Deficiencies (last 12 years)
Deficiencies (over 12 years)
16.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
177% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
94% occupied
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-07-31.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2024-08-31. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 9
Date: Jul 31, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility failed to develop comprehensive care plans addressing individual resident needs, including medication management, wound care, fall prevention, mental health support, and antibiotic stewardship. Deficiencies were noted in medication oversight, care plan documentation, fall risk interventions, and staffing data submission.
Deficiencies (9)
F 0656: The facility failed to develop comprehensive care plans for residents including antipsychotic medication use, diabetes management with insulin pumps, wound care, and antibiotic use, placing residents at risk for impaired care due to uncommunicated needs.
F 0657: The facility failed to revise the care plan for a resident to reflect current health needs related to skin tears, placing the resident at risk for impaired care due to uncommunicated care needs.
F 0684: The facility failed to implement interventions to prevent skin tears and failed to provide treatment for skin sores, placing residents at risk for further skin injury and complications.
F 0689: The facility failed to identify root causes of falls and implement effective person-centered interventions for residents at risk for falls, placing them at risk for further falls and injury.
F 0742: The facility failed to provide appropriate mental health treatment and services to a resident with mental disorder, lacking nonpharmacological interventions prior to psychotropic medication use, placing the resident at risk for unmet mental health care needs.
F 0756: The facility failed to ensure the consultant pharmacist identified and reported inappropriate use of antipsychotic and antianxiety medications without approved indications or required documentation, placing residents at risk for inappropriate medication use.
F 0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions prior to or during psychotropic medication use and failed to limit PRN psychotropic orders to 14 days, placing residents at risk for unintended effects.
F 0851: The facility failed to submit complete and accurate direct care staffing information to CMS Payroll Based Journaling, placing residents at risk for unidentified staffing inadequacies.
F 0881: The facility failed to implement antibiotic stewardship protocols to monitor and evaluate appropriateness and effectiveness of antibiotic use, placing residents at risk for adverse effects and antibiotic resistance.
Report Facts
Resident census: 30
PRN Ativan administrations: 21
Antibiotic treatment duration: 10
Nitrofurantoin dose: 80
Rexulti dose: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified medication and care plan deficiencies, including lack of stop dates and inappropriate indications |
| Licensed Nurse H | Licensed Nurse | Provided observations and statements regarding resident care, medication use, and behaviors |
| Certified Nurse Aide P | Certified Nurse Aide | Reported on resident behaviors, care, and medication administration |
| Certified Nurse Aide M | Certified Nurse Aide | Observed assisting resident with ambulation and care |
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 9
Date: Jul 31, 2024
Visit Reason
The facility underwent an annual inspection survey to assess compliance with regulatory requirements related to resident care, medication management, staffing, and safety.
Findings
The facility failed to develop comprehensive care plans addressing individual resident needs, including medication management, wound care, fall prevention, and mental health support. Deficiencies were noted in the use and monitoring of psychotropic and antibiotic medications, incomplete or missing care plan documentation, inadequate fall prevention interventions, and inaccurate staffing data submission to CMS.
Deficiencies (9)
F0656: The facility failed to develop comprehensive care plans for residents' specific needs including antipsychotic medication use, diabetes management, wound care, and antibiotic use, placing residents at risk for impaired care due to uncommunicated needs.
F0657: The facility failed to revise the care plan for a resident to reflect current health needs related to skin tears, placing the resident at risk for impaired care due to uncommunicated care needs.
F0684: The facility failed to implement interventions to prevent skin tears and failed to provide treatment for skin sores, placing residents at risk for further skin injury and complications.
F0689: The facility failed to identify root causes of falls and implement meaningful interventions to prevent falls for residents, placing them at risk for further falls and injury.
F0742: The facility failed to provide appropriate mental health support and services before administering psychotropic medication, placing a resident at risk for unmet mental health care needs.
F0756: The facility failed to ensure the consultant pharmacist identified and reported unapproved indications, lack of stop dates, and missing documentation for psychotropic medications, placing residents at risk for inappropriate medication use.
F0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications and failed to limit PRN orders to 14 days, placing residents at risk for unintended effects.
F0851: The facility failed to submit complete and accurate direct care staffing information to CMS, placing residents at risk for unidentified issues with inadequate staffing.
F0881: The facility failed to implement antibiotic use protocols to avoid unnecessary and inappropriate antibiotic use, placing residents at risk for adverse effects and antibiotic resistance.
Report Facts
Resident census: 30
PRN Ativan administrations: 21
UTI treatment duration: 10
Nitrofurantoin dose: 80
Rexulti dose: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified medication and care plan deficiencies, including psychotropic medication issues and care plan omissions |
| Licensed Nurse H | Licensed Nurse | Provided information on resident conditions, medication use, and care practices |
| Certified Nurse Aide P | Certified Nurse Aide | Reported on resident care, behaviors, and medication administration observations |
| Certified Nurse Aide M | Certified Nurse Aide | Observed assisting resident R13 with ambulation and care |
| Administrative Staff A | Administrative Staff | Responsible for PBJ submission and verified inaccurate staffing data submission |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 9
Date: Jul 31, 2024
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to assess compliance with care plan development, medication use, fall prevention, infection control, and staffing requirements.
Complaint Details
The inspection was triggered by a complaint investigation #KS00186564.
Findings
The facility failed to develop comprehensive care plans addressing individual resident needs, failed to ensure appropriate use and documentation of psychotropic and antibiotic medications, failed to implement fall prevention interventions, and failed to submit accurate staffing data. These deficiencies placed residents at risk for impaired care, adverse medication effects, falls, and antibiotic resistance.
Deficiencies (9)
F656: The facility failed to develop comprehensive care plans addressing individual resident needs including wound care, medication management, and specialized treatments for residents R17, R12, R5, R13, and R26.
F657: The facility failed to revise the care plan for Resident R3 to reflect current health needs related to skin tears, placing the resident at risk for impaired care.
F684: The facility failed to implement interventions to prevent skin tears for Resident R3 and failed to provide appropriate skin care for Resident R29 with multiple sores, placing residents at risk for further injury.
F689: The facility failed to identify and implement fall prevention interventions for Residents R25 and R13, placing them at risk for further falls and injuries.
F742: The facility failed to provide Resident R2 with appropriate mental health support and services before administering psychotropic medication, placing the resident at risk for unmet mental health care needs.
F756: The facility failed to ensure the Consultant Pharmacist identified and reported unapproved indications and lack of required documentation for ongoing use of antipsychotic and antianxiety medications for Residents R12 and R13, placing residents at risk for inappropriate medication use.
F758: The facility failed to ensure Residents R2, R4, R12, and R13 did not receive psychotropic medications without appropriate indications, documentation, or required stop dates, placing residents at risk for adverse side effects.
F851: The facility failed to submit complete and accurate direct care staffing information to CMS Payroll Based Journal, placing residents at risk for unidentified staffing issues.
F881: The facility failed to implement antibiotic stewardship protocols and monitor appropriateness of antibiotic use for Residents R5 and R12, placing residents at risk for antibiotic resistance and adverse effects.
Report Facts
Resident census: 30
PRN Ativan use: 21
Dates with no Licensed Nurse coverage: 13
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Jul 31, 2024
Visit Reason
This document is a Plan of Correction submitted in response to the annual survey that ended on July 31, 2024, addressing deficiencies identified during that inspection.
Findings
The facility identified multiple deficiencies related to care plan accuracy, timely revisions, infection control, medication management, fall prevention, and reporting compliance. The Plan of Correction outlines specific actions to address these issues by August 31, 2024.
Deficiencies (9)
F656-E: The facility failed to maintain proper records and accurate care plans for residents, requiring updates to multiple residents' care plans by August 31, 2024.
F657-D: The facility had an untimely care plan revision for Resident 3, which was corrected by updating the care plan by August 31, 2024.
F684-D: The facility did not ensure residents received treatment and care according to professional standards, requiring physician interventions for skin tear prevention to be implemented by August 31, 2024.
F689-D: The facility failed to identify and mitigate hazards related to resident falls, necessitating root cause analyses and care plan updates by August 31, 2024.
F742-D: The facility did not provide appropriate mental health services, planning to offer services through a Mental Health Nurse Practitioner by August 31, 2024.
F756-D: The facility failed to ensure appropriate drug regimens, requiring regular pharmacy reviews and physician notifications for missing rationale or stop dates by August 31, 2024.
F758-E: The facility did not appropriately monitor psychotropic medication use, planning quarterly reviews to reduce unnecessary medications by August 31, 2024.
F851-F: The facility failed to submit required data for the Quarter 2 2024 PBJ Submission Deadline, with plans to improve submission processes by August 31, 2024.
F881-D: The facility lacked a consistent infection prevention and control program, planning to implement antibiotic stewardship updates and physician communications by August 31, 2024.
Report Facts
Plan of Correction completion date: Aug 31, 2024
Quarter: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Mondero | Registered Pharmacist | Pharmacy consultant involved in medication and drug regimen reviews |
| Carter Olson | Administrator | Administrator who submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 1
Date: Dec 28, 2022
Visit Reason
The inspection was conducted as an abbreviated complaint investigation KS00176192 regarding a resident fall incident.
Complaint Details
The visit was triggered by complaint investigation KS00176192. The facility was found noncompliant for failing to prevent a fall of Resident 1 during bathing. The deficient practice was determined to be past noncompliance after staff education was completed.
Findings
The facility failed to ensure Resident 1 was free from falls by not following the care plan requiring two staff assistance during bathing, resulting in a fall from a shower chair and a serious injury including a subdural hematoma. The facility provided education to staff after the incident and was determined to be past noncompliance.
Deficiencies (1)
F 689 Accidents. The facility failed to ensure Resident 1 was free from falls by not following the care plan requiring two staff assistance during bathing, resulting in a fall from a shower chair and a laceration with brain bleeds requiring intensive care.
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 | Reported Resident 1 was a two-person assist getting into shower chair but one-person assist during shower | |
| Administrative Nurse D | Verified Resident 1's care plan required two staff assistance with bathing |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 21, 2022
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies related to a resident fall incident.
Findings
The facility failed to prevent a resident from falling in the shower room due to not following the individualized care plan regarding bathing, resulting in acute injury requiring intensive care hospitalization. The facility completed staff education on following appropriate levels of assistance and care plan directives.
Deficiencies (2)
The facility failed to prevent a resident from falling in the shower room due to not following her individualized care plan regarding bathing, resulting in acute injury requiring intensive care. The facility completed education for all staff on following appropriate assistance levels and care plan directives.
The facility failed to prevent a resident from falling in the shower room due to not following her individualized care plan regarding bathing, resulting in acute injury requiring intensive care. The facility completed education for all staff on following appropriate assistance levels and care plan directives.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 28, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-08-02.
Findings
All deficiencies cited in the prior inspection were corrected by the compliance date of 2022-08-31. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Routine
Census: 31
Deficiencies: 8
Date: Aug 2, 2022
Visit Reason
Routine inspection of The Nicol Home to assess compliance with regulatory requirements including resident care, medication management, safety, and vaccination policies.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during medication administration, incomplete care planning for antipsychotic medication use, lack of safe smoking evaluations, inadequate toileting programs, improper medication labeling and storage, failure to ensure appropriate use and monitoring of antipsychotic medications, and failure to assess residents for pneumococcal vaccination eligibility.
Deficiencies (8)
F 0550: The facility failed to treat residents with respect, dignity, and privacy during medication administration, placing residents at risk for impaired psychosocial wellbeing.
F 0656: The facility failed to develop and implement a care plan for antipsychotic medication use for Resident 3, placing the resident at risk for unmet care needs.
F 0689: The facility failed to complete a safe smoking evaluation for Resident 6, placing the resident at risk for unsafe smoking practices and accidents.
F 0690: The facility failed to develop and initiate a toileting program for Resident 4, who was a good candidate for bladder retraining, placing the resident at risk for increased incontinence.
F 0756: The facility failed to ensure the consultant pharmacist identified and reported inappropriate diagnoses for antipsychotic medication use for Residents 3, 14, and 26, and failed to ensure physician response, placing residents at risk for adverse effects.
F 0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions for antipsychotic medications and failed to ensure appropriate diagnoses for Residents 3, 14, and 26, placing residents at risk for adverse effects.
F 0761: The facility failed to label and date insulin vials for Residents 12 and 29, failed to discard expired insulin pens and stock medications, placing residents at risk for ineffective medications.
F 0883: The facility failed to assess Residents 3, 5, 14, and 28 for eligibility to receive pneumococcal vaccine, placing residents at risk for illness and pneumonia infection.
Report Facts
Residents in census: 31
Sample residents reviewed: 12
Expired aspirin tablets: 100
Expired Vitamin C tablets: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Observed medication administration and verified expired medications | |
| Administrative Nurse D | Verified medication administration practices and diagnosis appropriateness | |
| Administrative Nurse E | Verified care planning and medication monitoring deficiencies | |
| Certified Nurse Aid O | Provided observations on resident behavior and care | |
| Certified Nurse Aid M | Provided observations on resident continence and care | |
| Certified Nurse Aid N | Provided observations on resident continence and toileting |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Aug 2, 2022
Visit Reason
This document is a Plan of Correction submitted in response to an annual survey inspection that ended on August 2, 2022, addressing deficiencies found during that inspection.
Findings
The facility outlined corrective actions to address deficiencies related to dignity and privacy during medication administration, care plan accuracy, smoking safety, bowel and bladder incontinence screening, medication regimen reviews, psychotropic medication monitoring, medication storage, and immunization tracking.
Deficiencies (8)
F550-D: The facility failed to ensure dignity and privacy during medication administration. Staff will receive education on these policies and monitor compliance over three months.
F656-D: The care plan for Resident 3 lacked information on Seroquel use and behavior interventions. The care plan was updated and relevant parties notified.
F689-D: The facility did not adequately ensure safe smoking practices for residents who smoke. A smoking assessment was completed and staff will receive education on safety procedures.
F690-D: The facility failed to provide timely bowel and bladder incontinence screenings and retraining programs. Resident 4 was screened and a bladder retraining program initiated.
F756-D: The facility did not consistently review pharmacy medication and drug regimen reports. Regular reviews and consultations with the pharmacy consultant will continue quarterly.
F758-D: The facility failed to appropriately monitor psychotropic medication use. Quarterly AIMS reviews and pharmacy consultations will be conducted to reduce unnecessary medications.
F761-E: Medications and biologicals were not always stored safely or properly monitored for expiration. Staff were educated and monthly expiration checks instituted.
F883-E: The facility lacked adequate tracking and administration of influenza and pneumococcal vaccines. Access to immunization records was gained and vaccination arrangements are in progress.
Report Facts
Plan of Correction completion dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Mondero | Registered Pharmacist | Pharmacy consultant involved in medication and drug regimen reviews |
| Carter Olson | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 8
Date: Aug 2, 2022
Visit Reason
Health resurvey to assess compliance with resident rights, care planning, accident hazards, medication management, and immunization policies.
Findings
The facility failed to treat residents with dignity during medication administration, did not care plan antipsychotic medication use, failed to complete safe smoking evaluations, and did not develop toileting programs for eligible residents. The consultant pharmacist did not identify inappropriate antipsychotic medication diagnoses, and the facility failed to ensure proper labeling and disposal of medications. Additionally, the facility did not assess several residents for pneumococcal vaccine eligibility.
Deficiencies (8)
F550 Resident Rights: The facility failed to treat residents with respect, dignity, and privacy during medication administration, placing residents at risk for impaired psychosocial wellbeing.
F656 Care Plan: The facility failed to develop and implement a comprehensive care plan for antipsychotic medication use for Resident 3, placing the resident at risk for unmet care needs.
F689 Accident Hazards: The facility failed to complete a safe smoking evaluation for Resident 6, placing the resident at risk for unsafe smoking practices and accidents.
F690 Incontinence Care: The facility failed to develop and initiate a toileting program for Resident 4, who was a good candidate for bladder retraining, placing the resident at risk for increased incontinence.
F756 Drug Regimen Review: The facility failed to ensure the consultant pharmacist identified and reported inappropriate antipsychotic medication diagnoses and the physician responded, placing residents 3, 14, and 26 at risk for adverse effects.
F758 Psychotropic Medications: The facility failed to ensure antipsychotic medications were used for appropriate diagnoses and monitored properly, placing residents 3, 14, and 26 at risk for adverse effects.
F761 Medication Labeling and Storage: The facility failed to label insulin vials with date opened and expiration, failed to discard expired insulin pens and stock medications, placing residents at risk for ineffective medications.
F883 Immunizations: The facility failed to assess residents 3, 5, 14, and 28 for pneumococcal vaccine eligibility and document education or declination, placing residents at risk for pneumonia infection.
Report Facts
Facility census: 31
Residents reviewed: 12
Antipsychotic medication use: 7
Expired medication count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Observed medication labeling and expiration issues |
| Administrative Nurse D | Administrative Nurse | Verified inappropriate medication diagnoses and care planning failures |
| Administrative Nurse E | Administrative Nurse | Verified medication care planning and immunization documentation failures |
| Certified Nurse Aid O | Certified Nurse Aid | Observed resident behavior and medication effects |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 3, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2021-03-31.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2021-04-22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 6
Date: Mar 31, 2021
Visit Reason
Annual inspection of The Nicol Home to assess compliance with regulatory requirements related to resident care, medication management, fall prevention, hydration, and infection control.
Findings
The facility had multiple deficiencies including failure to thoroughly investigate and prevent resident falls, inadequate monitoring of fluid restrictions, failure to monitor and follow up on medication regimens including blood pressure and anticoagulant monitoring, failure to attempt gradual dose reductions of antipsychotic medications, and lack of an effective antibiotic stewardship program.
Deficiencies (6)
F0689: The facility failed to thoroughly investigate the reason for a resident's falls to identify fall risks and implement effective interventions to prevent further falls.
F0692: The facility failed to adequately monitor a resident's fluid restriction, placing the resident at risk for fluid overload.
F0756: The consultant pharmacist failed to notify the Director of Nursing or physician of the lack of blood pressure monitoring for a resident, and the facility failed to follow up on pharmacist recommendations for gradual dose reduction of an antipsychotic medication.
F0757: The facility failed to monitor the effects of prescribed medications for a resident, including failure to obtain physician ordered labwork to monitor coumadin and lack of blood pressure monitoring for two medications.
F0758: The facility failed to monitor adverse side effects and attempt a gradual dose reduction for a resident receiving an antipsychotic medication, placing the resident at risk for adverse effects.
F0881: The facility failed to ensure an effective antibiotic stewardship program which included a system to assess the appropriateness of antibiotic usage in the facility.
Report Facts
Resident census: 29
Fall Risk Assessment score: 75
Fall Risk Assessment score: 55
Fluid restriction: 2500
Average daily fluid intake: 1087
Medication doses: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified failures in care plan updates, medication monitoring, and antibiotic stewardship |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding resident care and medication monitoring |
| Certified Medication Aide M | Certified Medication Aide | Reported lack of knowledge about resident fluid restriction |
| Social Service Designee X | Social Service Designee / Certified Nurse Aide | Provided information on resident toileting assistance |
| CNA N | Certified Nurse Aide | Provided information on resident supervision and toileting needs |
| CNA M | Certified Nurse Aide | Provided information on resident urinary incontinence and toileting program |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 31, 2021
Visit Reason
This document is a Plan of Correction submitted in response to the annual survey that ended on March 31, 2021, outlining corrective actions to address deficiencies identified during the survey.
Findings
The facility identified multiple areas needing improvement including fall risk interventions, nutritional status monitoring, medication regimen reviews, infection prevention and control, and antibiotic stewardship. The Plan of Correction details steps to improve documentation, staff training, monitoring, and communication to ensure compliance and resident safety.
Deficiencies (6)
F689-D: The facility must investigate all falls and fall risks thoroughly and implement proper interventions to prevent further falls. Immediate interventions must be documented and communicated promptly to leadership.
F692-D: The facility must maintain acceptable nutritional status by monitoring therapeutic diets and fluid restrictions, ensuring proper assessments and adjustments are made.
F756-D: The facility must ensure drug regimens are appropriate by regularly reviewing pharmacy reports and taking necessary actions from pharmacists and nursing staff.
F757-D: The facility must monitor blood pressure daily for Resident #13 and ensure lab work and physician notifications are completed to monitor medication effectiveness and safety.
F758-D: The facility must monitor and reduce unnecessary psychotropic medications through quarterly reviews and pharmacist consultations, ensuring proper education and documentation.
F881-F: The facility must maintain an infection prevention and control program with antibiotic stewardship, including appointing a Director of Antibiotic Stewardship and tracking infections and antibiotic use.
Report Facts
Plan of Correction completion dates: Apr 22, 2021
QAPI meetings: 3
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 | Consultant Pharmacist | Provides medication and drug regimen reviews and participates in QAPI meetings. |
| Carter Olson | Administrator | Submitted the Plan of Correction. |
| Tammy Blackwood | Added the Plan of Correction on 04/05/2021. | |
| Terry Riley | Modified the Plan of Correction on 06/03/2021. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 6
Date: Mar 31, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #153124 to assess compliance with regulatory requirements.
Complaint Details
The inspection was triggered by a complaint investigation #153124.
Findings
The facility was found deficient in multiple areas including failure to investigate and prevent resident falls, inadequate monitoring of fluid restrictions, failure to follow up on pharmacist recommendations for medication management, failure to monitor effects of prescribed medications, failure to attempt gradual dose reductions of psychotropic drugs, and failure to maintain an effective antibiotic stewardship program.
Deficiencies (6)
F689: The facility failed to thoroughly investigate the reason for Resident 3's falls and implement effective interventions to prevent further falls related to toileting assistance.
F692: The facility failed to adequately monitor Resident 26's fluid restriction and did not record fluid intake as ordered by the physician.
F756: The facility consultant pharmacist failed to notify the Director of Nursing or physician of the lack of blood pressure monitoring for Resident 13 and failed to follow up on the pharmacist's recommendation for gradual dose reduction of Geodon for Resident 11.
F757: The facility failed to monitor the effects of prescribed medications for Resident 13 by not obtaining physician ordered labwork for Coumadin and lacked monitoring of blood pressure for medications affecting blood pressure.
F758: The facility failed to monitor adverse side effects and attempt a gradual dose reduction for Resident 11 receiving Geodon, placing the resident at risk for adverse medication effects.
F881: The facility failed to consistently utilize an antibiotic stewardship program that included tracking and monitoring of infections and antibiotic use.
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
Medication doses: 40
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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 have been corrected as of the compliance date of 06/23/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 16, 2020
Visit Reason
The document is a Plan of Correction submitted by The Nicol Home to address compliance with regulation F880 related to visitation restrictions and infection control 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 ensure compliance with COVID-19 regulations.
Deficiencies (1)
F880-F visitation generally prohibited except for compassionate care situations with screening and precautions. The facility restricted visitors and non-essential personnel and implemented social distancing and protective measures for residents and staff.
Report Facts
Completion date for corrective actions: Jun 23, 2020
Inspection Report
Abbreviated Survey
Census: 31
Deficiencies: 1
Date: 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 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 residents at risk for infection. The facility was initially cited for Immediate Jeopardy but removed it after implementing corrective actions.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to restrict visitation and enforce social distancing during resident dining, contrary to CMS and CDC COVID-19 guidelines, potentially exposing 31 residents to infection.
Report Facts
Visitor screenings: 314
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided statements regarding visitation policies and compliance with 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
Date: Jul 12, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-05-28.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2019-06-14, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: 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 for multiple deficiencies including inaccurate resident assessments, untimely care plan revisions, insufficient nursing aide in-service training, unnecessary drugs in resident regimens, and improper food receiving and storage practices.
Deficiencies (5)
F641-D: The facility had an inaccurate resident assessment for resident #9, requiring an MDS modification and staff training to prevent future lapses.
F657-D: The facility failed to revise a resident care plan in a timely manner for resident #27, with plans to improve oversight and communication during fall investigations.
F730-E: The facility did not meet the required 12-hour annual certified nursing aide in-service training, with plans to schedule and monitor educational sessions.
F757-D: The facility had unnecessary drugs in resident drug regimens, verified for resident #29, with weekly medication audits and staff education planned.
F812-F: The facility had deficient food receiving and storage practices, corrected by immediate inventory checks and labeling procedures for refrigerators.
Report Facts
Deficiency severity counts: 3
Deficiency severity counts: 1
Deficiency severity counts: 1
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
Date: May 28, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #137164 and #137373.
Complaint Details
The inspection included complaint investigations #137164 and #137373.
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 education, failure to administer medications as ordered, and unsanitary food storage practices.
Deficiencies (5)
F641 Accuracy of Assessments. The facility's Minimum Data Set assessment failed to accurately reflect Resident #9's pressure ulcer status, placing the resident at risk for inappropriate care.
F657 Care Plan Timing and Revision. The facility failed to review and revise Resident #27's care plan following a fall with fractures, placing the resident at risk for further falls and injury.
F730 Nurse Aide Performance Review. The facility failed to provide required 12 hours of in-service education annually for nurse aides employed at least one year, risking improper care and safety.
F757 Drug Regimen is Free from Unnecessary Drugs. The facility failed to administer Resident #29's medications as ordered, resulting in missed doses and potential decreased therapeutic effectiveness.
F812 Food Procurement, Storage, Preparation, and Service. The facility failed to label and date opened bottles of juice in the refrigerator, risking residents receiving expired fluids.
Report Facts
Resident census: 28
Sample size: 9
Nurse aides lacking 12 hours in-service: 5
Medication doses missed: 20
Opened juice bottles without date: 2
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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: 2
Date: Jan 4, 2019
Visit Reason
This document is a plan of correction submitted by The Nicol Home to comply with state and federal law following a statement of deficiencies.
Findings
The facility acknowledged staffing deficiencies related to Registered Nurse coverage and outlined corrective actions including staffing schedule adjustments, recruitment efforts, and use of partner agencies for coverage.
Deficiencies (2)
F0000 Preparation and execution of this plan of correction does not constitute admission of deficiencies. The plan serves as the allegation of compliance and will be reviewed by the QAPI Committee on January 23, 2019.
F727 The Nicol Home lacked sufficient RN coverage but has implemented a plan to provide at least 8 hours of RN coverage daily starting January 3, 2019, with ongoing recruitment and staffing strategies.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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.
Deficiencies (1)
The facility had a "F" level deficiency constituting noncompliance with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Date: Jan 2, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #135290 and #136610 regarding nursing staff coverage.
Complaint Details
The findings represent the results of complaint investigations #135290 and #136610. The complaint was substantiated as the facility had lapses in RN coverage, especially on weekends.
Findings
The facility failed to provide 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.
Deficiencies (1)
CFR 483.35(b) Registered nurse requirement was not met as the facility lacked 8 consecutive hours of RN coverage on multiple dates in November and December 2018. This failure affected all 28 residents in the facility.
Report Facts
Deficiency cited: 1
Resident census: 28
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 24, 2018
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-08-20.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2018-09-17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 12
Date: Aug 20, 2018
Visit Reason
Health Resurvey complaint investigation KS#132384 and Extended Health Resurvey.
Complaint Details
The complaint investigation was triggered by allegations of abuse involving Resident #17 and Resident #15, including verbal threats and physical assault. The investigation found substantiated abuse and failures in supervision and reporting.
Findings
The facility failed to provide supervision to protect a resident from abuse by another resident, failed to report a verbal threat timely, failed to develop comprehensive care plans for smoking and diabetic management, failed to provide restorative services for limited range of motion, failed to identify significant weight loss and monitor nutrition, failed to ensure required nurse aide in-service training, failed to provide necessary behavioral health care, failed to monitor drug regimens adequately, failed to employ a certified dietary manager, failed to maintain food safety and sanitary conditions in the kitchen, and failed to provide a safe environment for cognitively impaired residents.
Deficiencies (12)
F600: Facility failed to provide supervision to protect Resident #15 from abuse by Resident #17, who verbally threatened and later hit Resident #15 causing injury.
F607: Facility failed to report a verbal threat by Resident #17 toward another resident to administrative staff in a timely manner.
F636: Facility failed to develop comprehensive care plans for Resident #22 for smoking and Residents #18 and #23 for diabetic management.
F688: Facility failed to ensure Resident #10 with limited range of motion received appropriate treatment and services to prevent decrease in range of motion.
F692: Facility failed to identify and intervene for significant weight loss of 10.9% in 6 months for Resident #4, placing the resident at risk for impaired nutrition.
F730: Facility failed to ensure 23 of 23 nurse aides received required 12 hours of in-service training including dementia and abuse/neglect training.
F740: Facility failed to provide necessary behavioral health care and services to maintain highest practicable mental and psychosocial well-being for Resident #17 with ongoing behaviors.
F756: Facility's consultant pharmacist failed to identify and report irregularities including inadequate monitoring of blood sugar, blood pressure, and bowel movements for multiple residents.
F757: Facility failed to adequately monitor blood sugar readings, notify physician of abnormal blood pressures, and monitor bowel movements for multiple residents.
F801: Facility failed to employ a full-time certified dietary manager to supervise and prepare meals, placing residents at risk for inadequate nutrition.
F812: Facility failed to store, prepare, distribute and serve food in safe and sanitary conditions in the kitchen, including sticky floors, unclean equipment, improper glove use, and lack of hair nets.
F921: Facility failed to provide a safe, hazard-free environment for 4 cognitively impaired independently mobile residents, including unlocked chemical storage and accessible hazardous items.
Report Facts
Resident census: 30
Weight loss percentage: 10.9
Missing blood sugar entries: 1
Days without bowel movement: 7
Days without bowel movement: 6
Days without bowel movement: 14
Days without bowel movement: 7
Number of nurse aides lacking training: 23
Number of residents affected by bowel movement monitoring: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff AA | Dietary Manager | Not certified, preparing pureed diets incorrectly, improper glove use, no hair net. |
| Nurse Aide R | Certified Nurse Aide | Reported Resident #17's verbal threat and attempted redirection. |
| Nurse Aide M | Certified Nurse Aide | Reported Resident #17's aggressive behaviors and injuries to Resident #15. |
| Nurse G | Nurse | Reported Resident #17's behavior and supervision issues. |
| Administrative Nurse D | Administrative Nurse | Verified expectations for reporting threats and monitoring. |
| Consultant Staff HH | Consultant Staff | Verified lack of nurse aide training documentation. |
| Social Services Staff P | Social Services Designee | Reported behavioral changes and risks related to Resident #17. |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: 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, outlining corrective actions to address issues related to resident safety, care planning, staff training, and other regulatory requirements.
Findings
The plan addresses multiple deficiencies including resident safety monitoring, staff education on abuse and neglect, care planning for smoking and diabetic residents, restorative nursing services, behavioral health interventions, dietary management, food safety, and safe storage of chemicals and sharp items.
Deficiencies (12)
F600-J: Resident #17 was placed on one-on-one monitoring after an incident on 8-13-18. Staff received in-service education on abuse, neglect, exploitation, and behavior policy on 8-16-18.
F607-D: Policies and procedures were in place to ensure resident safety at the time of the incident. Staff received training on abuse, neglect, and exploitation reporting on 2/14/18 and 8-16-18.
F636-D: Care plans for residents who smoke were updated by 9/17/18 to include appropriate interventions and smoking assessments will be completed quarterly.
F688-D: Resident #10 received OT assessment and orders for positioning in August 2018. Staff will be educated on stretching exercises and restorative nursing plans will be reviewed monthly.
F692-D: Resident #4 will be weighed weekly for 4 weeks starting 8/29/18. Nutrition care plans were updated and staff trained on weight monitoring policies.
F730-F: In-service training on abuse, neglect, exploitation, and dementia is provided regularly. Facility will monitor training compliance and attendance.
F740-D: Resident #17 admitted to inpatient behavioral health unit on 8/14/18. Facility will continue to address psychosocial needs and coordinate with outside resources.
F756-E: Bowel protocol implemented and staff educated on monitoring bowel movements and diabetic blood sugar checks. Pharmacy consultant notified for ongoing monitoring.
F757-E: Staff educated on bowel protocol and diabetic care plans updated. In-service provided on notifying doctors for out-of-parameter vitals and medication refusals.
F801-F: Facility will employ a certified dietary manager or ensure current candidate enrolls in certification program. Dietary consulting firm will provide support.
F812-F: Food prepared, stored, and served safely with thorough cleaning schedules. Staff will receive Serve Safe training and kitchen performance will be audited weekly.
F921-E: Facility will develop and implement a plan to keep harmful chemicals and sharp items locked and away from residents. Staff instructed on safe storage and supervision.
Report Facts
Date of incident: Aug 13, 2018
Date of staff in-service: Feb 14, 2018
Date of staff in-service: Aug 16, 2018
Date of care plan update: Sep 17, 2018
Date of OT assessment: Aug 17, 2018
Date of behavioral health admission: Aug 14, 2018
Date of bowel protocol education: Aug 28, 2018
Date of dietary manager plan completion: Sep 17, 2018
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 10, 2018
Visit Reason
A complaint survey was conducted on 2018-05-10 for complaint #KS128540.
Complaint Details
Complaint #KS128540 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2018
Visit Reason
A complaint survey was conducted for complaint #KS128540 to investigate allegations made in the complaint.
Complaint Details
Complaint #KS128540 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 6, 2018
Visit Reason
An off-site survey was conducted to address a deficiency cited on February 21, 2018.
Findings
The deficiency cited on February 21, 2018, was corrected as of the compliance date of March 21, 2018.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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 review and updating of resident care plans, completion of chair risk assessments for residents, staff education on resident safety, and ongoing monitoring by the Director of Nursing or designee.
Deficiencies (1)
F689-D: Resident #1's care plan was reviewed to include use of a proper chair cushion. Resident #2 had a chair risk assessment showing independence with a lift chair. Staff education and monitoring on safety and risk assessments are planned.
Report Facts
Plan of correction completion date: Mar 21, 2018
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 13, 2018
Visit Reason
A complaint survey was conducted for complaint #KS00127171 to investigate allegations made in the complaint.
Complaint Details
The complaint allegations were investigated and found to be unsubstantiated.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 13, 2018
Visit Reason
A complaint survey was conducted on 2018-03-13 for complaint #KS00127171.
Complaint Details
Complaint #KS00127171 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 13, 2018
Visit Reason
A complaint survey was conducted for complaint #KS00127171 to investigate allegations made in the complaint.
Complaint Details
Complaint #KS00127171 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 2
Date: Feb 21, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#126594) regarding accident hazards and supervision issues at the facility.
Complaint Details
Complaint investigation #126594 focused on accident hazards and supervision failures related to falls of two residents involving recliners.
Findings
The facility failed to provide an environment free of accident hazards and adequate supervision to prevent accidents for 2 of 3 residents reviewed. Both residents had falls related to improper use or lack of assessment of recliners, placing them at risk for further falls.
Deficiencies (2)
F 689: The facility failed to provide an environment free of accident hazards and adequate supervision to prevent accidents for Resident #1, who fell out of a recliner after staff placed a pillow under the resident, increasing fall risk.
F 689: The facility failed to provide an environment free of accident hazards and adequate supervision for Resident #2, who had two falls out of a recliner, with no recliner assessment completed, placing the resident at risk for further falls.
Report Facts
Resident census: 30
Residents reviewed for accidents: 3
Falls for Resident #2: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide M | Nurse Aide | Verified placing pillow under Resident #1 and observations related to Resident #2 falls |
| Nurse G | Nurse | Verified that pillow should not have been placed under Resident #1 and confirmed Resident #2's fall circumstances |
| Administrative Nurse D | Administrative Nurse | Verified pillow placement incident and lack of recliner assessment for Resident #2 |
| Nurse Aide N | Nurse Aide | Verified Resident #2's fall circumstances and behavior |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 21, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found 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.
Deficiencies (1)
The facility had a 'D' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 were corrected as of the revisit date. The report lists multiple regulation citations with corrections completed on 02/08/2017.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 8, 2017
Visit Reason
This visit was conducted as a follow-up 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) was corrected as of 02/08/2017. No other deficiencies are listed as outstanding.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 02/08/2017.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jan 26, 2017
Visit Reason
This document is a Plan of Correction submitted by The Nicol Home to address deficiencies identified in a prior inspection and to comply with state and federal law.
Findings
The plan outlines corrective actions for deficiencies related to Medicare notices, housekeeping and maintenance, chemical safety, RN coverage, food preparation sanitation, and nutrition services supervision. The facility commits to monitoring and ensuring compliance through staff training, environmental rounds, and administrative oversight.
Deficiencies (6)
F156-D Nicol Home provides required Medicare notices regarding coverage and payment using CMS forms. Training on proper use is scheduled and monitored by the Administrator.
F253-E Nicol Home provides housekeeping and maintenance services to maintain a clean and sanitary environment, including carpet cleaning and new flooring installation for affected residents.
F323-E Nicol Home assures the environment is free from accident hazards by securing chemicals and locking the shower room when not in use.
F354-F Nicol Home assures all RN coverage requirements are met with 8 consecutive hours of RN services daily, with administrative nurse coverage as backup.
F371-F Nicol Home provides a sanitary environment in food preparation and dish cleaning areas, with cleaning schedules and repairs in progress.
S0600-F Nicol Home assures appropriate supervision of Nutrition Services through qualified staff and contracting with a professional Dietician, with ongoing training enrollment.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 10, 2017
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies 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 based on the credible allegation of compliance and evidence of correction.
Deficiencies (1)
The survey identified 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated the acceptance of the plan of correction. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Jan 10, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation based on multiple complaint numbers (#96656, #102259, #102442, and #109460).
Complaint Details
The visit was complaint-related, involving a Health Resurvey and Complaint Investigation with complaint numbers #96656, #102259, #102442, and #109460.
Findings
The facility failed to provide services of a full-time certified dietary manager for the 29 residents receiving meals from the facility's kitchen. Observations and interviews confirmed the dietary staff was not certified and no policy on a certified dietary manager was provided.
Deficiencies (1)
28-39-158(a) Dietary Services: The facility failed to employ a full-time certified dietary manager to oversee residents' nutritional needs and food services for 29 residents. The dietary staff assisting with meal preparation was not certified and no policy on a certified dietary manager was available.
Report Facts
Resident census: 29
Sample size: 12
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 18, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited with deficiencies at an 'F' level under the Life Safety Code survey, indicating issues with compliance to federal fire safety regulations. These deficiencies posed no immediate jeopardy but had potential for more than minimal harm.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the survey report and enforcement letter. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Dec 24, 2015
Visit Reason
This document is a Plan of Correction submitted by The Nicol Home in response to previously identified deficiencies during a regulatory inspection.
Findings
The plan addresses multiple deficiencies including resident-to-resident altercations, communication and dignity issues, restorative communication status accuracy, care plan updates, medication management, call light maintenance, and staffing concerns. Corrective actions include staff education, policy reviews, monitoring by the Director of Nursing, and procedural improvements.
Deficiencies (10)
F225-D Resident #8 was discharged after a resident-to-resident altercation. Staff received education on reporting and investigating such altercations, and policies will be reviewed and revised.
F241-E Staff education was provided on communication of resident information and dignity. Policies on confidentiality and resident rights will be reviewed and monitored.
F278-D MDS assessments for residents 30, 27, and 21 were corrected to reflect restorative communication status. Staff education on the restorative program was planned.
F280-D Care plans will be reviewed and revised for significant condition changes. Resident #25's care plan was updated to include fall risk interventions.
F309-D Resident #8 was admitted to a Special Care Unit for evaluation. Staff education on managing unmanageable residents was scheduled.
F323-D Resident #25 had a new fall risk assessment completed and care plan review scheduled by the Director of Nursing.
F354-F Facility will advertise for weekend RN coverage and pursue a waiver due to limited rural resources. Staffing policies will be reviewed.
F431-D Outdated insulin was discarded and replaced. A nightly checklist for medication management will be implemented, and staff will be educated on medication administration rights.
F463-E Call lights in resident bathrooms were replaced and weekly checks for replacements and repairs will be conducted by nursing staff.
S0600-C The Food Service manager will continue CDM course studies and be mentored by a Licensed Dietician.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 24, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of the revisit date. The report lists multiple regulation numbers with corrections completed on 12/24/2015.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 24, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 2015-12-24.
Inspection Report
Enforcement
Deficiencies: 1
Date: Nov 24, 2015
Visit Reason
The visit was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 24, 2015.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey findings. |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 9
Date: Nov 24, 2015
Visit Reason
The inspection was a Health Resurvey and complaint investigation triggered by a resident-to-resident altercation and other compliance concerns.
Complaint Details
The complaint investigation was triggered by a resident-to-resident altercation involving Resident #8 who shoved another resident and exhibited aggressive behavior. The facility failed to report and investigate this incident properly.
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 fall prevention interventions, failed to provide necessary care for aggressive behavior, failed to provide adequate supervision to prevent accidents, failed to provide RN coverage for 8 hours a day 7 days a week, failed to label insulin medication properly, and failed to maintain functioning bathroom call lights for some residents.
Deficiencies (9)
F225: The facility failed to thoroughly investigate and report a resident-to-resident altercation involving Resident #8 who shoved another resident's shoulders and told him/her to sit down.
F241: The facility failed to promote care for residents in a manner that maintains dignity and respect, including staff speaking loudly about residents' conditions within hearing range of others.
F278: The facility failed to provide assessments that accurately reflect restorative communication programs for Residents #21, #27, and #30.
F280: The facility failed to revise Resident #25's care plan with appropriate fall prevention interventions after multiple falls.
F309: The facility failed to provide necessary care and individualized interventions related to aggressive behavior of Resident #8.
F323: The facility failed to ensure a safe environment free of accident hazards and adequate supervision to prevent falls and accidents for Residents #8 and #25.
F354: The facility failed to provide Registered Nurse services for 8 consecutive hours a day, 7 days a week.
F431: The facility failed to label insulin medication appropriately; Resident #8's insulin vial was expired but still in use.
F463: The facility failed to have functioning bathroom call lights for Residents #19 and #28.
Report Facts
Resident census: 27
Resident sample size: 13
Dates without RN coverage: 19
Fall risk assessment score: 15
Insulin vial open duration: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Verified lack of RN coverage, confirmed failure to report resident altercation, and confirmed failure to update care plans. |
| Nurse Aide F | Nurse Aide | Verified Resident #8's aggressive behavior and resident-to-resident incident. |
| Nurse E | Nurse | Verified expired insulin vial was still in use. |
| Administrative Nurse C | Administrative Nurse | Verified lack of bathroom call lights for Residents #19 and #28. |
| Nurse F | Nurse | Provided information about Resident #25's falls and care needs. |
| Administrative Staff A | Administrative Staff | Verified RN coverage requirements and call light system checks. |
| Administrative Staff B | Administrative Staff | Verified lack of RN coverage and inadequate restorative assessments. |
| Nurse Aide G | Nurse Aide | Provided information about Resident #25's independence and fall history. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 28, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required and enforcement remedies were recommended if substantial compliance is not achieved.
Report Facts
Effective date for denial of payments: Nov 28, 2015
Provider agreement termination date: Feb 28, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 20, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies identified on the CMS-2567 have been corrected as of 09/26/2014.
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Sep 26, 2014
Visit Reason
This document is a Plan of Correction submitted by The Nicol Home addressing deficiencies cited in a prior inspection report. It outlines corrective actions to achieve substantial compliance with Federal Medicare and Medicaid requirements.
Findings
The plan details corrective actions including review and revision of employment and facility policies, environmental repairs, care plan updates, water temperature safety measures, food preparation and infection control improvements, and staff in-service trainings.
Deficiencies (10)
F226-E Employment files will be reviewed to ensure criminal background checks have been requested. Facility hiring policy will be revised and new employee files audited quarterly.
F253-E Contractor contacted to estimate repairs for linoleum, door kick plates, drywall, and vent covers. Environmental and cleaning policies will be revised and staff in-serviced.
F280-D Care plans for all current residents will be reviewed and pressure ulcer risk assessments completed. Staff will be in-serviced on skin breakdown interventions.
F314-D Care plans and pressure ulcer risk assessments will be reviewed for all current residents. Staff in-service on skin breakdown interventions will be completed.
F323-L Hot water tank temperature adjusted and monitored to maintain safe levels. Shower was out of order until temperatures were safe. Staff received in-service on water temperature safety and burn risks.
F364-E Food temperature logs will be audited monthly. Food preparation policy will be reviewed and staff in-serviced. Kitchen sanitary audits will be conducted quarterly.
F371-E Contractor contacted to estimate repair/replacement of yellow ceiling tiles. Fire protection hood cleaned and kitchen sanitary audits scheduled quarterly.
F441-F Infection tracking log updated to include suspected infections. Cleaning and infection control policies revised and staff in-serviced. Resident rooms audited quarterly for cleanliness.
F456-F Gas turned off and residents removed from dining room during pilot light repairs. Staff trained on manual stove lighting and gas leak procedures.
S0600-C Facility will advertise for a Certified Dietary Manager and assign supervisory responsibility to a qualified employee with dietitian oversight. Policies and procedures will be implemented for dietary functions.
Inspection Report
Census: 23
Deficiencies: 9
Date: Aug 27, 2014
Visit Reason
The inspection was conducted as a Health Resurvey, Extended Health ReSurvey, and Complaint Investigations.
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 sanitation practices, infection control deficiencies, and unsafe kitchen equipment.
Deficiencies (9)
F226: The facility failed to obtain criminal background checks in a timely manner for 5 of 5 staff hired since last survey.
F253: The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on 2 of 2 halls and common areas.
F280: The facility failed to revise or update the care plan for Resident #22 with multiple pressure ulcers and a shearing wound.
F314: The facility failed to provide necessary treatment and services to prevent the development of pressure ulcers for Resident #22.
F323: The facility failed to ensure resident environment was free from accident hazards due to unsafe water temperatures (132-141°F) in multiple resident rooms and shower room, placing residents in immediate jeopardy.
F364: The facility failed to serve food at the proper temperature to residents, with roast beef served at temperatures as low as 119°F.
F371: The facility failed to prepare food under sanitary conditions, including greasy oven hood and improper glove use by dietary staff.
F441: The facility failed to maintain an infection control program to provide a safe, sanitary, and comfortable environment, including improper glove use by staff and unsanitary cleaning practices.
F456: The facility failed to maintain essential mechanical and electrical equipment in safe operating condition, including a gas leak from a broken pilot tube on the kitchen stove and grill.
Report Facts
Census: 23
Staff background check delays: 5
Resident sample size: 13
Water temperatures: 132
Water temperatures: 141
Food temperature: 119
Food temperature: 157
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 27, 2014
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not in substantial compliance and was cited for conditions constituting immediate jeopardy to resident health or safety from July 10, 2014 through August 19, 2014. The noncompliance was determined to be Substandard Quality of Care.
Deficiencies (1)
F323"L", CFR 01-483.25(h) deficiency was cited for substandard quality of care constituting immediate jeopardy to resident health or safety.
Report Facts
Denial of payment effective date: Nov 27, 2014
Provider agreement termination date: Feb 27, 2015
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Willie Novotony | Administrator | Named as facility administrator in relation to the enforcement action. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 14, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be widespread 'F' level deficiencies with no harm but potential for more than minimal harm, not constituting 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 was not achieved.
Deficiencies (1)
The facility was found to have widespread 'F' level deficiencies in Life Safety Code compliance with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Jul 14, 2014
Provider agreement termination date: Oct 14, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process regarding cited deficiencies. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated survey certification. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 9, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report confirms that the previously identified deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 2013-08-09.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 9, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-07-15.
Findings
All previously cited deficiencies identified by regulation numbers were corrected as of the revisit date 2013-08-09. The report confirms completion of corrective actions for multiple regulatory requirements.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Jul 26, 2013
Visit Reason
This document is a Plan of Correction submitted by The Nicol Home in response to deficiencies cited during a prior inspection. It outlines corrective actions to address identified regulatory compliance issues.
Findings
The plan details corrective actions including staff in-service training on dignity and feeding policies, monthly audits of resident assessments, care plan updates, monitoring of residents at risk for weight changes, compliance with FDA medication guidelines, and improvements in dietary services and food safety.
Deficiencies (9)
F241-D: Staff will receive in-service training on Quality of Life-Dignity policy and feeding procedures for residents who cannot feed themselves. Monitoring of meals will be conducted weekly by DON or Administrator.
F272-D: Monthly audits of all resident MDS and CAAs will ensure yearly CAAs are completed for all residents and new admissions. A calendar will track annual review dates.
F279-D: Care plans will be developed on admission and updated quarterly or as needed, including dental service preferences and post-dialysis care plans.
F323-D: Care plans will be updated immediately after incidents with interventions suited to residents' abilities. Charge Nurses will be educated on fall policies.
F325-D: DON and Dietary Manager will monitor residents at risk for weight changes weekly, updating care plans and notifying providers as needed. CNA will be responsible for weights and notifications.
F329-E: Consultant Pharmacist was informed of new FDA guidelines and will receive written reports. DON will monitor alerts and pharmacy reviews monthly.
F371-F: Facility will ensure food is from approved sources and handled under sanitary conditions. Dietary staff will be trained on hygiene and equipment cleaning with ongoing monitoring.
F428-E: Education will be provided to Pharmacy Consultant, Medical Director, Medical Records, and Charge Nurses on pharmacy recommendations and physician responses. Monthly monitoring will be conducted.
S0600-F: Dietary services will have full-time qualified supervisory staff with adequate support and written policies. Dietary Manager is enrolled in a training course with completion expected in Spring 2014.
Report Facts
Plan of Correction completion dates: Aug 9, 2013
Plan of Correction submission date: Jul 26, 2013
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 |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 15
Deficiencies: 8
Date: Jul 15, 2013
Visit Reason
The visit was a health resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including dignity and respect during dining, comprehensive assessments, care planning, accident hazard prevention, nutrition status maintenance, drug regimen management, and sanitary food handling and storage.
Deficiencies (8)
F241: The facility failed to promote dignity and respect toward residents during dining, including improper use of clothing protectors and inappropriate staff behavior.
F272: The facility failed to complete Care Area Assessments after the annual Minimum Data Set assessment for a sampled resident.
F279: The facility failed to develop comprehensive care plans for two residents, including dental care and dialysis care plans.
F323: The facility failed to provide an environment free of accident hazards by not following the plan of care for a resident at high fall risk.
F325: The facility failed to initiate interventions for a resident with a gradual 7.2% weight loss over 74 days.
F329: The facility failed to ensure drug regimens were free from unnecessary drugs by prolonged use of Prilosec and lack of dose reduction for Ativan in multiple residents.
F371: The facility failed to store and serve food in a sanitary environment, including expired food, dirty freezers, improper food handling, and lack of sanitation monitoring.
F428: The facility's consultant pharmacist failed to report drug irregularities and ensure drug regimens were free from unnecessary medications by prolonged use of Prilosec and lack of dose reduction for Ativan.
Report Facts
Resident census: 15
Weight loss percentage: 7.2
Expired food date: 2013
Medication dosage: 20
Medication dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse I | Verified dignity concerns, care plan deficiencies, fall follow-up, nutrition interventions, and medication monitoring issues | |
| Nurse A | Observed administering medication improperly and assisting resident with meals in an undignified and unsanitary manner | |
| Nurse H | Verified medication monitoring and dose reduction needs | |
| Dietary Staff D | Verified expired food, dirty freezer, and sanitation monitoring deficiencies | |
| Pharmacy Consultant K | Failed to monitor medication start dates and report drug irregularities |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Findings
The plan outlines corrective actions to ensure that medication labels, doctor's orders, and MARs match exactly and that discrepancies are reported promptly. Policies and procedures will be updated accordingly.
Deficiencies (1)
F431-D: The Charge Nurse will verify that medication labels, original Doctors Orders, and MARs match exactly upon arrival. Discrepancies will be reported to the DON, Physician, or Pharmacy and orders verified before signature.
Report Facts
Plan of Correction completion date: Jun 4, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Doering | Director of Nursing | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 31, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report confirms that the previously reported deficiency under regulation 483.60(b), (d), (e) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.60(b), (d), (e): Previously cited deficiency was corrected by the revisit date of 05/31/2012.
Inspection Report
Re-Inspection
Census: 18
Deficiencies: 2
Date: May 21, 2012
Visit Reason
The visit was a Health Resurvey to assess compliance with medication labeling and administration requirements.
Findings
The facility failed to ensure that residents' medications were labeled and administered as prescribed by the physician for two residents. Medication labels did not match physician orders, leading to medication errors.
Deficiencies (2)
F 431: The facility failed to ensure medications were labeled as prescribed for Resident #15; the eye drop label instructed administration to the left eye only, contrary to the physician's order for both eyes.
F 431: The facility failed to ensure the medication label for Resident #2's Lortab did not match the physician's order, which instructed administration twice a day, but the label allowed 1 to 2 tablets every 6 hours.
Report Facts
Resident census: 18
Sample size: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015004 POC 5TP211
Visit Reason
This document is a Plan of Correction related to a previous inspection event identified as 5TP211 for facility State ID N015004.
Findings
No deficiency details or findings are provided in this document. It serves solely as a record of the Plan of Correction submission.
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