Inspection Report Summary
The most recent inspection on September 6, 2024, found the facility in compliance with all regulations and no new deficiencies. Prior inspections identified recurring issues primarily related to care plan accuracy and timely updates, medication management including psychotropic drug use, infection prevention, fall prevention, and reporting compliance. Complaint investigations substantiated some deficiencies, including a fall resulting in injury due to failure to follow a care plan, and concerns about resident supervision and abuse from earlier years. Enforcement actions included an immediate jeopardy finding in 2020 related to COVID-19 visitation controls and a prior immediate jeopardy in 2014 for substandard quality of care, but no fines or license suspensions were listed in the available reports. The facility appears to have improved over time, with recent inspections showing correction of previously cited deficiencies and no new noncompliance noted.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
158% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
30 residents
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 6, 2024
Visit Reason
An offsite revisit survey was conducted on 09/06/24 to verify correction of all previous deficiencies cited on 07/31/24.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/31/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 9
Jul 31, 2024
Visit Reason
This document is a Plan of Correction submitted in response to the annual survey inspection that ended on July 31, 2024, addressing deficiencies found during that inspection.
Findings
The Nicol Home identified multiple deficiencies related to care plan accuracy, timely revisions, infection prevention, medication management, fall prevention, and reporting compliance. The facility outlined corrective actions including care plan updates, physician and family notifications, root cause analyses, enhanced pharmacy reviews, and improved reporting procedures to achieve compliance by August 31, 2024.
Severity Breakdown
D: 5
E: 2
F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to maintain proper records and accurate care plans for residents. | E |
| Untimely care plan revisions for residents. | D |
| Failure to ensure treatment and care in accordance with professional standards and resident choices. | D |
| Failure to identify and mitigate hazards related to resident falls. | D |
| Failure to provide appropriate treatment and services to attain highest practicable mental and psychosocial well-being. | D |
| Failure to ensure appropriate drug regimen reviews and medication management. | D |
| Failure to appropriately monitor and reduce unnecessary psychotropic medications. | E |
| Failure to submit data for the Quarter 2 2024 PBJ Submission Deadline in a timely manner. | F |
| Failure to maintain an established infection prevention and control program with antibiotic stewardship. | D |
Report Facts
Deficiencies cited: 9
Plan of Correction completion date: Aug 31, 2024
QAPI meeting dates: Aug 21, 2024
Root cause analysis start date: Aug 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Mondero | Registered Pharmacist | Pharmacy consultant responsible for medication and drug regimen reviews |
| Carter Olson | Administrator | Administrator who submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 9
Jul 31, 2024
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements and investigate complaints.
Findings
The facility failed to develop and implement comprehensive care plans addressing individual resident needs, failed to revise care plans after significant changes, and failed to provide appropriate mental health and antibiotic stewardship services. Additionally, the facility did not submit accurate staffing data and failed to prevent falls and skin injuries adequately.
Complaint Details
The inspection included a complaint investigation identified as #KS00186564.
Severity Breakdown
SS=E: 2
SS=D: 5
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to develop comprehensive care plans addressing individual resident needs including wound care, medication management, and specialized services. | SS=E |
| Failed to revise care plans to reflect current health needs after assessments. | SS=D |
| Failed to provide appropriate quality of care including prevention and treatment of skin tears and sores. | SS=D |
| Failed to ensure a safe environment and adequate supervision to prevent falls. | SS=D |
| Failed to provide appropriate treatment and services for mental and psychosocial well-being. | SS=D |
| Failed to ensure drug regimen review identified and reported irregularities related to psychotropic medications and PRN orders. | SS=D |
| Failed to ensure residents did not receive unnecessary psychotropic medications and failed to limit PRN psychotropic drug orders to 14 days without proper evaluation. | SS=E |
| Failed to submit complete and accurate direct care staffing information to CMS Payroll Based Journal. | SS=F |
| Failed to implement antibiotic stewardship protocols to monitor and evaluate appropriateness of antibiotic use. | SS=D |
Report Facts
Resident sample size: 13
Dates with no Licensed Nurse coverage: 13
PRN Ativan administrations: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including care plan issues, medication irregularities, and antibiotic use. |
| Licensed Nurse H | Licensed Nurse | Provided information on resident care, medication use, and fall interventions. |
| Certified Nurse Aide P | Certified Nurse Aide | Reported on resident care, fall interventions, and medication administration. |
| Administrative Nurse E | Administrative Nurse | Observed wound care and verified care plan deficiencies. |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted residents with ambulation and reported on fall interventions. |
| Certified Nurse Aide O | Certified Nurse Aide | Reported on resident behaviors and skin conditions. |
| Administrative Staff A | Administrative Staff | Responsible for PBJ submission and verified inaccurate staffing data submission. |
| Social Service X | Social Service | Reported lack of involvement with resident regarding anxiety and depression. |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 1
Dec 28, 2022
Visit Reason
The inspection was conducted as an abbreviated complaint investigation (KS00176192) regarding a fall incident involving Resident 1 (R1).
Findings
The facility failed to ensure R1 was free from falls by not following the care plan requiring two staff assistance during bathing, resulting in R1 falling from a shower chair, sustaining a laceration and subdural hematoma requiring intensive care. The deficient practice was determined to be past noncompliance after staff education was completed.
Complaint Details
The visit was triggered by a complaint investigation KS00176192. The deficiency involved failure to prevent a fall of Resident 1 during bathing, resulting in injury. The deficient practice was determined to be past noncompliance.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure Resident 1 was free from falls by not following care plan for two staff assistance with bathing, resulting in a fall and injury. | SS=G |
Report Facts
Resident census: 26
Laceration size: 2.2
Laceration size: 2.3
Morse Fall Scale score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse's Aide (CNA) M | Assisted Resident 1 in shower and left resident unattended, leading to fall | |
| Certified Nurse's Aide (CNA) N | Stated Resident 1 was a two-person assist getting into shower chair but one-person assist with actual shower | |
| Administrative Nurse D | Verified Resident 1's care plan required two staff assistance with bathing |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 28, 2022
Visit Reason
An offsite revisit survey was conducted on 09/28/22 for all previous deficiencies cited on 08/02/22 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/31/22, 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: 8
Aug 2, 2022
Visit Reason
This document is a Plan of Correction submitted in response to the annual survey that ended on August 2, 2022, addressing deficiencies identified during that survey.
Findings
The Plan of Correction outlines multiple corrective actions to address deficiencies related to dignity and privacy during medication administration, care plan accuracy, smoking safety, bowel and bladder incontinence management, medication regimen reviews, psychotropic medication monitoring, medication storage, and immunization tracking.
Severity Breakdown
D: 6
E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to maintain dignity and privacy during medication administration | D |
| Inaccurate or incomplete care plans for residents | D |
| Inadequate safety measures for residents who smoke | D |
| Failure to provide appropriate bowel and bladder incontinence screenings and retraining | D |
| Inadequate medication regimen reviews and pharmacist consultation | D |
| Inappropriate use and monitoring of psychotropic medications | D |
| Improper storage and handling of medications and biologicals | E |
| Failure to ensure immunizations for residents, including influenza and pneumonia vaccines | E |
Report Facts
Deficiencies cited: 8
QAPI meetings: 3
Residents notified: 3
Dates of completion: Aug 31, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Mondero | Registered Pharmacist | Pharmacy consultant providing medication and drug regimen reviews and participating in QAPI meetings |
| Carter Olson | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 8
Aug 2, 2022
Visit Reason
Health resurvey inspection conducted to assess compliance with resident rights, care planning, accident hazards, medication management, and immunization policies.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during medication administration, inadequate care planning for antipsychotic medication use, failure to complete safe smoking evaluations, lack of toileting programs for residents with incontinence, failure to ensure pharmacist and physician oversight on antipsychotic medication diagnoses and use, improper medication labeling and storage, and failure to assess residents for pneumococcal vaccination eligibility.
Severity Breakdown
SS=D: 6
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to treat residents with respect, dignity, and privacy during medication administration. | SS=D |
| Failed to develop and implement comprehensive care plans for antipsychotic medication use. | SS=D |
| Failed to complete safe smoking evaluation for a resident who smokes. | SS=D |
| Failed to develop and initiate a toileting program for a resident assessed as a good candidate for bladder retraining. | SS=D |
| Failed to ensure consultant pharmacist identified and reported inappropriate diagnoses for antipsychotic medication use and ensure physician response. | SS=D |
| Failed to ensure psychotropic medications were used for appropriate diagnoses per CMS guidelines. | SS=D |
| Failed to label insulin vials with date opened and expiration, discard expired insulin pens and expired stock medications. | SS=E |
| Failed to assess residents for eligibility to receive pneumococcal vaccine and document education or declination. | SS=E |
Report Facts
Census: 31
Sample size: 12
Antipsychotic medication days: 7
Expired medication count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Observed medication administration and verified expired medications |
| Administrative Nurse D | Administrative Nurse | Provided statements on medication administration and diagnosis appropriateness |
| Administrative Nurse E | Administrative Nurse | Verified care planning and medication monitoring deficiencies |
| Certified Nurse Aid O | Certified Nurse Aid | Observed resident behavior and medication effects |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 3, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 03/31/2021.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 04/22/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 7
Mar 31, 2021
Visit Reason
This document is a Plan of Correction submitted in response to an annual survey inspection that ended on March 31, 2021, outlining corrective actions to address deficiencies identified during the survey.
Findings
The Plan of Correction details multiple corrective actions to improve resident care quality, including fall prevention interventions, nutritional status monitoring, medication regimen reviews, blood pressure monitoring, psychotropic medication management, and infection prevention and control enhancements.
Severity Breakdown
D: 6
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Falls and fall risks are to be thoroughly investigated with proper interventions implemented. | D |
| Maintenance of acceptable nutritional status through monitoring therapeutic diets and fluid restrictions. | D |
| Regular pharmacy medication and drug regimen reviews to ensure appropriateness of drug regimens. | D |
| Monitoring blood pressure daily for Resident #13 and reporting to PCP. | D |
| Correction of inaccurate antipsychotic medication reporting and education on Gradual Dose Reduction. | D |
| Ensuring resident drug regimens are free from unnecessary drugs, including psychotropic medications. | D |
| Establishment and maintenance of an infection prevention and control program with antibiotic stewardship. | F |
Report Facts
Dates for corrective actions: Apr 22, 2021
QAPI meetings: 3
Blood pressure monitoring start date: Apr 2, 2021
Labwork completion date: Apr 16, 2021
Antibiotic Stewardship Director appointment date: Apr 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Ptacek | Registered Dietician | Reviewed fluid restriction for Resident #26 |
| Kevin Norris | Primary Care Physician | Reviewed fluid restriction for Resident #26 |
| Chris Mondero | Pharmacy Consultant, Registered Pharmacist | Conducts medication and drug regimen reviews and participates in QAPI meetings |
| Carter Olson | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 6
Mar 31, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #153124 to evaluate compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to investigate and prevent resident falls, inadequate monitoring of fluid restrictions, failure to monitor and act on medication irregularities, failure to attempt gradual dose reduction of antipsychotic medication, and lack of an effective antibiotic stewardship program.
Complaint Details
The visit was triggered by a complaint investigation #153124.
Severity Breakdown
SS=D: 5
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate the reason for resident falls and implement effective interventions to prevent further falls for Resident 3. | SS=D |
| Failure to adequately monitor Resident 26's fluid restriction. | SS=D |
| Consultant pharmacist failed to notify the Director of Nursing or physician of lack of blood pressure monitoring for Resident 13 and failure to follow up on pharmacist recommendation for gradual dose reduction of Geodon for Resident 11. | SS=D |
| Failure to obtain physician ordered labwork to monitor use of Coumadin and lack of monitoring of blood pressure for medications affecting blood pressure for Resident 13. | SS=D |
| Failure to monitor adverse side effects and attempt gradual dose reduction for Resident 11 receiving Geodon. | SS=D |
| Failure to consistently utilize an antibiotic stewardship program including tracking and monitoring of infections and antibiotic use. | SS=F |
Report Facts
Resident census: 29
Fall Risk Assessment score: 75
Fall Risk Assessment score: 55
Fluid restriction: 2500
Resident weight: 77
Resident weight: 81
Fluid intake: 1087
Geodon dose: 40
Lasix dose: 80
Metoprolol dose: 50
Losartan dose: 100
Coumadin dose: 2.5
Coumadin dose: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified failures in monitoring, medication management, and antibiotic stewardship |
| Licensed Nurse G | Licensed Nurse | Provided information on resident toileting and medication monitoring |
| Certified Nurse Aide N | CNA | Provided information on resident supervision and toileting |
| Certified Nurse Aide M | CNA | Provided information on resident incontinence and supervision |
| Social Service Designee X | SSD/CNA | Provided information on resident toileting assistance |
| Dietary Staff BB | Dietary Staff | Provided information on fluid restriction monitoring |
| Certified Medication Aide M | CMA | Provided information on fluid restriction knowledge |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 31, 2020
Visit Reason
A revisit survey was conducted on 08/31/2020 to verify correction of all previous deficiencies cited on 06/16/2020.
Findings
All deficiencies cited in the previous inspection have been corrected as of 06/23/2020, 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: 1
Jun 16, 2020
Visit Reason
The document is a Plan of Correction submitted by The Nicol Home to ensure compliance with regulation F880 related to visitation restrictions and infection control measures during the COVID-19 pandemic.
Findings
The facility restricted visitation to compassionate care situations only, implemented social distancing during communal dining, limited group activities, and enforced screening and protective measures for staff and residents to prevent COVID-19 transmission.
Deficiencies (1)
| Description |
|---|
| Visitation generally prohibited, except for compassionate care situations with screening and precautions. |
Report Facts
Maximum number of people in dining room: 15
Temperature and vitals check frequency: 4
Plan completion date: Jun 23, 2020
Inspection Report
Abbreviated Survey
Census: 31
Deficiencies: 1
Jun 16, 2020
Visit Reason
The visit was a Targeted Infection Control Survey/COVID-19 Focused Survey conducted to assess the facility's compliance with CMS and CDC guidelines regarding COVID-19 infection prevention and control.
Findings
The facility failed to restrict visitation and enforce social distancing during resident dining as required by CMS and CDC COVID-19 guidelines, placing 31 residents at risk for infection. The facility was placed in Immediate Jeopardy but removed it after implementing restricted visitation, social distancing, and staff education.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to restrict visitation to control and prevent potential spread of COVID-19 between residents and staff. | Immediate Jeopardy |
Report Facts
Census: 31
Visitors screened: 314
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided information about visitation policies and awareness of CDC recommendations | |
| Nurse G | Charge Nurse | Responsible for screening residents' family members and clergy before visits |
| Administrative Nurse D | Stated facility allowed family visits after screening and mask provision |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 12, 2019
Visit Reason
An offsite revisit survey was conducted on 7/12/2019 for all previous deficiencies cited on 5/28/2019.
Findings
All deficiencies have been corrected as of the compliance date of 6/14/2019, 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: 5
May 28, 2019
Visit Reason
This document is a Plan of Correction submitted in response to the annual survey inspection that ended on May 28, 2019, addressing deficiencies found during that survey.
Findings
The Plan of Correction outlines corrective actions to address deficiencies related to inaccurate assessments, untimely care plan revisions, nursing aide in-service training, unnecessary drug regimens, and food safety practices. The facility commits to staff education, audits, policy reviews, and ongoing monitoring to ensure compliance and quality care.
Severity Breakdown
D: 3
E: 1
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Inaccurate resident assessment requiring MDS modification for resident #9 | D |
| Untimely care plan revision for resident #27 | D |
| Failure to meet required 12 hour annual certified nursing aide in-services | E |
| Unnecessary drugs in resident drug regimen for resident #29 | D |
| Deficient food receiving and storage practices | F |
Report Facts
Deficiency correction completion date: Jun 14, 2019
Medication administration audit duration (weeks): 6
Annual certified nursing aide in-service hours required: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Novotny | Wound Certified Registered Nurse | Consultant providing wound and assessment consultation |
| Carter Olson | Administrator | Administrator submitting the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 5
May 28, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #137164 and #137373 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to revise care plans after incidents, inadequate nurse aide in-service training, failure to administer medications as ordered, and improper food storage practices.
Complaint Details
The visit was complaint-related as indicated by the Health Resurvey and Complaint Investigations #137164 and #137373 mentioned in the initial comments.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| The facility's Minimum Data Set assessment failed to accurately reflect Resident #9's pressure ulcer status. | SS=D |
| The facility failed to review and revise the care plan for Resident #27 following a fall with fractures. | SS=D |
| The facility failed to provide the required 12 hours in-service education for nurse aides employed at least one year. | SS=E |
| The facility failed to ensure Resident #29 received medications as physician ordered, with multiple missed doses documented. | SS=D |
| The facility failed to store and serve food under sanitary conditions, specifically failing to date opened bottles of juice in the refrigerator. | SS=F |
Report Facts
Census: 28
Sample size: 9
Nurse aides lacking 12 hours in-service: 5
Medication doses missed: 20
Opened juice bottles without date: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Verified quarterly MDS did not include resident's pressure ulcer and stated facility was out of Depakote medication. |
| Administrative Nurse D | Administrative Nurse | Verified missing medication administration and proper procedures for unavailable medications. |
| Administrative Staff A | Administrative Staff | Verified care plan had not been updated following resident's fall and lack of nurse aide in-service documentation. |
| Staff Nurse G | Staff Nurse | Observed removing wound dressing revealing pressure ulcer. |
| Dietary Staff CC | Dietary Staff | Verified open bottles of juice were not dated. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 17, 2019
Visit Reason
A desk review was completed for the deficiency cited on January 2, 2019.
Findings
The deficiency was placed into compliance with an effective date of January 4, 2019.
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 4, 2019
Visit Reason
This document is a Plan of Correction submitted by Homestead Health Center in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses staffing deficiencies, specifically ensuring at least 8 hours of RN coverage daily through part-time and PRN nursing staff, recruitment efforts, and scheduling oversight by the Director of Nursing and Administrator.
Deficiencies (1)
| Description |
|---|
| Failure to provide adequate RN coverage daily as required. |
Report Facts
Date correction implemented: Jan 3, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Carter Olson | Facility Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Jan 2, 2019
Visit Reason
The inspection was conducted as a result of complaint investigations #135290 and #136610 regarding nursing staff coverage.
Findings
The facility failed to provide the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week, placing residents at risk for lack of registered nursing assessment and appropriate care.
Complaint Details
The findings represent the results of complaint investigations #135290 and #136610. The facility had occasional lapses in RN coverage, usually on weekends.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. | SS=F |
Report Facts
Deficiency dates: 20
Resident census: 28
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jan 2, 2019
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 a 'F' level deficiency constituting noncompliance with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective January 4, 2019.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be a 'F' level deficiency constituting noncompliance with potential for more than minimal harm that is not immediate jeopardy. | F |
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
Re-Inspection
Deficiencies: 0
Sep 24, 2018
Visit Reason
A revisit survey was conducted on 9/24/18 to verify correction of all previous deficiencies cited on 8/20/18.
Findings
All deficiencies have been corrected as of the compliance date of 9/17/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 11
Aug 20, 2018
Visit Reason
The inspection was conducted as a Health Resurvey complaint investigation KS#132384 and Extended Health Resurvey.
Findings
The facility failed to provide supervision to protect Resident #15 from abuse by Resident #17, who made verbal threats and later physically hit Resident #15, placing the resident in immediate jeopardy. The facility also failed to report the threat in a timely manner, failed to develop comprehensive care plans for some residents, failed to provide appropriate restorative services for limited range of motion, failed to adequately monitor nutrition and hydration status, failed to ensure required nurse aide training, failed to provide necessary behavioral health services, failed to adequately monitor drug regimens, failed to employ a certified dietary manager, failed to maintain sanitary food service conditions, and failed to provide a safe environment for cognitively impaired residents.
Complaint Details
The complaint investigation focused on abuse and neglect related to Resident #17's verbal threats and physical abuse of Resident #15, as well as the facility's failure to provide supervision and timely reporting.
Severity Breakdown
G: 1
F: 3
E: 3
D: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to provide supervision to protect Resident #15 from abuse by Resident #17, who made verbal threats and later physically hit Resident #15. | G |
| Failed to report a threat made by Resident #17 toward another resident to administrative staff in a timely manner. | D |
| Failed to develop comprehensive care plans for 3 sampled residents including smoking and diabetic management. | D |
| Failed to ensure a resident with limited range of motion received appropriate treatment and services to increase or prevent decrease in range of motion. | D |
| Failed to identify significant weight loss and maintain nutrition/hydration status for a resident. | D |
| Failed to ensure required 12 hours of in-service training for all nurse aides. | F |
| Failed to provide necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for a cognitively impaired resident with ongoing behaviors. | D |
| Consultant pharmacist failed to identify and report irregularities including inadequate monitoring of blood sugar, blood pressure, and bowel movements for multiple residents. | E |
| Failed to employ a full time certified dietary manager to supervise and prepare meals. | F |
| Failed to store, prepare, distribute and serve food in safe and sanitary conditions in the kitchen. | F |
| Failed to provide a safe, hazard free environment for cognitively impaired independently mobile residents. | E |
Report Facts
Resident census: 30
Weight loss percentage: 10.9
Missing blood sugar readings: 1
Days without bowel movement: 7
Days without bowel movement: 14
Days without bowel movement: 7
Number of CNA staff lacking required training: 23
Number of residents with limited range of motion reviewed: 1
Number of residents reviewed for unnecessary medications: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff AA | Dietary Manager | Identified as dietary manager but not certified and currently enrolled in certification class; prepared pureed foods incorrectly and failed to change soiled gloves |
| Nurse Aide R | Certified Nurse Aide | Involved in redirecting Resident #17 from Resident #15's room during abuse incident |
| Nurse Aide M | Certified Nurse Aide | Reported observations of Resident #17's aggressive behaviors and injuries to Resident #15 |
| Nurse G | Nurse | Reported Resident #17's behavior and supervision status |
| Administrative Nurse D | Administrative Nurse | Verified expectations for reporting threats and behaviors, and monitoring of blood sugar and bowel movements |
| Consultant Staff HH | Consultant Staff | Verified lack of documentation of abuse/neglect and dementia training for nurse aides |
Inspection Report
Plan of Correction
Deficiencies: 11
Aug 13, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection, addressing corrective actions to ensure compliance with Federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions taken and planned to address multiple deficiencies including resident safety, abuse and neglect training, smoking care plans, diabetic management, restorative nursing programs, behavioral health interventions, dietary management, food safety, and safe storage of chemicals.
Deficiencies (11)
| Description |
|---|
| Resident #17 placed on one on one monitoring after incident; staff trained on Abuse, Neglect, and Exploitation and behavior policy. |
| Policies and procedures established to ensure resident safety from harm; staff trained on Abuse, Neglect, and Exploitation reporting. |
| Care plans updated for residents who smoke; smoking assessments to be completed quarterly. |
| OT assessment and orders for Resident #10 to maintain or increase range of motion; staff education on restorative nursing. |
| Resident #4 to be weighed weekly for 4 weeks; care plan updated for nutrition; staff trained on weight monitoring policy. |
| Educational training on Abuse, Neglect, and Exploitation and dementia provided; training compliance monitored. |
| Behavioral health interventions for Resident #17 with Traumatic Brain Injury; ongoing psychosocial support and monitoring. |
| Bowel protocol implemented; staff educated on monitoring bowel movements and diabetic blood sugar checks. |
| Facility to employ certified dietary manager; dietary consulting firm engaged for training and compliance. |
| Food prepared, stored, and served safely with cleaning schedules and staff training on food handling. |
| Plan developed to keep harmful chemicals and sharp objects locked and away from residents; staff instructed on safety protocols. |
Report Facts
Dates for completion of corrective actions: Sep 17, 2018
Date of incident: Aug 13, 2018
Date of resident admission to behavioral health unit: Aug 14, 2018
Date of staff training on Abuse, Neglect, and Exploitation: Feb 14, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
May 10, 2018
Visit Reason
A complaint survey was conducted on 2018-05-10 for complaint #KS128540.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint #KS128540 was investigated and found to be not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 10, 2018
Visit Reason
A complaint survey was conducted on 5/10/18 for complaint #KS128540.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint #KS128540 was investigated and found to be unsubstantiated with no noncompliance identified.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 6, 2018
Visit Reason
An off-site survey was conducted to verify correction of a deficiency cited on February 21, 2018.
Findings
The deficiency cited previously was corrected as of the compliance date of March 21, 2018.
Report Facts
Compliance date: Mar 21, 2018
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 21, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility to address alleged deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions including reviewing and updating care plans for residents, completing chair risk assessments, educating staff on resident safety and fall risk assessments, and monitoring by the Director of Nursing or designee.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure proper chair cushion use and adequate chair risk assessments for residents. | D |
Report Facts
Date of compliance: Mar 21, 2018
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2018
Visit Reason
A complaint survey was conducted on 3/13/18 for complaint #KS00127171.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint #KS00127171 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2018
Visit Reason
A complaint survey was conducted on 3/13/18 for complaint #KS00127171.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint #KS00127171 was investigated and found to be unsubstantiated with no noncompliance identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2018
Visit Reason
A complaint survey was conducted on 3/13/18 for complaint #KS00127171 to investigate the allegations made in the complaint.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility was in compliance with all regulations surveyed.
Complaint Details
Complaint #KS00127171 was investigated and found to be unsubstantiated with no noncompliance identified.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Feb 21, 2018
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 March 21, 2018.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Feb 21, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#126594) regarding the facility's failure to provide an environment free of accident hazards and adequate supervision to prevent accidents for residents.
Findings
The facility failed to provide a safe environment and adequate supervision for two residents, resulting in falls from recliners. Resident #1 fell after staff placed a pillow under the buttocks in a recliner, and Resident #2 had two falls from a recliner due to inadequate supervision and lack of recliner assessment.
Complaint Details
The complaint investigation #126594 found the facility failed to prevent falls and provide adequate supervision for residents with dementia and mobility impairments, resulting in falls from recliners and risk for further injury.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide an environment free of accident hazards and adequate supervision to prevent accidents for 2 of 3 residents reviewed for accidents. | SS=D |
Report Facts
Census: 30
Residents reviewed for accidents: 3
Falls: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide M | Nurse Aide | Verified placing pillow under Resident #1 and observations related to Resident #2 |
| Nurse G | Nurse | Verified pillow placement was inappropriate and confirmed Resident #2's fall circumstances |
| Administrative Nurse D | Administrative Nurse | Verified pillow placement incident and lack of recliner assessment |
| Nurse Aide N | Nurse Aide | Verified Resident #2's fall and behavior regarding call light use |
Inspection Report
Follow-Up
Deficiencies: 1
Feb 8, 2017
Visit Reason
This revisit report documents the correction of previously reported deficiencies at The Nicol Home, verifying that corrective actions have been completed.
Findings
The report confirms that the previously identified deficiency related to regulation 28-39-158(a) was corrected as of 02/08/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 28-39-158(a) |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 8, 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 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18), 483.10(i)(2), 483.25(d)(1)(2)(n)(1)-(3), 483.35(b)(1)-(3), and 483.60(i)(1)-(3) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 6
Jan 11, 2017
Visit Reason
This document is a Plan of Correction submitted by The Nicol Home to address deficiencies identified in a prior inspection, outlining corrective actions to comply with state and federal regulations.
Findings
The Plan of Correction details multiple areas of concern including Medicare notice provision, housekeeping and maintenance, chemical safety, RN coverage, food preparation sanitation, and nutrition services supervision, with specific corrective actions and monitoring plans described for each.
Deficiencies (6)
| Description |
|---|
| Failure to provide required Medicare notices regarding coverage and payment using CMS forms. |
| Housekeeping and maintenance issues including carpet cleanliness and flooring replacement. |
| Environment not free from accident hazards due to unsecured chemicals in shower room. |
| Insufficient RN coverage; assurance of 8 consecutive hours of RN services 7 days a week. |
| Sanitary deficiencies in food preparation and dish cleaning areas. |
| Inadequate supervision of Nutrition Services department and incomplete enrollment of Dietary Manager in CDM course. |
Report Facts
Residents referenced for carpet cleaning: 4
RN coverage hours: 8
Plan of Correction review date: Jan 26, 2017
Inspection Report
Re-Inspection
Deficiencies: 1
Jan 10, 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 deficiencies to be '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 accepted, and the facility was found to be in substantial compliance effective February 8, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies were 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date of substantial compliance: Feb 8, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter and contact for questions regarding the survey |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Jan 10, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to dietary services at the facility.
Findings
The facility failed to provide a full-time certified dietary manager to oversee nutritional concerns and food services for the 29 residents, placing residents at risk of inadequate nutrition.
Complaint Details
The findings represent the results of a Health Resurvey and Complaint Investigation #96656, #102259, #102442, and #109460.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee ordering, preparation, and storage of food. | SS=F |
Report Facts
Census: 29
Sample size: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff D | Observed assisting with meal preparation and supervising dietary staff; verified not enrolled in Certified Dietary Manager course. | |
| Administrative Staff B | Verified Dietary Staff D had not taken the certified dietary manager course and that the facility did not have a certified dietary manager employed. |
Inspection Report
Life Safety
Deficiencies: 1
Nov 18, 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 enforcement 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 that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Feb 18, 2017
Provider agreement termination date: May 18, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned as responsible for enforcement |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 9
Dec 24, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies were corrected as of the revisit date, with corrections completed for multiple regulatory requirements.
Deficiencies (9)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.20(g) - (j) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.30(b) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.70(f) |
Report Facts
Deficiencies corrected: 9
Inspection Report
Follow-Up
Deficiencies: 1
Dec 24, 2015
Visit Reason
This revisit report documents the follow-up inspection to verify correction of previously reported deficiencies at The Nicol Home.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 12/24/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited |
Inspection Report
Re-Inspection
Deficiencies: 1
Nov 24, 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 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 based on the credible allegation of compliance and the plan of correction.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 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 | Enforcement Coordinator | Signed the enforcement decision letter and communicated the acceptance of the plan of correction. |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 9
Nov 24, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation related to allegations of abuse, neglect, and compliance with care standards.
Findings
The facility failed to thoroughly investigate and report a resident-to-resident altercation, failed to promote dignity and respect, failed to accurately assess restorative communication services, failed to revise care plans with appropriate fall interventions, failed to provide necessary care for aggressive behavior, failed to provide RN coverage for 8 hours daily 7 days a week, failed to properly label and date insulin vials, and failed to maintain functioning bathroom call lights for some residents.
Complaint Details
The complaint investigation focused on allegations of abuse, neglect, mistreatment, and failure to report a resident-to-resident altercation involving Resident #8. The facility failed to report the incident to the state agency and failed to provide adequate supervision and care related to aggressive behaviors.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate and report a resident-to-resident altercation involving Resident #8. | SS=D |
| Failed to promote care in a manner that maintains or enhances residents' dignity and respect. | SS=E |
| Failed to provide accurate assessments reflecting restorative communication status for multiple residents (#21, #27, #30). | SS=D |
| Failed to revise care plan with appropriate fall prevention interventions for Resident #25. | SS=D |
| Failed to provide necessary care and services related to aggressive behavior for Resident #8. | SS=D |
| Failed to ensure resident environment free of accident hazards and provide supervision to prevent accidents for Residents #8 and #25. | SS=D |
| Failed to provide Registered Nurse services for 8 consecutive hours a day, 7 days a week. | SS=F |
| Failed to label and date insulin vials appropriately; expired insulin was administered to Resident #8. | SS=D |
| Failed to have functioning bathroom call lights for Residents #19 and #28. | SS=E |
Report Facts
Census: 27
Sample size: 13
Fall risk score: 15
Expired insulin days: 48
Dates without RN coverage: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide F | Verified resident #8 pushed another resident and displayed aggressive behaviors | |
| Administrative Nurse B | Verified resident #8's aggressive behaviors, lack of incident reporting, falls for Resident #25, and lack of RN coverage | |
| Nurse E | Verified expired insulin vial in use for Resident #8 | |
| Administrative Nurse C | Verified lack of bathroom call lights for Residents #19 and #28 | |
| Nurse Aide G | Reported Resident #25's history of falls when transferring from electric scooter to recliner | |
| Nurse F | Reported Resident #25's decline in self-care and locomotion after spouse's death | |
| Administrative Staff A | Verified RN coverage requirements and call light system checks |
Inspection Report
Plan of Correction
Deficiencies: 10
Nov 20, 2015
Visit Reason
This document is a Plan of Correction submitted by The Nicol Home in response to deficiencies identified during a prior inspection, addressing issues such as resident-to-resident altercations, communication, care plans, medication management, and staffing.
Findings
The Plan of Correction outlines corrective actions including staff education, policy reviews, monitoring by the Director of Nursing, and procedural changes to address deficiencies related to resident safety, communication, care planning, medication storage, and staffing shortages.
Deficiencies (10)
| Description |
|---|
| Resident-to-resident altercation reporting and investigation |
| Communication of resident information and dignity |
| Accurate restorative communication status documentation |
| Care plan review and updating for significant condition changes |
| Management of unmanageable residents |
| Fall risk assessment and care plan updates |
| Staffing and RN coverage due to limited rural resources |
| Medication storage and outdated insulin replacement |
| Call light replacements and maintenance |
| Food service management and licensing |
Report Facts
Deficiency completion dates: Dec 24, 2015
Resident IDs referenced: 4
Date of resident discharge: Nov 26, 2015
Date of resident admission to Special Care Unit: Nov 24, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Teresa Shore | Administrator | Submitted Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
Aug 28, 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 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility found to have 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Nov 28, 2015
Provider agreement termination date: Feb 28, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report and is the Enforcement Coordinator for the Survey, Certification and Credentialing Commission |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 9
Oct 20, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report documents that all previously cited deficiencies were corrected as of 09/26/2014, with no uncorrected deficiencies remaining at the time of the revisit.
Deficiencies (9)
| Description |
|---|
| Deficiency related to regulation 483.13(c) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulations 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulations 483.35(d)(1)-(2) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(c)(2) |
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 8
Sep 26, 2014
Visit Reason
This document is a Plan of Correction submitted by The Nicol Home in response to deficiencies cited in a prior inspection report, outlining corrective actions to achieve compliance with Federal Medicare and Medicaid requirements.
Findings
The Plan of Correction addresses multiple deficiencies including employment file reviews for criminal background checks, environmental repairs, care plan reviews, hot water temperature safety, food preparation policies, infection control, and dietary service supervision.
Deficiencies (8)
| Description |
|---|
| Employment files for all current employees will be reviewed to ensure criminal background checks have been requested. |
| Contractor contacted to provide estimate for replacement and repair of linoleum, door kick plates, drywall, and vent covers. |
| Care plans for all current residents reviewed; pressure ulcer risk assessments to be completed; staff in-service on skin breakdown interventions. |
| Hot water tank temperature adjusted and monitored to maintain safe levels; staff in-serviced on water temperature safety and burn risks. |
| Food temperature logs to be audited monthly; food preparation policy reviewed and in-serviced to staff. |
| Infection tracking log updated; cleaning and disinfection policies reviewed and in-serviced; deep cleaning checklist implemented. |
| Gas turned off and pilot lights repaired; dietary staff trained on manual lighting procedures and gas leak protocols. |
| Facility to advertise and employ a Certified Dietary Manager; supervisory responsibility assigned to qualified employee with dietitian oversight. |
Report Facts
Date of Plan Completion: Sep 26, 2014
Hot water temperature: 120
Hot water temperature: 122
Hot water temperature: 116
Date of hot water tank adjustments: Aug 19, 2014
Date of fire protection cleaning: Sep 3, 2014
Date gas turned off: Aug 18, 2014
Date pilot lights repaired: Aug 20, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MARCHUYGHEBAERT | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 9
Aug 27, 2014
Visit Reason
The inspection was conducted as a Health Resurvey, Extended Health ReSurvey, and Complaint Investigations #75543, #75536, and #75683.
Findings
The facility was found deficient in multiple areas including failure to obtain timely criminal background checks for new staff, inadequate housekeeping and maintenance, failure to revise care plans for residents with pressure ulcers, unsafe water temperatures in resident rooms and shower, improper food temperature and sanitary food preparation, infection control lapses, and unsafe kitchen equipment.
Complaint Details
The visit included complaint investigations #75543, #75536, and #75683 as part of the Health Resurvey and Extended Health ReSurvey.
Severity Breakdown
SS=E: 4
SS=D: 2
SS=L: 1
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to obtain criminal background checks in a timely manner for 5 of 5 staff members hired since last survey. | SS=E |
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment on 2 of 2 halls and common areas. | SS=E |
| Failed to revise or update the care plan for Resident #22 who had multiple pressure ulcers and developed a shearing wound. | SS=D |
| Failed to provide necessary treatment and services to prevent the development of pressure ulcers for Resident #22. | SS=D |
| Failed to ensure resident environment remained free from accident hazards due to unsafe water temperatures above 120 degrees Fahrenheit in multiple resident rooms and shower room. | SS=L |
| Failed to provide food prepared at the proper temperature for residents receiving meals in the dining room. | SS=E |
| Failed to prepare food under sanitary conditions, including improper glove use and unclean kitchen equipment. | SS=E |
| Failed to establish and maintain an Infection Control Program to provide a safe, sanitary, and comfortable environment and prevent disease transmission. | SS=F |
| Failed to maintain all essential mechanical and electrical equipment in safe operating condition; gas leak and broken pilot tube in kitchen stove. | SS=F |
Report Facts
Number of residents: 23
Number of staff with delayed background checks: 5
Water temperatures: 132
Water temperatures: 141
Water temperatures: 139
Temperature of roast beef: 119
Temperature of roast beef: 156
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Verified findings related to care plan, infection control, water temperature, and food temperature deficiencies |
| Nurse Aide H | Nurse Aide | Provided statements regarding resident care and water temperature monitoring |
| Nurse C | Nurse | Stated no new interventions were implemented after resident developed shearing wound |
| Housekeeping Staff P | Housekeeping Staff | Observed cleaning toilets with same brush for all rooms |
| Dietary Staff K | Dietary Staff | Reported gas leak and conducted in-service on stove lighting |
| Local Contractor G | Contractor | Inspected and adjusted water heater and stove pilot lights |
Inspection Report
Enforcement
Deficiencies: 1
Aug 27, 2014
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not in substantial compliance, with conditions constituting immediate jeopardy to resident health or safety from July 10, 2014 through August 19, 2014, specifically related to substandard quality of care under F323"L" CFR 01-483.25(h). Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were recommended.
Severity Breakdown
L: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F323"L", CFR 01-483.25(h) constituting substandard quality of care and immediate jeopardy to resident health or safety. | L |
Report Facts
Denial of payment effective date: Nov 27, 2014
Provider agreement termination date: Feb 27, 2015
Civil Money Penalty minimum amount: 5000
Immediate jeopardy period start date: Jul 10, 2014
Immediate jeopardy period end date: Aug 19, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Novotony | Administrator | Named as facility administrator in relation to the enforcement survey. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
Inspection Report
Life Safety
Deficiencies: 1
Apr 14, 2014
Visit Reason
A Life Safety Code survey was conducted 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 'F' level, 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jul 14, 2014
Provider agreement termination date: Oct 14, 2014
IDR request timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Francis Tatro | Administrator | Named as facility administrator in the report. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator for Kansas Department for Aging and Disability Services. |
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 9, 2013
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
The report confirms that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 08/09/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously reported has been corrected. |
Report Facts
Deficiency correction date: Aug 9, 2013
Inspection Report
Follow-Up
Deficiencies: 8
Aug 9, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by their regulation numbers were corrected by the revisit date of 08/09/2013, as documented in the report.
Deficiencies (8)
| Description |
|---|
| Deficiency identified under regulation 483.15(a) |
| Deficiency identified under regulation 483.20(b)(1) |
| Deficiency identified under regulation 483.20(d), 483.20(k)(1) |
| Deficiency identified under regulation 483.25(h) |
| Deficiency identified under regulation 483.25(i) |
| Deficiency identified under regulation 483.25(l) |
| Deficiency identified under regulation 483.35(i) |
| Deficiency identified under regulation 483.60(c) |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 9
Jul 18, 2013
Visit Reason
This document is a Plan of Correction submitted by The Nicol Home to address deficiencies identified in a prior inspection, detailing corrective actions to achieve compliance with Federal Medicare and Medicaid requirements.
Findings
The Plan of Correction outlines multiple corrective actions including staff in-service training on feeding policies, monthly audits of resident assessments, development and updating of individualized care plans, monitoring of residents at risk for weight changes, adherence to new FDA guidelines by the pharmacy consultant, and improvements in dietary services including staff education and sanitation practices.
Severity Breakdown
D: 5
E: 2
F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to comply with Quality of Life-Dignity policy and feeding procedures for residents who cannot feed themselves. | D |
| Incomplete yearly resident assessments (MDS and CAAs). | D |
| Care plans not developed or updated appropriately on admission and quarterly. | D |
| Plan of care not updated with interventions after incidents to prevent further occurrences. | D |
| Inadequate monitoring and reporting of residents at risk for significant weight changes. | D |
| Failure to notify Consultant Pharmacist of new FDA guidelines and monitor medication alerts. | E |
| Dietary services not consistently providing food from approved sources and maintaining sanitary conditions. | F |
| Lack of detailed pharmacy recommendation forms and inadequate tracking of physician responses. | E |
| Insufficient supervisory responsibility and support staff for dietary services. | F |
Report Facts
Complete Date: Aug 9, 2013
Course Completion Timeframe: 6
Course Completion Timeframe: 8
Exam Date: 201403
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Doering | RN/DON | Submitted the Plan of Correction |
| Marsha Ptack | Dietary Consultant | Acting as preceptor for Dietary Manager training course |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 15
Deficiencies: 7
Jul 15, 2013
Visit Reason
The inspection was a Health Resurvey to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to promote dignity and respect during dining, incomplete comprehensive assessments and care plans, failure to provide a safe environment free of accident hazards, inadequate nutritional interventions, prolonged use of unnecessary medications without proper monitoring, and unsanitary food storage and handling practices.
Severity Breakdown
SS=D: 5
SS=E: 1
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to promote dignity and respect toward residents during dining service. | SS=D |
| Failure to conduct comprehensive assessments (Care Area Assessment Summary) after annual MDS. | SS=D |
| Failure to develop comprehensive care plans for residents including dental and dialysis care. | SS=D |
| Failure to provide an environment free of accident hazards by not following the plan of care for a resident at high fall risk. | SS=D |
| Failure to maintain nutrition status by not initiating interventions for resident with recent weight loss. | SS=D |
| Failure to ensure drug regimen is free from unnecessary drugs including prolonged use of Prilosec and lack of dose reduction for Ativan. | SS=E |
| Failure to store and serve food in a sanitary environment including expired food, dirty freezer, improper food handling, and lack of sanitation monitoring. | SS=F |
Report Facts
Deficiencies cited: 7
Resident census: 15
Weight loss percentage: 7.2
Medication dose: 20
Medication dose: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse I | Administrative Nurse | Verified dignity concerns, care plan deficiencies, fall follow-up, nutritional interventions, and medication monitoring issues. |
| Nurse A | Nurse | Observed administering medications and involved in dignity and food handling concerns. |
| Nurse H | Nurse | Provided statements regarding resident care and medication monitoring. |
| Dietary Staff D | Dietary Staff | Verified expired food, dirty freezer, and sanitation monitoring issues. |
| Pharmacy Consultant K | Pharmacy Consultant | Failed to monitor prolonged medication use and notify physician or facility leadership. |
Inspection Report
Plan of Correction
Deficiencies: 1
May 31, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection related to medication administration and compliance with Federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions including verification of medication labels against doctor's orders and MAR by the Charge Nurse and Medical Records, reporting discrepancies to appropriate personnel, and updating policies and procedures accordingly.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure medication labels, doctor's orders, and MAR matched exactly upon receipt of new medication. | D |
Report Facts
Complete Date: Jun 4, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Doering | Director of Nursing | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 1
May 31, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that the deficiency identified under regulation 483.60(b), (d), (e) with ID prefix F0431 was corrected as of 05/31/2012.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.60(b), (d), (e) previously cited |
Report Facts
Deficiency correction date: May 31, 2012
Inspection Report
Re-Inspection
Census: 18
Deficiencies: 2
May 21, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with medication labeling and storage regulations.
Findings
The facility failed to ensure that residents' medications were labeled and administered as prescribed by the physician for two residents, including incorrect labeling of Sulfacetamide ophthalmic drops and Lortab pain medication.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the resident's Sulfacetamide ophthalmic drops were labeled as prescribed, with discrepancies between the physician's order, medication administration record, and medication label. | SS=D |
| Failed to ensure the resident's Lortab medication was labeled correctly according to the physician's order and medication administration record. | SS=D |
Report Facts
Census: 18
Sample size: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Staff A administered and verified medication orders | ||
| Administrative Nursing Staff B | Verified medication error with Sulfacetamide eye drop label | |
| Nurse D | Administered Lortab medication and verified physician orders | |
| Nurse B | Verified incorrect medication label on Lortab |
Inspection Report
Plan of Correction
Deficiencies: 1
N015004 POC 20IZ11
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies related to a resident fall incident due to failure to follow the individualized care plan regarding bathing.
Findings
The facility failed to prevent a resident from falling in the shower room because staff did not follow the resident's individualized care plan, resulting in acute injury requiring intensive care hospitalization. The facility completed staff education to address the deficient practice.
Deficiencies (1)
| Description |
|---|
| Failure to prevent resident fall in shower room due to not following individualized care plan regarding bathing, resulting in acute injury requiring intensive care. |
Report Facts
Complete Date: Nov 21, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felicia Majewski | RN KDADS | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
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