Inspection Reports for Tanglewood Nursing and Rehabilitation

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.

All previously cited deficiencies listed with their regulation numbers were marked as corrected and completed as of 02/24/2017.

This report documents a revisit inspection to verify that previously reported deficiencies at Tanglewood Nursing & Rehabilitation have been corrected.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was conducted as a Health Resurvey and Complaint Investigation related to ventilation and air conditioning system deficiencies.

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.

The visit was triggered by complaints #105627, 104565, and 106096 as part of a Health Resurvey and Complaint Investigation.

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.

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.

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.

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.

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.

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.

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.

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.

Health Resurvey and Complaint Investigation #100667 and #98363 conducted to assess compliance with regulatory requirements.

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.

The inspection was triggered by complaints #100667 and #98363, focusing on background checks, resident safety, medication management, and food sanitation.

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.

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.

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.

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.

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.

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.

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.

All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.

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.

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.

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.

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.

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.

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.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey conducted on 05/18/2016.

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.

This Plan of Correction is related to deficiencies cited during a complaint investigation survey conducted on 05/18/2016.

The inspection was a partial extended complaint survey investigation triggered by complaints #100347 and #100454 regarding pressure ulcer prevention and care.

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.

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.

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.

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.

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.

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.

Health Resurvey and Complaint Investigation #96582 conducted to assess compliance with regulatory requirements.

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 Investigation #96582 triggered the survey.

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.

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.

This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as of the revisit date.

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.

This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.

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.

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.

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.

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.

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.

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.

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.

The inspection was triggered by a complaint investigation #KS00089532 focusing on multiple areas of resident care and facility compliance.

This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected.

The report shows that all previously cited deficiencies were corrected by 06/26/2015 as documented by the correction completion dates for each deficiency.

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.

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.

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.

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.

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.

The inspection was conducted based on complaint investigations regarding medication administration, resident falls, pressure ulcers, and abuse allegations.

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.

The investigation was triggered by complaints related to medication errors, resident falls, pressure ulcers, and abuse allegations.

This post-certification revisit was conducted to verify that previously cited deficiencies identified in an earlier survey had been corrected.

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.

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.

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.

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.

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.

The enforcement action was based in part on deficiencies cited during this survey and a prior Complaint investigation conducted on April 21, 2014.

Routine health resurvey and inspection of Tanglewood Nursing & Rehabilitation to assess compliance with federal regulations including resident care, medication management, safety, and facility environment.

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.

This is a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-03-24.

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.

This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited in a complaint investigation inspection.

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.

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.

This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-03-25.

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.

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.

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.

The visit was triggered by complaints and a non-compliance revisit related to pressure sores and urinary incontinence issues.

This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited during a complaint investigation survey.

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.

This plan of correction is in response to deficiencies cited during a complaint investigation survey.

The inspection was a Partial Extended Survey and Complaint Investigations triggered by multiple complaint investigations.

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.

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.

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.

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.

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.

All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date, November 27, 2013.

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.

The revisit report shows that all previously cited deficiencies identified by regulation numbers were corrected as of the revisit date.

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.

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.

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.

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.

The visit was triggered by complaint investigations #KS69347, #KS69394, and #KS69737 and included a non-compliance revisit.

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.

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.

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.

All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date 09/05/2013.

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.

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.

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.

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.

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.

Health Resurvey and Complaint Investigation #65265 and #654345 conducted to assess compliance with regulatory requirements and investigate complaints.

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 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.

This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.

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.

This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited in a complaint investigation.

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.

This plan of correction is related to a complaint investigation identified as Westwood Manor 101912 Complaint.

Complaint Investigation #59727, 59799, 60551, 60928 was conducted to assess medication administration and pharmaceutical services compliance at the facility.

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.

The investigation was triggered by complaints #59727, 59799, 60551, and 60928 regarding medication administration and pharmaceutical service deficiencies.

This document is a Plan of Correction submitted by Westwood Manor in response to cited deficiencies found during a regulatory inspection.

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.

This report documents a revisit inspection to verify that previously reported deficiencies have been corrected at the facility.

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.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.

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.

The inspection was conducted as a Non-Compliant Revisit and Complaint Investigations #KS00057001, #KS00057051, #KS00056892 to assess compliance with infection control regulations.

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.

The visit was triggered by complaint investigations #KS00057001, #KS00057051, and #KS00056892. The findings confirmed non-compliance related to TB skin testing for new employees.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey inspection.

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.

The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.

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.