Inspection Reports for The Evangelical Lutheran Good Samaritan Society
108 E. ASH STREET, KS, 67749
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 29, 2025, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed a pattern of citations related to documentation of discharge summaries, medication management including insulin pen labeling, nursing coverage reporting, and dietary manager certification, all of which were addressed and corrected by December 15, 2025. Earlier complaint investigations substantiated incidents of resident abuse, both staff-to-resident and resident-to-resident, as well as issues with resident dignity, staffing levels, and fall prevention. Enforcement actions included suspension and termination of involved staff, and fines or license suspensions were not listed in the available reports. The facility’s trend shows improvement over time, with repeated deficiencies being corrected in subsequent revisit surveys and no new deficiencies found in the most recent inspection.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
18.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
202% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
18 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 29, 2025
Visit Reason
An off-site revisit survey was conducted to verify correction of all previous deficiencies cited on 11/26/25.
Findings
All deficiencies have been corrected as of the compliance date of 12/15/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 7
Nov 26, 2025
Visit Reason
This document is a Plan of Correction submitted by Good Samaritan Society - Decature County Revised RS in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses multiple deficiencies including discharge summaries, notification to the Ombudsman, use of visual assistive devices, nursing coverage documentation, securing of the Ekit, blood pressure parameter documentation, insulin pen labeling, and dietary manager certification. Corrective actions include staff education, audits, policy adherence, and ongoing monitoring to achieve substantial compliance by 12/15/2025.
Severity Breakdown
D: 4
F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to complete discharge summaries and notify Ombudsman timely. | D |
| Inadequate management of visual assistive devices (glasses). | D |
| Inaccurate or incomplete PBJ reporting and nursing coverage documentation. | F |
| Ekit not secured properly and lack of procedure adherence. | F |
| Lack of documented blood pressure parameters for residents on medications. | D |
| Insulin pen not labeled properly. | D |
| Dietary Manager not yet certified, pending exam completion. | F |
Report Facts
Deficiencies cited: 7
Plan of Correction completion date: Dec 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Tamiklinedinst | NHA | Submitted the Plan of Correction |
| Debharper | Added and modified the Plan of Correction |
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 7
Nov 17, 2025
Visit Reason
The inspection was a Health Recertification Survey conducted to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including discharge process documentation, activities of daily living support, sufficient nursing staff reporting, pharmacy services and medication management, unnecessary drug monitoring, drug labeling and storage, and qualified dietary staff requirements.
Severity Breakdown
SS = D: 4
SS = F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to notify the Office of the Long-Term Care Ombudsman and provide written bed hold policy information for a resident transferred to hospital; failed to complete a discharge summary recapitulation and medication reconciliation for another resident. | SS = D |
| Failed to ensure a resident had a functional pair of glasses for impaired vision. | SS = D |
| Failed to submit complete and accurate licensed nurse staffing information through Payroll Based Journaling (PBJ) despite having adequate licensed nurse coverage. | SS = F |
| Failed to provide a system of medication records for emergency medication kit (E-Kit) reconciliation and failed to label and date an insulin pen. | SS = F |
| Failed to obtain physician-ordered blood pressure parameters for a resident receiving antihypertensive medication. | SS = D |
| Failed to date an opened insulin aspart pen for a resident. | SS = D |
| Failed to ensure the director of food and nutrition services met the required qualifications of a certified dietary manager. | SS = F |
Report Facts
Census: 18
Dates with no licensed nurse coverage reported in PBJ: 5
Residents reviewed: 8
Residents reviewed for unnecessary medications: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in findings related to discharge summary responsibility, medication reconciliation, and E-Kit audit |
| Licensed Nurse G | Licensed Nurse | Involved in medication room inspection and E-Kit handling |
| Licensed Nurse H | Licensed Nurse | Discussed E-Kit inventory and pharmacy communication |
| Licensed Nurse I | Licensed Nurse | Provided information on blood pressure monitoring and medication parameters |
| Dietary BB | Dietary Staff | Identified as director of food and nutrition services candidate lacking certification |
| Consultant GG | Pharmacist Consultant | Provided information on E-Kit delivery and inventory |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 8, 2025
Visit Reason
An offsite revisit survey was conducted on 07/08/25 for all previous deficiencies cited on 04/28/25 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 06/10/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 4
Apr 28, 2025
Visit Reason
Complaint investigation regarding resident rights, activities, staffing, and activities of daily living at Good Samaritan Society - Decatur County.
Findings
The facility failed to provide residents R2, R3, R4, R5, R6, and R7 with dignified care, including adequate grooming, personal hygiene, and appropriate activities. Staffing shortages were reported by multiple CNAs and staff, impacting resident care and activity engagement. Activities were described as outdated and insufficient to meet resident needs.
Complaint Details
The investigation was triggered by complaints KS00194853, KS00194833, and KS00194800 regarding resident care, staffing, and activities.
Severity Breakdown
SS=E: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide residents with a dignified existence, including grooming, cleanliness, and appropriate clothing. | SS=E |
| Failure to provide appropriate ADL care to maintain residents' dignity and quality of life. | SS=E |
| Failure to provide resident-centered activities that meet interests and psychosocial needs. | SS=E |
| Insufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and well-being. | SS=F |
Report Facts
Resident census: 14
Staffing hours for activities/social services: 3.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse's Aide M | Certified Nurse's Aide | Reported staffing shortages and inadequate resident care. |
| Certified Nurse's Aide N | Certified Nurse's Aide | Responsible for restorative program; reported staffing shortages and subpar activities. |
| Certified Nurse's Aide O | Certified Nurse's Aide | Reported staffing shortages and lack of administrative support. |
| Administrative Nurse D | Administrative Nurse | Reported staffing issues, emotional distress over resident care, and lack of awareness of activity staff absence. |
| Administrative Staff A | Administrative Staff | Reported staffing was appropriate but acknowledged activity calendar did not meet all resident needs. |
| Activities Staff/Social Services Staff Z | Activities and Social Services Staff | Responsible for activities and social services; reported limited hours and lack of coverage on survey day. |
Inspection Report
Plan of Correction
Deficiencies: 5
Apr 28, 2025
Visit Reason
This document is a Plan of Correction submitted by Good Samaritan Society Decatur County in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies related to resident dignity, assistance with activities of daily living (ADLs), activity planning, staffing levels, and supervision. Corrective actions include staff education, implementation of Angel Rounds, wheelchair cleaning schedules, activity calendar updates, staffing evaluations, and ongoing audits to ensure compliance.
Severity Breakdown
E: 4
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Residents’ hair was combed, wheelchairs were cleaned, clothes were changed and face/mouth were cleaned immediately; fresh water and ice were added to water pitchers within reach of residents. | E |
| Staff education on promoting resident dignity and resident rights, with Angel Rounds initiated to monitor dignity and psychosocial concerns. | E |
| Care plans reviewed and updated to reflect ADL preferences; wheelchair cleaning schedule implemented. | E |
| Activity Interest UDAs completed; activity calendar updated based on resident input; staffing evaluation conducted to increase activity staff hours. | E |
| Comprehensive staffing review conducted; new care efficiencies and supervision programs implemented; ongoing audits of Angel Rounding findings. | F |
Report Facts
Plan of Correction completion date: 2025
Audit frequency: 4
Audit frequency: 2
Staffing evaluation date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Tami Klinedinst | NHA | Submitted the Plan of Correction |
| Deb Harper | Added and modified the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 3, 2024
Visit Reason
A revisit survey was conducted on 04/03/2024 to verify correction of all previous deficiencies cited on 02/28/2024.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 03/15/2024, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Feb 28, 2024
Visit Reason
The inspection was conducted as an abbreviated survey and complaint investigation related to allegations of abuse and neglect at the facility.
Findings
The facility failed to ensure Resident 1 was free from abuse and neglect when a Certified Nurse Aide (CNA M) forcefully grabbed the resident's wrist, took a glass of orange juice from her hand and slammed it on the table, aggressively handled the resident's wheelchair, and yelled at her. Multiple staff witnessed the incident, and the CNA was suspended and subsequently quit. The resident was at risk for physical harm, pain, and mental anguish due to the aggressive treatment.
Complaint Details
The complaint investigation substantiated abuse by CNA M against Resident 1 on 02/09/24. The abuse was witnessed by multiple staff members, and the facility considered the event to be abuse. CNA M was suspended pending investigation and subsequently quit.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure Resident 1 remained free from abuse and neglect when CNA M forcefully grabbed the resident's wrist, took a glass of orange juice from her hand, slammed it on the table, aggressively handled the wheelchair, and yelled at the resident. | SS=G |
Report Facts
Census: 31
Date of incident: Feb 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in abuse and neglect finding for forcefully handling Resident 1 |
| Social Services X | Social Services Staff | Witnessed abuse incident and intervened |
| Administrative Staff A | Administrative Staff | Reported abuse incident and confirmed CNA M quit |
| Licensed Nurse G | Licensed Nurse | Witnessed abuse incident |
| Dietary Staff BB | Dietary Staff | Witnessed abuse incident |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 28, 2024
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated 02/28/2024, specifically addressing an incident of staff to resident abuse.
Findings
The facility failed to prevent an incident of staff to resident abuse involving Resident 1. Immediate actions included removal of the resident from the event, assessments, staff suspension, education on abuse and dementia care, and termination of the involved staff member.
Deficiencies (1)
| Description |
|---|
| The facility failed to prevent an incident of staff to resident abuse to Resident 1. |
Report Facts
Date of staff termination: Feb 9, 2024
Date of QAPI and Safety Committee review: Mar 20, 2024
Date of All Staff Quarterly Inservice: Mar 14, 2024
Plan of Correction completion date: Mar 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tami Klinedinst | NHA | Submitted the Plan of Correction |
| Felicia Majewski | Modified the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 26, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 12/11/23.
Findings
All deficiencies have been corrected as of the compliance date of 01/17/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 12, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-11-30.
Findings
All previously cited deficiencies have been corrected as of the compliance date 2024-01-05, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Dec 11, 2023
Visit Reason
The inspection was conducted as an abbreviated complaint survey (KS00184480) to investigate allegations of abuse involving resident-to-resident inappropriate touching.
Findings
The facility failed to ensure Resident 1 was free from abuse when Resident 2 touched Resident 1 in a sexually inappropriate manner. Resident 1 was severely cognitively impaired and unable to consent, placing her at risk for continued abuse and impaired psychosocial well-being. The facility took steps to investigate, notify appropriate parties, and implement interventions for Resident 2.
Complaint Details
The complaint investigation substantiated that Resident 2 touched Resident 1 inappropriately. The facility conducted interviews, observations, and notifications to family, physician, police, and the Long-Term Care Ombudsman. Resident 2 was placed on 15-minute checks and monitored visually when out of his room.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to prevent an incident of resident to resident abuse where Resident 2 touched Resident 1 in a sexually inappropriate manner. | SS=D |
Report Facts
Census: 32
BIMS score: 3
Date of incident: Dec 5, 2023
Date of survey completion: Dec 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Witnessed the abuse and removed Resident 1 from Resident 2 |
| LN G | Licensed Nurse | Received report of abuse from CNA M and assisted in removing Resident 1 |
| Administrative Staff A | Administrator | Notified of incident and responsible for facility oversight |
| Administrative Nurse D | Administrative Nurse | Notified of incident and involved in care plan changes for Resident 2 |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 11, 2023
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited related to an incident of resident to resident abuse at the facility.
Findings
The facility failed to prevent an incident of resident to resident abuse involving Resident 1 and Resident 2. Immediate actions included removal of involved residents, assessments, monitoring, education, audits, and plans for discharge and ongoing oversight to ensure compliance.
Deficiencies (1)
| Description |
|---|
| The facility failed to prevent an incident of resident to resident abuse to Resident 1. |
Report Facts
Complete Date for Plan of Correction: Jan 17, 2024
Date of Ombudsman Visit: Dec 13, 2023
BIMS Score Threshold: 9
Check Interval: 15
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 8
Nov 30, 2023
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to investigate bruises of unknown origin on a resident, inaccurate resident assessments, inadequate assistance with activities of daily living, failure to provide proper positioning and skin care, lack of a certified dietary manager, improper preparation and serving of food, unsanitary food storage and preparation areas, failure to check food temperatures, and inadequate infection control practices.
Severity Breakdown
SS=D: 6
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to investigate Resident 16's bruises of unknown origin on left arm and breast. | SS=D |
| Failed to accurately assess Resident 12's cognition on Minimum Data Set assessment. | SS=D |
| Failed to provide Resident 21 appropriate activities of daily living care including incontinence care. | SS=D |
| Failed to provide Resident 21 necessary care for positioning and skin assessment, resulting in risk for skin breakdown. | SS=D |
| Failed to employ a full-time certified dietary manager. | SS=F |
| Failed to prepare food that conserved nutritive value, flavor, and appearance; dietary staff failed to follow recipes for pureed diets. | SS=D |
| Failed to prepare, store, and serve food in accordance with professional food safety standards; unsanitary refrigerators and food prep areas; failure to check food temperatures prior to serving. | SS=F |
| Failed to follow infection control practices; staff failed to change gloves and perform hand hygiene when providing incontinent care to Resident 23. | SS=D |
Report Facts
Census: 32
Sample size: 12
BIMS score: 7
BIMS score: 8
Braden Scale score: 8
Temperature: 149
Temperature: 112
Measurement: 0.5
Inspection Report
Plan of Correction
Deficiencies: 8
Nov 30, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during the inspection of GSS Decatur County RS on 11/30/2023.
Findings
The facility failed to implement required interventions related to skin injury assessments, comprehensive MDS completion, assistive ADL care, assistive positioning, dietary management certification, pureed diet preparation, food service safety, and hand hygiene during incontinence care. Corrective actions including staff education, audits, and care plan updates were initiated with a target substantial compliance date of 01/05/2024.
Severity Breakdown
D: 6
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure interventions were implemented with measuring of injuries of unknown origin. | D |
| Failed to ensure interventions were implemented with completion of comprehensive MDS. | D |
| Failed to ensure interventions were implemented with providing assistive ADL care as directed in the care plan. | D |
| Failed to ensure interventions were implemented with providing assistive positioning as directed in the care plan. | D |
| Failed to ensure interventions were implemented with professional standards for employment of a full time certified dietary manager. | F |
| Failed to ensure interventions were implemented to follow a recipe while preparing for pureed diets. | D |
| Failed to ensure interventions were implemented with professional standards for food service safety in not checking food temperatures prior to serving, ensuring clean and sanitary refrigerators and food preparation areas. | F |
| Failed to ensure interventions were implemented with following hand hygiene during Incontinence Care, and Proper Glove Use. | D |
Report Facts
Deficiencies cited: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Tami Klinedinst | NHA | Submitted the Plan of Correction to KDADS |
| Felicia Majewski | Added and modified the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 25, 2023
Visit Reason
A revisit survey was conducted on 10/25/23 to verify correction of all previous deficiencies cited on 09/11/23.
Findings
All deficiencies have been corrected as of the compliance date of 10/01/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Abbreviated Survey
Census: 30
Deficiencies: 1
Sep 11, 2023
Visit Reason
The inspection was conducted as a result of an abbreviated survey and complaint investigation identified by KS00182673 and KS00182633.
Findings
The facility failed to implement adequate interventions to prevent Resident 1 from falling out of bed, resulting in multiple falls and an acute left hip fracture. The motion sensor alarm intended to alert staff was found not to be functioning properly during the last fall incident, placing the resident at risk for further injuries.
Complaint Details
The visit included a complaint investigation as indicated by the citations resulting from complaint investigation KS00182673 and KS00182633.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure interventions were implemented to prevent Resident 1 from falling out of bed and to prevent injuries after multiple falls. | SS=G |
Report Facts
Resident census: 30
Brief Interview for Mental Status score: 3
Fall Risk Assessment date: Jul 14, 2023
Fall Care Plan revision date: Sep 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Assessed Resident 1 after fall incidents and noted hip injury. | |
| CNA M | Found Resident 1 on the floor and reported motion sensor alarm was not sounding. | |
| Laundry Staff GG | Reported Resident 1 fell out of bed and motion sensor alarm was not heard. | |
| Administrative Staff A | Expected appropriate fall interventions and stated investigation of motion sensor alarm. | |
| Administrative Nurse D | Investigated fall and motion sensor alarm functionality. |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 11, 2023
Visit Reason
The visit was conducted as a complaint survey related to a resident fall resulting in an acute left hip fracture, to investigate the facility's interventions and compliance with fall prevention protocols.
Findings
The facility failed to ensure interventions were implemented to prevent a resident from falling out of bed and sustaining an acute left hip fracture. The facility provided investigation materials and implemented multiple corrective actions including staff education, care plan audits, and risk management updates.
Complaint Details
Complaint survey conducted on 2023-09-11. Investigation materials were provided. The event was immediately reported to KDADS on 2023-09-04. The complaint survey report was received on 2023-09-25.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure interventions were implemented to prevent a resident falling out of bed and receiving injuries of an acute left hip fracture. |
Report Facts
Resident care plans reviewed: 32
Audit review period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tami Klinedinst | NHA | Submitted the plan of correction to KDADS. |
| Felicia Majewski | Added and modified the plan of correction. |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 20, 2023
Visit Reason
An offsite revisit survey was conducted on 06/20/23 for all previous deficiencies cited on 05/10/23 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 06/10/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Abbreviated Survey
Census: 32
Deficiencies: 1
May 10, 2023
Visit Reason
The inspection was conducted as an abbreviated survey and complaint investigation (KS00179229) to assess compliance with pressure ulcer prevention and treatment regulations.
Findings
The facility failed to implement a turning/repositioning program and did not contact the registered dietician for nutritional support for Resident 1, who developed a facility-acquired unstageable pressure ulcer on the left heel. This failure placed the resident at risk for impaired and delayed healing.
Complaint Details
The visit included a complaint investigation identified as KS00179229.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement a repositioning program and failure to contact the registered dietician for nutritional support to promote healing of a facility-acquired pressure ulcer. | SS=D |
Report Facts
Resident census: 32
Pressure ulcer size: 3
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1.5
Pressure ulcer risk score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Stated Resident 1 had not been wearing pressure relieving boots until after pressure ulcer developed and was not on a turning/repositioning program. | |
| Licensed Nurse H | Verified Resident 1 was not on a turning/repositioning program after reviewing EMR. | |
| Certified Nurse's Aide M | Stated Resident 1 had not worn pressure relieving boots until after pressure ulcer developed and was not on a turning/repositioning program. | |
| Administrative Nurse D | Verified no turning/repositioning task in Resident 1's care plan and RD had not been contacted regarding pressure ulcer. |
Inspection Report
Plan of Correction
Deficiencies: 1
May 10, 2023
Visit Reason
The visit was conducted to investigate deficiencies related to the facility's failure to implement a turning/repositioning schedule and failure to notify the Registered Dietician for additional protein or vitamin needs necessary to heal a resident's pressure ulcer.
Findings
The facility failed to implement a turning/repositioning schedule and failed to notify the Registered Dietician for additional nutritional needs for Resident 1, placing the resident at risk for impaired or delayed healing. Corrective actions and monitoring plans were established to address these deficiencies.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement a turning/repositioning schedule and failure to notify the Registered Dietician for additional protein or vitamin needs necessary to heal Resident 1's pressure ulcer. | D |
Report Facts
Deficiency citation date: May 10, 2023
Plan of correction completion date: Jun 10, 2023
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 12, 2022
Visit Reason
A revisit survey was conducted on 09/12/22 to verify correction of all previous deficiencies cited on 07/14/22.
Findings
All deficiencies cited in the previous inspection have been corrected as of 08/06/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 8
Jul 14, 2022
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility failed to submit a completed investigation for a resident's injury of unknown origin within the required timeframe, failed to investigate and develop comprehensive care plans for residents with pressure ulcers and hypertension, failed to monitor wound healing adequately, failed to prevent catheter-related infections, and failed to administer medication per physician orders.
Severity Breakdown
SS=D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to submit completed investigation to State Agency within required five days for Resident 17's injury of unknown origin. | SS=D |
| Failed to investigate injury and fall for Resident 17 with pubic ramus fracture. | SS=D |
| Failed to develop comprehensive care plan for hypertension and pressure wounds for Resident 2. | SS=D |
| Failed to develop and revise comprehensive care plan for pressure ulcers for Resident 7 and Resident 8. | SS=D |
| Failed to monitor and assess recurring pressure ulcer for Resident 7 and failed to evaluate treatment options for Resident 31. | SS=D |
| Failed to maintain catheter drainage bag properly for Resident 31, placing resident at risk for infection. | SS=D |
| Consultant pharmacist failed to identify and report irregularities related to Norvasc medication administration for Resident 2. | SS=D |
| Failed to administer Norvasc medication when blood pressure was out of parameters for Resident 2. | SS=D |
Report Facts
Resident census: 35
Medication non-administration days: 38
Pressure ulcer size: 2.5
Pressure ulcer size: 5.4
Pressure ulcer size: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified failure to locate investigation for Resident 17's fall and injury; verified failure to develop care plans and medication administration issues |
| Administrative Nurse F | Administrative Nurse | Verified failure to develop care plans for hypertension and pressure ulcers; verified medication administration issues |
| Licensed Nurse I | Licensed Nurse | Verified medication order clarity and failure to administer Norvasc |
| Consultant Pharmacist HH | Consultant Pharmacist | Failed to identify and report medication irregularities for Resident 2 |
| Administrative Nurse E | Administrative Nurse | Verified wound measurements and catheter drainage bag infection control issues |
| Consultant II | Commented on wound care and preventive measures for Resident 8 | |
| Licensed Nurse G | Licensed Nurse | Observed wound care for Resident 8 |
| Licensed Nurse H | Licensed Nurse | Provided wound care observations and verified care plan issues |
| Certified Nurse Aide M | Certified Nurse Aide | Reported on wound care for Resident 8 |
| Certified Nurse Aide N | Certified Nurse Aide | Observed catheter drainage bag touching floor and emptying |
| Certified Nurse Aide O | Certified Nurse Aide | Observed catheter drainage bag touching floor and emptying |
Inspection Report
Plan of Correction
Deficiencies: 10
Jul 11, 2022
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a state survey visit conducted from 07/11/2022 to 07/14/2022 at Good Sam Decatur County.
Findings
The facility failed in multiple areas including timely submission of investigation reports, investigation of resident injuries, development and revision of comprehensive care plans for hypertension and pressure injuries, prevention of recurrent urinary tract infections, and medication administration errors related to Norvasc. Corrective actions and education plans were outlined to address these deficiencies.
Severity Breakdown
D: 9
G: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to submit the completed investigation related to R17's fracture of undetermined origin within the required timeframe. | D |
| Failed to investigate an injury and fall for resident R17 with a fracture of her pubic ramus. | D |
| Failed to develop a comprehensive care plan for hypertension and pressure injury risk and treatment for residents R2 and R7. | D |
| Failed to revise the comprehensive care plan for R8 to include interventions and treatment for pressure injuries. | D |
| Failed to monitor skin condition and wound treatment effectiveness for resident R184. | D |
| Failed to identify risk for pressure injuries and implement preventative interventions for R8 and failed to discuss treatment plan with R31. | G |
| Failed to prevent recurrent urinary tract infections for R31 and failed to keep urinary drainage bag from touching the floor. | D |
| Consultant pharmacist failed to identify and report multiple episodes of Norvasc medication not administered when blood pressure was out of parameters for R2. | D |
| Failed to administer Norvasc when blood pressures were out of parameters for resident R2. | D |
| Failed to maintain catheter drainage bag for R31, placing resident at risk for bacterial contamination and infections. | D |
Report Facts
Survey visit dates: Survey conducted from 2022-07-11 to 2022-07-14
Plan of Correction completion date: All corrective actions planned to be completed by 2022-08-06
Audit frequency: 6
Audit frequency: 3
Audit frequency: 4
Audit frequency: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Bunch | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction | |
| Felicia Majewski | Modified Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 6, 2021
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 01/27/21.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 02/25/21, and no noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 7
Feb 25, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection, detailing corrective actions taken or planned to address those deficiencies.
Findings
The Plan of Correction addresses multiple deficiencies including missing fentanyl patches, pressure ulcer management, recliner risk assessments, medication management particularly related to PRN psychotropic drugs, dietary management, and infection control practices related to glucometer use. The facility outlines education, audits, policy reviews, and communication with relevant staff and external consultants to ensure compliance and resident safety.
Severity Breakdown
D: 4
G: 1
C: 1
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Missing fentanyl patch from 12-13-20 reported and investigated; staff educated on patch application, disposal, and reporting procedures. | D |
| Pressure ulcer management including physical therapy evaluation, wound care nurse involvement, and staff education on wound documentation and interventions. | G |
| Recliner risk assessment and care plan updates for residents with recliners, with staff education and auditing. | D |
| Pharmacist notified about PRN Xanax medication status; medication discontinued due to non-use; ongoing medication review process established. | D |
| Discontinuation of anti-anxiety medication related to non-use; review of psychotropic PRN medications for 14-day stop orders; staff education and audits planned. | D |
| Dietary manager progressing through Certified Dietary Manager course; dietician reviews resident data and reports findings regularly. | C |
| Glucometer cleaning and infection control procedures implemented; staff education and competency assessments planned; audits scheduled. | F |
Report Facts
Audit frequency: 3
Audit frequency: 2
Audit frequency: 2
Date: Feb 1, 2021
Date: Feb 23, 2021
Date: Feb 22, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| JENNATANDE | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 7
Jan 27, 2021
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with regulatory requirements, including reporting of alleged violations, pressure ulcer prevention and treatment, accident hazards, drug regimen review, dietary staffing, and infection control.
Findings
The facility failed to report a missing Fentanyl patch for a resident, did not provide adequate interventions to prevent a facility-acquired pressure ulcer, failed to provide a safe environment for a resident who fell from a recliner, did not ensure proper drug regimen review for PRN Xanax, lacked a full-time certified dietary manager, and failed to disinfect the glucometer between resident uses.
Severity Breakdown
SS=D: 4
SS=G: 1
SS=C: 1
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to report Resident 33's missing Fentanyl patch to the state agency. | SS=D |
| Failed to provide interventions to prevent development of Resident 13's facility-acquired unstageable pressure ulcer. | SS=G |
| Failed to provide a safe environment for Resident 137 who fell from his electric lift recliner. | SS=D |
| Consultant pharmacist failed to report irregularities including lack of duration of use for Resident 28's PRN Xanax. | SS=D |
| Resident 28 received PRN Xanax without a 14 day stop date, contrary to psychotropic drug regulations. | SS=D |
| Facility failed to employ a full-time certified dietary manager to supervise meal preparation. | SS=C |
| Failed to clean the glucometer between resident uses, placing residents at risk for infection. | SS=F |
Report Facts
Census: 40
Sample size: 12
Pressure ulcer measurement: 6.3
Pressure ulcer measurement: 3
Fall risk score: 18
Xanax dosage: 0.5
Xanax frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Verified failure to report missing Fentanyl patch, confirmed pressure ulcer development and falls, and acknowledged PRN Xanax lacked stop date | |
| Licensed Nurse J | Administered medications to Resident 33 and verified missing Fentanyl patch | |
| Certified Nurse Aide O | Reported Resident 33 removed pain patches frequently | |
| Licensed Nurse I | Observed wound care for Resident 13 and verified falls for Resident 137 | |
| Certified Nurse Aide N | Assisted with mechanical lift for Resident 137 and verified resident's unsafe use of recliner | |
| Certified Nurse Aide M | Assisted with mechanical lift for Resident 137 | |
| Licensed Nurse G | Verified falls from recliner and resident's impaired cognition | |
| Dietary Staff BB | Dietary Staff | Oversaw meal preparation, not certified dietary manager, enrolled in dietary manager classes |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 28, 2020
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2020-11-05.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2020-12-17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Abbreviated Survey
Census: 38
Deficiencies: 1
Nov 5, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted due to concerns about infection control practices related to COVID-19.
Findings
The facility was found not to be in substantial compliance with infection control regulations, specifically failing to provide ongoing COVID-19 related training to staff, resulting in immediate jeopardy to residents. The immediate jeopardy was removed after the facility implemented a corrective plan, but deficiencies remained at a G scope and severity.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide continued training to staff on COVID-19 related Infection Control Practices. | G |
Report Facts
Residents tested positive for COVID-19: 14
Residents tested positive for COVID-19: 4
Residents present during inspection: 38
Residents tested positive for COVID-19: 2
Resident deaths due to COVID-19: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 29, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 29, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 06/29/2020 to assess compliance with COVID-19 related infection control practices.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Jan 16, 2020
Visit Reason
A complaint survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS to investigate a medication error involving Resident 1 receiving Resident 2's medications.
Findings
The facility failed to administer medications according to professional standards when Resident 1 was given Resident 2's medications, resulting in severe sedation, very low blood pressure, and hospitalization, constituting immediate jeopardy. The medication error was identified as past non-compliance and corrected by disciplinary action and re-education of staff.
Complaint Details
The complaint investigation found the medication error was substantiated, with immediate jeopardy beginning on 2020-01-04 when the error was discovered. The facility took corrective actions including final warning and suspension of Licensed Nurse G, monitoring of medication administration, and re-education of all licensed nurses and medication aides.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure Resident 1 was free of significant medication errors when she received Resident 2's medications causing severe sedation and very low blood pressure. | Immediate Jeopardy |
Report Facts
Census: 40
Medication doses administered in error: 6
Activated charcoal dose: 25
Normal Saline bolus doses: 2250
Licensed Nurse G monitoring shifts: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Administered wrong medications to Resident 1, received final warning, was suspended and monitored upon return |
| Administrative Nurse D | Administrative Nurse | Monitored medication administration after error and provided statements regarding corrective actions |
| Consultant GG | Consultant | Verified medication error and its impact on Resident 1's condition |
| Administrative Staff A | Administrative Staff | Notified Licensed Nurse G suspension and return to work details |
Inspection Report
Plan of Correction
Deficiencies: 2
Jan 6, 2020
Visit Reason
This document is a Plan of Correction submitted in response to past noncompliance deficiencies identified during a prior inspection.
Findings
The Plan of Correction addresses past noncompliance issues identified under tags F0000 and F760-J, with corrective actions completed by January 6, 2020.
Deficiencies (2)
| Description |
|---|
| Past noncompliance under tag F0000 |
| Past noncompliance under tag F760-J |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 2, 2019
Visit Reason
An offsite revisit survey was conducted on 7/2/2019 for all previous deficiencies cited on 5/16/2019.
Findings
All deficiencies have been corrected as of the compliance date of 6/18/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 7
May 16, 2019
Visit Reason
The inspection was a Health Resurvey conducted to evaluate compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including respect and dignity, comprehensive care planning, activity programming, quality of care related to skin integrity, accident hazard prevention, provision of social services, and medication management including psychotropic drug use and unnecessary medications.
Severity Breakdown
SS=E: 1
SS=D: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| The facility failed to promote respect and dignity by allowing staff to discuss residents' personal medical information in non-private areas. | SS=E |
| The facility failed to develop and implement comprehensive care plans for residents, including lack of interventions for skin integrity and depression. | SS=D |
| The facility failed to provide an activity program that supports the physical, mental, and psychosocial well-being of residents. | SS=D |
| The facility failed to provide necessary care and treatment for skin integrity for a resident with a large bruise and did not investigate bruising of unknown origin. | SS=D |
| The facility failed to provide adequate social services to support psychosocial well-being for a resident. | SS=D |
| The facility failed to obtain an appropriate diagnosis and behavior monitoring for the use of Seroquel, an antipsychotic medication, placing a resident at risk for adverse effects. | SS=D |
| The facility failed to document the need for an as needed antianxiety medication and lacked documentation of behaviors justifying its use. | SS=D |
Report Facts
Deficiency sample size: 12
Residents reviewed for unnecessary medications: 6
Bruise size: 13.5
Bruise size: 16.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified direct care staff should not obtain vital signs in dining room; verified lack of care plan for skin integrity; verified lack of bruise investigation; verified lack of behavior documentation for Seroquel use. |
| Administrative Nurse E | Administrative Nurse | Verified resident received Seroquel and diagnosis; verified lack of behavior documentation; verified resident not currently receiving Zoloft; stated facility lacked mental health provider. |
| Administrative Nurse F | Administrative Nurse | Verified resident did not have a care plan for skin integrity. |
| Nurse Aide M | Nurse Aide | Reported resident bruised easily and staff notified nurse; stated resident did not have behaviors. |
| Licensed Nurse G | Licensed Nurse | Verified resident had periods of forgetfulness; stated resident was social and did not act depressed; stated resident had anxiety and behaviors; stated behavior was charted when medication given. |
| Social Service Staff X | Social Service Staff | Verified resident's discharge plan changed and facility failed to provide psychosocial adjustment. |
Inspection Report
Plan of Correction
Deficiencies: 8
May 12, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, detailing corrective actions to address identified issues.
Findings
The Plan of Correction outlines multiple corrective actions including resident interviews about privacy preferences, care plan updates for various residents, staff education on care plan review and dignity issues, audits of staff compliance, and ongoing monitoring to ensure substantial compliance by June 18, 2019.
Severity Breakdown
E: 1
D: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Privacy concerns regarding sharing vital signs, accu-checks, oxygen saturation, and insulin administration in non-private areas. | E |
| Care plans not updated to include depression, skin integrity interventions, and other resident-specific needs. | D |
| Resident admitted with compromised skin area requiring offloading; care plan updates and activity engagement improvements needed. | D |
| Skin integrity interventions and audits not consistently completed. | D |
| Investigation and reporting of injuries of unknown origin and related care plan updates. | D |
| Discharge plan changes and mental health service needs not fully addressed. | D |
| Proper diagnosis documentation for residents on antipsychotic medications lacking or incomplete. | D |
| Medication administration documentation and monitoring for PRN antianxiety medications inadequate. | D |
Report Facts
Audit frequency: 4
Audit frequency: 2
Audit frequency: 2
Plan of Correction completion date: Jun 18, 2019
Resident interview completion date: May 30, 2019
Resident interview completion date: Jun 10, 2019
Mandatory education date: Jun 12, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Burton | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 6
Aug 15, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies related to various regulatory requirements were corrected as of 08/04/2017, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.12(a)(3)(4)(c)(1)-(4) |
| Deficiency related to regulation 483.12(b)(1)-(3), 483.95(c)(1)-(3) |
| Deficiency related to regulation 483.24, 483.25(k)(l) |
| Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3) |
| Deficiency related to regulation 483.90(d)(2)(e) |
| Deficiency related to regulation 483.35(d)(7) |
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Jul 20, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation related to resident elopement and staff training at the facility.
Findings
The facility identified deficiencies related to timely reporting of incidents, verification of nurse aide registry status, assessment and supervision of residents at risk of elopement, and ensuring essential safety equipment is operational. The plan outlines corrective actions including staff education, audits, installation of safety devices, and ongoing monitoring.
Severity Breakdown
D: 3
J: 1
E: 1
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to report all investigations to the administrator and State Survey Agency within required timeframes. | D |
| Failure to verify certified nursing assistants are current on the nurse aide registry and have adequate training. | D |
| Failure to properly assess residents at risk of elopement at admission, change, and incident times. | D |
| Failure to ensure adequate supervision and assistance devices to prevent accidents and elopements. | J |
| Failure to ensure essential equipment, including wandergard door exits and motion detectors, are in safe operating condition. | E |
| Failure to ensure nurse aides receive required 12 hours of continuing education annually. | F |
Report Facts
Compliance completion dates: Jul 20, 2017
Compliance completion date: Aug 4, 2017
Audit frequency: 3
Continuing education hours: 12
Testing duration: 45
Testing duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Charla Roberts | Administrator | Administrator named in report submission and responsible for corrective actions |
| Caryl Gill | Person who modified the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 6
Jul 13, 2017
Visit Reason
Complaint investigation #116435 and partial extended survey conducted to investigate allegations of abuse, neglect, and elopement risks at the facility.
Findings
The facility failed to report and thoroughly investigate allegations of abuse for one resident, failed to check nurse aide registry for two newly hired aides, failed to assess and supervise residents at risk for elopement, and failed to maintain safe operating conditions of wander guard devices on exit doors. Additionally, the facility did not ensure nurse aides received required annual in-service training.
Complaint Details
Complaint investigation #116435 focused on allegations of abuse, neglect, and elopement risks involving residents #1 and #2. The facility failed to report abuse allegations timely and did not thoroughly investigate. The investigation revealed multiple safety and supervision failures placing residents at risk.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 1
SS=J: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to report to the state agency and thoroughly investigate allegations of abuse for 1 of 3 residents. | SS=D |
| Failed to check the appropriate nurse aide registry for 2 of 3 nurse aides hired since 3/1/17. | SS=D |
| Failed to assess residents for risk of elopement and provide timely assessment for 2 of 3 residents who exited the facility. | SS=D |
| Failed to provide adequate supervision to prevent residents from leaving the building, placing 2 residents in immediate jeopardy. | SS=J |
| Failed to ensure each exit door accessible to residents had a wander guard device installed and maintained in safe operating condition. | SS=E |
| Failed to ensure each nurse aide received 12 hours of continuing education in a 12 month period as required by the State. | SS=F |
Report Facts
Census: 40
Nurse aides lacking required in-service hours: 11
Temperature: 166.4
Minutes: 30
Minutes: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse K | Nurse | Documented resident found in basement and assisted resident back upstairs; assessed resident without vital signs after elopement |
| Nurse Aide L | Nurse Aide | Found resident stuck in basement activity room and assisted resident; documented wandering behavior |
| Dietary Supervisor F | Dietary Supervisor | Found resident outside facility after elopement and accompanied resident back inside |
| Nurse D | Nurse | Responded to exit door alarm and radioed for help; silenced wander guard alarm after resident returned |
| Nurse E | Nurse | Assisted resident back inside after elopement; did not document physical assessment or vital signs |
| Nurse Aide G | Nurse Aide | Observed resident exit facility; documented resident's exit seeking behavior |
| Nurse H | Nurse | Reported resident's wandering and exit seeking behavior |
| Administrative Nurse B | Administrative Nurse | Verified lack of elopement assessments and elevator safety procedures; verified missing wander guard devices on exit doors; verified lack of nurse aide in-service tracking |
| Maintenance Supervisor J | Maintenance Supervisor | Verified wander guard devices not tested on exit doors; elevator malfunctioning and locked at basement level |
| Nurse C | Nurse | Verified resident was care planned for elopement risk but not assessed due to prior knowledge |
| Nurse Aide I | Nurse Aide | Observed resident wandering and opening exit doors without difficulty |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jul 13, 2017
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety related to F323, "J", CFR 483.25(d)(1)(2)(n)(1)-(3). Enforcement remedies including denial of payment for new admissions were imposed.
Severity Breakdown
immediate jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F323, "J", CFR 483.25(d)(1)(2)(n)(1)-(3) constituting immediate jeopardy to resident health or safety | immediate jeopardy |
Report Facts
Denial of payment effective date: Aug 6, 2017
Provider agreement termination date: Jan 13, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charla Roberts | Administrator | Named as facility administrator |
| Caryl Gill | Complaint Coordinator | Signed letter as complaint coordinator |
Inspection Report
Follow-Up
Deficiencies: 5
Jan 12, 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 identified by regulation numbers 483.25, 483.25(f)(1), 483.25(l), 483.60(c), and 483.65 were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(f)(1) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 5
Inspection Report
Follow-Up
Deficiencies: 1
Jan 12, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to confirm the date such corrective actions were accomplished.
Findings
The report indicates that the previously cited deficiency with regulation 28-39-158(a) was corrected and completed as of the revisit date. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 28-39-158(a) |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Dec 13, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #107908 to assess compliance with dietary services regulations.
Findings
The facility failed to provide services of a full-time certified dietary manager for the 41 residents receiving meals from one kitchen, placing residents at risk of inadequate nutrition. Dietary staff serving meals were not certified dietary managers, though one was enrolled in an online dietary manager course.
Complaint Details
The visit was triggered by a complaint investigation #107908. The facility was found non-compliant regarding dietary services staffing.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide services of a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee food ordering, preparation, and storage. | SS=C |
Report Facts
Census: 41
Sample size: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff C | Dietary staff serving meals who was not a certified dietary manager but enrolled in an online dietary manager course. | |
| Administrative Staff A | Verified that Dietary Staff C was not a certified dietary manager and had started working in April 2016. |
Inspection Report
Re-Inspection
Deficiencies: 1
Dec 13, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
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, and the facility was found to be in substantial compliance effective January 12, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | F |
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: 6
Dec 13, 2016
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 address issues related to resident care, medication management, staff education, and infection control.
Findings
The plan addresses multiple deficiencies including inadequate pain management, behavioral health interventions, psychotropic medication monitoring, proper gloving during pericare, and housekeeping procedures. The facility outlines staff education, audits, and monitoring processes to ensure compliance and resident safety.
Severity Breakdown
D: 4
F: 1
C: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Inadequate pain management for Resident #14, including medication timing and care plan adherence. | D |
| Failure to provide appropriate treatment and services for Resident #38's mental or psychosocial adjustment difficulties. | D |
| Inadequate monitoring of psychotropic medications for Resident #38. | D |
| Failure to ensure each resident's drug regimen is reviewed monthly by a licensed pharmacist and irregularities reported. | D |
| Improper gloving during perineal care by nursing staff, risking infection transmission. | F |
| Dietary manager's ongoing progress toward certification and oversight by Registered Dietician. | C |
Report Facts
Date of substantial compliance: Jan 12, 2017
Medication dosage: 650
Medication dosage: 2.5
Medication dosage: 100
Medication dosage: 50
Medication dosage: 2
Medication dosage: 0.5
Training completion date: Dec 31, 2017
Inspection Report
Life Safety
Deficiencies: 1
Aug 2, 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 the facility to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Nov 2, 2016
Provider agreement termination date: Feb 2, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 11
Sep 10, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers have been corrected as of the revisit date.
Deficiencies (11)
| Description |
|---|
| Deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency identified under regulation 483.15(a) |
| Deficiency identified under regulation 483.15(c)(1)-(5) |
| Deficiency identified under regulation 483.20(b)(1) |
| Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency identified under regulation 483.25 |
| Deficiency identified under regulation 483.25(a)(3) |
| Deficiency identified under regulation 483.25(h) |
| Deficiency identified under regulation 483.25(l) |
| Deficiency identified under regulation 483.55(b) |
| Deficiency identified under regulation 483.65 |
Report Facts
Deficiencies corrected: 11
Inspection Report
Plan of Correction
Deficiencies: 11
Sep 10, 2015
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 address identified issues.
Findings
The plan addresses multiple deficiencies including care plan revisions, staff training on dignity and respect, resident safety measures, dental care follow-up, bowel management, and infection control related to respiratory equipment. Root cause analyses were conducted and corrective actions with responsible parties and timelines were established.
Severity Breakdown
D: 6
E: 3
F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Care plans for residents reviewed and revised to reflect appropriate ADL care and reporting of incidents. | D |
| Mandatory staff training on resident dignity and respect. | D |
| Resident council meetings scheduled and monitored. | E |
| Timely completion of Care Area Assessments (CAA) ensured. | D |
| Care plans updated to include dental health interventions and follow-up. | D |
| Necessary care provided for positioning, pain management, and bowel care. | E |
| Care plans reviewed for dining assistance and staff training provided. | D |
| Resident safety improved by securing doors and elevator access; care plans revised for supervision. | E |
| Monitoring and management of bowel movements improved with staff education. | D |
| Provision of timely dental services ensured with follow-up and family communication. | D |
| Safe and sanitary environment maintained with proper storage of respiratory equipment and staff education. | F |
Report Facts
Months of audit monitoring: 6
Months of audit monitoring: 3
Training dates: 2
Scheduled dental hygienist visits: 2
Weekly audits: 4
Months of audit monitoring: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Janice Shobe | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction | |
| DON | Director of Nursing | Responsible for multiple corrective actions and trainings |
| QAPI coordinator | Responsible for training, auditing, and reporting to QAPI committee | |
| Infection control nurse | Responsible for infection control education and audits | |
| Administrator | Responsible for elevator safety measures and staff training |
Inspection Report
Deficiencies: 1
Aug 11, 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 September 10, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| "F" level deficiency, widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy | F |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 10
Aug 11, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation #89621.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate and report falls with injury, failure to maintain dignity and respect during dining, failure to ensure resident council meetings, incomplete care area assessments, failure to revise care plans appropriately, inadequate care and services for pain management, wheelchair positioning, and bowel elimination, failure to provide adequate supervision to prevent accidents, failure to ensure drug regimens free from unnecessary drugs, failure to provide dental services, and failure to maintain infection control related to oxygen equipment storage.
Complaint Details
The inspection was a complaint investigation triggered by complaint #89621.
Severity Breakdown
SS=D: 6
SS=E: 2
SS=F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate and report a fall with injury to the state agency for 2 sampled residents. | SS=D |
| Failed to maintain an environment that enhanced dignity and respect during dining for Resident #31. | SS=E |
| Failed to ensure regular resident council meetings during absence of resident council president. | SS=D |
| Failed to complete Care Area Assessment in a timely manner for Resident #27. | SS=D |
| Failed to revise care plan with appropriate new interventions including dietary and oral hygiene for Resident #22. | SS=D |
| Failed to provide necessary care and services to attain or maintain highest practicable well-being for Residents #35, #41, and #2. | SS=E |
| Failed to ensure resident environment free of accident hazards and provide adequate supervision to prevent accidents for Resident #41 and others. | SS=D |
| Failed to ensure drug regimen free from unnecessary drugs by inadequate bowel management monitoring and interventions for Resident #32. | SS=D |
| Failed to ensure provision of dental services for Resident #22 with jagged and broken/missing tooth. | SS=F |
| Failed to establish and maintain infection control program to prevent spread of infection related to inappropriate storage of respiratory equipment for 3 residents receiving oxygen. | SS=F |
Report Facts
Residents sampled: 11
Residents reviewed for medication: 5
Residents reviewed for accidents: 3
Residents reviewed for dental: 1
Residents reviewed for oxygen: 3
Fall medication administration count: 40
Bowel movement absence days: 6
Bowel movement absence days: 9
Bowel movement absence days: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse E | Licensed Nurse | Named in fall with injury finding for Resident #41. |
| Nurse Aide B | Nurse Aide | Mentioned in relation to Resident #41 fall and wandering. |
| Administrative Nurse F | Administrative Nurse | Provided statements regarding Resident #41 fall and wandering. |
| Nurse Aide A | Nurse Aide | Mentioned in dignity and respect during dining for Resident #31. |
| Social Service Staff D | Social Service Staff | Verified resident council meeting schedule. |
| Nurse I | Licensed Nurse | Mentioned in fall with injury and bowel management for Resident #2. |
| Administrative Nurse M | Administrative Nurse | Provided statements regarding Resident #41 pain complaints. |
| Therapy Aide P | Therapy Aide | Verified no occupational therapy evaluation for wheelchair positioning for Resident #35. |
| Nurse Aide K | Nurse Aide | Mentioned in bowel management and Resident #2 care. |
| Licensed Nurse S | Licensed Nurse | Performed digital stool removal for Resident #2. |
| Administrative Nurse C | Administrative Nurse | Verified elevator motion sensor and accident hazards. |
| Maintenance Staff J | Maintenance Staff | Verified elevator door issues and basement clutter. |
| Social Service Staff H | Social Service Staff | Verified dental services and resident dental issues. |
| Dietary Manager G | Dietary Manager | Verified resident diet and dental soft diet order. |
Inspection Report
Follow-Up
Deficiencies: 2
Aug 15, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the deficiencies related to regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) were corrected as of 08/15/2014.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Jul 23, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Good Sam Decatur Co.
Findings
The plan addresses fall prevention interventions, care plan updates, training for charge nurses and case managers, and implementation of a neuro check checklist for falls with potential head injury. Audits and coaching are planned to ensure compliance.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Care plan for the resident was updated with new interventions related to fall prevention including white noise, change in incontinence product, enhanced rest periods, and contacting family if restless. | D |
| A new neuro check checklist was initiated as part of the falls packet to ensure timely assessments for falls with potential head injury. | D |
Report Facts
Audit period for falls interventions: 30
Audit period for random falls: 25
Audit period for neuro checks: 100
Audit period for neuro checks random: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janice Shobe | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Added the Plan of Correction. | |
| Mary Jane Kennedy | Modified the Plan of Correction. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jul 16, 2014
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies, 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 based on the credible allegation of compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'D' level indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Jul 16, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#76342) focusing on the facility's failure to revise the plan of care and implement interventions to prevent further falls for a sampled resident.
Findings
The facility failed to revise the care plan for one resident reviewed for falls and did not implement individualized interventions to prevent further falls. Neurological assessments were not completed as required after falls, and the facility did not consistently update care plans or follow their own policies regarding fall prevention and post-fall care.
Complaint Details
Complaint investigation #76342. The facility failed to revise the plan of care and implement interventions for Resident #3 after multiple falls, and failed to complete neurological assessments per facility policy.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to revise the plan of care for a resident reviewed for falls. | SS=D |
| Failure to ensure the resident environment was free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents. | SS=D |
Report Facts
Census: 36
Sample size: 3
Falls documented: 4
Neurological check gaps: 14
Neurological check gaps: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Stated nurses do not implement new interventions after every fall and neurological assessments depend on the fall circumstances. | |
| Administrative Nurse B | Stated neurological checks are required when a resident hits their head and verified some assessments were not completed in the required timeframe. |
Inspection Report
Follow-Up
Deficiencies: 10
Jun 27, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-05-28.
Findings
All previously reported deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date 2014-06-27.
Deficiencies (10)
| Description |
|---|
| Deficiency identified under regulation 483.13(c) |
| Deficiency identified under regulation 483.15(h)(2) |
| Deficiency identified under regulation 483.20(d), 483.20(k)(1) |
| Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency identified under regulation 483.25(c) |
| Deficiency identified under regulation 483.25(h) |
| Deficiency identified under regulation 483.35(i) |
| Deficiency identified under regulation 483.60(b), (d), (e) |
| Deficiency identified under regulation 483.65 |
| Deficiency identified under regulation 483.70(h)(3) |
Report Facts
Deficiencies corrected: 10
Inspection Report
Plan of Correction
Deficiencies: 10
Jun 27, 2014
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 of Correction addresses multiple deficiencies including reference checks for new hires, cleaning and maintenance of resident rooms, updating care plans for residents at risk of skin breakdown and falls, wound care documentation, chemical safety, food expiration and temperature control, controlled substance medication storage and monitoring, infection control procedures, and securing handrails.
Severity Breakdown
D: 5
E: 4
F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to obtain reference checks on new hires. | D |
| Sinks and toilet bowls stained; chipped paint and gouges in resident rooms. | E |
| Resident care plans not updated to address potential skin breakdown and pressure ulcers. | D |
| Care plans for residents at risk of falls and pressure ulcers not adequately reviewed or updated. | D |
| Inadequate wound care documentation for residents with pressure ulcers. | D |
| Chemicals not properly secured; lack of staff training on chemical safety. | E |
| Expired milk and cheese found; inadequate food expiration and temperature monitoring. | F |
| Controlled substance medications not stored in double locked storage and inadequate monitoring of medication expiration dates. | E |
| Infection control procedures not properly followed, especially handling contaminated items. | D |
| Handrails not securely affixed. | E |
Report Facts
Audit frequency: 3
Training completion date: Jun 27, 2014
Date of QA meetings: Jun 11, 2014
Date of licensed nurse meeting: Jun 10, 2014
Date expired milk disposed: May 22, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janice Shobe | Administrator | Administrator who submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Re-Inspection
Deficiencies: 1
May 28, 2014
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, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 9
May 28, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to implement abuse/neglect policies, maintain sanitary conditions, develop comprehensive care plans, provide necessary treatment for pressure ulcers, ensure a safe environment free of hazards, maintain sanitary food storage and preparation, properly store and manage medications, prevent infection transmission, and maintain secure handrails.
Severity Breakdown
Level D: 3
Level E: 4
Level F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to implement policies prohibiting mistreatment, neglect, and abuse by not screening one of three newly hired staff for references. | Level E |
| Failed to maintain sanitary environment in 8 resident bathrooms on one hallway. | Level D |
| Failed to develop comprehensive care plans for residents related to pressure ulcers and falls. | Level D |
| Failed to provide necessary treatment and services to promote healing and prevent infection for residents with pressure ulcers, including failure to document wound condition daily. | Level E |
| Failed to ensure resident environment was free of accident hazards by storing chemicals accessible to cognitively impaired residents. | Level F |
| Failed to store and distribute food under sanitary conditions by using expired milk and failing to hold cheese at proper cold temperature. | Level E |
| Failed to store controlled substances in double locked compartments, failed to monitor medication refrigerator temperatures, and failed to remove expired medications. | Level D |
| Failed to prevent infection transmission by improper handling of contaminated items after treatment of a resident with an eye infection. | Level E |
| Failed to have firmly secured handrails on one of four hallways. | Level E |
Report Facts
Residents sampled for care plan review: 14
Falls experienced by resident #33: 17
Residents identified as independently mobile with cognitive impairment: 8
Temperature of medication room refrigerators: 38
Expired medications found: 2
Temperature of cheese on salad bar: 44.2
Resident #14 pressure ulcer wound measurements: 4
Resident #14 pressure ulcer wound measurements: 2
Resident #14 pressure ulcer wound measurements: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse M | Licensed Nurse | Failed to remove contaminated gloves after administering eye drops to resident #33 |
| Staff N | Administrative Staff | Reported failure to obtain work or personal references for newly hired staff |
| Staff G | Environmental Staff | Observed unsanitary conditions in resident bathrooms |
| Staff B | Administrative Nursing Staff | Verified failure to update care plans and failure to double lock narcotics |
| Staff C | Licensed Nurse | Reported expired medications not routinely checked and failure to monitor medication refrigerator temperatures |
| Staff O | Dietary Staff | Confirmed expired milk was not discarded and lack of routine temperature monitoring of cold foods |
| Staff P | Dietary Staff | Placed cheese on salad bar at improper temperature |
| Staff L | Direct Care Staff | Observed transferring resident #33 |
| Staff T | Direct Care Staff | Observed transferring resident #33 |
| Staff J | Direct Care Staff | Observed repositioning resident #42 |
| Staff K | Direct Care Staff | Observed repositioning resident #42 |
| Staff H | Direct Care Staff | Observed repositioning resident #42 |
| Staff E | Licensed Nursing Staff | Reported resident #33 falls and care plan issues |
| Staff D | Administrative Nursing Staff | Reported resident #42 pressure ulcer and care plan deficiencies |
| Staff F | Licensed Nursing Staff | Observed dressing change for resident #35 pressure ulcer |
| Staff A | Administrative Staff | Reported 8 cognitively impaired residents independently mobile |
| Staff G | Maintenance Staff | Confirmed handrails not firmly secured |
Inspection Report
Follow-Up
Deficiencies: 4
Mar 4, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers F0279, F0329, F0428, and F0441 were corrected as of the revisit date.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Feb 6, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection, outlining corrective actions to address issues related to resident care plans, medication management, and infection control.
Findings
The facility identified deficiencies related to updating care plans for residents with MRSA wounds, ensuring drug regimens are free from unnecessary medications, monitoring bowel movements, and maintaining infection control practices including proper nebulizer cleaning and MRSA precautions. The facility outlined detailed corrective actions, staff education, and audit schedules to achieve substantial compliance by March 4, 2013.
Severity Breakdown
D: 3
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to update resident care plans to include history of MRSA in wounds. | D |
| Failure to verify that each resident's drug regimen is free from unnecessary drugs. | D |
| Failure to ensure licensed pharmacist reviews drug regimens monthly and reports irregularities. | D |
| Failure to establish and monitor an infection control program to prevent disease transmission. | E |
Report Facts
Date of licensed nurse meeting: Feb 6, 2013
Date of QAPI committee meeting: Feb 13, 2013
Compliance target date: Mar 4, 2013
Depakote level result: 43.2
Audit frequency: 3
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 7
Feb 4, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements including care planning, drug regimen monitoring, infection control, and other care standards.
Findings
The facility failed to develop comprehensive care plans addressing infection control for MRSA wounds, adequately monitor residents' drug regimens to prevent unnecessary drug use, ensure proper bowel management, and implement infection control measures to prevent spread of infection including proper handling of linens and nebulizer equipment.
Severity Breakdown
SS=D: 4
SS=E: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan to address infection control interventions for a wound infected with MRSA for Resident #15. | SS=D |
| Failed to adequately monitor the efficacy of residents' medications to ensure the drug regimen was free of unnecessary drugs for 3 residents (#18, #13, #8). | SS=D |
| Failed to adequately monitor bowel elimination programs and provide timely interventions as ordered by the physician for residents. | SS=D |
| Pharmacist Consultant failed to notify Director of Nursing of irregularities such as lack of bowel elimination monitoring and prolonged use of Prilosec without risk/benefit education for 3 residents (#18, #13, #8). | SS=D |
| Failed to implement appropriate infection control interventions for MRSA infected wound of Resident #15, including lack of care plan, improper handling of soiled dressings and linens, and failure to shower resident last. | SS=E |
| Failed to notify Infection Control nurse of Resident #49's infectious MRSA wound and failed to maintain accurate infection control records. | SS=E |
| Failed to provide sanitary environment to prevent spread of infection for Residents #21 and #42 by improper storage and handling of nebulizer breathing masks. | SS=E |
Report Facts
Census: 37
Sample size: 14
Residents reviewed for unnecessary drugs: 10
Residents with drug regimen issues: 3
Depakote blood level: 43.2
MRSA positive wound cultures: 3
Pressure ulcers: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Observed wound care and dressing changes for Resident #15; described infection control practices | |
| Nurse C | Administrative Nurse | Verified lack of care plan for MRSA infection control and improper linen handling |
| Nurse D | Described bowel management procedures and medication administration | |
| Nurse A | Provided wound care and described infection control notification procedures | |
| Nurse B | Described bowel alert record and interventions | |
| Nurse Consultant F | Pharmacist Consultant | Failed to notify Director of Nursing of drug regimen irregularities and lack of bowel monitoring |
| Nurse Aide H | Described linen handling and infection control practices | |
| Laundry Staff J | Described linen handling and lack of red bag use for MRSA infected linens |
Inspection Report
Plan of Correction
Deficiencies: 1
N020001 POC UYDT11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection related to COVID-19 policies, infection prevention, and PPE use.
Findings
The facility implemented education and training for staff on COVID-19, infection prevention, and PPE policies, with ongoing audits and competency checks planned to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Deficiencies related to COVID-19 policies, infection prevention, and PPE use. |
Report Facts
PPE audit frequency: 4
PPE competency checks frequency: 3
In-person training frequency (monthly): 3
In-person training frequency (quarterly): 2
Staff education completion date: Nov 16, 2020
Loading inspection reports...
