Inspection Reports for The Evangelical Lutheran Good Samaritan Society
810 E. 30TH AVE, HUTCHINSON, KS, 67502
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 5, 2019, found no deficiencies and confirmed the facility was in compliance with all surveyed regulations. Earlier inspections showed a pattern of deficiencies primarily related to resident care issues such as bathing preferences, oxygen tubing management, infection control, dementia education, medication administration, and pressure ulcer prevention. Complaint investigations mostly identified issues with care planning, supervision, and medication management, with one substantiated case involving inadequate monitoring of anticoagulant therapy that resulted in a resident’s hospitalization and death. Enforcement actions included denial of payment for new Medicare and Medicaid admissions at various times due to substandard care findings, but fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, as more recent inspections show correction of prior deficiencies and achievement of substantial compliance.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
27.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
357% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
64 residents
Based on a January 2019 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
An offsite revisit survey was conducted on 03/05/2019 for all previous deficiencies cited on 01/30/2019.
Findings
All deficiencies have been corrected as of the compliance date of 02/28/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Feb 5, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report dated 01/30/2019. It outlines corrective actions to address specific deficiencies related to resident care and facility practices.
Findings
The plan addresses deficiencies including resident bathing preferences, oxygen tubing management, and dementia education for staff. Root cause analyses were completed, and corrective actions such as staff education, audits, and procedural updates are planned to ensure substantial compliance by 02/28/2019.
Deficiencies (3)
Resident #51's care plan did not match bathing preference; emergency bathing procedure needed updating.
Oxygen tubing for residents #22 and #51 was not properly managed; storage and staff education required.
All residents potentially affected by lack of dementia education among staff; education and audits planned.
Report Facts
Complete Date: Feb 28, 2019
Audit Frequency: 4
Audit Frequency: 3
Audit Frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Janda | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 30, 2019
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at a 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective 02/28/2019.
Deficiencies (1)
Most serious deficiency at a 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 3
Date: Jan 30, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations for multiple complaint case numbers.
Complaint Details
The visit was triggered by complaint investigations identified by case numbers KS00128367, KS00125309, KS00125262, and KS00122003.
Findings
The facility failed to ensure residents received baths according to their schedules and failed to implement proper infection control practices related to respiratory care. Additionally, the facility did not provide required annual dementia care in-service training for most nurse aides sampled.
Deficiencies (3)
Failed to ensure 2 of 5 residents reviewed for activities of daily living were given baths according to their bathing schedule.
Failed to implement infection control practices related to respiratory care when resident's oxygen tubing and nasal cannula touched the floor and was reused without cleansing or changing, and failed to store oxygen tubing according to infection control standards.
Failed to provide required annual dementia care in-service training for 4 of 5 direct care staff sampled.
Report Facts
Facility census: 64
Residents reviewed for ADLs: 5
Residents not bathed per schedule: 2
Direct care staff sampled for training: 5
Direct care staff without required training: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 12, 2018
Visit Reason
A complaint survey was conducted on 3/12/18 for complaint #KS127358.
Complaint Details
Complaint #KS127358 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 23, 2018
Visit Reason
An off-site survey was conducted to verify correction of deficiencies cited on January 2, 2018.
Findings
The deficiencies cited in the prior inspection were corrected as of the compliance date of January 18, 2018.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jan 18, 2018
Visit Reason
This document is a Plan of Correction submitted in response to a statement of deficiencies identified during a prior inspection. It outlines corrective actions to address issues related to workplace investigations and policies for abuse and neglect.
Findings
The plan details root cause analyses and corrective actions including updates to guidelines and policies, staff education, and ongoing audits to ensure compliance with abuse and neglect reporting and investigation procedures.
Deficiencies (3)
Guidelines for Conducting Workplace Investigations were updated and staff educated on handling evidence, investigating violations, and protecting residents.
Policy and Procedure for Abuse and Neglect was updated and staff educated on reporting all alleged rough treatment to appropriate leadership and the State Survey and Certification Agency.
Policy and Procedure for Abuse and Neglect was updated and staff educated on fully investigating allegations of rough treatment and documenting investigations.
Report Facts
Complete Date: Jan 18, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Janda | Administrator | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 2, 2018
Visit Reason
An abbreviated survey was conducted on January 2, 2018, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the facility was in substandard care for deficiency F607, with a severity level initially 'F' but later reduced to 'C'. Due to the history of noncompliance, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions effective January 23, 2018.
Deficiencies (1)
Substandard quality of care related to F607, CFR 483.12(b)(1)-(3)
Report Facts
Civil Money Penalty minimum amount: 10483
Enforcement effective date: Jan 23, 2018
Substantial compliance deadline: Jul 2, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to instructions for informal dispute resolution and contact for questions |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 3
Date: Jan 2, 2018
Visit Reason
The inspection was a partial extended survey conducted in response to complaint investigations #123951 and #124419.
Complaint Details
The complaint investigation involved allegations of staff mistreatment of resident #3, who reported rough and rude peri care by a nurse. The resident could not recall specific details about the incident. The facility investigated but did not report the allegation to the State agency, concluding no proof of mistreatment. The investigation lacked thoroughness, missing interviews with other residents or staff and documentation.
Findings
The facility failed to develop adequate written policies regarding abuse, neglect, and exploitation, specifically lacking guidance on handling evidence, investigation procedures, and protective measures. Additionally, the facility failed to report one alleged staff mistreatment to the State agency and did not thoroughly investigate the allegation, lacking documentation and interviews with other residents or staff.
Deficiencies (3)
Failed to develop written abuse, neglect, and exploitation policies including guidance on handling evidence, investigation, and protective measures.
Failed to report to the State agency one alleged violation of staff mistreatment.
Failed to thoroughly investigate one allegation of staff mistreatment, including lack of documentation and incomplete interviews.
Report Facts
Residents in census: 69
Residents in sample: 3
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Interviewed regarding policies and investigation follow-up | |
| Social service staff E | Interviewed resident and documented concerns | |
| Direct care staff D | Interviewed about resident complaints and care | |
| Licensed nursing staff B | Interviewed about resident care and staff behavior | |
| Administrative nursing staff F | Followed up on resident concern form and investigation |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 19, 2017
Visit Reason
An offsite visit was completed on 10/19/2017 to verify correction of previous deficiencies cited on 09/15/2017.
Findings
The deficiencies previously cited have been corrected and no new non-compliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Sep 21, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection identifying deficiencies related to resident care, including infection control, falls, pressure ulcer prevention, lab result management, and transfer assistance.
Findings
The plan addresses multiple deficiencies including inaccurate MDS documentation, fall risk and care plan updates, pressure ulcer prevention and repositioning protocols, antibiotic treatment follow-up, lab result communication, and proper resident transfers. The facility outlines corrective actions, staff education, monitoring, and quality assurance processes to achieve substantial compliance by October 12, 2017.
Deficiencies (5)
Inaccurate MDS documentation related to infections and falls
Falls care plan interventions not updated or followed
Pressure ulcer prevention and repositioning protocols deficient
Failure to obtain and communicate lab results timely
Improper resident transfers and lack of care plan updates
Report Facts
Residents identified at high risk for pressure ulcers: 6
Residents reviewed for lab orders: 7
Date for substantial compliance: Oct 12, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Janda | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 15, 2017
Visit Reason
A Minimum Data Set survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency, isolated, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 10/12/2017.
Deficiencies (1)
Most serious deficiency was a 'D' level deficiency, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Named as contact and signatory related to findings and plan of correction acceptance. |
Inspection Report
Routine
Census: 66
Deficiencies: 5
Date: Sep 15, 2017
Visit Reason
The inspection was conducted as an MDS (minimum data set) Focus Survey to assess compliance with federal regulations related to resident assessments, care planning, pressure ulcer prevention and treatment, urinary tract infection treatment, fall prevention, and resident safety.
Findings
The facility was found deficient in accurately coding resident assessments, revising care plans after falls, providing timely and appropriate treatment for pressure ulcers and urinary tract infections, repositioning residents as care planned, and ensuring safe transfer practices. Specific failures included inaccurate MDS coding for UTIs and falls, failure to revise care plans after a fall, failure to provide timely antibiotic treatment for a UTI resistant to initial medication, failure to reposition residents leading to worsening pressure ulcers, and failure to implement appropriate fall prevention strategies and transfer assistance.
Deficiencies (5)
Failed to accurately code 2 of 12 sampled residents' MDS assessments for urinary tract infections and falls.
Failed to revise 1 of 12 resident's care plans after a fall.
Failed to provide care to prevent and treat pressure ulcers, including failure to reposition residents timely, float heels, and provide treatment orders for pressure ulcers.
Failed to provide timely treatment for a urinary tract infection with an appropriate antibiotic sensitive to the bacteria.
Failed to determine root cause and implement appropriate fall intervention after a fall and failed to ensure staff transferred resident as care planned.
Report Facts
Census: 66
Sampled residents: 12
MDS assessments inaccurate: 2
Care plans not revised: 1
Pressure ulcers stage 2: 3
Days antibiotic delayed: 6
Falls identified: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Administrative Nurse | Verified inaccurate MDS coding for UTI and falls |
| Nurse D | Administrative Nurse | Verified failure to revise care plan after fall and failure to implement fall prevention interventions |
| Nurse G | Licensed Nurse | Verified care plan lacked fall prevention revision and dressing orders for pressure ulcer |
| Nurse H | Licensed Nurse | Confirmed transfer assistance requirements and care plan deficiencies |
| Nurse I | Licensed Nurse | Discussed antibiotic treatment delay and dressing orders |
| Staff N | Direct Care Staff | Provided information on resident care and UTI history |
| Staff O | Direct Care Staff | Discussed resident transfer and repositioning practices |
| Staff M | Direct Care Staff | Observed transferring resident without assistance |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Aug 9, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were marked as corrected and completed as of the revisit date.
Deficiencies (8)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(e)(2)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.75(l)(1)
Inspection Report
Deficiencies: 1
Date: Jul 18, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective August 9, 2017.
Deficiencies (1)
Most serious deficiency was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to the survey findings and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jul 18, 2017
Visit Reason
This document is a Plan of Correction submitted by Good Sam Hutchinson in response to deficiencies cited during a facility inspection conducted on July 18, 2017.
Findings
The plan addresses multiple deficiencies related to resident care including pressure ulcer prevention, restorative nursing documentation, blood sugar monitoring, medication storage, food safety, and wound documentation. The facility outlines corrective actions, staff education, audits, and quality assurance measures to achieve substantial compliance by August 9, 2017.
Deficiencies (8)
Resident #43 required an every 2 hour turn schedule; 11 residents at high risk for pressure ulcers were reassessed and care plans updated.
Resident #35’s restorative program was reviewed; education provided to restorative aides regarding documentation.
Resident #69 had blood sugars out of parameters; insulin adjusted; residents on blood sugar monitors and psychotropic medications reviewed and care plans updated.
Unmarked and expired food items removed; cleaning protocols and audits implemented.
Pharmacist to review blood glucose readings monthly and notify DNS of irregularities; care plans updated for psychoactive medications.
Medication carts checked for expired medications; medication storage protocol developed and staff educated.
Treatment carts checked for used lancets and expired sanitation solution; staff educated on glucose monitoring and chemical rotation procedures.
Pressure ulcer documentation reviewed; nurses re-educated; audits to ensure documentation accuracy.
Report Facts
Residents at high risk for pressure ulcers: 11
Plan of correction compliance date: Aug 9, 2017
Inspection date: Jul 18, 2017
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 8
Date: Jul 18, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations related to multiple complaint numbers.
Complaint Details
The inspection included complaint investigations #110148, #109143, #100925, and #99452.
Findings
The facility was found deficient in multiple areas including failure to implement pressure ulcer prevention interventions, failure to provide restorative range of motion as planned, failure to ensure drug regimens were free from unnecessary drugs, failure to maintain sanitary food storage and kitchen cleanliness, failure to maintain infection control practices, and failure to maintain complete and organized clinical records.
Deficiencies (8)
Failure to implement planned interventions of repositioning every 2 hours for a resident with pressure ulcers.
Failure to perform nursing rehabilitation restoration as care planned for a resident with limited range of motion.
Failure to ensure residents did not receive unnecessary medications related to failure to monitor effectiveness of antianxiety medications and failure to notify physician of high blood glucose readings.
Failure to store food in a sanitary manner by having expired, undated food items and failure to maintain clean kitchen equipment.
Failure to maintain an infection control program by using expired cleaning solution, improper disposal of used lancets, and failure to wear gloves during blood glucose testing.
Failure to discard outdated medications in medication carts.
Failure to include systematically organized documentation of pressure ulcers in the medical record.
Failure to ensure the consultant pharmacist identified and reported missing behavior monitoring and failure to notify physician of blood glucose readings greater than 401.
Report Facts
Census: 63
Pressure ulcer measurements: 3
Blood sugar readings: 481
Blood sugar readings: 454
Blood sugar readings: 417
Expired medication dates: 5
Expired cleaning solution date: Jun 30, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Nurse | Observed not wearing gloves during blood sugar testing. |
| Staff T | Licensed Nurse | Observed placing used lancets into basket of clean lancets. |
| Staff S | Direct Care Staff | Reported checking medication carts weekly but unaware of need to check PRN medications. |
| Staff M | Housekeeping Staff | Used expired cleaning solution to clean bathrooms. |
| Staff Q | Dietary Staff | Reported kitchen equipment was heavily soiled and cleaning schedules were not followed. |
| Administrative Nursing Staff D | Administrator | Provided wound measurement data and reported on wound nurse leave and documentation issues. |
| Consultant Pharmacist Staff W | Consultant Pharmacist | Did not report irregularities related to missing behavior monitoring or physician notification of high blood sugars. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 29, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the previously cited deficiencies, including those under regulation 483.25(d)(1)(2)(n)(1)-(3), were corrected by 06/27/2017 as documented in the report.
Deficiencies (1)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3)
Report Facts
Date of revisit: Jun 29, 2017
Date correction completed: Jun 27, 2017
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 29, 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
The revisit confirmed that all previously cited deficiencies were corrected as of 06/15/2017, with no uncorrected deficiencies remaining.
Deficiencies (3)
Deficiency related to regulation 483.45(d)(e)(1)-(2)
Deficiency related to regulation 483.45(a)(b)(1)
Deficiency related to regulation 483.45(c)(1)(3)-(5)
Report Facts
Deficiencies corrected: 3
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 15, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 27, 2017.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Date: Jun 15, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#6466) related to concerns about the facility's failure to adequately monitor a resident who unintentionally touched another resident.
Complaint Details
The complaint investigation #6466 found that the facility failed to adequately monitor a resident with dementia and Alzheimer's disease who unintentionally touched another resident's chest. The facility determined the touch was unintentional and related to the resident's cognitive impairment.
Findings
The facility failed to adequately monitor one resident with advanced cognitive impairment who unintentionally touched another resident's chest area. The resident had a history of inappropriate sexual behaviors, and the care plan did not fully address monitoring in all common areas. Staff monitored the resident one-on-one after the incident, but the facility did not prevent unintentional touching in all common areas.
Deficiencies (1)
Failure to adequately monitor a resident to prevent unintentional touching of another resident in all common areas of the facility.
Report Facts
Facility census: 61
Sample size: 4
BIMS score: 8
Brief interview for mental status score: 6
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 6, 2017
Visit Reason
The visit was related to a complaint investigation concerning Resident #1's sexually inappropriate unintentional touching of a female resident, leading to evaluation and treatment at an external behavior unit.
Complaint Details
Complaint related to sexually inappropriate behavior by Resident #1; substantiation status not explicitly stated.
Findings
Resident #1 was taken to the Emergency Room and admitted to Kinsley Behavior Unit for evaluation and treatment of sexually inappropriate behavior. The facility implemented multiple corrective actions including private room placement, monitoring, staff education, and ongoing resident and staff interviews to ensure safety and compliance.
Deficiencies (1)
Resident #1 exhibited sexually inappropriate unintentional touching and comments requiring evaluation and treatment.
Report Facts
Monitoring frequency: 15
Interview frequency: 1
Interview frequency: 3
Interview frequency: 2
Interview frequency: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 25, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an 'E' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective June 15, 2017.
Deficiencies (1)
An 'E' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 3
Date: May 25, 2017
Visit Reason
The inspection was conducted as a complaint investigation (KS00116036) to evaluate concerns related to medication administration and pharmaceutical services at the facility.
Complaint Details
The complaint investigation KS00116036 focused on medication administration errors, including failure to hold medications per physician parameters and failure to administer medications due to unavailability or resident sleeping.
Findings
The facility failed to ensure that medications were administered according to physician orders, including holding Metoprolol when the resident's pulse was below ordered parameters, and failed to have a system to ensure medications were available and administered as ordered. The consultant pharmacist did not identify or report irregularities related to medication administration failures during the monthly drug regimen review for all sampled residents.
Deficiencies (3)
Failure to hold Metoprolol when resident's pulse was below physician ordered parameters.
Failure to ensure accurate pharmaceutical services including dispensing and administration of medications as ordered for 5 of 5 residents.
Failure of consultant pharmacist to identify and report drug regimen irregularities related to medication availability and administration for 5 of 5 residents.
Report Facts
Census: 62
Residents sampled: 5
Medication administration failures: 59
Medication administration failures: 3
Medication administration failures: 4
Medication administration failures: 3
Medication administration failures: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Interviewed regarding medication administration failures and consultant pharmacist reporting |
| Consultant Pharmacist E | Consultant Pharmacist | Failed to identify and report medication irregularities during monthly drug regimen review |
| Direct Care Staff B | Direct Care Staff | Reported re-approaching residents to administer medications if initially found sleeping |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: May 25, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation related to medication administration and monitoring.
Complaint Details
This Plan of Correction is linked to the Gd Sam Hutchinson complaint dated 05/25/2017.
Findings
The plan addresses multiple deficiencies including failure to follow medication parameters, missed medication doses, and inadequate monitoring. Corrective actions include education, audits, root cause analysis, and ongoing quality assurance reviews.
Deficiencies (3)
Failure to follow medication parameters for Metoprolol Tartrate and other residents with specific hold orders based on vital signs.
Multiple residents had medications not given as ordered, with notification to MD and DPOA and audits planned.
Consultant pharmacist training and audits to monitor medication administration irregularities including missed, unavailable, refused, or sleeping residents.
Report Facts
Complete Date: Jun 15, 2017
Audit Frequency: 3
Audit Frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Janda | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 21, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the previously cited deficiency related to regulation 483.45(a)(b)(1) was corrected as of 05/02/2017. No other deficiencies were noted in this report.
Deficiencies (1)
Deficiency related to regulation 483.45(a)(b)(1)
Report Facts
Deficiency correction date: May 2, 2017
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 28, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all cited deficiencies related to regulations 483.24, 483.25(k)(l), 483.45(d)(e)(1)-(2), and 483.45(c)(1)(3)-(5) were corrected as of 04/28/2017.
Deficiencies (3)
Deficiency related to regulation 483.24, 483.25(k)(l)
Deficiency related to regulation 483.45(d)(e)(1)-(2)
Deficiency related to regulation 483.45(c)(1)(3)-(5)
Inspection Report
Re-Inspection
Census: 66
Deficiencies: 1
Date: Apr 28, 2017
Visit Reason
This inspection was a non-compliance revisit to verify correction of previously cited deficiencies related to pharmaceutical services and accurate medication administration.
Findings
The facility failed to ensure one resident received accurate doses of Coumadin as ordered, with doses given incorrectly on consecutive days. Interviews with nursing staff confirmed the medication was not administered according to the physician's alternating dose order.
Deficiencies (1)
Failure to ensure accurate medication administration with doses of Coumadin given incorrectly for one resident.
Report Facts
Census: 66
Residents reviewed for unnecessary medications: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nursing Staff | Interviewed regarding medication administration and PT/INR testing |
| Administrative Nurse A | Administrative Nurse | Interviewed regarding medication order clarification |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 28, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective May 2, 2017.
Deficiencies (1)
A 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and coordinator related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 26, 2017
Visit Reason
The plan of correction addresses deficiencies related to a Coumadin medication error identified during a prior inspection.
Findings
The Director of Nursing notified the physician of a medication error involving resident #10, conducted a root cause analysis, reviewed all residents with Coumadin orders, and provided education and training to licensed nurses to prevent recurrence. The facility implemented systemic changes including daily audits and competency checks to ensure compliance.
Deficiencies (1)
Coumadin medication error involving resident #10
Report Facts
Date of root cause analysis and corrective actions: Apr 26, 2017
Date of substantial compliance: May 2, 2017
Date of QAPI committee review: May 3, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Notified physician of medication error and led root cause analysis |
| Quality Performance Improvement Consultant | Quality Performance Improvement Consultant | Completed root cause analysis with floor nurse |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Date: Mar 30, 2017
Visit Reason
Partial extended abbreviated survey conducted for complaint investigation #KS00112259 regarding resident care and monitoring.
Complaint Details
Complaint investigation #KS00112259 focused on inadequate care and monitoring of resident #1 who was on anticoagulant therapy and experienced a change in condition leading to hospitalization and death.
Findings
The facility failed to ensure adequate assessment and monitoring of resident #1 who was on anticoagulant therapy, resulting in delayed lab monitoring and failure to detect signs of bleeding. The resident was transferred to the emergency room with septic shock and elevated INR and subsequently died. The facility also failed to act on pharmacy consultant recommendations regarding lab monitoring.
Deficiencies (3)
Failure to perform timely and adequate assessments including vital signs monitoring for resident #1 prior to transfer to emergency room.
Failure to monitor and report potential signs and symptoms of anticoagulant therapy complications and failure to obtain ordered PT/INR labs for over 2 months.
Failure to act upon pharmacy consultant recommendations to obtain required PT/INR laboratory monitoring for resident #1.
Report Facts
Census: 68
PT lab values: 48.5
PT lab values: 41
PT lab values: 28.8
PT lab values: 21.7
PT lab values: 24
INR lab values: 5.2
INR lab values: 4.2
INR lab values: 2.7
INR lab values: 1.89
INR lab values: 2.14
Hemoglobin: 5.3
Hematocrit: 19.4
PT lab value: 90
INR lab value: 9
PTT lab value: 87.7
Temperature: 99
Oxygen saturation: 86
Oxygen saturation: 93
Oxygen saturation: 94
Blood pressure: 10858
Pulse: 92
Respirations: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Nursing Staff | Reported resident's change in condition, took vital signs, notified physician, attempted to contact DPOA |
| Staff C | Licensed Nursing Staff | Called family, arranged 911 transport to ER, reported resident condition |
| Staff E | Direct Care Staff | Noticed resident oxygen saturation in 80's, reported to nurse, took vitals multiple times |
| Staff H | Direct Care Staff | Provided total care, reported resident's odd respirations and pale skin |
| Staff L | Licensed Nursing Staff | Failed to enter lab order for PT/INR on treatment administration record |
| Staff B | Administrative Nursing Staff | Acknowledged failure to check PT/INR, planned improvements |
| Staff A | Administrative Staff | Expected vital signs and assessments to be documented, acknowledged failure to enter lab order |
| Staff Q | Consultant Pharmacy Staff | Identified missing PT/INR lab in February 2017, reported to DON and leadership |
| Physician I | Physician | Ordered Coumadin, instructed staff during resident's change in condition |
| Physician N | Physician | Reviewed ER findings, stated sepsis or blood loss caused death |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Mar 30, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the Good Sam Hutch complaint investigation dated 03/30/2017.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Good Sam Hutch dated 03/30/2017.
Findings
The plan outlines corrective actions including root cause analyses, staff education, audits, and monitoring to address deficiencies related to change in condition assessments, lab monitoring for residents on Coumadin, and pharmacy recommendation follow-up. The facility aims to achieve substantial compliance by 04/11/2017.
Deficiencies (3)
Deficiency related to proper assessment, follow-up, notification, and monitoring of residents with change in condition.
Deficiency related to lab monitoring and PT/INR tracking for residents receiving Coumadin.
Deficiency related to timely review and follow-up of pharmacy recommendations.
Report Facts
Dates for corrective actions and reviews: Apr 11, 2017
Frequency of PT/INR audits: 5
Frequency of pharmacy audits: 6
Dates of committee reviews: Apr 5, 2017
Dates of committee reviews: Apr 27, 2017
Dates of committee reviews: May 23, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 30, 2017
Visit Reason
An abbreviated survey was conducted on March 30, 2017, by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety related to F329, "J", CFR 483.45(d)(e)(1)-(2). Enforcement remedies including denial of payment for new Medicare and Medicaid admissions effective April 25, 2017, were imposed.
Deficiencies (1)
Noncompliance with F329, "J", CFR 483.45(d)(e)(1)-(2) constituting immediate jeopardy and substandard quality of care.
Report Facts
Denial of payment effective date: Apr 25, 2017
Provider agreement termination date: Sep 30, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Janda | Administrator | Facility administrator named in the report |
| Caryl Gill | Complaint Coordinator | Named as contact for questions regarding the letter and enforcement action |
| Lisa Hauptman | CMS contact for questions regarding the matter | |
| Codi Thurness | Commissioner | Commissioner of KDADS mentioned in relation to enforcement and dispute resolution |
| Teresa Fortney | Regional Manager | KDADS Regional Manager copied on the letter |
| Denise German | Director | KDADS Director copied on the letter |
| LaNae Workman | KDADS staff copied on the letter | |
| Benton Williams | CMS Survey & Certification Branch staff copied on the letter |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jan 24, 2017
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were completed.
Findings
The revisit inspection found that all previously cited deficiencies were corrected as of 01/24/2017, with no outstanding deficiencies noted.
Deficiencies (4)
Deficiency related to regulation 26-41-101 (g)
Deficiency related to regulation 26-41-106
Deficiency related to regulation 26-41-202 (d)
Deficiency related to regulation 26-41-104 (d)
Inspection Report
Re-Inspection
Census: 11
Deficiencies: 4
Date: Jan 11, 2017
Visit Reason
This inspection was a licensure resurvey of an Assisted Living/Residential Healthcare facility to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including failure to post policies and procedures related to resident services in an accessible location, failure to conduct resident council meetings quarterly, failure to review negotiated service agreements at least annually, and failure to conduct annual fire drills including resident evacuation.
Deficiencies (4)
Failure to ensure availability of policies and procedures related to resident services were posted in a place accessible to residents.
Failure to conduct resident council meetings on a quarterly basis between October 2015 and April 2016.
Failure to review at least once annually the negotiated service agreement for a resident.
Failure to conduct annual fire drills that included evacuation of residents to a secure location.
Report Facts
Residents present: 11
Resident sample size: 3
Months between fire drills with evacuation: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff A | Reported on policy availability and resident council meetings | |
| Direct care staff C | Reported on emergency fire drills and evacuation participation | |
| Administrative staff B | Verified fire drill dates and understanding of annual drill requirements | |
| Maintenance staff D | Verified fire drill dates |
Inspection Report
Life Safety
Deficiencies: 1
Date: Dec 15, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in 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. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm not constituting immediate jeopardy.
Report Facts
Effective date for denial of payments: 2017
Effective date for provider agreement termination: 2017
Days to submit plan of correction: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and responsible for enforcement |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 21, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report confirms that the previously reported deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Deficiency related to regulation 483.13(c) was corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 27, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be F226, a 'C' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
Deficiency F226, 'C' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Oct 27, 2016
Visit Reason
The inspection was conducted as a complaint survey (#107240) to investigate the facility's compliance with policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property.
Complaint Details
The complaint survey (#107240) found the facility did not meet requirements for ANE policies and training, specifically regarding unauthorized photographs/videos and social media. The training provided was incomplete and not mandatory, with some staff not attending.
Findings
The facility failed to develop and implement a policy including training for current and new staff regarding abuse, neglect, and exploitation (ANE) related to unauthorized photographs or video recordings of residents and social media networks. Approximately one-third of staff did not attend the ANE training meeting, and the existing training was not specific to recent CMS regulatory changes.
Deficiencies (1)
Failure to develop and implement a policy including training for staff regarding abuse, neglect, and exploitation related to unauthorized photographs or video recordings of residents and social media networks.
Report Facts
Facility census: 78
Staff attendance: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Interviewed regarding training and policy implementation for ANE and social media/photographs/videos |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 26, 2016
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified related to abuse and social media/photographs/video policies following a complaint investigation dated 10/27/2016.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Good Sam Hutch complaint 10272016.
Findings
The facility identified deficiencies related to abuse and social media/photographs/video policies that had the potential to affect all residents. The facility updated policies, re-educated staff, and implemented ongoing education and audits to ensure compliance.
Deficiencies (1)
Policies and procedures pertaining to abuse and social media/photographs/video were deficient and had the potential to affect all residents.
Report Facts
Dates for Quality Assurance Performance Improvement committee review: November 8th and December 13th, 2016
Date of policy review: 10/26/16
Date of RCA completion: 10/31/16
Mandatory staff education completion date: 11/21/16
Weekly education frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Baker | Director of Financial Services | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 12, 2016
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 the previously reported deficiencies, including the one identified under regulation 483.25(h), were corrected by 08/09/2016.
Deficiencies (1)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiency correction completion date: Aug 9, 2016
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 15, 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 the Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be at 'G' level, resulting in enforcement remedies including a denial of payment for new Medicare and Medicaid admissions effective October 15, 2016, until substantial compliance is achieved.
Deficiencies (1)
Most serious deficiency found at 'G' level
Report Facts
Denial of Payment effective date: Oct 15, 2016
Termination recommendation date: Jan 15, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: Jul 15, 2016
Visit Reason
The inspection was conducted as a result of complaint investigations KS00101976, KS00102742, and KS00101286 focusing on resident falls and supervision.
Complaint Details
The visit was complaint-related, investigating allegations regarding inadequate supervision and fall prevention for residents who experienced multiple falls with injuries.
Findings
The facility failed to provide adequate supervision and fall prevention interventions for two sampled residents who experienced multiple falls, including serious injuries such as fractured ribs and closed head injury. Root cause analyses were consistently incomplete or missing, and appropriate interventions were not developed or implemented after falls.
Deficiencies (1)
Failure to provide adequate supervision and fall prevention interventions for residents with repeated falls, including failure to complete root cause analyses and implement interventions.
Report Facts
Census: 73
Residents sampled: 3
Falls documented for Resident #2: 7
Falls documented for Resident #1: 5
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 15, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the Good Sam Hutchinson complaint investigation dated 07/15/2016.
Complaint Details
This plan of correction is related to the Good Sam Hutchinson complaint dated 07/15/2016.
Findings
The plan addresses deficiencies related to fall prevention, bowel and bladder assessments, staff education, and implementation of a falls performance improvement plan. The facility aims to achieve substantial compliance by 08/09/2016.
Deficiencies (1)
Need for bowel and bladder assessment for residents and staff education on fall prevention policies and interventions.
Report Facts
Dates referenced: Jul 20, 2016
Dates referenced: Jul 13, 2016
Dates referenced: Jul 21, 2016
Compliance target date: Aug 9, 2016
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 7, 2015
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies listed with their regulation numbers were corrected as of the revisit date, December 7, 2015.
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Dec 7, 2015
Visit Reason
This document is a Plan of Correction submitted by Good Sam Hutchinson Village in response to deficiencies cited in a prior inspection report. It outlines corrective actions to address identified deficiencies and achieve substantial compliance by December 7, 2015.
Findings
The Plan of Correction details multiple corrective actions including care plan reviews and updates, pain management improvements, bathing preference adherence, bowel and bladder monitoring, medication monitoring, staffing improvements, and order entry accuracy. Root Cause Analyses were completed for each deficiency, and education and audits are planned to ensure compliance.
Deficiencies (8)
Resident care plans were not consistently reviewed and updated.
Pain management assessments and physician notifications were incomplete.
Bathing preferences were not consistently honored or documented.
Inadequate monitoring and documentation of bowel and bladder function.
Inadequate monitoring of PT INR and orthostatic vital signs for residents on certain medications.
Staffing shortages and inadequate training identified.
Inaccurate entry and verification of physician orders in the electronic medical record.
Pharmacist involvement and medication monitoring processes needed improvement.
Report Facts
Deficiencies cited: 8
Audit frequency: 5
Dates of corrective actions: Nov 10, 2015
Dates of corrective actions: Nov 19, 2015
Dates of corrective actions: Dec 7, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Janda | Administrator | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Date: Nov 9, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 7, 2015.
Deficiencies (1)
Most serious deficiencies found were an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter regarding enforcement and plan of correction acceptance. |
Inspection Report
Census: 70
Deficiencies: 8
Date: Nov 9, 2015
Visit Reason
The inspection was a Health Resurvey and complaint investigations for Good Samaritan Society - Hutchinson Village.
Findings
The facility failed to review and revise care plans for two residents regarding falls and pain management, failed to provide adequate pain management, failed to ensure dependent residents received baths as care planned, failed to implement fall prevention interventions, failed to secure hazardous items, failed to monitor medications adequately, failed to transcribe physician orders correctly, and failed to maintain sufficient nursing staff to meet resident needs.
Deficiencies (8)
Failed to review and revise care plans for 2 sampled residents regarding falls and pain.
Failed to provide necessary care and services to maintain highest practicable physical and mental well-being related to pain management for 1 resident.
Failed to ensure dependent residents received baths as care planned for 2 residents.
Failed to implement planned interventions to prevent repeated falls for 1 resident and failed to secure hazardous items accessible to cognitively impaired residents.
Failed to ensure adequate medication monitoring for 2 residents, including blood pressure and lab monitoring.
Failed to have sufficient 24-hour nursing staff to meet resident needs, including pain management, bathing, supervision, and accident prevention.
Failed to provide accurate transcription of physician orders resulting in a resident not receiving ordered medications for 10 days.
Failed to ensure consultant pharmacist identified medication irregularities and report them to physician and director of nursing, and failed to act on pharmacist recommendations.
Report Facts
Residents sampled: 23
Residents with deficiencies: 6
Baths missed: 9
Baths missed: 14
Blood pressure readings below threshold: 9
Days medication not administered: 10
Months since last PT/INR lab: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide Q | Nurse Aide | Verified storage cabinet was unsecured with hazardous items accessible |
| Administrative Nurse B | Administrative Nurse | Stated storage cabinet should be locked and confirmed resident did not receive medications due to transcription error |
| Licensed Nurse J | Licensed Nurse | Provided list of residents needing baths and described blood pressure monitoring procedures |
| Consultant Pharmacist W | Consultant Pharmacist | Reported failure to monitor PT/INR labs and blood pressure irregularities |
| Physician Extender U | Physician Extender | Notified of missed medications for resident #10 |
| Licensed Nursing Staff D | Licensed Nurse | Identified missed medications for resident #10 |
| Licensed Nursing Staff C | Licensed Nurse | Described admission medication order check process |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 14, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was not in substantial compliance with Life Safety Code requirements.
Deficiencies (1)
Facility found to have an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Oct 14, 2015
Provider agreement termination date: Jan 14, 2016
Days to request Informal Dispute Resolution: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 16, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously cited in the Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were found to be corrected as of 08/14/2014, with no uncorrected deficiencies noted during this revisit.
Report Facts
Deficiency corrections: 17
Inspection Report
Plan of Correction
Deficiencies: 16
Date: Jul 19, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior statement of deficiencies, outlining corrective actions to address cited deficiencies and ensure compliance.
Findings
The plan details multiple corrective actions including staff education, audits, care plan updates, and monitoring related to dignity, call light accessibility, bowel and bladder assessments, pain management, oral care, skin assessments, medication orders, food service, and dental care. The facility aims to achieve substantial compliance by August 14, 2014.
Deficiencies (16)
Dignity and respect of individuality for all residents
Call light accessibility in bathing rooms
72 hour bowel and bladder assessment and care plan updates
Care plan revisions for left shoulder pain and interventions
Pain assessment and care plan updates for residents with wounds
Assistance with oral care and denture care
Thorough skin assessment and interventions for pressure relief
Bowel and bladder assessments for new admissions and changes
Audit and control of chemicals and gait belt availability
Medication orders review and blood pressure parameter audits
Proper food temperature and handling
Honoring resident food choices and offering substitutes
Proper handling of food services and items like straws
Following dentist recommendations and denture care audits
Care plan interventions for dentures and poor fitting dentures
Verification and audit of medication orders by pharmacist
Report Facts
Audit frequency: 8
Audit frequency: 4
Audit frequency: 5
Audit frequency: 3
Audit percentage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Janda | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jul 16, 2014
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. The visit was triggered by deficiencies found and a history of noncompliance from a prior complaint investigation.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the deficiencies and prior noncompliance, the facility was not given an opportunity to correct before enforcement remedies were imposed, including denial of payment for all new Medicare admissions effective August 4, 2014.
Deficiencies (1)
Deficiency related to F314, Pressure Ulcers, indicating noncompliance with prevention and care requirements.
Report Facts
Effective date of denial of payment: Aug 4, 2014
Timeframe for potential termination: Jan 16, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Janda | Administrator | Facility administrator named in the report header |
| Irina Strakhova | Enforcement Coordinator | Named as contact for questions concerning the instructions in the letter |
| Joe Ewert | Commissioner | Recipient of written requests for Informal Dispute Resolution |
| Sherriann Pater | Branch Manager | Authorized the report |
Inspection Report
Census: 71
Deficiencies: 16
Date: Jul 16, 2014
Visit Reason
The inspection was a Health Resurvey and Complaint investigations for multiple complaint numbers.
Complaint Details
The inspection included complaint investigations for complaint numbers KS00076805, KS00075573, KS00075623, and KS00075867.
Findings
The facility was cited for multiple deficiencies including failure to promote dignity and respect, failure to accommodate resident needs, failure to develop comprehensive care plans especially related to urinary incontinence, inadequate pain management, failure to provide appropriate denture care, failure to prevent and treat pressure ulcers, failure to implement appropriate toileting schedules, failure to maintain a safe environment, failure to avoid unnecessary medications, failure to ensure food temperature and substitutions, failure to handle food hygienically, and failure to provide routine and emergency dental services.
Deficiencies (16)
Facility failed to address residents by their preferred names in the dining room.
Call light in the 100 hall bathhouse was not accessible to residents using the whirlpool.
Failed to develop comprehensive care plans related to urinary incontinence for 2 residents.
Failed to revise care plan for resident #120 regarding pain after emergency room visit.
Failed to ensure adequate pain management for resident #69 with fractures and pressure ulcer.
Failed to provide denture care assistance and apply Fixodent as recommended for resident #116.
Failed to provide necessary treatment and services to prevent and heal pressure ulcers for residents #69 and #116.
Failed to implement appropriate toileting schedules for residents #14 and #51 with urinary incontinence.
Failed to ensure resident environment free of accident hazards and implement fall interventions for resident #116; hazardous chemicals accessible to residents.
Failed to ensure residents free from unnecessary medications; lack of orders to restart Lasix for resident #53 and failure to monitor antihypertensive effectiveness for resident #120.
Failed to ensure food served was at proper temperature prior to service.
Failed to offer substitute food of similar nutritive value to residents who refused food.
Failed to properly handle resident straws without contaminating drinking surfaces.
Failed to follow dentist's recommendation for denture adhesive for resident #116.
Failed to implement planned denture care interventions for resident #28.
Failed to ensure consultant pharmacist identified and reported drug irregularities for resident #53.
Report Facts
Facility census: 71
Resident sample size: 19
Pressure ulcer wound size: 5.8
Pressure ulcer wound size: 3
Pressure ulcer wound size: 1.6
Blood pressure: 150
Blood pressure: 102
Blood pressure: 91
Blood pressure: 53
Blood pressure: 91
Blood pressure: 56
Average fluid intake: 1037
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Expected staff to follow care plans and verified lack of individualized toileting plan for resident #14 |
| Staff Q | Direct Care Staff | Assisted resident #14 and reported on toileting checks |
| Staff T | Licensed Nursing Staff | Confirmed care plan issues and toileting schedule for resident #14 |
| Staff N | Licensed Nursing Staff | Reported on blood pressure monitoring for resident #53 |
| Staff C | Dietary Staff | Reported food temperature procedures and expectations |
| Staff K | Direct Care Staff | Reported on denture care and resident #116's denture use |
| Staff J | Direct Care Staff | Reported on denture care and resident #28's oral care |
| Staff AA | Direct Care Staff | Reported on resident #69 pressure ulcer care |
| Staff F | Social Services Staff | Reported on dental appointments and resident #116 denture issues |
| Staff M | Maintenance Staff | Fixed lock to chemical storage and confirmed safety concerns |
| Staff O | Direct Care Staff | Reported chemical safety concerns and assisted residents |
| Staff P | Nursing Staff | Reported on chemical safety and blood pressure monitoring |
| Staff R | Direct Care Staff | Assisted resident #14 with toileting |
| Staff S | Direct Care Staff | Assisted resident #14 with toileting and reported on toileting care |
| Staff EE | Licensed Nurse | Interviewed about resident #51 incontinence and hospice care |
| Staff DD | Direct Care Staff | Interviewed about resident #51 incontinence care |
| Staff Y | Licensed Nurse | Performed dressing change for resident #69 pressure ulcer |
| Staff B | Administrative Nurse | Interviewed about resident #69 pain management and care plans |
| Staff EE | Licensed Nurse | Interviewed about resident #120 care plan and blood pressure monitoring |
| Staff GG | Pharmacy Consultant | Reported on pharmacy review and medication irregularities |
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 18, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: May 18, 2014
Provider agreement termination date: Aug 18, 2014
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process and cited deficiencies |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Sep 4, 2013
Visit Reason
This report documents a post-certification revisit to verify that previously identified deficiencies have been corrected as of the revisit date.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.30(a), 483.60(a),(b), and 483.75(o)(1) were corrected by 09/04/2013.
Deficiencies (3)
Deficiency related to regulation 483.30(a)
Deficiency related to regulation 483.60(a),(b)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Sep 4, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to achieve substantial compliance.
Findings
The plan addresses issues related to staffing levels and timely response to resident call lights, medication administration errors, and quality assurance processes. The facility implemented new procedures, staff education, and monitoring to ensure compliance and improvement in these areas.
Deficiencies (3)
Insufficient nursing staff coverage and delayed response to resident call lights.
Medication administration errors and lack of proper documentation and order verification.
Quality of care and quality of life concerns requiring ongoing quality assurance and improvement efforts.
Report Facts
Compliance deadline: Sep 4, 2013
Plan of Correction submission date: Aug 27, 2013
Plan of Correction addition date: Aug 16, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Janda | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 15, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from an earlier survey were corrected as of the revisit date.
Findings
The revisit report documents that all previously identified deficiencies were corrected by the revisit date of 08/15/2013, with multiple regulatory citations listed as corrected.
Report Facts
Deficiencies corrected: 26
Date of revisit: Aug 15, 2013
Date of original survey: Jun 14, 2013
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 3
Date: Aug 15, 2013
Visit Reason
The inspection was a Non-compliance Revisit and Complaint investigation triggered by complaints #66957 and #66752 regarding staffing and medication administration issues.
Complaint Details
The complaint investigation was related to staff not responding timely to resident call lights and failure to initiate and administer new medication orders properly. The investigation included observations, interviews, and record reviews confirming these issues.
Findings
The facility failed to ensure timely response to resident call lights, resulting in delayed assistance. Additionally, the facility failed to properly initiate and administer new physician medication orders for sampled residents, and lacked an effective Quality Assessment and Assurance program to address these deficiencies.
Deficiencies (3)
Failure to ensure staff responded to resident activated call lights in a timely manner.
Failure to have a system that ensured staff initiated new physician orders for medications for 2 of 3 sampled residents.
Failure to maintain a Quality Assessment and Assurance committee that develops and implements plans of action to correct identified quality deficiencies.
Report Facts
Facility census: 61
Call light activation duration: 24
Call light activation duration: 15
Medication administration delay: 2
Medication administration delay: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Nurse | Signed receipt for medications delivered on 6-16-13; reported new orders on MAR. |
| Administrative staff J | Administrative Staff | Reported on call light system, QA processes, and staffing guidelines. |
| Licensed nursing staff H | Licensed Nurse | Interviewed regarding staffing and call light response. |
| Direct care staff F | Direct Care Staff | Reported on call light response and staffing adequacy. |
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Jul 14, 2013
Visit Reason
This document is a Plan of Correction submitted by Good Sam Hutchinson facility in response to deficiencies cited during a prior inspection. It outlines corrective actions to address issues related to resident care, staff education, environment, and compliance with regulatory requirements.
Findings
The plan details multiple corrective actions including staff education on resident-specific care needs, pain management, privacy, dignity, nutrition, infection control, medication management, and environmental safety. It also describes implementation of monitoring, audits, and quality assurance activities to ensure compliance and ongoing improvement.
Deficiencies (19)
Residents at risk for skin issues and breakdown will be monitored and educated to prevent pressure sores.
Ensuring residents are dressed appropriately with privacy and dignity during care.
Staff re-education on reporting injuries, abuse, neglect, or exploitation immediately.
Care plans updated to include resident preferences and appropriate adaptive clothing.
Ensuring residents have appropriate equipment to meet their needs and preferences.
Coordination of resident rest times and activities of choice with nursing and therapy staff.
Environmental repairs and maintenance including doors, carpets, bathrooms, and labeling personal items.
Comprehensive care plans addressing pain, hygiene, and skin issues updated and monitored.
Dental care coordination and follow-up for residents with denture and dietary needs.
Comprehensive pain assessments and pain management procedures implemented and monitored.
Nail care services increased and scheduled for diabetic residents.
Sufficient staffing ensured with monitoring and education on assisting residents timely.
Daily posting and auditing of nurse staffing data sheets.
Dietary cleaning schedules and food preparation procedures improved and monitored.
Behavior care plans updated and medication monitoring enhanced for residents on psychoactive drugs.
Medication administration records double-checked and audits conducted for accuracy and compliance.
Expired medications disposed and medication storage secured with staff education.
Infection control program enhanced with staff education and environmental improvements.
Quality Assurance committee established to monitor and improve quality of care and compliance.
Report Facts
Residents at risk: 309
Dates of staff education: Jul 14, 2013
Resident discharge date: Jun 19, 2013
Dental appointment date: Aug 14, 2013
Incident report review frequency: 1
Deep cleaning frequency: 6
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 17
Date: Jun 14, 2013
Visit Reason
The inspection was an extended health resurvey and complaint investigation into complaints regarding resident care, privacy, abuse, staffing, and facility conditions.
Complaint Details
The inspection was triggered by complaints regarding resident privacy, abuse, neglect, staffing shortages, and quality of care issues including pain management and infection control.
Findings
The facility failed to ensure resident privacy, conduct proper background checks on staff, investigate abuse allegations, provide adequate care including pain management, nutrition, grooming, and pressure ulcer prevention, maintain a safe environment, and ensure sufficient staffing. Multiple deficiencies were cited related to resident rights, care planning, medication management, infection control, and facility maintenance.
Deficiencies (17)
Failure to honor residents' right to personal privacy by not ensuring residents were properly covered during care.
Failure to check licensure boards and obtain criminal background checks on new employees, and failure to thoroughly investigate and report abuse allegations.
Failure to promote dignity and respect by not dressing residents appropriately and putting clothing protectors on without permission.
Failure to provide choice of shower for resident unable to use shower chair due to size and pain.
Failure to accommodate resident's need for a larger shower chair to allow showering as desired.
Failure to provide ongoing activities program meeting residents' interests and needs, including assistance to attend preferred activities.
Failure to provide housekeeping and maintenance services to maintain sanitary, orderly, and comfortable interior, including proper storage of personal care items and repair of resident bathroom doors and walls.
Failure to develop comprehensive care plans addressing pain, skin and wound care, nutrition, and sleep hygiene for multiple residents.
Failure to involve residents in care planning and revise care plans to address ill-fitting dentures.
Failure to ensure registered nurses completed comprehensive pain assessments.
Failure to provide care and services to attain or maintain highest practicable well-being, including pain management, wound care, nutrition, and fall prevention.
Failure to maintain a safe environment free of accident hazards, including unsecured chemicals and unlocked exterior doors.
Failure to post nurse staffing information in a prominent, accessible place with total hours worked by licensed and unlicensed staff.
Failure to prepare and serve food under sanitary conditions, including failure to clean equipment and food contact surfaces properly.
Failure to provide or obtain dental services for resident with ill-fitting dentures.
Failure to provide pharmaceutical services ensuring emergency biologicals, accurate medication administration, and monitoring of medication effectiveness and side effects.
Failure to maintain infection control practices including hand hygiene, proper cleaning of isolation rooms, and sanitary storage of personal care equipment.
Report Facts
Residents present: 69
Residents sampled: 27
Medication errors: 10
Medication errors: 2
Medication errors: 3
Medication errors: 10
Weight loss: 12.6
Weight loss percent: 5.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse K | Licensed Nurse | Named in multiple findings including pain management and abuse investigation |
| Nurse C | Administrative Nurse | Named in multiple findings including pain management and infection control |
| Nurse EE | Licensed Nurse | Named in medication and infection control findings |
| Staff BB | Direct Care Staff | Named in medication administration and infection control findings |
| Staff G | Direct Care Staff | Named in pain management and staffing findings |
| Staff H | Direct Care Staff | Named in pain management and staffing findings |
| Staff X | Direct Care Staff | Named in pain management and staffing findings |
| Staff Y | Direct Care Staff | Named in staffing and infection control findings |
| Staff JJ | Direct Care Staff | Named in privacy and infection control findings |
| Staff RR | Social Service Staff | Named in privacy and resident care findings |
| Staff EE | Licensed Nurse | Named in grooming and infection control findings |
| Staff NN | Social Service Staff | Named in resident care findings |
| Staff PP | Administrative Nurse | Named in pain management findings |
| Staff MM | Consultant Staff | Named in nutrition findings |
| Staff T | Dietary Staff | Named in nutrition and kitchen sanitation findings |
| Staff W | Housekeeping Staff | Named in sanitation and infection control findings |
| Staff OO | Housekeeping Staff | Named in infection control findings |
| Staff DD | Direct Care Staff | Named in infection control findings |
| Staff EE | Licensed Nurse | Named in infection control findings |
| Staff NN | Direct Care Staff | Named in infection control findings |
| Staff PP | Direct Care Staff | Named in pain management findings |
| Staff HH | Direct Care Staff | Named in pain management and infection control findings |
| Staff DD | Direct Care Staff | Named in infection control findings |
| Staff EE | Licensed Nurse | Named in infection control findings |
| Staff LL | Direct Care Staff | Named in nutrition findings |
| Staff VV | Direct Care Staff | Named in behavioral findings |
| Staff S | Licensed Nurse | Named in infection control findings |
| Staff I | Consultant Pharmacist | Named in medication monitoring findings |
| Staff D | Licensed Nurse | Named in medication storage and infection control findings |
| Staff J | Licensed Nurse | Named in medication storage findings |
| Staff FF | Maintenance Staff | Named in environmental safety findings |
| Staff C | Administrative Nurse | Named in multiple findings including medication, infection control, and staffing |
| Staff K | Licensed Nurse | Named in multiple findings including pain management and abuse investigation |
| Staff EE | Licensed Nurse | Named in grooming and infection control findings |
| Staff GG | Housekeeping Staff | Named in infection control findings |
| Staff NN | Social Service Staff | Named in resident care findings |
| Staff PP | Administrative Nurse | Named in pain management findings |
| Staff KK | Physician | Named in QA&A and infection control findings |
| Staff JJJ | Physician | Named in wound care findings |
| Staff T | Dietary Staff | Named in nutrition and kitchen sanitation findings |
| Staff M | Direct Care Staff | Named in infection control findings |
| Staff N | Direct Care Staff | Named in infection control findings |
| Staff OO | Housekeeping Staff | Named in infection control findings |
| Staff BB | Direct Care Staff | Named in medication administration and infection control findings |
| Staff G | Direct Care Staff | Named in pain management and staffing findings |
| Staff H | Direct Care Staff | Named in pain management and staffing findings |
| Staff X | Direct Care Staff | Named in pain management and staffing findings |
| Staff Y | Direct Care Staff | Named in staffing and infection control findings |
| Staff JJ | Direct Care Staff | Named in privacy and infection control findings |
| Staff RR | Social Service Staff | Named in privacy and resident care findings |
| Staff EE | Licensed Nurse | Named in grooming and infection control findings |
| Staff NN | Social Service Staff | Named in resident care findings |
| Staff PP | Administrative Nurse | Named in pain management findings |
| Staff MM | Consultant Staff | Named in nutrition findings |
| Staff T | Dietary Staff | Named in nutrition and kitchen sanitation findings |
| Staff W | Housekeeping Staff | Named in sanitation and infection control findings |
| Staff OO | Housekeeping Staff | Named in infection control findings |
| Staff DD | Direct Care Staff | Named in infection control findings |
| Staff EE | Licensed Nurse | Named in infection control findings |
| Staff NN | Direct Care Staff | Named in infection control findings |
| Staff PP | Direct Care Staff | Named in pain management findings |
| Staff HH | Direct Care Staff | Named in pain management and infection control findings |
| Staff DD | Direct Care Staff | Named in infection control findings |
| Staff EE | Licensed Nurse | Named in infection control findings |
| Staff LL | Direct Care Staff | Named in nutrition findings |
| Staff VV | Direct Care Staff | Named in behavioral findings |
| Staff S | Licensed Nurse | Named in infection control findings |
| Staff I | Consultant Pharmacist | Named in medication monitoring findings |
| Staff D | Licensed Nurse | Named in medication storage and infection control findings |
| Staff J | Licensed Nurse | Named in medication storage findings |
| Staff FF | Maintenance Staff | Named in environmental safety findings |
| Staff C | Administrative Nurse | Named in multiple findings including medication, infection control, and staffing |
| Staff K | Licensed Nurse | Named in multiple findings including pain management and abuse investigation |
| Staff EE | Licensed Nurse | Named in grooming and infection control findings |
| Staff GG | Housekeeping Staff | Named in infection control findings |
| Staff NN | Social Service Staff | Named in resident care findings |
| Staff PP | Administrative Nurse | Named in pain management findings |
| Staff KK | Physician | Named in QA&A and infection control findings |
| Staff JJJ | Physician | Named in wound care findings |
| Staff T | Dietary Staff | Named in nutrition and kitchen sanitation findings |
| Staff M | Direct Care Staff | Named in infection control findings |
| Staff N | Direct Care Staff | Named in infection control findings |
| Staff OO | Housekeeping Staff | Named in infection control findings |
| Staff BB | Direct Care Staff | Named in medication administration and infection control findings |
| Staff G | Direct Care Staff | Named in pain management and staffing findings |
| Staff H | Direct Care Staff | Named in pain management and staffing findings |
| Staff X | Direct Care Staff | Named in pain management and staffing findings |
| Staff Y | Direct Care Staff | Named in staffing and infection control findings |
| Staff JJ | Direct Care Staff | Named in privacy and infection control findings |
| Staff RR | Social Service Staff | Named in privacy and resident care findings |
| Staff EE | Licensed Nurse | Named in grooming and infection control findings |
| Staff NN | Social Service Staff | Named in resident care findings |
| Staff PP | Administrative Nurse | Named in pain management findings |
| Staff MM | Consultant Staff | Named in nutrition findings |
| Staff T | Dietary Staff | Named in nutrition and kitchen sanitation findings |
| Staff W | Housekeeping Staff | Named in sanitation and infection control findings |
| Staff OO | Housekeeping Staff | Named in infection control findings |
| Staff DD | Direct Care Staff | Named in infection control findings |
| Staff EE | Licensed Nurse | Named in infection control findings |
| Staff NN | Direct Care Staff | Named in infection control findings |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jun 6, 2013
Visit Reason
The licensure survey was conducted to assess compliance for facility licensing.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N078004 POC 2ZCR11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions for deficiencies related to policy availability, resident council meetings, negotiated service agreements, and emergency evacuation fire drills, with monitoring and audits scheduled to ensure compliance.
Deficiencies (4)
Policies and procedures availability letter placed in common room and residents educated on access.
Resident Council meetings policy reviewed, president voted, and minutes management improved.
Negotiated Service Agreements reviewed and audits scheduled to ensure they are current.
Emergency evacuation fire drill scheduled and audits planned to verify compliance.
Report Facts
Residents educated on policy letter: 10
Residents total: 11
Plan of Correction completion dates: Jan 19, 2017
Plan of Correction completion dates: Jan 24, 2017
Emergency evacuation fire drill last conducted: Oct 16, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Baker | Director of Financial Services | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Modified the Plan of Correction document. |
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