Inspection Report Summary
The most recent inspection on February 5, 2014, found that all previously cited deficiencies had been corrected. Earlier inspections showed multiple deficiencies related mainly to medication management, abuse reporting, care planning after falls, pressure ulcer care, staffing licensure, housekeeping, maintenance, food service, and quality assurance processes. A complaint investigation in December 2013 substantiated issues with physician notification, abuse investigation, medication administration, and environmental safety. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, as the latest follow-up confirmed correction of prior deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
19.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
222% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
52 residents
Based on a December 2013 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 15
Feb 5, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report documents that all previously cited deficiencies identified in the prior survey have been corrected by 12/30/2013.
Deficiencies (15)
| Description |
|---|
| Deficiency with regulation 483.10(b)(11) |
| Deficiency with regulation 483.15(h)(2) |
| Deficiency with regulations 483.20(d)(3), 483.10(k)(2) |
| Deficiency with regulation 483.25 |
| Deficiency with regulation 483.25(l) |
| Deficiency with regulation 483.30(a) |
| Deficiency with regulation 483.30(b) |
| Deficiency with regulation 483.35(d)(1)-(2) |
| Deficiency with regulation 483.35(i) |
| Deficiency with regulation 483.35(i)(3) |
| Deficiency with regulations 483.60(a),(b) |
| Deficiency with regulation 483.60(c) |
| Deficiency with regulation 483.65 |
| Deficiency with regulation 483.70(h)(3) |
| Deficiency with regulation 483.75(g) |
Report Facts
Deficiencies corrected: 15
Inspection Report
Plan of Correction
Deficiencies: 17
Dec 18, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to achieve substantial compliance.
Findings
The plan addresses multiple deficiencies including medication ordering and administration, reporting of abuse, maintenance issues, falls prevention, pressure ulcer care, unnecessary medications, staff education, and facility audits. The facility commits to education, audits, and corrective actions with a target substantial compliance date of December 30, 2013.
Severity Breakdown
D: 5
E: 6
F: 5
C: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Medication ordering and notification policy not followed | D |
| Failure to report alleged or suspected mistreatment, neglect, or abuse | D |
| Maintenance issues including cracked floor tiles, holes near ceiling, and exhaust fan cleaning | E |
| Falls policy and care plan updates not followed | D |
| Pressure ulcer skin assessment and documentation deficiencies | D |
| Pressure ulcer wound documentation and protocol not followed | D |
| Falls prevention and care plan updates inadequate; facility maintenance issues | E |
| Unnecessary medications and medication administration errors | D |
| Tracking of staff licenses and certifications inadequate | F |
| Inadequate nursing coverage prior to hiring full-time Director of Nursing | F |
| Dietary staff education and food preparation deficiencies | E |
| Kitchen staff cleaning and hand washing procedures deficient | F |
| Dumpster lids not kept closed | C |
| Medication administration and unnecessary medication issues | E |
| Housekeeping staff chemical use education needed | F |
| Loose handrails in facility | E |
| QA committee needs to ensure identification and correction of quality issues | F |
Report Facts
Deficiencies cited: 17
Date: Dec 30, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Haase | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 18
Dec 11, 2013
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 was found deficient in multiple areas including failure to notify physicians of significant resident changes, failure to investigate and report abuse allegations, inadequate housekeeping and maintenance, failure to revise care plans after falls, inadequate care and services including skin assessments and neurological checks, failure to prevent accidents, improper medication administration, insufficient nursing staff licensure and coverage, food preparation and sanitation issues, and failure of the quality assessment and assurance committee to address identified deficiencies.
Complaint Details
The complaint investigation revealed failures in notification of physician of significant resident changes, medication administration, abuse investigation and reporting, and other quality of care issues.
Severity Breakdown
SS=D: 6
SS=E: 5
SS=F: 4
SS=C: 1
: 2
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to immediately notify physicians of significant changes in residents' status and omitted medication doses. | SS=D |
| Failed to thoroughly investigate and report alleged abuse and neglect involving resident altercations. | SS=E |
| Failed to provide necessary housekeeping and maintenance services to maintain a sanitary interior. | SS=D |
| Failed to review and revise nursing care plans after resident falls. | SS=D |
| Failed to provide necessary care and services including weekly skin assessments and neurological checks after falls. | SS=D |
| Failed to provide necessary treatment and services to promote healing and prevent infection of pressure ulcers. | SS=E |
| Failed to ensure resident environment was free from accident hazards and failed to provide adequate supervision to prevent falls. | SS=D |
| Failed to ensure residents did not receive unnecessary medications and failed to administer medications as ordered. | SS=F |
| Failed to ensure use of services of a licensed nurse with current license and failed to designate a licensed nurse as charge nurse on all shifts. | SS=F |
| Failed to ensure use of services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. | SS=E |
| Failed to provide food prepared by methods that conserve nutritive value and failed to serve food at proper temperature. | SS=F |
| Failed to store, prepare, and serve food under sanitary conditions including failure to maintain equipment sanitation and proper hand hygiene. | SS=C |
| Failed to properly dispose of garbage and refuse with dumpster lids left open. | SS=E |
| Failed to provide pharmaceutical services assuring accurate acquiring, receiving, dispensing, and administering of drugs. | — |
| Failed to maintain a safe/sanitary environment to help prevent infection by using disinfectants that meet healthcare infection control standards. | SS=E |
| Failed to equip corridors with firmly secured handrails on each side. | SS=F |
| Failed to employ licensed professional nursing staff with current licensure. | SS=F |
| Failed to maintain a quality assessment and assurance committee that identifies quality issues and implements corrective plans. | — |
Report Facts
Residents sampled: 22
Residents with medication omissions: 4
Residents with unnecessary medications: 2
Days nurse worked without license: 24
Missed doses of Xopenex: 135
Missed doses of Nystatin: 69
Vitamin D3 doses given: 33
Dumpster lids open: 4
Residents with falls: 2
Residents with pressure ulcers: 1
Residents receiving ground meat diet: 13
Residents receiving pureed diet: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff I | Interviewed about medication omissions and care plan updates | |
| Administrative staff B | Interviewed about medication omissions and facility policies | |
| Maintenance staff D | Interviewed about maintenance and housekeeping issues | |
| Dietary staff O | Observed and interviewed about food preparation and sanitation | |
| Consultant Pharmacist G | Consultant Pharmacist | Interviewed about medication irregularities |
| Administrative staff A | Interviewed about nursing licensure and QAA committee | |
| Licensed nursing staff E | Registered Nurse | Worked without current nursing license for 24 days |
Inspection Report
Re-Inspection
Deficiencies: 1
Sep 26, 2012
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 26-40-303 (b)(i)(ii)(iii)(iv)(c) with ID prefix S1166 was corrected as of 09/26/2012.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) |
Report Facts
Deficiency correction date: Sep 26, 2012
Inspection Report
Follow-Up
Deficiencies: 6
Sep 26, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date, 09/26/2012.
Deficiencies (6)
| Description |
|---|
| Deficiency with regulation 483.10(c)(6) |
| Deficiency with regulation 483.25(c) |
| Deficiency with regulation 483.25(h) |
| Deficiency with regulation 483.25(l) |
| Deficiency with regulation 483.60(c) |
| Deficiency with regulation 483.65 |
Report Facts
Deficiencies corrected: 6
Inspection Report
Census: 52
Deficiencies: 1
Aug 21, 2012
Visit Reason
The inspection was conducted to assess compliance with nursing facility support system requirements, specifically the presence and functionality of emergency call system enunciator panels in the facility.
Findings
The facility failed to have an enunciator panel or monitor screen at the nurses' workroom or area in the Long Term Care Unit (LTCU) and Special Care Unit (SCU) that indicates the location or room number of the toilet, shower, or bathtub call lights. The only enunciator panel was located in the main lobby.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have an enunciator panel or monitor screen at the nurses' workroom or area indicating the location or room number of the toilet, shower, or bathtub in the LTCU and SCU. | Level C |
Report Facts
Census: 52
Inspection Report
Plan of Correction
Deficiencies: 0
N091001 ILY211
Visit Reason
This document is a Plan of Correction related to a facility inspection event identified by State ID N091001 and ASPEN Event ID ILY211.
Findings
No specific deficiencies or findings are listed in this document. It appears to be a placeholder or summary page indicating no records found for the Plan of Correction details.
Inspection Report
Plan of Correction
Deficiencies: 7
N091001 POC KK9M11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to achieve substantial compliance.
Findings
The Plan of Correction details multiple corrective actions addressing deficiencies related to personal funds accounting, pressure sore prevention, chemical storage, medication monitoring, infection control, and nurse call system implementation, with timelines for substantial compliance.
Severity Breakdown
D: 3
E: 3
C: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Final accounting of personal funds and timely refund to residents or their estates. | D |
| Ensuring residents receive necessary treatment to prevent pressure sores, including timely repositioning. | D |
| Ensuring environment is free of accidental hazards, including locked storage of chemicals. | E |
| Assuring residents are free from unnecessary drug use without adequate monitoring or medical justification. | E |
| Consultant pharmacist monitoring medication documentation and notifying facility of deficiencies. | D |
| Establishing and maintaining an effective infection control program, including whirlpool tub sanitization and linen transport. | E |
| Implementation of a new nursing call system to ensure resident safety and timely staff response. | C |
Report Facts
Substantial compliance deadline: Sep 14, 2012
Substantial compliance deadline: Sep 21, 2012
Substantial compliance deadline: Sep 26, 2012
Substantial compliance deadline: Oct 31, 2012
Audit frequency: 6
Refund timeframe: 30
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