Inspection Reports for
Tanglewood Nursing and Rehabilitation
5015 SW 28TH STREET, TOPEKA, KS, 66614-2319
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
41.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
587% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
94% occupied
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 46
Capacity: 49
Deficiencies: 23
Date: Oct 17, 2024
Visit Reason
Routine inspection of Tanglewood Nursing & Rehabilitation to assess compliance with healthcare regulations and resident care standards.
Findings
The facility failed to maintain safe and comfortable temperature levels, ensure proper documentation and communication for resident transfers, provide consistent bathing and pressure ulcer care, maintain adequate staffing, and ensure proper medication administration and infection control practices.
Deficiencies (23)
F 0584: The facility failed to maintain safe and comfortable temperature levels, with temperatures as low as 46.9°F in resident rooms, causing physical discomfort and placing residents in immediate jeopardy.
F 0622: The facility failed to document Resident 7's transfer or discharge and failed to communicate appropriate information to the receiving healthcare institution, risking delayed treatment and impaired continuity of care.
F 0623: The facility failed to provide timely written notification of transfer to residents 33 and 44 or their representatives, impairing resident rights.
F 0641: The facility failed to accurately assess and document Resident 30's terminal condition on the Minimum Data Set assessment, risking an inaccurate care plan and unmet care needs.
F 0677: The facility failed to provide consistent bathing for Residents 17, 24, 44, and 45, placing them at risk for poor hygiene and related complications.
F 0686: The facility failed to provide appropriate pressure ulcer care for Residents 7 and 43, including delayed treatment and lack of nutritional support and pressure-reducing devices, risking delayed healing and increased pressure ulcer risk.
F 0689: The facility failed to ensure adequate supervision and fall prevention for Residents 17 and 45, resulting in a fall with a femoral fracture and placing residents at risk for accidents and injuries.
F 0690: The facility failed to provide sanitary indwelling urinary catheter care for Resident 45, including improper handling of catheter drainage bag, increasing risk for urinary tract infections.
F 0693: The facility failed to ensure Resident 7 had physician orders for gastrostomy tube flushes before and after bolus feedings, risking complications including dehydration and fluid overload.
F 0695: The facility failed to ensure Resident 30 had physician orders for oxygen therapy and failed to store respiratory equipment in a sanitary manner; also failed to ensure Resident 45's respiratory equipment was changed and stored properly, risking respiratory infections.
F 0697: The facility failed to have Resident 19's physician-ordered Norco pain medication available for administration as scheduled, resulting in missed doses and unmanaged pain.
F 0698: The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding Resident 19's dialysis care and health status, risking complications related to dialysis.
F 0727: The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week, placing all residents at risk of decreased quality of care.
F 0742: The facility failed to provide immediate physician involvement and supportive mental health services for Resident 30 after statements of self-harm, risking unmet mental health care needs.
F 0755: The facility failed to ensure accurate reconciliation of controlled medications, with 44 missed opportunities for staff signatures verifying narcotic counts, risking medication misappropriation and diversion.
F 0756: The facility failed to ensure the Consultant Pharmacist identified and reported that staff failed to administer insulin as ordered to Resident 44, risking physical decline and ineffective medication regimen.
F 0757: The facility failed to administer Resident 19's PRN hydralazine as ordered when systolic blood pressure was greater than 160 mmHg, risking medication-related complications.
F 0801: The facility failed to ensure the director of food and nutrition services had the required certified dietary manager qualifications, risking unmet dietary and nutritional needs.
F 0804: The facility failed to hold food at a safe temperature for Resident 36's room tray, placing the resident at risk for foodborne illness.
F 0805: The facility failed to provide Resident 37 with thickened liquids per physician orders, placing the resident at risk of aspiration.
F 0812: The facility failed to store food items in accordance with professional standards, including unlabeled and unsealed foods, risking foodborne illness and cross-contamination.
F 0851: The facility failed to submit accurate Payroll-Based Journal staffing data, incorrectly reporting no licensed nurse coverage on multiple days, risking unidentified and ongoing inadequate staffing.
F 0880: The facility failed to implement Enhanced Barrier Precautions for residents with indwelling devices and wounds, failed to use gloves during eye drop administration, and failed to store respiratory equipment properly, placing residents at risk for infections.
Report Facts
Residents affected by temperature issue: 46
Days without RN 8-hour coverage: 58
Missed narcotic reconciliation signatures: 44
Missed PRN hydralazine administrations: 47
Days with no licensed nurse coverage reported in PBJ: 8
Inspection Report
Routine
Census: 46
Capacity: 49
Deficiencies: 24
Date: Oct 17, 2024
Visit Reason
Routine inspection of Tanglewood Nursing & Rehabilitation to assess compliance with healthcare regulations and resident care standards.
Findings
The facility failed to maintain safe and comfortable temperature levels, ensure proper documentation and communication for resident transfers, provide consistent bathing and pressure ulcer care, maintain adequate staffing, ensure proper medication administration, and uphold infection control standards. Multiple residents experienced discomfort, unmet care needs, and risks related to these deficiencies.
Deficiencies (24)
F 0584: The facility failed to maintain safe and comfortable temperature levels, with temperatures as low as 46.9°F in resident areas, causing physical discomfort and immediate jeopardy to residents.
F 0622: The facility failed to document Resident 7's transfer or discharge and failed to communicate appropriate information to the receiving healthcare provider, risking delayed treatment and impaired continuity of care.
F 0623: The facility failed to provide timely written notification of transfer or discharge to residents 33 and 44 or their representatives, risking impaired rights.
F 0641: The facility failed to accurately assess and document Resident 30's terminal condition on the Minimum Data Set assessment, risking an inaccurate care plan and unmet care needs.
F 0677: The facility failed to provide consistent bathing for residents 17, 24, 44, and 45, placing them at risk for poor hygiene and related complications.
F 0686: The facility failed to provide appropriate pressure ulcer care and nutritional support for residents 7 and 43, risking delayed healing and increased risk for pressure ulcers.
F 0689: The facility failed to ensure fall prevention interventions for Resident 45, resulting in a fall with a femoral fracture and placing the resident at risk for future falls and injuries.
F 0690: The facility failed to provide sanitary indwelling urinary catheter care for Resident 45, risking urinary tract infections and catheter-related complications.
F 0693: The facility failed to ensure Resident 7 had physician orders for G-tube flushes before and after bolus feedings, risking complications including dehydration and fluid overload.
F 0695: The facility failed to ensure Resident 30 had physician orders for oxygen therapy and failed to store respiratory equipment in a sanitary manner, risking respiratory infections and complications.
F 0697: The facility failed to ensure Resident 19 had physician-ordered Norco pain medication available for administration as scheduled, resulting in missed doses and unmanaged pain.
F 0698: The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding Resident 19's dialysis care and health status, risking complications related to dialysis.
F 0727: The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week, placing all residents at risk of decreased quality of care.
F 0742: The facility failed to provide appropriate treatment and services to Resident 30 after statements of self-harm, including failure to notify the physician and provide monitoring, risking unmet mental health care needs.
F 0755: The facility failed to ensure accurate reconciliation of controlled medications, with 44 missed opportunities for staff signatures verifying narcotic counts, risking medication misappropriation and diversion.
F 0756: The facility failed to ensure the Consultant Pharmacist identified and reported that staff failed to administer insulin to Resident 44 as ordered, risking physical decline and ineffective medication regimen.
F 0757: The facility failed to administer Resident 19's PRN hydralazine as ordered when systolic blood pressure was greater than 160 mmHg, risking medication-related complications.
F 0801: The facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager, risking unmet dietary and nutritional needs.
F 0804: The facility failed to hold food at a safe temperature for Resident 36's room tray, placing the resident at risk for foodborne illness.
F 0805: The facility failed to provide Resident 37 with thickened liquids per physician orders, placing the resident at risk of aspiration.
F 0812: The facility failed to store food items in accordance with professional standards, risking foodborne illness and cross-contamination.
F 0851: The facility failed to submit accurate Payroll-Based Journal staffing data, misreporting licensed nurse coverage, risking unidentified and ongoing inadequate staffing.
F 0880: The facility failed to implement Enhanced Barrier Precautions for residents with indwelling devices and wounds, failed to use gloves during eye drop administration, and failed to store respiratory equipment properly, placing residents at risk for infections.
F 0908: The facility failed to ensure kitchen equipment including a stand-up freezer and plate warmer were in safe operating condition.
Report Facts
Residents affected by temperature issue: 46
Residents affected by transfer documentation issue: 49
Days without RN 8-hour coverage: 58
Missed narcotic reconciliation signatures: 44
Missed PRN hydralazine doses: 47
Temperature of cold food: 97.7
Temperature of cream of wheat: 139
Pressure ulcer wound measurements: 4.1
Pressure ulcer wound measurements: 6.2
Pressure ulcer wound measurements: 0.1
Dates with no licensed nurse coverage: 8
Days with no RN 8-hour coverage: 58
Missed insulin administrations: 6
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Jun 17, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify and obtain physician involvement for a resident's multiple medication refusals, which led to a seizure and subsequent death.
Complaint Details
The investigation was triggered by a complaint regarding the facility's failure to notify and obtain physician involvement for Resident 1's multiple refusals of seizure medication. The complaint was substantiated as the resident experienced a seizure requiring emergency medical services and was later admitted to the hospital where he died.
Findings
The facility failed to ensure Resident 1 received appropriate care consistent with standards of practice by not notifying the physician about multiple refusals of seizure medication. This failure resulted in a seizure requiring emergency intervention and hospitalization, ultimately leading to the resident's death.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences by not notifying the physician of Resident 1's repeated refusals of seizure medication, leading to a seizure and emergency hospitalization.
Report Facts
Resident census: 43
Inspection Report
Routine
Census: 44
Deficiencies: 17
Date: Apr 18, 2023
Visit Reason
Routine inspection of Tanglewood Nursing & Rehabilitation to assess compliance with regulatory requirements and resident care standards.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, honor resident preferences, protect resident privacy, follow up on grievances, report and investigate incidents, revise care plans, provide adequate personal care, ensure RN coverage, reconcile narcotics, monitor blood sugars, and enforce infection control policies.
Deficiencies (17)
F 0550: The facility failed to promote care in a manner to maintain and enhance dignity and respect for Resident 18, who was unnecessarily exposed, placing the resident at risk for undignified care and services.
F 0561: The facility failed to honor Resident 8's preference to receive two showers a week, placing the resident at risk for decreased self-determination and impaired psychosocial well-being.
F 0583: The facility failed to keep Resident 23's protected health information private on a medication cart laptop screen visible to the public, placing the resident at risk for impaired privacy.
F 0585: The facility failed to follow-up or resolve resident council grievances regarding bathing, placing residents at risk for unresolved concerns and decreased quality of life.
F 0609: The facility failed to report a resident-to-resident altercation between Residents 22 and 29 to the state agency and failed to investigate the incident, placing residents at risk for further injury and unidentified abuse.
F 0610: The facility failed to investigate a fall of Resident 17 during transport to dialysis and failed to investigate a resident-to-resident altercation, placing residents at risk for further injury and mistreatment.
F 0657: The facility failed to revise Resident 26's care plan to reflect preferences and changes related to edema treatment and leg elevation, placing the resident at risk for inappropriate care and unmet needs.
F 0677: The facility failed to provide adequate assistance for Resident 2 with personal hygiene, grooming, and cleaning of eyeglasses, placing the resident at risk for poor hygiene and undignified quality of life.
F 0677: The facility failed to provide consistent bathing services as care planned for Residents 27, 29, 2, and 22, placing residents at risk for poor hygiene.
F 0677: The facility failed to shave Resident 22 during ADL care and showers, placing the resident at risk for unmet grooming and hygiene needs.
F 0684: The facility failed to elevate Resident 26's legs per standards of practice for dependent edema treatment, placing the resident at risk for complications related to edema.
F 0689: The facility failed to ensure Resident 17 was properly secured during transport and failed to investigate a fall related to transport, placing the resident at risk for further falls and injury.
F 0689: The facility failed to identify and investigate the occurrence related to Resident 8's fractured left arm, placing the resident at risk for ongoing falls and injuries.
F 0727: The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week, placing residents at risk of lack of assessments and inappropriate care.
F 0755: The facility failed to ensure consistent reconciliation of narcotic medications between shifts, placing residents at risk for misappropriation and/or drug diversion.
F 0757: The facility failed to obtain physician ordered blood sugar checks for Resident 17 receiving insulin, placing the resident at risk for complications related to high or low blood sugars.
F 0880: The facility failed to ensure vendors wore masks during high county COVID transmission rates, placing residents at risk for COVID infection.
Report Facts
Residents affected: 44
Sample size: 14
Missing narcotic reconciliation signatures: 7
RN coverage missing days: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified multiple findings including dignity failure, privacy breach, grievance follow-up failure, resident altercation reporting failure, narcotic reconciliation, and infection control |
| Certified Nurse Aide P | Certified Nurse Aide | Observed resident dignity failure and edema assessment |
| Certified Nurse Aide OO | Certified Nurse Aide | Reported bathing schedule issues and resident cooperation |
| Licensed Nurse G | Licensed Nurse | Verified narcotic reconciliation and bathing documentation |
| Administrative Staff A | Administrative Staff | Discussed RN coverage and incident reporting |
| Certified Nurse Aide M | Certified Nurse Aide | Verified personal hygiene care needs for Resident 2 |
| Certified Nurse Aide Q | Certified Nurse Aide | Verified personal hygiene care needs for Resident 2 |
| Certified Nurse Aide PP | Certified Nurse Aide | Observed fall incident during transport |
Inspection Report
Routine
Census: 45
Deficiencies: 5
Date: Dec 8, 2021
Visit Reason
Routine inspection of Tanglewood Nursing & Rehabilitation to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility failed to document a discharge recapitulation for one resident, failed to ensure bathing was provided for eight residents requiring assistance, failed to maintain a safe environment leading to a resident fall, failed to retain dialysis communication sheets for one resident, and failed to ensure sanitary food storage and equipment cleaning.
Deficiencies (5)
F0661: The facility failed to document a recapitulation of the facility stay upon discharge for Resident 45, risking impaired continuum of care.
F0677: The facility failed to ensure bathing was provided as scheduled for eight residents requiring extensive assistance, risking skin breakdown and impaired psychosocial wellbeing.
F0689: The facility failed to assess and remove hazards in a resident's environment, resulting in a fall due to slipping on urine, increasing risk of injury.
F0698: The facility failed to retain dialysis communication sheets for Resident 40, risking unwarranted physical complications related to dialysis.
F0812: The facility failed to ensure sanitary food storage and routine cleaning of the ice machine, placing residents at risk for foodborne illnesses.
Report Facts
Residents reviewed: 14
Residents requiring bathing assistance: 8
Bathing refusals or missed baths: 20
Dates with incomplete dialysis communication forms: 4
Dates with missing dialysis communication forms: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in findings related to discharge documentation, bathing procedures, and dialysis communication |
| Administrative Nurse D | Administrative Nurse | Named in findings related to discharge process, bathing schedule, and dialysis communication |
| Certified Nurse Aide M | Certified Nurse Aide | Named in findings related to bathing assistance and dialysis preparation |
| Certified Nurse Aide D | Certified Nurse Aide | Named in findings related to restroom cleaning and fall hazard |
| Dietary Staff BB | Dietary Staff | Named in findings related to food storage and ice machine cleaning |
| Dietary Staff DD | Dietary Staff | Named in findings related to ice machine cleaning and food safety |
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 deficiencies previously cited were marked as corrected with completion dates of 02/24/2017. No uncorrected deficiencies were noted at the time of this revisit.
Report Facts
Deficiencies corrected: 8
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 18, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 26-40-305 (c)(1)(2) was corrected as of 02/24/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 26-40-305 (c)(1)(2) deficiency was corrected as of 02/24/2017.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Feb 24, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a 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, comprehensive assessments, medication administration for dialysis patients, food safety, infection control, and facility maintenance. Corrective actions include staff education, audits, and procedural changes to ensure compliance.
Deficiencies (9)
F156 Notice of Rights, Rules, Services, and Charges: Resident #21 no longer resides in the facility. Additional wording will be added to the Notice of Medicare Notice of Non Coverage form to clarify therapy service payment options.
F159 Facility Management of Personal Funds: Residents with trust funds were educated on access procedures. Funds placed in a lock box for after-hours access and staff educated on proper fund management.
F160 Conveyance of Personal Funds Upon Death: Procedures established to convey funds within 20 days after discharge, eviction, or death. Staff educated on proper conveyance procedures.
F272 Comprehensive Assessments: MDS and CAA updates completed for residents #17, #27, and #60. Staff educated on proper completion and audits implemented.
F278 Assessment Accuracy/Coordination/Certified: MDS corrected for residents #17 and #60 to reflect current status. Staff education and audits planned to ensure accuracy.
F309 Provide Care/Services for Highest Well Being: Medication regimens for dialysis patients reviewed and staff educated on medication refusal and scheduling. Audits to ensure compliance implemented.
F371 Food Procure, Store/Prepare/Serve – Sanitary: Expired food items disposed. Dietary staff educated on labeling and expiration checks. Audits and monitoring of food safety practices established.
F441 Infection Control Prevent Spread, Linens: Droplet isolation ended for residents #48 and #46 with proper room cleaning. Staff educated on cleaning techniques and hand hygiene. Audits scheduled.
S1354 Heating, Ventilation and A.C.: Exhaust fan in beauty shop repaired and added to preventive maintenance program with monthly checks.
Report Facts
Deficiencies cited: 9
Audit frequency: 4
Resident trust fund shortfall: 200
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Patterson | Administrator | Administrator submitting the plan of correction and responsible for oversight |
Inspection Report
Enforcement
Deficiencies: 0
Date: Feb 23, 2017
Visit Reason
A Health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs. The survey was part of a licensure and certification process with no opportunity to correct deficiencies before remedies are imposed.
Findings
The survey found serious deficiencies at a level of no harm with potential for more than minimal harm, not immediate jeopardy. Based on these deficiencies and the facility's history of noncompliance on a prior Life Safety Code survey, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Report Facts
Denial of payment effective date: Mar 5, 2017
Noncompliance identification date: Feb 23, 2017
Noncompliance identification date: Feb 13, 2017
Termination recommendation date: Aug 13, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Named as contact and signatory related to enforcement and survey findings |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Feb 13, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for multiple complaint numbers (#105627, 104565, and 106096).
Complaint Details
The visit was triggered by a complaint investigation involving citations #105627, 104565, and 106096. The complaint was substantiated by the finding that the facility failed to maintain an exhaust fan in the beauty shop.
Findings
The facility failed to maintain an exhaust fan in the beauty shop to eliminate fumes. The beauty shop lacked an exhaust fan, and the facility did not provide a policy regarding the exhaust fan as requested.
Deficiencies (1)
26-40-305 (c)(1)(2) Heating, Ventilation and A.C. The facility failed to maintain an exhaust fan in the beauty shop to eliminate fumes, violating ventilation requirements.
Report Facts
Resident census: 44
Inspection Report
Life Safety
Deficiencies: 0
Date: 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 an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit a plan of correction within ten calendar days.
Report Facts
Effective date for discretionary denial of payments: 2017.0305
Provider agreement termination date: 2017.0813
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report as Licensure Certification & Enforcement Manager. |
| William Patterson | Administrator | Named as facility administrator. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 6, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the facility's plan of correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.25(h), 483.25(l), 483.35(i), 483.60(c), and 483.60(b), (d), (e) were corrected as of 08/18/2016.
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Aug 18, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The plan addresses multiple deficiencies including employee background checks, assist bar safety, medication regimen issues, sanitary food preparation, and proper drug storage. The facility implemented audits, staff education, and monitoring systems to ensure compliance and correction of cited deficiencies.
Deficiencies (6)
F225: A background check was completed on Nurse H and all current employees. The facility will monitor and ensure background checks are completed before scheduling new hires.
F323: Assist bars for residents were replaced with FDA-compliant bars. Physical Restraint Evaluations will be conducted prior to assist bar use and monitored quarterly.
F329: The physician was notified of resident #58's blood pressure results outside ordered parameters. Staff were educated on timely physician notification and audits will monitor compliance.
F371: Dietary staff deep cleaned the kitchen and implemented a weekly cleaning schedule. Staff were trained on proper hair net use and compliance will be monitored with audits.
F428: Resident #58 was assessed with no adverse reactions and physician notified of abnormal blood pressure. Monthly pharmacy reports and daily audits will ensure timely review and notification.
F431: Medication carts were audited and expired or undated eye drops discarded. Staff were trained on proper medication storage and dating. Audits will continue regularly.
Report Facts
Deficiencies cited: 6
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 6
Date: Aug 9, 2016
Visit Reason
Health Resurvey and Complaint Investigation #100667 and #98363 conducted to assess compliance with regulatory requirements.
Complaint Details
The visit was triggered by complaints #100667 and #98363 involving background checks, resident safety, medication monitoring, and sanitary conditions.
Findings
The facility failed to complete a criminal background check timely for a licensed nurse, ensure resident safety from accident hazards related to bed rails for five residents, maintain sanitary food preparation and serving conditions, and properly monitor and report abnormal blood pressure readings for one resident. Additionally, expired medications were found in medication carts.
Deficiencies (6)
F225: Facility failed to complete a criminal background check within two days of employment for one licensed nurse who provided resident care.
F323: Facility failed to ensure five residents were free from accident hazards related to bed rails with gaps exceeding FDA recommended measurements, risking entrapment.
F329: Facility failed to identify and notify the physician of resident #58's abnormal blood pressure levels as ordered.
F371: Facility failed to prepare and serve food in a sanitary manner, including dietary staff not properly wearing hairnets and presence of houseflies in food preparation areas.
F428: Consultant pharmacist failed to identify and report lack of physician notification for resident #58's abnormal blood pressure levels as ordered.
F431: Facility failed to identify and remove outdated and expired medications in medication carts affecting seven residents.
Report Facts
Resident census: 36
Sample size: 14
Blood pressure notifications missed: 14
Expired eye medications: 8
Residents affected by expired medications: 7
Bed rail gap measurements: 6.5
Inspection Report
Enforcement
Deficiencies: 0
Date: Aug 9, 2016
Visit Reason
The 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.
Report Facts
Denial of Payment Effective Date: Nov 9, 2016
Termination Recommendation Date: Feb 9, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed letter as the manager responsible for the survey and enforcement. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 11, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected and to confirm the date such corrective action was accomplished.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.25(c) and 483.75(o)(1) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 483.25(c) deficiency was corrected as of 07/11/2016.
Regulation 483.75(o)(1) deficiency was corrected as of 07/11/2016.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Jul 11, 2016
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit dates indicated in the report.
Deficiencies (6)
Regulation 483.20(d), 483.20(k)(1) deficiency was corrected by 07/11/2016.
Regulation 483.25(c) deficiency was corrected by 06/10/2016.
Regulation 483.25(h) deficiency was corrected by 07/11/2016.
Regulation 483.25(l) deficiency was corrected by 07/11/2016.
Regulation 483.60(c) deficiency was corrected by 07/11/2016.
Regulation 483.60(b), (d), (e) deficiencies were corrected by 07/11/2016.
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 6
Date: Jun 15, 2016
Visit Reason
This is a re-inspection visit to verify correction of previous deficiencies related to care plans, treatment of pressure sores, fall prevention, drug regimen, and medication management.
Findings
The facility failed to develop comprehensive care plans to prevent falls and pressure sores, failed to provide appropriate interventions and supervision to prevent falls and pressure ulcers, and failed to properly monitor and report abnormal blood sugar levels for a diabetic resident. Additionally, medication storage and labeling deficiencies were found.
Deficiencies (6)
F279: The facility failed to develop a care plan to prevent falls for a resident with a history of falls and high fall risk.
F314: The facility failed to provide appropriate repositioning and off-loading interventions for a resident with a heel pressure ulcer, resulting in inadequate pressure ulcer care.
F323: The facility failed to provide adequate supervision and interventions to prevent falls for a resident with repeated falls and high fall risk.
F329: The facility failed to notify the physician of abnormal blood sugar levels outside ordered parameters for a diabetic resident.
F428: The consultant pharmacist failed to identify and report the lack of physician notification for abnormal blood sugar levels for a diabetic resident.
F431: The facility failed to properly label and store insulin pens, multi-dose vials, and inhalers, some of which were undated or expired, risking ineffective treatment.
Report Facts
Facility census: 42
Residents in sample: 12
Blood sugar readings above 250 mg/dL: 12
Blood sugar reading below 70 mg/dL: 1
Opened Novolog insulin vial days: 47
Opened Lantus insulin vial days: 30
Opened Levemir insulin vial days: 48
Opened Levemir insulin vial days: 47
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 15, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jun 15, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a revisit inspection conducted on 06/15/2016.
Findings
The plan addresses multiple deficiencies including fall risk assessments, pressure sore prevention, drug regimen reviews, and medication storage. The facility implemented corrective actions such as audits, staff in-services, and care plan updates to ensure compliance and prevent recurrence.
Deficiencies (6)
F279D Develop Comprehensive Care Plans. Resident #22's falls from 5/12/16 were investigated and interventions were implemented and added to the care plan. Residents will be assessed for fall risk upon admission, quarterly, after significant changes, and after falls.
F314D Treatment/Services to Prevent/Heal Pressure Sores. Resident #9's left heel wound has healed. Residents will have skin assessments upon admission and weekly thereafter, with interventions updated as needed.
F323D Free of Accident/Hazards/Supervision/Devices. Resident #22's falls were investigated and interventions added to the care plan to prevent recurrence.
F329D Drug Regimen is Free from Unnecessary Drugs. Resident #47 was assessed with no adverse reactions; physician was notified of blood sugars outside ordered parameters. Audits and staff training on notification procedures were conducted.
F428D Drug Regimen Review. Resident #47 was assessed with no adverse reactions; physician was notified of abnormal blood glucose results. The Administrator and DON met with pharmacy to review expectations for communication during monthly drug regimen reviews.
F431E Drug Records, Label/Store Drugs & Biologicals. Medication carts were audited; open and undated insulin and inhalers were discarded and replaced. Staff received in-service on proper storage and dating of medications.
Report Facts
Deficiencies cited: 6
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 15, 2016
Visit Reason
The visit was a first revisit conducted on June 15, 2016, following a 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 to be 'E' level deficiencies related to pressure ulcers. Due to noncompliance, a denial of payment for new Medicare and Medicaid admissions was imposed effective June 8, 2016, and termination of the provider agreement was recommended.
Deficiencies (1)
F314, Pressure Ulcers: The facility was noncompliant in preventing avoidable pressure ulcers and ensuring appropriate care to prevent increased complexity of existing pressure ulcers.
Report Facts
Denial of payment effective date: Jun 8, 2016
Recommended termination date: Sep 22, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Author of the report and contact for questions |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Date: 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.
Complaint Details
The complaint investigation revealed failure to prevent an avoidable pressure ulcer in resident #1, which led to serious complications including sepsis and gangrene. The ulcer required multiple surgical interventions and colostomy placement. The facility's quality assurance processes were inadequate to address these issues.
Findings
The facility failed to develop and implement effective interventions to prevent an avoidable pressure ulcer for resident #1, which led to 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.
Deficiencies (2)
F314: The facility failed to prevent the development of an avoidable pressure ulcer for resident #1, resulting in hospitalization for sepsis and gangrene requiring surgical debridements and colostomy placement.
F520: The facility failed to maintain an effective Quality Assurance and Assessment committee that developed and implemented appropriate plans of action to correct quality deficiencies related to pressure ulcer prevention.
Report Facts
Resident census: 41
Resident sample size: 3
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
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 18, 2016
Visit Reason
An abbreviated 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 facility was found not in substantial compliance and was cited for immediate jeopardy related to pressure ulcers (F314) from May 3 through May 13, 2016. Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were recommended.
Deficiencies (1)
F314, Pressure Ulcers: The facility failed to implement corrective actions to prevent avoidable pressure ulcers and ensure appropriate care to prevent worsening of existing ulcers.
Report Facts
Denial of payment effective date: Jun 8, 2016
Recommended termination date: Sep 22, 2016
Civil Money Penalty minimum: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter as Complaint Coordinator for the Kansas Department for Aging & Disability Services |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 3, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey related to skin integrity and wound care.
Findings
The facility identified deficiencies in skin assessment and wound care practices, including failure to properly monitor and document skin changes and wounds. The plan outlines corrective actions, staff education, and ongoing monitoring to ensure compliance and prevent skin breakdown.
Deficiencies (2)
F314: The facility failed to ensure residents had timely skin assessments and appropriate treatment for skin integrity changes. Nursing staff will monitor skin changes and notify physicians for treatment orders.
F520: The facility failed to maintain an effective Quality Assurance/Performance Improvement Committee to monitor and address skin management system deficiencies. The committee will meet quarterly to review and plan corrective actions.
Report Facts
Date of resident transfer: May 3, 2016
Plan of Correction submission date: Jun 10, 2016
QA/PI Committee meeting date: May 19, 2016
Staff training completion date: May 13, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Patterson | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Added the Plan of Correction and contact for assistance | |
| Irina Strakhova | Modified the Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 20, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 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.
Inspection Report
Enforcement
Deficiencies: 0
Date: Mar 22, 2016
Visit Reason
The inspection 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 an 'F' level, resulting in enforcement remedies including a denial of payment for new Medicare and Medicaid admissions effective June 22, 2016.
Report Facts
Denial of Payment Effective Date: Jun 22, 2016
Termination Recommendation Date: Sep 22, 2016
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
Plan of Correction
Deficiencies: 19
Date: 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 facility identified multiple deficiencies related to resident care, including bathing choices, linen availability, comprehensive assessments, care planning, infection control, medication management, staffing, dietary services, and safety hazards. Corrective actions and monitoring plans were implemented to address these issues.
Deficiencies (19)
F242 Self Determination to Make Choices: Residents #3, 43, and 47 were reassessed for bathing choices. Facility will assess all residents for bathing preferences and update care plans accordingly.
F254 Clean Bed/Bath Linens: Linen availability was addressed by observing 10 resident rooms and providing washcloths and towels to residents #63 and 41. Linen supply and delivery procedures were revised.
F274 Comprehensive Assess after significant change: Residents #8 and 42 had MDS updated to reflect current status. Staff education on identifying significant changes was implemented.
F279 Develop Comprehensive Care Plans: Care plans for residents #55, #31, and #25 were updated to reflect current status. Care plans will be updated timely upon assessments and changes.
F280 Right to Participate in Care Planning: Resident #24's care plan was updated to reflect refusal of care. Staff education on addressing refusals was provided.
F309 Provide Care/Services for Highest Well Being: Resident #55 assessed for dialysis complications; hospice coordination for resident #31 improved. Staff education on assessments and coordination provided.
F312 ADL Care Provided for Dependent Residents: Residents #3 and 43 reassessed for bathing choices. Bathing preferences will be regularly reviewed and updated.
F314 Treatment/SVCS to Prevent/Heal Pressure Ulcer: Pressure ulcer measurements obtained for resident #24; preventative interventions reviewed and monitored.
F315 No catheter, Prevent UTI, Restore Bladder: Resident #25 received incontinent care when prompted. Staff educated on timely care and individualized toileting plans.
F323 Free of Accident Hazards: Call light for resident #42 was placed in reach. Staff educated on call light placement and monitoring implemented.
F329 Unnecessary drugs: Care plans for residents #3, #4, and #47 updated to include monitoring of black box warnings. Orders for residents #21 and #46 clarified.
F353 Sufficient 24-HR Nursing Staff per care plans: Staffing patterns reviewed and education provided. Resident interviews and labor hours monitored.
F356 Posted Nursing Staff Information: Staffing information posted daily and collected for 18 months. Monitoring of posting compliance conducted.
F362 Sufficient Dietary Support Personnel: Residents #4, #22, and #24 received appropriate meal service. Dining room service revised and satisfaction surveys conducted.
F371 Store/Prepare/Serve - Sanitary: Dietary personnel educated on thawing techniques and hygiene. Daily monitoring of refrigerator temperatures and sanitation rounds conducted.
F428 Drug Regimen Review, Report, Irregular, Act on: Care plans and orders updated for residents with blood pressure medications with black box warnings. Pharmacy consultation and audits implemented.
F431 Drug Records, Label/Store Drugs and Biologicals: Medication cart and room audited for proper storage and labeling. Staff educated and audits scheduled.
F441 Infection Control, prevent spread, linens: Residents #31 and #12 assessed with no negative outcomes. Staff educated on glove use and peri-care; competency checks conducted.
F464 Requirements for Dining and Activity Rooms: Residents #40 and #63 assessed with no negative outcomes. Staff educated on mobility assistance and furniture arranged for accessibility.
Report Facts
Resident rooms observed: 10
Residents reassessed for bathing choices: 2
Residents reassessed for bathing choices: 3
Care plan audits per week: 3
Random resident interviews: 2
Medication administration audits per week: 2
Resident interviews on staff response: 2
Staff posting monitoring frequency: 2
Dining satisfaction surveys: 6
Dining satisfaction surveys: 2
Audit rounds frequency: 3
Audit rounds frequency: 3
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 16
Date: Mar 22, 2016
Visit Reason
Health Resurvey and Complaint Investigation #96582 conducted to assess compliance with resident care, infection control, medication management, staffing, and safety regulations.
Complaint Details
Complaint investigation #96582 focused on resident care, infection control, medication management, staffing, and safety concerns.
Findings
The facility failed to honor resident bathing preferences, ensure clean linens availability, complete significant change assessments, develop individualized care plans, provide adequate assistance with ADLs, prevent and treat pressure ulcers, provide timely incontinent care, prevent accidents, monitor medications properly, maintain sufficient staffing, serve meals timely, store food and medications properly, and follow infection control practices.
Deficiencies (16)
F242 - The facility failed to assess and accommodate resident bathing preferences for 3 residents, lacking policies and documentation of preferences.
F254 - The facility failed to ensure residents had clean towels and washcloths readily available, with staff reporting inconsistent stocking.
F274 - The facility failed to complete significant change assessments for 2 residents with documented declines in condition and care needs.
F279 - The facility failed to develop individualized care plans for 3 residents including those with impaired cognition, hospice care, and urinary incontinence.
F309 - The facility failed to perform and document post-dialysis assessments and coordinate hospice services for residents receiving these treatments.
F312 - The facility failed to provide required assistance with bathing for 2 residents, despite scheduled bathing and care plan instructions.
F314 - The facility failed to provide necessary treatment and services to promote healing of pressure ulcers for 1 resident, lacking wound assessments and interventions.
F315 - The facility failed to provide timely incontinent care and toileting for a dependent resident, with incomplete toileting program documentation.
F323 - The facility failed to provide adequate supervision and assistive devices to prevent falls for 1 resident, and failed to ensure call light accessibility.
F329 - The facility failed to ensure residents were free from unnecessary medications and failed to monitor for medication side effects and effectiveness for 5 residents.
F356 - The facility failed to post daily nurse staffing information in a publicly accessible location and failed to maintain records for at least 18 months.
F362 - The facility failed to provide sufficient dietary staff to serve meals in a timely manner, resulting in residents waiting up to 53 minutes or leaving without being served.
F371 - The facility failed to store, serve, and prepare food in a sanitary manner, including improper food storage temperatures and staff not wearing hairnets properly.
F431 - The facility failed to dispose of expired medications in medication carts, including insulin pens and inhalers without open dates.
F441 - The facility failed to follow infection control practices, including improper glove use during incontinence care, resulting in cross contamination.
F464 - The facility failed to provide adequate space in the dining room to safely accommodate residents, creating safety hazards during ambulation and emergency access.
Report Facts
Resident census: 47
Bathing frequency: 2
Meal wait time: 53
Blood sugar readings above 351 mg/dl: 38
Medication carts with expired meds: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff D | Administrative Nursing Staff | Provided multiple interviews regarding care plan expectations, staffing, and infection control |
| Licensed Nursing Staff H | Licensed Nurse | Interviewed regarding care plan expectations and medication monitoring |
| Direct Care Staff O | Direct Care Staff | Interviewed regarding bathing assistance and medication reporting |
| Direct Care Staff QQ | Direct Care Staff | Administered medication and discussed blood pressure monitoring |
| Administrative Staff A | Administrative Staff | Interviewed regarding nurse staffing posting and refrigerator issues |
| Dietary Staff DD | Dietary Staff | Interviewed regarding meal service and refrigerator monitoring |
| Licensed Nurse I | Licensed Nurse | Interviewed regarding medication monitoring and infection control |
| Pharmacy Consultant KK | Pharmacy Consultant | Interviewed regarding medication review and monitoring |
| Direct Care Staff VV | Direct Care Staff | Observed and interviewed regarding glove use during incontinence care |
| Direct Care Staff R | Direct Care Staff | Observed and interviewed regarding glove use and incontinence care |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 15, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies listed with their regulation numbers were corrected by the dates indicated, mostly on 10/16/2015, with one correction completed on 10/16/2016.
Report Facts
Deficiency corrections: 12
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 15, 2015
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiency identified as Reg. # 26-40-302 (h) with ID Prefix S0972 was corrected by 10/16/2015. No other deficiencies or findings are listed.
Deficiencies (1)
Regulation 26-40-302 (h) deficiency was corrected as of 10/16/2015.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: 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. It outlines corrective actions to address the cited deficiencies and ensure 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 audits, 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 correct and prevent recurrence of these issues.
Deficiencies (12)
F159: Resident trust accounts were not properly managed; residents were informed and monthly reviews will be conducted for balances approaching resource limits.
F160: Refunds for resident trust accounts after death were delayed; policies were reviewed and audits will ensure timely closure and disbursement.
F243: Resident Council meetings were inconsistently facilitated; monthly meetings will be documented and participation encouraged.
F248: Activity programming lacked individualized support; 1:1 programming was re-implemented and participation records maintained.
F272: Care plans were outdated; interdisciplinary team reviewed and revised care plans to reflect current resident needs.
F315: Urinary incontinence assessments and individualized toileting plans were incomplete; audits were completed and staff educated.
F318: Restorative nursing programs were not consistently applied; audits were completed and care plans updated accordingly.
F334: Influenza vaccine education and administration lacked consistency; residents and representatives will be educated prior to vaccination.
F362: Meal time schedules did not support policy; education provided and dining times monitored for compliance.
F371: Food storage and defrosting practices were deficient; dietary staff received education and audits will ensure compliance.
F441: Infection control logs were reviewed with no infection clusters found; nurses educated on infection reporting and logs monitored monthly.
S972: Weekly testing of the wireless call system was not documented; maintenance staff educated and documentation will be reviewed regularly.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 11
Date: Oct 1, 2015
Visit Reason
Health Resurvey and Complaint Investigation #KS00089532 conducted to assess compliance with regulatory requirements related to resident personal funds management, resident rights, activities, assessments, infection control, dietary services, and other care standards.
Complaint Details
The inspection was triggered by a complaint investigation #KS00089532 focusing on multiple areas of resident care and facility compliance.
Findings
The facility was found deficient in multiple areas including failure to properly manage resident personal funds, failure to ensure resident participation in groups, inadequate activity programs, incomplete comprehensive assessments, failure to develop individualized toileting programs, failure to provide restorative nursing services, failure to provide education prior to immunizations, delayed meal service, improper food storage and sanitation, and ineffective infection control program.
Deficiencies (11)
F159: Facility failed to obtain written authorization for managing resident funds, failed to place funds over $50 in interest-bearing accounts, failed to notify Medicaid residents when funds approached resource limits, and failed to provide quarterly statements.
F160: Facility failed to convey deceased resident's personal funds and final accounting within 30 days to the estate administrator.
F243: Facility failed to ensure residents' right to participate in resident groups as resident council meetings were not held for several months.
F248: Facility failed to provide an ongoing activity program meeting residents' interests and needs and failed to document individual activities for sampled residents.
F272: Facility failed to conduct comprehensive assessments using the Resident Assessment Instrument (RAI) with adequate documentation and care planning for sampled residents.
F315: Facility failed to develop an individualized toileting program for a resident with urinary incontinence.
F318: Facility failed to provide restorative nursing services to maintain or improve range of motion for a resident with severe cognitive impairment and functional limitations.
F334: Facility failed to provide education regarding benefits and potential side effects prior to offering influenza immunizations to sampled residents.
F362: Facility failed to serve meals within scheduled timeframes, with delays up to 45 minutes for breakfast and lunch.
F371: Facility failed to properly store food, including unlabeled and undated items, excessive ice buildup in freezers, and improper disinfectant concentration.
F441: Facility failed to maintain an effective infection control program including lack of infection tracking, trending, and corrective actions.
Report Facts
Resident census: 40
Residents with personal funds managed: 28
Resident personal fund balances: 1993.87
Resident personal fund balances: 2054.92
Resident personal fund balances: 2994.92
Resident personal fund balance: 1495.54
Minutes of physical therapy: 285
Minutes of occupational therapy: 180
Disinfectant concentration: 10
Meal service delay: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff B | Provided information and confirmed findings related to resident personal funds management | |
| Administrative staff A | Provided information related to resident council meetings and activity program | |
| Administrative nursing staff D | Provided information on restorative nursing services, infection control program, and immunization education | |
| Dietary staff DD | Provided information on meal service times and kitchen sanitation |
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 30, 2015
Visit Reason
A Life Safety Code survey was conducted on September 30, 2015 by the State Fire Marshal's Office, followed by a Health survey on October 1, 2015 by the Kansas Department for Aging and Disability Services to determine compliance with Federal participation requirements for nursing homes.
Findings
Both surveys found the most serious deficiencies in the facility to be at the 'F' level. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions will be imposed effective January 1, 2016 until substantial compliance is achieved.
Report Facts
Denial of Payment Effective Date: Jan 1, 2016
Compliance Deadline: Apr 1, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact for questions concerning instructions in the letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution for Life Safety Code Survey |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 11, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the dates indicated, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiency corrections completed: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Date: 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.
Findings
The facility identified multiple deficiencies related to medication administration, notification of changes, investigation and reporting of incidents, comprehensive assessments, wound care, safety and accident prevention, and pharmaceutical services. Corrective actions include audits, staff education, notification procedures, and monitoring plans to ensure compliance and resident safety.
Deficiencies (6)
F157 D Notification of Changes: Resident #3's physician was notified of missed medications. Licensed nurses were educated on notification and medication administration documentation.
F225 D Investigate and Report: Resident #2 was assessed for fall risk and referred to therapy. Staff educated on abuse, neglect, and incident reporting.
F272 D Comprehensive Assessments: Resident #1's care plan was updated after review. Audits of comprehensive assessments were conducted to ensure completion.
F314 G Wounds/Pressure Ulcers: Residents #1 and #2 had skin assessments with physician notification and treatment orders implemented. Weekly skin assessments and staff education were conducted.
F323 G Safety/Free of unnecessary accidents: Resident #2 assessed for fall risk with interventions implemented. Staff educated on accident prevention and incident documentation.
F425 D Pharmaceutical services-accurate procedures: Resident #3's physician notified of missed medications. Medication administration audits and staff education conducted.
Report Facts
Audit start date: Jun 23, 2015
Education dates: Jun 18, 2015
Education dates: Jun 24, 2015
Discharge date: Jun 1, 2015
Audit date: Jun 24, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 15, 2015
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services to determine compliance with Federal participation requirements for nursing homes in Medicare and Medicaid programs.
Complaint Details
The enforcement action is based in part on deficiencies found during a complaint survey conducted on October 7, 2014.
Findings
The survey found deficiencies at a level of actual harm that is not immediate jeopardy. Based on these deficiencies and a prior history of noncompliance from a complaint survey on October 7, 2014, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Deficiencies (1)
F314 Pressure Ulcers: The facility is noncompliant with requirements to prevent avoidable pressure ulcers and to provide appropriate care to prevent increased complexity of existing pressure ulcers.
Report Facts
Enforcement effective date: Jul 8, 2015
Termination recommendation date: Dec 15, 2015
Civil Money Penalty threshold: 5000
IDR request deadline: 10
Hearing request deadline: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Smith | Administrator | Named as facility administrator |
| Jane Weiler | CMS Contact | Contact person for questions regarding the matter |
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning instructions in the letter |
| Gregg Brandush | Branch Manager | Authorized the letter |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 6
Date: Jun 15, 2015
Visit Reason
Complaint investigations were conducted related to medication administration, resident falls, skin integrity, and abuse allegations.
Complaint Details
The investigation was triggered by complaints regarding medication administration errors, resident falls, skin integrity issues, and abuse allegations. The facility failed to properly investigate and report these issues as required.
Findings
The facility failed to timely notify the physician of missed medications for a resident with urinary tract infection and major depression. The facility also failed to thoroughly investigate unwitnessed falls, burns, and allegations of resident-to-resident sexual abuse, and failed to report abuse allegations to the state agency. Additionally, comprehensive assessments including Care Area Assessments were incomplete for residents with pressure ulcers and fall risks. The facility failed to provide adequate preventive treatments and interventions to prevent avoidable pressure ulcers for multiple residents. Supervision and assistive devices were inadequate to prevent accidents for residents with repeated falls and injuries. Medication administration errors were not properly investigated or reported.
Deficiencies (6)
F157: The facility failed to notify the physician timely for a resident who missed physician-ordered medications for urinary tract infection and major depression.
F225: The facility failed to thoroughly investigate unwitnessed falls, burns, and allegations of resident-to-resident sexual abuse, and failed to report abuse allegations to the state agency.
F272: The facility failed to complete comprehensive assessments including Care Area Assessments for pressure ulcers and falls for residents with cognitive impairment and pressure ulcers.
F314: The facility failed to provide preventive treatments and effective interventions to prevent avoidable pressure ulcers for multiple dependent residents.
F323: The facility failed to ensure supervision and assistive devices to prevent accidents for residents with repeated unwitnessed falls and injuries.
F425: The facility failed to notify the responsible party and physician timely about missed medications and failed to investigate medication errors for a resident with urinary tract infection and major depression.
Report Facts
Resident census: 48
Missed medication doses: 4
Pressure ulcer measurements: 6
Pressure ulcer measurements: 4
Bruise measurement: 6
Bruise measurement: 2
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 2.8
Pressure ulcer measurements: 0.1
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 5, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the Plan of Correction.
Findings
The revisit confirmed that all previously identified deficiencies listed on the CMS-2567 Statement of Deficiencies were corrected by the dates indicated, primarily on 10/24/2014.
Report Facts
Deficiencies corrected: 21
Inspection Report
Plan of Correction
Deficiencies: 18
Date: 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 to demonstrate correction and compliance with federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions for multiple deficiencies including notification of responsible parties, resident personal funds access, missing dentures investigation, abuse/neglect reporting and staff education, environmental cleanliness, individualized care plans, fall risk assessments, transfer safety, ADL documentation, medication management, and staff hygiene practices.
Deficiencies (18)
F157D Social Service confirmed resident #13 consented to notify his son of changes; staff educated on notification procedures and monitoring established.
F159E Facility ensured resident access to personal funds by placing money in medication cart; staff trained and monitoring implemented.
F174D Investigation initiated for missing dentures of resident #16; responsible party contacted and grievance procedures implemented.
F221D Resident #25 assessed with physician and family notified; staff trained on abuse/neglect and restraint use with monitoring.
F225D Report made to KDADS on allegations by resident #57; staff educated on abuse/neglect policy and reporting; monitoring of grievances and staff interaction established.
F226D Investigation initiated on resident #25 abuse allegations; staff educated and abuse neglect coordinator sign posted with monitoring.
F253E Facility maintained clean environment with deep cleaning, repairs, and new maintenance program; staff trained on reporting issues.
F279E Care plans individualized for residents including lap belt use and ADL preferences; audits and reviews scheduled.
F280D Fall risk assessment completed for resident #30; care plans revised and falls audited with ongoing monitoring.
F309G Resident #13 assessed for transfer capabilities; staff educated on transfer safety and care plans updated with therapy input.
F312D Resident #21 provided ADL care including shaving; staff trained on documentation and refusals monitored.
F314G Resident #13 assessed and treated with updated care plans; staff educated on documenting supplement intake and monitoring.
F323D Resident #25 care plan reviewed and fall risk updated; therapy assessing resident #8 for lift chair safety; staff educated on safety.
F329E Behavior monitoring sheets revised for multiple residents; staff trained on documentation and bowel movement monitoring.
F356C Licensed nurses trained on posting nurse staffing information; monitoring of postings implemented.
F371D Dietary staff educated on hygiene and sanitary practices; maintenance and monitoring of refrigerator and freezer cleanliness established.
F428E Pharmacy consultant completed drug regime reviews for residents; education planned on psychotropic drug management.
F431E Staff educated on medication cart management and insulin expiration; monitoring of insulin storage implemented.
Report Facts
QA review frequency: 2
Monitoring frequency: 3
Monitoring frequency: 4
Monitoring frequency: 2
Monitoring frequency: 2
Inspection Report
Re-Inspection
Census: 48
Deficiencies: 17
Date: Oct 7, 2014
Visit Reason
Health resurvey inspection to evaluate compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to notify family of significant resident changes, improper management of personal funds, missing personal property investigation, use of physical restraints for convenience, failure to investigate and report abuse allegations, inadequate housekeeping, incomplete care plans, failure to prevent pressure ulcers, inadequate fall prevention interventions, inconsistent monitoring of psychotropic medications, failure to post nurse staffing data correctly, unsanitary food handling, and improper medication storage.
Deficiencies (17)
F157: The facility failed to notify a resident's family member of injury, pressure ulcers, worsening toe condition requiring surgery, and hospital transfer.
F159: The facility failed to ensure residents had access to personal funds after business hours and on weekends.
F174: The facility failed to investigate lost lower dentures for a cognitively impaired resident.
F221: The facility failed to ensure a resident was free from physical restraints used for staff convenience.
F225: The facility failed to investigate and report allegations of abuse for two residents and failed to implement abuse policies and posting requirements.
F226: The facility failed to implement abuse investigation policies and failed to post required staff reporting information.
F253: The facility failed to maintain a clean and comfortable environment in common areas and some resident rooms.
F279: The facility failed to develop individualized comprehensive care plans for four residents, including failure to address lap belt use, nail care preferences, facial grooming, and fall interventions.
F309: The facility failed to provide necessary care and services to prevent worsening and promote healing of pressure ulcers for one resident, including failure to educate resident on wedge use and inconsistent nutritional supplement documentation.
F312: The facility failed to provide grooming services consistently for one resident requiring extensive assistance.
F314: The facility failed to provide services and treatment to prevent pressure ulcers and promote healing for one resident, including failure to educate resident on wedge use, inconsistent offloading, and incomplete nutritional monitoring.
F323: The facility failed to provide timely and effective fall prevention interventions for two residents and failed to ensure safety with use of an electric lift chair.
F329: The facility failed to consistently monitor behaviors and bowel movements for five residents receiving psychotropic medications and failed to develop appropriate target behaviors.
F356: The facility failed to post current nursing staff information for one of four days on survey.
F371: The facility failed to serve, prepare, and store food in a sanitary manner, including failure to wear beard nets and maintain clean refrigerators.
F428: The facility failed to consistently monitor behaviors for five residents receiving psychotropic medications, failed to monitor bowel movements for one resident, and failed to discard expired insulin.
F431: The facility failed to store medications securely and failed to discard expired insulin vial.
Report Facts
Resident census: 48
Deficiency cited: 16
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
Medication monitoring shifts missing: 14
Medication monitoring shifts missing: 14
Medication monitoring shifts missing: 14
Medication monitoring shifts missing: 14
Medication monitoring shifts missing: 15
Medication monitoring shifts missing: 14
Expired insulin vial date: 2014
Inspection Report
Enforcement
Deficiencies: 1
Date: 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 that is not immediate jeopardy. Due to prior noncompliance on an April 21, 2014 complaint investigation, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.
Deficiencies (1)
Noncompliance with F314 related to Pressure Ulcers was identified, indicating the facility failed to prevent avoidable pressure ulcers and provide appropriate care to prevent worsening of existing ulcers.
Report Facts
Enforcement effective date: Denial of payment for all new Medicare admissions effective October 27, 2014
Termination recommendation date: If substantial compliance is not achieved by April 7, 2015, termination from Medicare program is recommended
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter and contact for questions regarding enforcement |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 12, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that corrections were completed for deficiencies related to regulations 483.25(c), 483.25(d), and 483.25(h) as of the revisit date.
Deficiencies (3)
Regulation 483.25(c): Previously cited deficiency was corrected by 06/12/2014.
Regulation 483.25(d): Previously cited deficiency was corrected by 06/12/2014.
Regulation 483.25(h): Previously cited deficiency was corrected by 06/12/2014.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: 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.
Findings
The plan addresses multiple deficiencies including administration of supplements, wound care management, resident assessments, care plan revisions, and safety interventions such as fall risk management and toileting programs. Staff training and monitoring procedures have been implemented to ensure compliance.
Deficiencies (3)
F314: All ordered supplements have been placed on the MAR and CMAs are responsible for administration and documentation. Risk assessments and care plans for resident #12 were revised to address pressure ulcers and weight changes.
F315: Bowel and bladder assessments and voiding diaries were completed for residents #11 and #12 to identify voiding patterns. Staff were re-in-serviced on documentation and care plans were updated accordingly.
F323: Resident #11 received physical therapy and a new fall risk assessment. Care plans were revised and safety interventions including bed and chair alarms were implemented and monitored.
Report Facts
Plan of Correction completion date: May 14, 2014
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Date: Apr 23, 2014
Visit Reason
The inspection was conducted as a Non-compliance Revisit and Complaint Investigation related to pressure sores, urinary incontinence, and fall prevention.
Complaint Details
The visit was a complaint investigation triggered by allegations related to pressure ulcers, urinary incontinence, and fall prevention failures.
Findings
The facility failed to prevent the development of avoidable pressure ulcers and provide effective treatment for residents with pressure ulcers. The facility also failed to maintain or restore urinary function for residents with incontinence and did not provide adequate fall prevention measures including functioning bed alarms and fall mats.
Deficiencies (3)
F314: The facility failed to prevent avoidable pressure ulcers and provide necessary treatment and services to promote healing for 3 sampled residents with pressure ulcers.
F315: The facility failed to maintain or restore urinary function and did not complete adequate bladder assessments or individualized toileting programs for 2 sampled residents with urinary incontinence.
F323: The facility failed to ensure the resident's bed alarm functioned and did not provide a fall mat as planned for a resident at risk for falls.
Report Facts
Resident census: 48
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
Inspection Report
Follow-Up
Deficiencies: 4
Date: Apr 23, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the plan of correction.
Findings
The report shows that all previously identified deficiencies were corrected by the revisit date of April 23, 2014.
Deficiencies (4)
Regulation 483.13(c): Previously cited deficiency corrected as of 04/23/2014.
Regulation 483.15(g)(1): Previously cited deficiency corrected as of 04/23/2014.
Regulation 483.25: Previously cited deficiency corrected as of 04/23/2014.
Regulation 483.25(a)(3): Previously cited deficiency corrected as of 04/23/2014.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 28, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint survey.
Findings
The facility identified multiple deficiencies related to resident care including code status identification, medication refusal tracking, skin breakdown prevention, bathing and dining assistance, pressure ulcer prevention, and elopement risk management. Corrective actions and systemic changes were implemented to address these issues.
Deficiencies (6)
F224J: The facility failed to properly identify Do Not Resuscitate (DNR) status on resident face sheets and care plans, and failed to communicate code status effectively.
F250E: The facility failed to adequately track and manage medication refusals and resident behaviors, including notification of physicians and care plan adjustments.
F309G: The facility failed to properly assess and manage residents at risk for skin breakdown, including documentation and pressure relief protocols.
F312E: The facility failed to ensure residents received appropriate bathing and dining assistance according to their preferences and needs.
F314G: The facility failed to adequately protect residents at risk for pressure ulcers through proper positioning and care plan interventions.
F323J: The facility failed to properly assess and manage residents at risk for elopement, including use of wander guard devices and door alarms.
Report Facts
Staff CPR certifications: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Royer | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Added and modified the Plan of Correction document. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 6
Date: Mar 25, 2014
Visit Reason
Partial Extended Survey and Complaint Investigations were conducted due to multiple complaints and concerns about resident care and safety.
Complaint Details
The complaint investigation was triggered by multiple allegations including failure to perform CPR, inadequate social services, poor wound care, insufficient bathing and meal assistance, pressure ulcer care deficiencies, and inadequate supervision leading to elopement and falls.
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 adequately, and failed to provide adequate supervision to prevent elopement and falls.
Deficiencies (6)
483.13(c) The facility failed to perform CPR for a full code resident who expired, placing the resident in immediate jeopardy.
483.15(g)(1) The facility failed to provide timely and effective medically related social services for a resident whose behavior significantly disrupted the living environment.
483.25 The facility failed to provide adequate treatment for a resident with a diabetic ulcer, including pressure offloading and nutritional support.
483.25(a)(3) The facility failed to provide bathing twice weekly and timely meal assistance for cognitively impaired residents dependent on staff.
483.25(c) The facility failed to prevent development of an avoidable pressure ulcer and failed to provide treatment that promoted healing for a resident with a Stage 2 pressure ulcer.
483.25(h) The facility failed to accurately assess and provide supervision to prevent elopement of a resident and failed to provide timely and effective interventions to prevent falls for a resident who sustained a fracture.
Report Facts
Resident census: 47
Staff CPR certified: 3
Weight loss: 7
Pressure ulcer size: 2.6
Fall risk score: 15
Elopement risk score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse L | Licensed Nurse | Named in CPR failure incident for resident #2. |
| Licensed nurse M | Licensed Nurse | Named in CPR failure incident for resident #2. |
| Administrative nursing staff D | Administrative Nursing Staff | Provided information on CPR incident and elopement. |
| Social service staff H | Social Service Staff | Provided information on resident #5's behavior and social services. |
| Licensed nurse J | Licensed Nurse | Provided information on resident #3's fall and fracture. |
| Licensed nurse K | Licensed Nurse | Provided information on resident #3's fall and fracture. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 20, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Jun 20, 2014
Provider agreement termination date: Sep 20, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Nov 27, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as required by the Medicare, Medicaid, and Clinical Laboratory Improvement Amendments programs.
Findings
All deficiencies previously reported on the CMS-2567 were corrected by the revisit date of 11/27/2013, as documented by the correction completion dates for each cited regulation.
Deficiencies (5)
Regulation 483.15(h)(2): Deficiency previously cited was corrected by 11/27/2013.
Regulation 483.25(h): Deficiency previously cited was corrected by 11/27/2013.
Regulation 483.25(l): Deficiency previously cited was corrected by 11/27/2013.
Regulation 483.65: Deficiency previously cited was corrected by 11/27/2013.
Regulation 483.75(o)(1): Deficiency previously cited was corrected by 11/27/2013.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 30, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the Plan of Correction.
Findings
All previously reported deficiencies were corrected by the revisit date of 10/30/2013, as documented by the correction completion dates for each cited regulation.
Report Facts
Correction completion date: Oct 30, 2013
Follow-up survey completion date: Jul 2, 2013
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Oct 30, 2013
Visit Reason
This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited in a prior inspection report dated 10/30/2013.
Findings
The plan addresses multiple deficiencies including maintenance issues with drains and ceilings, resident smoking and elopement risk assessments, medication regimen accuracy, infection control practices, and quality assurance committee activities. Corrective actions include repairs, staff re-inservices, monitoring procedures, and policy revisions.
Deficiencies (5)
F253 The facility will provide a sanitary and safe environment for the residents. Maintenance repaired drains and monitors ceilings for leaks during daily rounds.
F323 New smoking and elopement assessments were completed for residents, with monitoring cameras installed and staff educated on supervision procedures.
F329 Resident #47 was re-assessed by a nurse practitioner using the correct weight and orders were updated accordingly.
F441 All staff were re-in-serviced on infection control, and housekeeping staff were retrained on cleaning standards with routine audits scheduled.
F520 The facility maintains a quality assessment and assurance committee that meets weekly to review audits, reports, and plans of action to resolve deficient practices.
Report Facts
Plan of Correction completion dates: Nov 12, 2013
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 5
Date: Oct 23, 2013
Visit Reason
The inspection was a Non-compliance Revisit and Complaint investigations #KS69347, #KS69394, and #KS69737 to assess the facility's compliance with regulatory requirements.
Complaint Details
The visit was triggered by complaint investigations #KS69347, #KS69394, and #KS69737 and a non-compliance revisit.
Findings
The facility failed to maintain housekeeping and maintenance services, ensure resident safety and supervision, prevent unnecessary drug use, maintain infection control practices, and operate an effective Quality Assurance program.
Deficiencies (5)
F 253: The facility failed to provide effective maintenance services, evidenced by a bathtub with pooled blackish water and water leaks in a resident's closet ceiling.
F 323: The facility failed to provide adequate supervision to prevent accidents for a resident with a history of falls and seizures who smoked unsupervised on the patio.
F 329: The facility failed to ensure a resident's drug regimen was free from unnecessary drugs, administering medications for weight loss despite no actual weight loss.
F 441: The facility failed to follow disinfectant contact time protocols and maintain sanitary conditions, including improper handling of a resident's drinking cup.
F 520: The facility's Quality Assessment and Assurance committee failed to identify and correct multiple quality deficiencies including maintenance, resident supervision, medication monitoring, and infection control.
Report Facts
Resident census: 49
Sample size: 13
Resident #57 elopement risk score: 18
Resident #57 fall risk score: 13
Resident #47 weight measurements: 120
Inspection Report
Plan of Correction
Deficiencies: 11
Date: 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 issues and ensure compliance with state and federal regulations.
Findings
The plan 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 risk assessments, perineal care, elopement risk, behavior monitoring, RN staffing, medication storage, housekeeping, and quality assessment.
Deficiencies (11)
F0000: The facility submitted this plan of correction as required by law, without admitting the accuracy of citations or deficiencies.
F225-D: The facility will investigate and report all allegations of abuse/neglect and provide staff in-service on related policies.
F314-G: Residents will be assessed for pressure ulcer risk on admission, quarterly, and with condition changes, with staff in-serviced on proper care and positioning.
F322-D: Policy revised for staff providing perineal care to residents with feeding tubes; staff will be in-serviced and monitored.
F323-J: Staff in-serviced on elopement policies and procedures; residents at risk reassessed and monitored with sensors checked each shift.
F329-D: Licensed nursing staff in-serviced on monitoring residents' behaviors with revised behavior monitoring sheets for individual medications.
F354-F: The facility will provide an RN for at least 8 consecutive hours daily; staffing schedules will be audited to ensure coverage.
F428-D: Consultant pharmacist engaged to review behavior monitoring for residents on psychotropic medications; DON will monitor system.
F431-D: Nursing staff in-serviced on medication storage and disposal of expired medications; medication carts and rooms checked biweekly.
F441-E: Floor mats replaced and monitored for good repair; housekeeping staff re-inserviced on cleaning policies with audits scheduled.
F520-F: Quality assessment and assurance committee to identify issues and implement plans of action; meetings increased to bi-monthly.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 10
Date: Sep 5, 2013
Visit Reason
Health Resurvey and Extended Survey including Complaint Investigations #KS 67317 and #67275.
Complaint Details
The complaint investigation revealed failure to investigate and report neglect, failure to prevent pressure ulcers, failure to prevent elopement, and other quality and safety deficiencies.
Findings
The facility failed to investigate and report an allegation of neglect, failed to provide necessary services to prevent pressure ulcers, failed to maintain proper positioning during tube feeding, failed to prevent elopement of a cognitively impaired resident, failed to maintain safe environment and infection control, failed to monitor psychotropic medication effectiveness, failed to ensure 8 consecutive hours of RN coverage daily, and failed to maintain an effective Quality Assurance program.
Deficiencies (10)
F225: The facility failed to investigate or report an allegation of neglect for resident #42 involving a feeding tube cap left in bed causing skin injury.
F314: The facility failed to provide necessary services to prevent and treat pressure ulcers for resident #42, resulting in stage 2 pressure ulcers persisting for 6 weeks.
F322: The facility failed to maintain the head of bed elevated during tube feeding for resident #20, risking aspiration.
F323: The facility failed to provide supervision to prevent elopement of resident #77, failed to safeguard keypad codes, and failed to maintain a safe environment in bathing areas, placing the resident in immediate jeopardy.
F329: The facility failed to adequately monitor targeted behaviors for psychotropic medications for resident #19, lacking individualized behavior monitoring and medication effectiveness assessment.
F354: The facility failed to provide 8 consecutive hours of registered nurse coverage daily on multiple dates in July and August 2013.
F428: The facility's pharmacist failed to identify and report irregularities in monitoring psychotropic medication effectiveness for resident #19.
F431: The facility failed to remove expired medications and failed to monitor insulin expiration, with expired Vitamin E and Tylenol found in medication storage.
F441: The facility failed to follow cleaning policies for isolation rooms, including improper use of personal protective equipment and inadequate cleaning of equipment, and failed to maintain cleanable surfaces on fall mats.
F520: The facility failed to maintain an effective Quality Assessment and Assurance committee that addressed multiple identified quality deficiencies including neglect investigations, pressure ulcer development, elopement supervision, psychotropic medication monitoring, RN coverage, pharmacy services, drug expiration, and infection control.
Report Facts
Resident census: 51
Sample size: 16
Days Novolog insulin open at room temperature: 33
Dates lacking 8 consecutive RN hours: 21
Fall mats with tears: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Nursing Staff | Named in neglect and elopement findings for resident #42 and #77. |
| Staff Q | Direct Care Staff | Provided care and statements regarding resident #42 neglect incident. |
| Staff A | Administrative Nursing Staff | Involved in investigation and interviews related to neglect and elopement. |
| Staff P | Direct Care Staff | Interviewed regarding resident #77 elopement and resident #19 behaviors. |
| Staff Z | Housekeeping/Maintenance Staff | Involved in cleaning isolation room and noted for improper cleaning practices. |
| Consultant LL | Pharmacy Consultant | Interviewed regarding failure to identify medication monitoring irregularities. |
| Administrative Staff A | Administrator | Interviewed regarding RN coverage and QAA committee. |
| Administrative Nursing Staff D | Administrative Nursing Staff | Interviewed regarding elopement policy and QAA committee. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 5, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the prior survey completed on 2013-07-02.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date 2013-09-05.
Report Facts
Deficiencies corrected: 13
Inspection Report
Plan of Correction
Deficiencies: 21
Date: 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. It outlines corrective actions to address regulatory compliance issues.
Findings
The facility has developed and implemented multiple corrective actions to address deficiencies related to resident personal funds access, privacy during care, incident investigations, updated policies, bathing schedules, activity programs, housekeeping and maintenance, care plan revisions, pain management, food intake monitoring, continence programs, accident prevention, medication monitoring, infection control, and environmental repairs.
Deficiencies (21)
F159E The facility will ensure residents have access to his/her personal funds. The business office will maintain $20 in an envelope in the medication cart when the office is closed.
F164D The facility will provide privacy for residents during toileting and transfers. Staff received in-service training and will be monitored for compliance.
F225D The facility will investigate falls and report to the state agency as required. Staff will be in-serviced on incident reporting and investigations.
F226D The facility updated the Abuse, Neglect, Exploitation (ANE) policy and will in-service all staff on the updated policy.
F242E The facility will assess residents for bathing schedule preferences on admission and quarterly, adjusting schedules accordingly.
F248D The facility will offer ongoing activity programs to meet residents' interests, with participation and refusals documented and reviewed quarterly.
F253E The facility will implement housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior, with monitoring by administration.
F279D Residents' care plans will be reviewed and revised as needed by the MDS Coordinator and interdisciplinary team during weekly risk management meetings.
F280D The facility will ensure family members or legal representatives are invited to participate in care plan development and will document contact.
F309D The pain management program and care plan for resident #36 have been reviewed and revised. Nursing staff will be in-serviced on pain assessment and documentation.
F314D Nursing staff have been re-in-serviced on recording food intake and offering alternatives if residents consume less than 50% of meals.
F315D A new voiding trial has been implemented for resident #40 and reassessment for resident #25. Staff will be in-serviced on continence care.
F323E The facility will ensure the resident environment is free of accident hazards and will investigate falls thoroughly with effective interventions.
F329E Staff will be in-serviced on monitoring residents' behaviors and medication effectiveness. Lab audits and follow-ups have been completed for specific residents.
F371E Staff were in-serviced on proper handling of food and feeding procedures. Monitoring will be conducted during meal service.
F406D The facility will review all PASSAR for specialized services prior to admission and provide transportation and follow-up for appointments.
F428D Drug regime reviews for residents #19, #29, and #45 will be re-evaluated by the pharmacy consultant and monitored by the DON.
F431D Staff will be in-serviced on policy for storing and disposing of expired medications. Medication carts will be checked weekly for compliance.
F441E Nursing and housekeeping staff have been re-in-serviced on infection control techniques and cleaning procedures for residents with clostridium difficile.
F463E Call lights for residents #16, #46, and two others were repaired. Maintenance will increase call light system checks to bi-weekly.
F465F The front entry sidewalk cracks and raised areas will be repaired by maintenance. A preventative maintenance tool will be used for ongoing inspections.
Report Facts
Date: Jul 31, 2013
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 20
Date: Jun 19, 2013
Visit Reason
Health Resurvey and Complaint Investigation triggered by complaints #65265 and #654345.
Complaint Details
Complaint investigation revealed multiple deficiencies including resident rights violations, inadequate care, and unsafe environment.
Findings
The facility had multiple deficiencies including failure to ensure residents' access to personal funds, privacy violations during toileting and transfers, failure to investigate and report falls, inadequate abuse and neglect policies, failure to accommodate resident choices, insufficient activity programs, unsanitary conditions, incomplete care plans, ineffective pain management, improper medication monitoring, infection control lapses, and unsafe environment hazards.
Deficiencies (20)
F159: The facility failed to ensure residents had ongoing access to their personal funds, including petty cash availability after hours and on weekends.
F164: The facility failed to provide privacy for residents during toileting and transfers, and lacked policies to ensure dignity.
F225: The facility failed to investigate and report a resident fall as required by regulations.
F226: The facility's abuse, neglect, and misappropriation policy was incomplete and outdated, lacking key components and crime reporting.
F242: The facility failed to accommodate and document resident choices for bathing schedules and waking times for multiple residents.
F248: The facility failed to provide ongoing activity programs that met the interests of residents during evenings and weekends.
F253: The facility failed to maintain a sanitary and comfortable environment, with multiple maintenance and housekeeping deficiencies noted.
F279: The facility failed to develop comprehensive care plans for sampled residents, including hospice care and pain management.
F280: The facility failed to invite resident and family participation in care planning for a sampled resident.
F309: The facility failed to provide effective pain management and failed to develop care plans addressing pain for a sampled resident.
F314: The facility failed to provide services to promote healing and prevent new pressure ulcers for a resident with a Stage 3 pressure ulcer.
F315: The facility failed to provide appropriate incontinence care and timely toileting, and failed to reassess voiding patterns after medication changes for residents.
F323: The facility failed to provide a safe environment by not addressing fall risks, incomplete fall investigations, and unsafe bathroom equipment.
F329: The facility failed to monitor effectiveness of as needed medications and behavioral medications, and failed to document targeted behaviors for psychotropic drugs.
F406: The facility failed to provide specialized rehabilitative services as required by the resident's PASSAR.
F428: The facility failed to monitor medication regimens monthly for effectiveness and adverse effects, including pain and behavioral medications.
F431: The facility failed to properly store medications and dispose of expired medications on medication carts.
F441: The facility failed to maintain infection control practices including hand hygiene, isolation precautions, and proper storage of oxygen equipment.
F463: The facility failed to maintain functioning call lights in resident bathrooms.
F465: The facility failed to maintain a safe, functional, sanitary, and comfortable environment, including exterior sidewalk repairs.
Report Facts
Resident census: 52
Fall Risk Assessment score: 10
Stage 3 pressure ulcer size: 3
Stage 4 pressure ulcer size: 1.8
Expired medication date: 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff D | Administrator | Named in multiple findings including privacy, fall investigations, care planning, infection control |
| Licensed nurse I | Licensed Nurse | Named in pain management and fall care findings |
| Direct care staff Q | Certified Nursing Assistant | Named in toileting and perineal care findings |
| Maintenance staff X | Maintenance Staff | Named in environmental and safety findings |
| Housekeeping staff Y | Housekeeping Staff | Named in environmental sanitation findings |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Nov 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 confirms that deficiencies previously reported under regulations 483.25(l), 483.60(a),(b), and 483.60(b),(d),(e) have been corrected as of 11/18/2012.
Deficiencies (3)
Regulation 483.25(l): Previously cited deficiency has been corrected as of 11/18/2012.
Regulation 483.60(a),(b): Previously cited deficiency has been corrected as of 11/18/2012.
Regulation 483.60(b),(d),(e): Previously cited deficiency has been corrected as of 11/18/2012.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 18, 2012
Visit Reason
This document is a Plan of Correction submitted by Westwood Manor in response to deficiencies cited during a complaint investigation.
Complaint Details
This Plan of Correction addresses deficiencies cited in a complaint investigation at Westwood Manor.
Findings
The facility was found deficient in assessing residents' pain levels before and after medication administration, documenting the placement and rotation of medication patches, and ensuring medication carts are securely locked when unattended.
Deficiencies (3)
F329-D: The facility failed to assess residents' pain levels prior to administration of pain medication and follow up on effectiveness. Licensed staff are now trained to assess and document pain levels before and after medication.
F425-D: The facility did not properly document the location and rotation of medication patches on the MAR. The medication administration policy was revised and staff training initiated to ensure proper documentation.
F431-E: The facility failed to ensure medication carts were securely locked when out of nurse's view. Staff training on locking medication carts is ongoing and monitoring is in place.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 3
Date: Oct 19, 2012
Visit Reason
Complaint investigations were conducted based on allegations identified by complaint numbers #59727, 59799, 60551, and 60928.
Complaint Details
The inspection was triggered by complaint investigations #59727, 59799, 60551, and 60928. The complaints involved medication administration and safety concerns.
Findings
The facility failed to properly monitor and assess the effectiveness of pain medications for multiple residents, failed to follow medication administration policies including patch placement and removal, and failed to keep medication carts locked when unattended.
Deficiencies (3)
F 329: The facility failed to monitor the effectiveness of pain medications and assess pain levels prior to and after administration for multiple residents, and did not document patch placement or rotation.
F 425: The facility failed to follow medication administration policies for multiple residents, including failure to remove previous medication patches before applying new ones and failure to document patch locations.
F 431: The facility failed to keep medication carts locked when unattended on multiple shifts, risking unauthorized access to medications.
Report Facts
Resident census: 46
Sample size: 5
Medication administrations: 17
Medication administrations: 15
Medication administrations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Stated expectations regarding medication patch removal and documentation, and medication cart security | |
| Licensed nurse C | Provided statements on medication administration procedures and medication cart security | |
| Direct care staff E | Commented on medication patch removal and medication cart locking |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: May 18, 2012
Visit Reason
This document is a Plan of Correction submitted by Westwood Manor in response to cited deficiencies from a prior inspection, outlining corrective actions to address the deficiencies.
Findings
The facility identified deficiencies related to perineal care, food preparation and storage, equipment maintenance, quality assurance processes, and employee health screening. Corrective actions include staff training, procedural changes, equipment repairs, and enhanced monitoring.
Deficiencies (5)
F315D: The facility will provide complete perineal care. A peri care clinic has been established requiring staff training and competency testing with ongoing education and daily monitoring.
F371F: The facility will prepare, store, and distribute food in a sanitary manner. Dietary staff changes and training on glove use, handwashing, food temperatures, and serving procedures have been implemented with ongoing monitoring.
F456E: The facility will maintain the stand-up lift to prevent skin tears and provide a clean surface during transfers. Torn upholstery will be replaced and inspection frequency increased to weekly with daily monitoring.
F520F: The facility will maintain a quality assessment and assurance committee to identify concerns, plan interventions, and monitor effectiveness with monthly meetings and external vendor support.
S0815E: The facility has implemented a system to ensure new employees receive a TB skin test upon hiring, with monitoring by the Business Office Manager and DON prior to work start.
Report Facts
Date of completion: May 18, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valarie Harris | Received peri care training | |
| Stacy Hughes | Received peri care training | |
| Charlotte Bozeman | Received peri care training | |
| Nona | Received peri care training | |
| Carlaroyer | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: May 18, 2012
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency with regulation number 28-39-161 (ID Prefix S0815) was corrected as of 05/18/2012. No other deficiencies or findings are noted.
Deficiencies (1)
Regulation 28-39-161 deficiency identified by prefix S0815 was corrected on 05/18/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 18, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as indicated in the facility's plan of correction.
Findings
The revisit confirmed that all previously reported deficiencies identified on the CMS-2567 have been corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: May 10, 2012
Visit Reason
The inspection was conducted as a Non-Compliant Revisit and Complaint Investigations related to infection control and tuberculosis testing compliance.
Complaint Details
The visit was triggered by complaint investigations #KS00057001, #KS00057051, and #KS00056892. The findings confirmed noncompliance related to tuberculosis testing for new employees.
Findings
The facility failed to have evidence of tuberculosis (TB) skin testing for five employees who began employment without documented TB tests. The facility did not maintain a system to ensure new employees received TB skin tests upon hiring.
Deficiencies (1)
28-39-161 Infection Control: The facility failed to have evidence of tuberculosis skin testing for five employees who began employment without documented TB tests. The facility did not maintain a system to ensure new employees received TB skin tests upon hiring.
Report Facts
Census: 52
Employees without TB testing evidence: 5
Inspection Report
Plan of Correction
Deficiencies: 13
Date: 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 corrective actions addressing multiple deficiencies including care plan revisions for residents, staff in-service training, monitoring of medication administration, nutritional interventions, infection control, and equipment maintenance.
Deficiencies (13)
F0000: This plan of correction constitutes a written allegation of substantial compliance with federal Medicare and Medicaid requirements and outlines facility-wide corrective actions.
F279-D: The care plan for resident #16 was revised to address dental needs with an appointment made at the Marion Clinic; care plans will be reviewed regularly to assure dental needs are addressed.
F280-D: The care plan for resident #66 was revised to address pain relief methods if pain medication is held; care plans will be reviewed quarterly with random audits.
F309-D: Nursing staff were in-serviced on documenting held medications and contacting physicians if interventions are ineffective; monitoring will ensure procedures are followed.
F318-D: Physician order discontinued hand cone/roll for resident #33 due to agitation; nursing staff will be educated on obtaining physician orders and restorative program changes discussed weekly.
F325-G: Nursing staff re-inserviced on documentation of health shakes; care plans revised for residents #13 and #14 addressing nutrition and assistance with meals; weekly dietitian visits implemented.
F329-E: Care plans for residents with black box medication warnings were completed; pharmacy consultant monitors medication use monthly; DON reviews new orders and side effect care plans quarterly.
F371-F: Dietary equipment cleaned and placed on schedule; staff in-serviced on food handling and hygiene; dish machine to be replaced and monitored for proper function.
F412-D: Care plan for resident #16 revised for dental needs; licensed nurse completed pain assessment; nursing staff re-inserviced on dental care provision; social service audits medical records for compliance.
F425-D: Licensed nurses in-serviced on documenting accu checks and insulin administration; medication aides in-serviced on medication documentation; random audits of physician orders conducted.
F428-D: DON reviews new orders and side effect care plans for residents #48 and #13; monitors monthly drug regime review and reports to Quality Assurance Committee.
F441-F: Housekeeping in-serviced on cleaning techniques; chemical dispatch obtained for C-Diff cleaning; infection control worksheet implemented and reviewed weekly; nursing staff in-serviced on form use.
F456-D: Wheelchairs cleaned and repaired; nursing staff in-serviced on cleaning schedule; maintenance inspects weekly; administrator monitors during rounds.
Report Facts
Date of Plan of Correction completion: Apr 3, 2012
Number of residents referenced: 8
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 12
Date: Mar 14, 2012
Visit Reason
Health resurvey inspection to verify compliance with previously cited deficiencies and assess overall facility regulatory compliance.
Findings
The facility had multiple deficiencies including failure to develop and revise comprehensive care plans, failure to provide dental services, failure to provide alternative pain management, failure to maintain equipment and sanitary conditions, and failure to monitor medication regimens and side effects.
Deficiencies (12)
F279: Facility failed to develop a comprehensive care plan for resident #16 addressing dental needs despite documented cavities and pain.
F280: Facility failed to revise care plan for resident #66 to include pain management interventions during medication hold.
F309: Facility failed to provide alternative pain relief methods for resident #66 when pain medications were held and failed to document and monitor pain behaviors.
F318: Facility failed to provide a hand cone/splint as ordered for resident #33 with limited range of motion.
F325: Facility failed to prevent weight loss for residents #13 and #4 by not providing ordered nutritional supplements consistently and failing to document intake and provide assistance.
F329: Facility failed to ensure residents #48, #64, #13, #60, and #43 did not receive unnecessary or duplicative psychotropic medications and failed to monitor for side effects.
F371: Facility failed to maintain sanitary food preparation areas, failed to wash hands during meal preparation, and failed to maintain hair restraints in the kitchen.
F412: Facility failed to provide necessary dental services to resident #16 despite documented dental pain and poor dentition.
F425: Facility failed to monitor administration of insulin for resident #1 and failed to monitor administration of Fosamax for resident #4 as ordered.
F428: Facility failed to ensure pharmacist reported irregularities for residents #48, #13, and #43 regarding psychotropic medication use and failed to monitor for black box warnings.
F441: Facility failed to prevent cross-contamination and properly sanitize rooms of residents with C-Diff, failed to perform timely infection control surveillance, and failed to follow policy for disinfecting.
F456: Facility failed to maintain wheelchairs in safe and clean condition for residents #5 and #32.
Report Facts
Resident census: 51
Resident sample size: 21
Weight loss: 21
Fosomax dose: 70
Insulin doses missed: 9
Wheelchair arm pad damage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff V | Housekeeping Staff | Observed cleaning contact isolation room with improper glove use and cross contamination |
| Staff T | Dietary Staff | Observed not washing hands, improper glove use, and reported dishwasher temperature issues |
| Staff M | Direct Care Staff | Reported resident #66 voiced pain but was not offered non-pharmacological alternatives |
| Staff D | Administrative Licensed Nurse | Unaware of dental pain for resident #16 and failure to develop dental care plan |
| Staff H | Licensed Nursing Staff | Unaware of resident #66 pain and non-pharmacological alternatives; confirmed medication hold |
| Staff J | Licensed Nursing Staff | Confirmed medication holds and lack of exact timing for resumption |
| Staff N | Direct Care Staff | Reported nursing staff had schedule for wheelchair maintenance |
| Consultant Staff X | Consultant Pharmacist | Identified medication irregularities and lack of medical justification for psychotropic drugs |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089019 POC 44IE11
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility identified by State ID N089019 and Event ID 44IE11.
Findings
No deficiencies or findings are detailed in this document. It serves solely as a record of the Plan of Correction submission.
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