown
C: 1
D: 9
E: 6
F: 2
Deficiencies (19)
| Description | Severity |
|---|---|
| Self Determination to Make Choices regarding bathing | D |
| Clean Bed/Bath Linens availability | E |
| Comprehensive Assessment after significant change | D |
| Develop Comprehensive Care Plans | D |
| Right to Participate in Care Planning | D |
| Provide Care/Services for Highest Well Being | D |
| ADL Care Provided for Dependent Residents | D |
| Treatment/Services to Prevent/Heal Pressure Ulcer | D |
| No catheter, Prevent UTI, Restore Bladder | D |
| Free of Accident Hazards | D |
| Unnecessary drugs | E |
| Sufficient 24-HR Nursing Staff per care plans | F |
| Posted Nursing Staff Information | C |
| Sufficient Dietary Support Personnel | E |
| Store/Prepare/Serve - Sanitary | F |
| Drug Regimen Review, Report, Irregular, Act on | E |
| Drug Records, Label/Store Drugs and Biologicals | E |
| Infection Control, prevent spread, linens | D |
| Requirements for Dining and Activity Rooms | E |
Report Facts
Deficiencies cited: 19
Resident interviews: 2
Resident interviews: 2
Care plan audits: 3
Medication administration audits: 2
Audit duration: 4
Audit duration: 8
Monitoring period: 3
Resident interviews: 6
Resident interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly J Smith | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 11
Dec 15, 2015
Visit Reason
This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report documents that all previously identified deficiencies listed on the CMS-2567 have been corrected, with correction completion dates mostly on 10/16/2015 and one on 10/16/2016.
Deficiencies (11)
| Description |
|---|
| Deficiency related to regulation 483.10(c)(2)-(5) |
| Deficiency related to regulation 483.10(c)(6) |
| Deficiency related to regulation 483.15(c)(1)-(5) |
| Deficiency related to regulation 483.15(f)(1) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(e)(2) |
| Deficiency related to regulation 483.25(n) |
| Deficiency related to regulation 483.35(b) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.65 |
Report Facts
Correction completion date: Oct 16, 2015
Correction completion date: Oct 16, 2016
Inspection Report
Re-Inspection
Deficiencies: 1
Dec 15, 2015
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency identified by regulation 26-40-302 (h) with ID prefix S0972 was corrected as of 10/16/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-302 (h) |
Report Facts
Deficiency correction date: Oct 16, 2015
Inspection Report
Plan of Correction
Deficiencies: 11
Oct 16, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to achieve compliance with federal Medicare and Medicaid requirements.
Findings
The plan addresses multiple deficiencies including resident trust fund management, resident council facilitation, activity programming, care plan assessments, incontinence management, restorative nursing programs, influenza vaccination education, meal time scheduling, food storage practices, infection control, and wireless call system testing. The facility has implemented audits, education, and monitoring to ensure compliance and ongoing quality assurance.
Deficiencies (11)
| Description |
|---|
| Resident trust fund management issues including balances and refunds. |
| Resident council facilitation and participation. |
| Activity programming and resident participation support. |
| Care plan assessments and revisions for residents. |
| Urinary incontinence assessment and individualized toileting plans. |
| Restorative nursing program audits and education. |
| Influenza vaccine education and administration procedures. |
| Meal time scheduling and staff education on dining service. |
| Food storage, labeling, sealing, and defrosting practices. |
| Infection control logs review and infection reporting education. |
| Weekly testing and documentation of the wireless call system. |
Report Facts
Date of compliance: Oct 16, 2015
Resident trust account balance review threshold: 200
Resident trust account interest threshold: 50
Refund processing timeframe: 30
Audit completion date: Oct 9, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly J Smith | Administrator | Administrator named as submitter of the Plan of Correction and involved in education and audits. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Enforcement
Deficiencies: 1
Oct 1, 2015
Visit Reason
The inspection was conducted to assess compliance with Federal participation requirements for nursing homes participating in Medicare and Medicaid programs, including a Life Safety Code survey and a Health survey.
Findings
Both surveys found the most serious deficiencies in the facility to be at the 'F' level, resulting in enforcement remedies including a denial of payment for new Medicare and Medicaid admissions effective January 1, 2016, until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found in the facility at 'F' level | F |
Report Facts
Denial of Payment Effective Date: Jan 1, 2016
Termination Recommendation Date: Apr 1, 2016
Civil Money Penalty Threshold: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Smith | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Signed letter and contact for questions concerning instructions |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution for Life Safety Code Survey |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 11
Oct 1, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS00089532 to evaluate compliance with regulatory requirements related to resident personal funds management, resident rights, activities, assessments, infection control, dietary services, and other care aspects.
Findings
The facility was found deficient in multiple areas including failure to manage resident personal funds properly, failure to convey deceased resident funds timely, failure to ensure resident participation in resident groups, lack of an ongoing activity program, incomplete comprehensive assessments, failure to develop individualized toileting and restorative nursing programs, failure to provide education prior to influenza immunizations, failure to serve meals on schedule, improper food storage and sanitation, and ineffective infection control program.
Complaint Details
The inspection was triggered by a complaint investigation #KS00089532 focusing on multiple areas of resident care and facility compliance.
Severity Breakdown
SS=E: 5
SS=D: 3
SS=F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to obtain written authorization for managing resident personal funds, failure to place funds exceeding $50 in interest bearing accounts, failure to notify Medicaid residents when funds approached resource limits, and failure to provide quarterly statements. | SS=E |
| Failure to convey deceased resident's personal funds and final accounting within 30 days to the appropriate individual or probate jurisdiction. | SS=D |
| Failure to ensure residents had the right to participate in resident groups; resident council meetings were not held monthly as required. | SS=E |
| Failure to provide an ongoing activity program meeting residents' interests and needs; scheduled activities often did not occur and documentation was lacking. | SS=E |
| Failure to conduct comprehensive assessments using the Resident Assessment Instrument (RAI) and to document care area assessments adequately for multiple residents. | SS=F |
| Failure to develop an individualized toileting program for a resident with urinary incontinence. | SS=D |
| Failure to provide restorative nursing services to maintain or improve range of motion for a resident with severe cognitive impairment and functional limitations. | SS=D |
| Failure to provide education regarding benefits and potential side effects of influenza immunization prior to offering the vaccine to residents. | SS=E |
| Failure to serve meals within the scheduled time frames, with delays of 30 to 45 minutes observed for breakfast, lunch, and dinner. | SS=E |
| Failure to properly store food, including unlabeled and undated items, heavy ice buildup in freezers, thawing raw meats improperly, and use of disinfectant solution at incorrect concentration. | SS=F |
| Failure to maintain an effective infection control program, including lack of tracking and trending infection data and corrective actions. | SS=F |
Report Facts
Resident census: 40
Residents' personal funds accounts managed: 28
Resident personal fund balances: 1993.87
Resident personal fund balances: 2054.92
Resident personal fund balances: 2994.92
Deceased resident personal fund balance: 1495.54
Minutes of physical therapy: 285
Minutes of occupational therapy: 180
Disinfectant concentration: 10
Meal service delay: 45
Inspection Report
Follow-Up
Deficiencies: 6
Aug 11, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report shows that all previously cited deficiencies were corrected by 06/26/2015 as documented by the correction completion dates for each deficiency.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.60(a),(b) |
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Jun 26, 2015
Visit Reason
This document is a Plan of Correction submitted by Tanglewood Nursing in response to deficiencies cited during a complaint survey conducted on 2015-06-15.
Findings
The plan addresses multiple deficiencies including medication administration errors, failure to notify physicians and families, inadequate investigation and reporting of incidents, incomplete comprehensive assessments, wound and pressure ulcer care, safety and accident prevention, and pharmaceutical service procedures. The facility implemented corrective actions such as audits, staff education, and monitoring plans to ensure compliance and prevent recurrence.
Complaint Details
This Plan of Correction is in response to a complaint survey conducted on 2015-06-15. The facility addressed issues related to medication administration, fall risk, abuse reporting, comprehensive assessments, wound care, and safety.
Severity Breakdown
D: 4
G: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Notification of Changes - Resident #3's physician was notified of missed medications. | D |
| Investigate and Report - Resident #2 assessed for fall risk; staff educated on abuse and neglect reporting. | D |
| Comprehensive Assessments - Resident #1's care plan updated after review; audits of CAA completed. | D |
| Wounds/Pressure Ulcers - Head to toe skin assessments completed; treatment orders implemented. | G |
| Safety/Free of unnecessary accidents - Fall risk assessments completed; staff educated on accident prevention. | G |
| Pharmaceutical services-accurate procedures - Medication administration audits conducted; staff educated on 5 rights. | D |
Report Facts
Date of audit start: Jun 23, 2015
Date of education: Jun 18, 2015
Date of education: Jun 24, 2015
Date of skin assessment: Jun 19, 2015
Date of skin assessment: Jun 24, 2015
Date of fall risk audit: Jun 24, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly J Smith | Administrator | Administrator who submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 15, 2015
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 deficiencies at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the facility's history of noncompliance, no opportunity to correct deficiencies before remedies are imposed was given, resulting in denial of payment for new Medicare and Medicaid admissions effective July 8, 2015.
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314, Pressure Ulcers, including failure to prevent avoidable pressure ulcers and provide appropriate care and services to prevent increased complexity of existing pressure ulcers. | Level of actual harm |
Report Facts
Denial of payment effective date: Jul 8, 2015
Noncompliance history date: Oct 7, 2014
Termination recommendation date: Dec 15, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Smith | Administrator | Named as facility administrator |
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions regarding the letter |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 5
Jun 15, 2015
Visit Reason
The inspection was conducted based on complaint investigations regarding medication administration, resident falls, pressure ulcers, and abuse allegations.
Findings
The facility failed to timely notify the physician of missed medications for a resident with urinary tract infection and major depression, failed to thoroughly investigate unwitnessed falls, burns, and allegations of resident-to-resident sexual abuse, failed to complete comprehensive assessments including Care Area Assessments for pressure ulcers and falls, failed to provide preventive treatments for pressure ulcers, and failed to ensure supervision and assistive devices to prevent accidents for residents with a history of falls.
Complaint Details
The investigation was triggered by complaints related to medication errors, resident falls, pressure ulcers, and abuse allegations.
Severity Breakdown
SS=D: 3
SS=G: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify physician timely for missed medications for treatment of urinary tract infection and major depression. | SS=D |
| Failed to thoroughly investigate unwitnessed falls, burns, and allegations of resident-to-resident sexual abuse. | SS=D |
| Failed to complete comprehensive assessments including Care Area Assessments for pressure ulcers and falls. | SS=D |
| Failed to provide preventive treatments and effective interventions to prevent avoidable pressure ulcers. | SS=G |
| Failed to ensure supervision and assistive devices to prevent accidents for residents with repeated unwitnessed falls and injuries. | SS=G |
Report Facts
Resident census: 48
Missed medication doses: 4
Pressure ulcer measurements: 6
Pressure ulcer measurements: 4
Fall risk assessment scores: 21
Fall risk assessment scores: 22
Fall risk assessment scores: 19
Braden scale score: 11
Braden scale score: 22
Inspection Report
Follow-Up
Deficiencies: 18
Dec 5, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in an earlier survey had been corrected.
Findings
The report shows that all previously cited deficiencies were corrected by 10/24/2014, as documented by the correction completion dates for each deficiency listed.
Deficiencies (18)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.10(c)(2)-(5) |
| Deficiency related to regulation 483.10(k),(l) |
| Deficiency related to regulation 483.13(a) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.13(c) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| 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(c) |
| Deficiency related to regulation 483.25(h) |
| 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(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
Report Facts
Correction completion date: Oct 24, 2014
Follow-up survey date: Dec 5, 2014
Previous survey date: Oct 7, 2014
Inspection Report
Plan of Correction
Deficiencies: 18
Oct 24, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to achieve compliance with federal Medicare and Medicaid requirements.
Findings
The plan details multiple corrective actions including staff education, resident care plan updates, environmental cleaning, investigations of missing items, abuse reporting procedures, and monitoring protocols to ensure ongoing compliance and resident safety.
Severity Breakdown
D: 8
E: 6
G: 2
C: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to notify responsible parties or family members of changes | D |
| Residents not having access to personal funds after business office hours | E |
| Investigation and reporting of missing dentures and other items | D |
| Assessment and notification related to resident #25 and use of restraints | D |
| Failure to report allegations of abuse by staff | D |
| Investigation and reporting of abuse allegations for resident #25 | D |
| Maintenance and housekeeping issues including cleaning and repairs | E |
| Individualized care plan updates for residents including use of lap belts and ADL preferences | E |
| Fall risk assessments and care plan revisions | D |
| Transfer capability assessments and staff education on transfer safety | G |
| Documentation and monitoring of ADL care including shaving | D |
| Assessment and treatment updates for resident #13 including rehab and dietary supplements | G |
| Care plan review and fall risk interventions for resident #25 | D |
| Behavior monitoring and documentation improvements for multiple residents | E |
| Posting of nurse staffing information and monitoring | C |
| Employee hygiene and sanitary practices in dietary services | D |
| Drug regime reviews and education related to psychotropic medications | E |
| Medication cart management and insulin monitoring | E |
Report Facts
QA review frequency: 2
Amount of money placed in medication cart: 40
Amount of money counted every shift: 20
Monitoring frequency for Administrator on staffing posting: 4
Monitoring frequency for dietary supervisor on food handling: 3
Monitoring frequency for refrigerator and freezer cleanliness: 2
Monitoring frequency for insulin expiration: 2
Inspection Report
Enforcement
Deficiencies: 1
Oct 7, 2014
Visit Reason
A Health resurvey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found serious deficiencies at a level of actual harm but not immediate jeopardy. Due to the facility's history of noncompliance, no opportunity to correct deficiencies was given before enforcement remedies were imposed, including denial of payment for all new Medicare admissions effective October 27, 2014.
Complaint Details
The enforcement action was based in part on deficiencies cited during this survey and a prior Complaint investigation conducted on April 21, 2014.
Severity Breakdown
Level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at a level of actual harm that is not immediate jeopardy as evidenced by the CMS-2567L. | Level of actual harm |
Report Facts
Enforcement effective date: Oct 27, 2014
Noncompliance termination recommendation date: Apr 7, 2015
IDR request deadline days: 60
IDR submission window days: 10
Civil Money Penalty minimum amount: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning instructions in the letter |
| Joe Ewert | Commissioner | Recipient of written requests for Informal Dispute Resolution and hearing requests |
| Sherriann Pater | Branch Manager | Authorized the letter |
Inspection Report
Routine
Census: 48
Deficiencies: 15
Oct 7, 2014
Visit Reason
Routine health resurvey and inspection of Tanglewood Nursing & Rehabilitation to assess compliance with federal regulations including resident care, medication management, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to notify family of significant resident changes, improper management of personal funds, failure to investigate missing personal property, use of physical restraints for convenience, failure to investigate and report abuse allegations, inadequate housekeeping and maintenance, incomplete comprehensive care plans, failure to provide necessary care for pressure ulcers, inadequate fall prevention interventions, inconsistent monitoring of psychotropic medications, failure to post nurse staffing information, unsanitary food handling practices, and improper medication storage and disposal.
Severity Breakdown
SS=E: 7
SS=D: 6
SS=G: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to notify resident's family of injury, pressure ulcers, and hospital transfer. | SS=E |
| Failure to ensure residents had access to personal funds after business hours. | SS=D |
| Failure to investigate missing lower dentures for a cognitively impaired resident. | SS=D |
| Use of physical restraints for staff convenience on a resident with dementia. | SS=D |
| Failure to investigate and report allegations of abuse to the state agency. | SS=D |
| Failure to implement abuse/neglect policies and post required staff reporting information. | SS=E |
| Failure to maintain a clean and comfortable environment in common areas and some resident rooms. | SS=E |
| Failure to develop individualized comprehensive care plans addressing resident needs including lap belt use, grooming preferences, and fall risk interventions. | SS=D |
| Failure to provide necessary care and services to promote healing and prevent worsening of pressure ulcers. | SS=D |
| Failure to provide grooming services for a resident requiring extensive assistance. | SS=G |
| Failure to place timely and effective interventions to minimize falls and ensure resident safety with assistive devices. | SS=E |
| Failure to consistently monitor behaviors and bowel movements for residents receiving psychotropic medications. | SS=E |
| Failure to post current nursing staff information for 1 of 4 days on survey. | SS=D |
| Failure to serve, prepare, and store food in a sanitary manner including failure to wear beard net and hand hygiene by dietary staff. | SS=E |
| Failure to store medications safely and discard expired insulin vial. | SS=E |
Report Facts
Resident census: 48
Deficiency counts: 14
Medication monitoring shifts missing: 63
Medication monitoring shifts missing: 72
Medication monitoring shifts missing: 35
Medication monitoring shifts missing: 59
Medication monitoring shifts missing: 15
Medication monitoring shifts missing: 14
Weight: 215
Pressure ulcer size: 3.9
Pressure ulcer size: 1.8
Pressure ulcer size: 2.1
Pressure ulcer size: 0.2
Insulin vial expiration: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LL | Direct Care Staff | Left medication bubble packs unsecured in medication cart |
| D | Administrative Nursing Staff | Reported failure to notify family, failure to monitor medications, and medication storage issues |
| A | Administrative Staff | Responsible for posting nurse staffing and investigating abuse allegations |
| I | Licensed Nurse | Provided information on resident care and medication monitoring |
| J | Licensed Nurse | Provided information on resident care and medication monitoring |
| EE | Dietary Staff | Failed to follow hand hygiene and beard net policy |
| DD | Dietary Staff | Reported on sanitary practices and food storage |
| JJ | Consultant Pharmacy Staff | Reviewed behavior monitoring sheets and medication regimen |
Inspection Report
Follow-Up
Deficiencies: 3
Jun 12, 2014
Visit Reason
This is a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-03-24.
Findings
The report shows that deficiencies previously cited under regulations 483.25(c), 483.25(d), and 483.25(h) were corrected as of 2014-06-12.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 483.25(c) |
| Deficiency under regulation 483.25(d) |
| Deficiency under regulation 483.25(h) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 5
May 14, 2014
Visit Reason
This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited in a complaint investigation inspection.
Findings
The plan outlines corrective actions including staff in-service training, updated care plans, wound care management improvements, and monitoring procedures to address deficiencies related to resident care, supplement administration, wound care, bowel and bladder assessments, and fall risk interventions.
Complaint Details
This Plan of Correction is related to a complaint investigation as indicated by references to a complaint and the event ID linked to a complaint inspection.
Deficiencies (5)
| Description |
|---|
| Failure to properly administer ordered supplements and document intake. |
| Inadequate risk assessments and care planning for residents with significant changes in condition. |
| Insufficient wound care management and physician communication. |
| Incomplete bowel and bladder assessments and voiding diaries. |
| Lack of proper fall risk assessment and safety interventions including alarm audits. |
Report Facts
Date of Plan Completion: May 14, 2014
Inspection Report
Follow-Up
Deficiencies: 4
Apr 23, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-03-25.
Findings
The revisit confirmed that all previously reported deficiencies identified by their regulation numbers (483.13(c), 483.15(g)(1), 483.25, and 483.25(a)(3)) were corrected as of 2014-04-23.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.13(c) |
| Deficiency related to regulation 483.15(g)(1) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(a)(3) |
Report Facts
Deficiencies corrected: 4
Previous survey date: Mar 25, 2014
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Apr 23, 2014
Visit Reason
The inspection was conducted as a Non-compliance Revisit and Complaint Investigation #73644 and 74367 to assess compliance with regulations related to pressure sores, urinary incontinence, and fall prevention.
Findings
The facility failed to prevent the development of avoidable pressure ulcers and provide necessary treatment for 3 sampled residents, failed to maintain or restore urinary function for 2 residents, and failed to provide adequate supervision and assistive devices to prevent falls for 1 resident. Deficiencies included inadequate repositioning, incomplete voiding trials, lack of fall mats, and malfunctioning bed alarms.
Complaint Details
The visit was triggered by complaints and a non-compliance revisit related to pressure sores and urinary incontinence issues.
Severity Breakdown
SS=G: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to prevent development and promote healing of pressure ulcers for 3 residents. | SS=G |
| Failed to maintain/restore urinary function for 2 residents with urinary incontinence. | SS=G |
| Failed to ensure resident environment was free of accident hazards and provide adequate supervision and assistive devices to prevent falls for 1 resident. | SS=D |
Report Facts
Census: 48
Pressure ulcers: 3
Residents with urinary incontinence deficiencies: 2
Residents with fall prevention deficiencies: 1
Weight loss: 16
Pressure ulcer measurements: 0.8
Pressure ulcer measurements: 2.5
Braden Scale score: 7
Fall risk score: 15
Fall risk score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed practical nurse F | Licensed Practical Nurse | Confirmed pressure ulcers on resident #12's buttocks and applied wound care |
| licensed registered nurse I | Licensed Registered Nurse | Observed and confirmed pressure ulcers on resident #12 |
| direct care staff R | Assisted resident #12 with toileting and repositioning; noted resident was not incontinent at times | |
| direct care staff S | Assisted resident #12 with AM care and toileting; noted resident's brief saturated with urine | |
| licensed nurse J | Licensed Nurse | Stated staff toileted resident #12 every 2 hours |
| direct care staff T | Stated staff toileted resident #12 every hour and as needed | |
| administrative nursing staff D | Administrative Nursing Staff | Acknowledged failure to measure wounds timely and incomplete skin assessments |
| administrative nursing staff F | Administrative Nursing Staff | Confirmed voiding trial documentation incomplete and fall mat discontinued |
| licensed staff E | Licensed Staff | Confirmed barrier cream was not applied to resident #12 |
| direct care staff O | Performed incontinent care for resident #15; noted pressure ulcer without dressing | |
| administrative staff A | Administrative Staff | Checked resident #12 at 6:00 AM but did not confirm toileting |
Inspection Report
Plan of Correction
Deficiencies: 6
Mar 28, 2014
Visit Reason
This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited during a complaint investigation survey.
Findings
The plan addresses multiple deficiencies including identification and documentation of DNR status, medication refusals and behavior management, skin breakdown and pressure ulcer prevention, bathing and dining assistance, water temperature monitoring, elopement risk and fall prevention. The facility outlines corrective actions, staff training, policy revisions, and monitoring plans to ensure compliance and prevent recurrence.
Complaint Details
This plan of correction is in response to deficiencies cited during a complaint investigation survey.
Deficiencies (6)
| Description |
|---|
| Failure to properly identify and document Do Not Resuscitate (DNR) status for residents. |
| Inadequate tracking and management of medication refusals and resident behaviors. |
| Insufficient assessment and care planning for residents at risk of skin breakdown and pressure ulcers. |
| Inadequate bathing and dining assistance and failure to address resident refusals appropriately. |
| Failure to maintain safe water temperatures in resident rooms and showers. |
| Inadequate assessment and interventions for residents at risk of elopement and falls. |
Report Facts
Staff CPR certifications: 31
Water temperature range: 116
Water temperature range: 118
Date for substantial compliance: Mar 28, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Royer | Administrator | Administrator who submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Irina Strakhova | Person who added and modified the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 6
Mar 25, 2014
Visit Reason
The inspection was a Partial Extended Survey and Complaint Investigations triggered by multiple complaint investigations.
Findings
The facility failed to perform CPR on a full code resident resulting in immediate jeopardy, failed to provide timely and effective medically related social services for a resident with disruptive behavior, failed to provide adequate treatment for a resident with a diabetic ulcer, failed to provide bathing and timely meal assistance for dependent residents, failed to prevent and treat pressure ulcers properly, and failed to prevent elopement and provide fall prevention interventions for residents at risk.
Complaint Details
The complaint investigations involved failure to perform CPR on a full code resident resulting in immediate jeopardy, failure to provide timely and effective medically related social services for a resident with disruptive behavior, failure to prevent elopement of a cognitively impaired resident, and failure to provide fall prevention interventions for a resident who sustained a fracture.
Severity Breakdown
Immediate Jeopardy: 2
D: 1
G: 2
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to perform CPR for a full code resident resulting in immediate jeopardy. | Immediate Jeopardy |
| Failed to provide timely and effective medically related social services for a resident with disruptive behavior. | D |
| Failed to provide adequate treatment for a resident with a diabetic ulcer including pressure offloading and nutritional supplements. | G |
| Failed to provide bathing twice weekly and timely meal assistance for dependent residents. | E |
| Failed to prevent development of an avoidable pressure ulcer and failed to provide treatment that promoted healing. | G |
| Failed to accurately assess and provide supervision to prevent elopement of a resident placing him/her in immediate jeopardy and failed to provide timely and effective fall prevention interventions for a resident who sustained a fracture. | Immediate Jeopardy |
Report Facts
Resident census: 47
CPR certified nursing staff: 3
Weight loss: 7
Pressure ulcer size: 1.2
Fall risk score: 15
Elopement risk score: 9
Distance to hospital: 5.3
Temperature: 17.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse L | Licensed Nurse | Named in failure to perform CPR finding |
| Licensed nurse M | Licensed Nurse | Named in failure to perform CPR finding |
| Administrative nursing staff D | Administrative Nursing Staff | Named in failure to perform CPR and elopement findings |
| Social service staff H | Social Service Staff | Named in failure to perform CPR and medically related social services findings |
| Administrative staff A | Administrative Staff | Named in failure to perform CPR and elopement findings |
| Licensed nurse K | Licensed Nurse | Named in fall prevention and meal assistance findings |
| Direct care staff U | Direct Care Staff | Named in fall prevention and meal assistance findings |
| Administrative nursing staff G | Administrative Nursing Staff | Named in pressure ulcer treatment findings |
Inspection Report
Life Safety
Deficiencies: 1
Mar 20, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | F |
Report Facts
Effective date for denial of payments: Jun 20, 2014
Provider agreement termination date: Sep 20, 2014
Plan of correction submission timeframe: 10
IDR request timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Royer | Administrator | Facility administrator named in the report |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Follow-Up
Deficiencies: 5
Nov 27, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date, November 27, 2013.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Follow-Up
Deficiencies: 0
Oct 30, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report shows that all previously cited deficiencies identified by regulation numbers were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 5
Oct 30, 2013
Visit Reason
This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited in the facility's inspection report dated 10/30/2013.
Findings
The plan addresses multiple deficiencies including maintenance and repair of facility drains and ceilings, resident safety related to smoking and elopement risk, proper resident weight assessments, infection control practices, and the establishment of a quality assessment and assurance committee to monitor and improve compliance.
Severity Breakdown
E: 1
D: 2
F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to maintain a sanitary and safe environment including repair of drains and ceilings. | E |
| Inadequate assessment and supervision related to resident smoking and elopement risk. | D |
| Incorrect resident weight used for medical orders. | D |
| Infection control deficiencies including improper use of cleaning products and sanitation. | F |
| Failure to maintain an effective quality assessment and assurance committee. | F |
Report Facts
Date of repair: Oct 23, 2013
In-service date: Nov 4, 2013
Quality Assurance meeting date: Nov 8, 2013
Plan of Correction submission date: Nov 12, 2013
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Oct 23, 2013
Visit Reason
The inspection was conducted as a Non-compliance Revisit and Complaint investigations #KS69347, #KS69394, and #KS69737 to assess compliance with housekeeping, maintenance, supervision, drug regimen, infection control, and quality assurance requirements.
Findings
The facility failed to maintain effective housekeeping and maintenance services, failed to provide adequate supervision to prevent accidents for a resident at high risk of elopement, administered unnecessary medications due to inaccurate weight monitoring, failed to follow disinfectant contact time protocols, and lacked an effective Quality Assessment and Assurance (QAA) committee to address identified deficiencies.
Complaint Details
The visit was triggered by complaint investigations #KS69347, #KS69394, and #KS69737 and included a non-compliance revisit.
Severity Breakdown
SS=E: 1
SS=D: 2
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide effective maintenance services resulting in water pooling in a bathtub and water leaks in resident rooms. | SS=E |
| Failed to provide supervision to prevent accidents for a resident with seizures and fall risk who smoked unsupervised on the patio. | SS=D |
| Resident received unnecessary drugs due to inaccurate weight monitoring and failure to verify weight with physician. | SS=D |
| Failed to follow disinfectant contact time for cleaning surfaces and failed to maintain resident's drinking cup in a sanitary manner. | SS=F |
| Failed to maintain an effective Quality Assessment and Assurance committee to identify and correct quality deficiencies including maintenance, supervision, medication monitoring, and infection control. | SS=F |
Report Facts
Census: 49
Resident sample size: 13
Resident #57 elopement risk score: 18
Resident #57 fall risk score: 13
Resident #47 weight measurements: 104
Resident #47 weight measurements: 112
Resident #47 weight measurements: 114
Resident #47 weight measurements: 120
Disinfectant contact time: 3
Disinfectant contact time: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff S | Mentioned in relation to maintenance issue with bathtub drainage. | |
| Administrative staff A | Mentioned regarding knowledge of maintenance issues and QAA committee meetings. | |
| Housekeeping staff Y | Mentioned regarding water pooling in bathtub. | |
| Housekeeping staff AA | Mentioned regarding water removal from bathtub. | |
| Plumbing contractor EE | Mentioned regarding repair of bathtub drain. | |
| Maintenance staff Y | Mentioned regarding unawareness of water leaks in resident's closet. | |
| Administrative nursing staff D | Mentioned regarding maintenance forms, supervision policies, and QAA committee. | |
| Licensed nurse H | Mentioned regarding resident supervision and medication orders. | |
| Direct care staff O | Mentioned regarding resident supervision on patio. | |
| Dietary staff DD | Mentioned regarding physician weight log book. | |
| Housekeeping staff X | Mentioned regarding disinfectant use and cleaning practices. | |
| Housekeeping staff Z | Mentioned regarding disinfectant contact time. |
Inspection Report
Plan of Correction
Deficiencies: 10
Sep 23, 2013
Visit Reason
This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited in a prior inspection report. It outlines corrective actions to address identified deficiencies and ensure compliance with state and federal regulations.
Findings
The Plan of Correction details multiple corrective actions including staff in-services, policy revisions, monitoring procedures, and quality assurance activities to address deficiencies related to abuse/neglect investigations, pressure ulcer prevention, perineal care, elopement risk, behavior monitoring, RN staffing, medication storage and disposal, housekeeping, and quality assessment.
Severity Breakdown
D: 5
G: 1
J: 1
F: 2
E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to investigate and report all allegations of abuse/neglect to the state agency. | D |
| Inadequate assessment and intervention for residents at risk for pressure ulcers. | G |
| Improper perineal care provided to residents with feeding tubes. | D |
| Failure to properly assess and monitor residents at risk for elopement. | J |
| Inadequate monitoring and documentation of resident behaviors and medication effects. | D |
| Failure to provide RN coverage for at least 8 consecutive hours daily. | F |
| Inadequate monitoring of efficacy of psychoactive medication. | D |
| Improper storage and disposal of expired medications. | D |
| Floor mats in poor repair and inadequate housekeeping cleaning procedures. | E |
| Failure to maintain an effective quality assessment and assurance committee. | F |
Report Facts
Date of Plan of Correction completion: Sep 23, 2013
Date of in-service training: Sep 20, 2013
Dates of resident reassessment for elopement risk: Aug 29, 2013
Dates of resident reassessment for elopement risk: Aug 30, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Royer | Administrator | Administrator named as responsible for oversight and submission of Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 5, 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
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date 09/05/2013.
Report Facts
Deficiencies corrected: 13
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 9
Sep 5, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Extended Survey including Complaint Investigations #KS 67317 and #67275 to investigate allegations of neglect and other regulatory compliance issues.
Findings
The facility failed to investigate and report an allegation of neglect for one resident, failed to provide necessary services to prevent pressure ulcers, failed to maintain proper head of bed elevation during tube feeding, failed to provide supervision to prevent elopement placing a resident in immediate jeopardy, failed to maintain safe environment including cleaning and fall mat maintenance, failed to adequately monitor psychotropic medication effects, failed to maintain required RN coverage, failed to monitor drug expiration dates, and failed to maintain an effective Quality Assurance program.
Complaint Details
The complaint investigation was triggered by allegations of neglect and failure to provide adequate care and supervision, including an elopement incident placing a resident in immediate jeopardy.
Severity Breakdown
SS=D: 3
SS=G: 1
SS=J: 1
SS=F: 1
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to investigate or report an allegation of neglect for resident #42. | SS=D |
| Failed to provide necessary services to prevent and treat pressure ulcers for resident #42. | SS=G |
| Failed to maintain head of bed elevated during tube feeding for resident #20. | SS=D |
| Failed to provide supervision to prevent elopement for resident #77, failed to safeguard keypad code, and failed to maintain safe environment in bathing/shower rooms. | SS=J |
| Failed to adequately monitor targeted behaviors for psychotropic medications for resident #19. | SS=D |
| Failed to provide 8 consecutive hours of RN coverage 7 days a week. | SS=F |
| Failed to monitor expiration dates for medications and insulin storage. | — |
| Failed to follow cleaning policy for isolation rooms and failed to maintain cleanable surface on fall mats. | SS=E |
| Failed to maintain an effective Quality Assurance and Assessment Committee that addresses identified quality deficiencies. | — |
Report Facts
Resident census: 51
Sample size: 16
Pressure ulcer wound size: 1.5
Pressure ulcer wound size: 3
Pressure ulcer wound size: 1.2
Pressure ulcer wound size: 0.5
Tube feeding rate: 55
Fall risk score: 6
Distance resident eloped: 5
RN coverage missing days: 22
Expired medication date: 201302
Expired medication date: Mar 31, 2013
Insulin open date: Jul 24, 2013
Fall mats with tears: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Nursing Staff | Named in neglect and elopement findings |
| Staff Q | Direct Care Staff | Named in neglect and resident care findings |
| Staff A | Administrative Nursing Staff | Named in neglect and elopement findings |
| Staff P | Direct Care Staff | Named in elopement and resident behavior findings |
| Staff Z | Housekeeping/Maintenance Staff | Named in isolation room cleaning deficiencies |
| Staff Y | Housekeeping/Maintenance Staff | Named in isolation room cleaning deficiencies |
| Administrative Staff A | Administrator | Named in RN coverage and elopement findings |
| Administrative Nursing Staff D | Administrative Nursing Staff | Named in elopement and behavior monitoring findings |
| Pharmacy Consultant LL | Pharmacy Consultant | Named in psychotropic medication monitoring findings |
Inspection Report
Plan of Correction
Deficiencies: 21
Jul 31, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to achieve compliance with federal Medicare and Medicaid requirements.
Findings
The plan details multiple corrective actions including ensuring residents' access to personal funds, providing privacy during care, investigating falls, updating abuse policies, adjusting bathing schedules, maintaining a sanitary environment, revising care plans, improving pain management, and enhancing infection control and medication management.
Severity Breakdown
E: 8
D: 10
F: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Residents' access to personal funds not ensured. | E |
| Lack of privacy for residents during toileting and transfers. | D |
| Failure to investigate and report falls as required. | D |
| Inadequate policy on abuse, neglect, and exploitation (ANE). | D |
| Bathing schedule not based on resident choice. | E |
| Insufficient ongoing activity program for residents. | D |
| Housekeeping and maintenance services inadequate to maintain sanitary and comfortable environment. | E |
| Care plans not adequately reviewed and revised. | D |
| Resident family/legal representative not consistently involved in care planning. | D |
| Pain management program and documentation inadequate. | D |
| Food intake recording and offering alternatives not consistently done. | D |
| Incontinence care plans and toileting programs not properly implemented. | D |
| Resident environment not free of accident hazards; incident reports incomplete. | E |
| Monitoring of residents' behaviors and medication effectiveness inadequate. | E |
| Improper handling of food by staff. | E |
| Lack of review for specialized services prior to admission. | D |
| Drug regime reviews not adequately performed or documented. | D |
| Expired medication storage and disposal policies not followed. | D |
| Infection control procedures and staff training inadequate. | E |
| Call light system maintenance insufficient. | E |
| Exterior sidewalk cracks and raised areas not repaired. | F |
Report Facts
Date of plan completion: Jul 31, 2013
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 21
Jul 2, 2013
Visit Reason
Health Resurvey and Complaint Investigation #65265 and #654345 conducted to assess compliance with regulatory requirements and investigate complaints.
Findings
The facility was found deficient in multiple areas including management of personal funds, privacy during care, investigation and reporting of falls, abuse prevention policies, resident rights to make choices, activity programming, housekeeping and maintenance, comprehensive care planning, pain management, infection control, medication monitoring, and safety hazards.
Complaint Details
Complaint investigation included allegations related to resident funds access, privacy violations, fall investigations, abuse prevention policies, resident rights, activity programming, environmental safety, care planning, pain management, infection control, medication monitoring, and facility safety hazards.
Severity Breakdown
SS=E: 9
SS=D: 7
: 5
Deficiencies (21)
| Description | Severity |
|---|---|
| Failed to ensure residents had access to petty cash on an ongoing basis. | — |
| Failed to provide privacy for residents during toileting and transfers. | SS=D |
| Failed to investigate and report a fall incident as required. | SS=D |
| Facility's abuse, neglect, mistreatment and misappropriation policy lacked required components and reporting suspicion of a crime. | — |
| Failed to accommodate and document resident choices for bathing schedules and waking times. | SS=E |
| Failed to provide ongoing activity programs to meet resident interests, especially during evenings and weekends. | SS=D |
| Failed to maintain a sanitary and comfortable building; multiple environmental deficiencies noted including rust, dirt, odors, damaged fixtures, and lack of maintenance inspections. | SS=E |
| Failed to develop comprehensive care plans for hospice care, pain management, and psychotropic medication monitoring. | SS=D |
| Failed to invite resident or family to participate in care planning. | SS=D |
| Failed to provide effective pain management and monitor pain medication effectiveness. | SS=D |
| Failed to provide appropriate treatment and services to prevent and heal pressure ulcers. | SS=D |
| Failed to provide appropriate incontinence care and toileting program. | SS=D |
| Failed to maintain a safe environment; loose handrail and unsafe shower drain cover noted. | SS=E |
| Failed to provide adequate supervision and fall prevention interventions after multiple falls. | SS=E |
| Failed to monitor effectiveness of as needed medications and behavioral medications for multiple residents. | SS=E |
| Failed to provide specialized rehabilitative services as required by PASSAR. | — |
| Failed to properly store medications and dispose of expired medications. | — |
| Failed to handle food in a sanitary manner; staff touched food with ungloved hands. | — |
| Failed to utilize infection control precautions including hand hygiene, isolation procedures, and proper storage of oxygen tubing and sharps containers. | SS=E |
| Failed to maintain functioning call light in resident bathroom. | — |
| Failed to provide a safe, functional, sanitary, and comfortable environment; exterior sidewalks had missing concrete. | — |
Report Facts
Residents present: 52
Residents sampled: 22
Fall risk assessment score: 10
Stage 3 pressure ulcer size: 3
Stage 4 pressure ulcer size: 1.8
Medication doses: 5
Medication doses: 650
Medication doses: 0.5
Medication doses: 50
Medication doses: 150
Medication doses: 0.5
Medication doses: 30
Medication doses: 100
Medication doses: 250
Medication doses: 50
Medication doses: 7.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff D | Administrative Nursing Staff | Reported expectations for privacy, fall investigations, pain management, infection control, and medication monitoring. |
| Licensed nurse I | Licensed Nurse | Provided statements on privacy, pain management, and toileting care. |
| Direct care staff Q | Direct Care Staff | Observed and reported on privacy, toileting, and infection control practices. |
| Administrative nursing staff F | Administrative Nursing Staff | Discussed bathing schedules and resident care planning. |
| Maintenance staff X | Maintenance Staff | Acknowledged environmental deficiencies and maintenance responsibilities. |
| Housekeeping staff Y | Housekeeping Staff | Reported cleaning procedures and acknowledged environmental deficiencies. |
| Licensed nurse J | Licensed Nurse | Discussed privacy, pain management, and medication monitoring. |
| Direct care staff P | Direct Care Staff | Described fall incident and toileting assistance. |
| Administrative staff A | Administrative Staff | Discussed abuse policy deficiencies and fall incident investigation. |
| Administrative nursing staff E | Administrative Nursing Staff | Discussed behavior monitoring and infection control. |
| Licensed nurse H | Licensed Nurse | Discussed oxygen tubing storage and pain management. |
Inspection Report
Follow-Up
Deficiencies: 3
Nov 18, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report shows that deficiencies previously cited under regulations 483.25(l), 483.60(a),(b), and 483.60(b),(d),(e) were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 483.25(l) |
| Deficiency under regulation 483.60(a),(b) |
| Deficiency under regulation 483.60(b),(d),(e) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Nov 18, 2012
Visit Reason
This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited in a complaint investigation.
Findings
The plan addresses deficiencies related to pain assessment and documentation, proper application and documentation of medication patches, and ensuring medication carts are securely locked when not in view of nursing staff.
Complaint Details
This plan of correction is related to a complaint investigation identified as Westwood Manor 101912 Complaint.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assess resident's pain level prior to administration of pain medication and follow up on effectiveness. | D |
| Failure to appropriately apply patches and document the location of the patches on the Medication Administration Record (MAR). | D |
| Failure to ensure medication carts are securely locked at all times when out of nurse's view. | E |
Report Facts
Complete Date: Nov 18, 2012
In-service training date: Nov 2, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Carla Royer | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added the Plan of Correction | |
| Mary Jane Kennedy | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 4
Oct 19, 2012
Visit Reason
Complaint Investigation #59727, 59799, 60551, 60928 was conducted to assess medication administration and pharmaceutical services compliance at the facility.
Findings
The facility failed to monitor the effectiveness of pain medications for multiple residents, failed to properly manage medication patches including removal and documentation of placement, and failed to keep medication carts locked when unattended.
Complaint Details
The investigation was triggered by complaints #59727, 59799, 60551, and 60928 regarding medication administration and pharmaceutical service deficiencies.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to monitor effectiveness of pain medications for residents #3, #4, and #5. | SS=D |
| Failure to follow facility policy for administration of medications including improper management of Exelon patches for resident #1. | SS=D |
| Failure to have a system in place for proper placement and rotation of medication patches. | SS=D |
| Failure to keep medication carts locked when unattended. | SS=E |
Report Facts
Census: 46
Sample size: 5
Medication administrations: 17
Medication administrations: 15
Medication administrations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Licensed Nurse | Stated expectations regarding pain medication assessment and medication cart security. |
| Licensed nurse C | Licensed Nurse | Provided statements on pain medication assessment, patch placement documentation, and medication cart security. |
| Direct care staff E | Direct Care Staff | Commented on medication patch removal and documentation, and medication cart security. |
Inspection Report
Plan of Correction
Deficiencies: 5
May 18, 2012
Visit Reason
This document is a Plan of Correction submitted by Westwood Manor in response to cited deficiencies found during a regulatory inspection.
Findings
The plan addresses multiple deficiencies including incomplete perineal care, improper food preparation and handling, maintenance issues with stand-up lifts, and the need for quality assessment and assurance improvements. The facility outlines corrective actions such as staff training, procedural changes, increased monitoring, and implementation of new forms and vendor consultations.
Severity Breakdown
D: 1
F371: 1
F456: 1
F520: 1
S815: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Incomplete perineal care requiring staff training and competency testing. | D |
| Improper food preparation, storage, and distribution practices including disposal of contaminated items and staff training on hygiene and food temperature monitoring. | F371 |
| Maintenance issues with stand-up lifts including torn upholstery and increased inspection frequency. | F456 |
| Lack of effective quality assessment and assurance committee activities to monitor interventions and training. | F520 |
| Failure to ensure new employees receive TB skin tests prior to starting work. | S815 |
Report Facts
Date of completion: May 18, 2012
Inspection frequency: 4
Top residents monitored quarterly: 3
QAA meeting frequency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Valarie Harris | Received training on perineal care | |
| Stacy Hughes | Received training on perineal care | |
| Charlotte Bozeman | Received training on perineal care | |
| Nona | Received training on perineal care |
Inspection Report
Re-Inspection
Deficiencies: 1
May 18, 2012
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected at the facility.
Findings
The revisit confirmed that the previously identified deficiency with ID prefix S0815 and regulation number 28-39-161 was corrected as of 05/18/2012.
Deficiencies (1)
| Description |
|---|
| Previously reported deficiency with ID prefix S0815 and regulation number 28-39-161 |
Report Facts
Deficiencies corrected: 1
Inspection Report
Follow-Up
Deficiencies: 4
May 18, 2012
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report documents that all previously reported deficiencies identified by their regulation numbers and prefix codes were corrected by the revisit date of 05/18/2012.
Deficiencies (4)
| Description |
|---|
| Deficiency identified under regulation 483.25(d) with prefix F0315 |
| Deficiency identified under regulation 483.35(i) with prefix F0371 |
| Deficiency identified under regulation 483.70(c)(2) with prefix F0456 |
| Deficiency identified under regulation 483.75(o)(1) with prefix F0520 |
Report Facts
Deficiencies corrected: 4
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
May 10, 2012
Visit Reason
The inspection was conducted as a Non-Compliant Revisit and Complaint Investigations #KS00057001, #KS00057051, #KS00056892 to assess compliance with infection control regulations.
Findings
The facility failed to have evidence of Tuberculosis (TB) skin testing for five employees who began employment between March and April 2012. The facility did not maintain a system to ensure new employees received TB skin tests upon hiring.
Complaint Details
The visit was triggered by complaint investigations #KS00057001, #KS00057051, and #KS00056892. The findings confirmed non-compliance related to TB skin testing for new employees.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have evidence of Tuberculosis (TB) skin testing for five employees. | SS=E |
Report Facts
Census: 52
Number of employees without TB testing evidence: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse A | Licensed Nurse | Interviewed and provided information about TB testing procedures and responsibility. |
| Licensed nurse B | Licensed Nurse | Employee who began employment on 4/11/12 and lacked TB skin test evidence. |
| Direct care staff D | Employee who began employment on 4/10/12 and lacked TB skin test evidence. | |
| Direct care staff E | Employee who began employment on 3/27/12 and lacked TB skin test evidence. | |
| Direct care staff F | Employee who began employment on 3/5/12 and lacked TB skin test evidence. | |
| Direct care staff G | Employee who began employment on 3/19/12 and lacked TB skin test evidence. |
Inspection Report
Plan of Correction
Deficiencies: 12
Apr 3, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey inspection.
Findings
The facility has developed and implemented a facility-wide system to assure correction and continued compliance with federal Medicare and Medicaid requirements. Specific corrective actions include revisions to care plans for multiple residents, staff in-service trainings, monitoring by the Director of Nursing and Quality Assurance Committee, and increased oversight of medication, nutrition, dental care, infection control, and equipment maintenance.
Severity Breakdown
D: 7
G: 1
E: 1
F: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Care plan revisions to address dental needs for resident #16 | D |
| Care plan revisions to address pain relief methods for resident #66 | D |
| Nursing staff in-serviced on documentation when medication is held for resident #66 | D |
| Physician order discontinuing hand cone/roll for resident #33 and staff education on obtaining orders | D |
| Nursing staff re-inserviced on documentation of health shakes and nutrition interventions for residents #13 and #14 | G |
| Care plans completed for black box warnings and medication side effects monitoring for multiple residents | E |
| Dietary and food handling procedures improved including cleaning and staff in-service | F |
| Care plan revisions and staff in-service on dental care and pain assessment for resident #16 | D |
| In-service on accu checks and insulin documentation for resident #1 and medication administration documentation | D |
| Monitoring of side effects medication care plans and monthly drug regime review | D |
| Housekeeping in-serviced on cleaning techniques and infection control monitoring | F |
| Wheelchair cleaning and maintenance procedures implemented and monitored | D |
Report Facts
Date of staff in-service: Mar 21, 2012
Date of dietary cleaning and in-service: Mar 19, 2012
Date of wheelchair cleaning in-service: Mar 19, 2012
Date of cleaning schedule implementation: Apr 3, 2012
Resident weight stability duration: 5
Percentage of medical records audited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Royer | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 9
Mar 14, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to develop and revise comprehensive care plans, failure to provide dental services, failure to provide alternative pain management, failure to maintain nutrition status, failure to monitor and justify psychotropic medication use, failure to maintain sanitary food preparation areas, failure to maintain equipment in safe condition, and failure to prevent infection spread.
Severity Breakdown
SS=D: 6
SS=G: 1
SS=E: 1
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to develop a comprehensive care plan for dental needs for resident #16. | SS=D |
| Failure to revise care plan for pain management for resident #66 during medication hold. | SS=D |
| Failure to provide alternative pain relief methods for resident #66 while pain medications were held. | SS=D |
| Failure to provide a hand cone/splint as ordered for resident #33 with limited range of motion. | SS=D |
| Failure to implement effective interventions to prevent weight loss for residents #13 and #4. | SS=G |
| Failure to ensure drug regimen free from unnecessary drugs; duplication of therapy and lack of monitoring for residents #48, #64, #13, #60, and #43. | SS=E |
| Failure to provide routine and emergency dental services to resident #16 as needed. | SS=D |
| Failure to maintain sanitary food preparation area, including failure to wash hands, improper storage of food, and inadequate dishwasher sanitation. | SS=F |
| Failure to maintain wheelchairs in safe operating condition for residents #5 and #32. | SS=D |
Report Facts
Resident census: 51
Resident sample size: 21
Weight loss: 21
Fosomax dose: 70
Insulin units: 3
Insulin units: 8
Dishwasher rinse temperature: 142.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff V | Housekeeping Staff | Observed cleaning contact isolation room without changing gloves and improper handling of contaminated items |
| Staff T | Dietary Staff | Observed preparing food with exposed facial hair and acknowledged dishwasher temperature issues |
| Staff M | Direct Care Staff | Interviewed regarding resident pain and medication administration |
| Staff D | Administrative Licensed Nursing Staff | Interviewed regarding pain management, medication monitoring, and infection control |
| Staff H | Licensed Nursing Staff | Interviewed regarding resident pain and medication administration |
| Staff J | Licensed Nursing Staff | Acknowledged wheelchair maintenance issues and medication administration documentation problems |
| Consultant Staff X | Consultant Pharmacist | Interviewed regarding medication justification and black box warnings |
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