Inspection Reports for
Topside Manor Inc
210 KANSAS AVE, GOODLAND, KS, 67735-1602
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Census: 45
Deficiencies: 2
Date: Apr 29, 2025
Visit Reason
The inspection was conducted to assess compliance with nursing staff licensure requirements and administrative oversight related to nursing staff competency and licensure status.
Findings
The facility failed to ensure that nursing staff possessed current licensure as required, placing residents at risk for not attaining or maintaining the highest practicable well-being. The facility also failed to have adequate administrative oversight to monitor and ensure all nurses maintained active licenses.
Deficiencies (2)
F 0726: The facility failed to ensure nursing staff possessed current licensure as required, with one Licensed Practical Nurse working after her license expired. This placed residents at risk for inadequate care.
F 0835: The facility failed to provide adequate administrative oversight to monitor and ensure all nurses maintained active licenses, placing residents at risk for lack of quality nursing care.
Report Facts
Resident census: 45
Days worked with expired license: 8
Total days in month: 23
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 12
Date: Aug 29, 2024
Visit Reason
Annual inspection of Topsides Manor Inc nursing home to assess compliance with regulatory requirements including resident dignity, notification procedures, accident prevention, respiratory care, staffing, dementia care, dietary services, food safety, and immunizations.
Findings
The facility had multiple deficiencies including failure to promote resident dignity, inadequate notification of hospital transfers, failure to prevent falls, inadequate respiratory care, insufficient RN coverage, inadequate dementia care, lack of certified dietary manager, improper food preparation and storage, inaccurate staffing data submission, and failure to offer pneumococcal vaccination to a resident.
Deficiencies (12)
F 0550: The facility failed to promote dignity for Resident 22 when staff called her 'Honey' multiple times instead of her proper name, placing her at risk for undignified care.
F 0582: The facility failed to provide correct Medicare Skilled Nursing Facility Advance Beneficiary Notices to three residents, risking uninformed decisions regarding skilled services.
F 0623: The facility failed to provide timely written notice to residents or representatives and notify the Long-Term Care Ombudsman of hospital transfers for three residents, risking uninformed care choices.
F 0689: The facility failed to ensure staff placed a bed alarm under Resident 9 as required by her care plan, resulting in a fall and risk of injury.
F 0695: The facility failed to provide adequate respiratory care for Resident 22 by not providing oxygen during a meal and improperly storing oxygen tubing, risking respiratory complications.
F 0727: The facility failed to provide Registered Nurse coverage for eight consecutive hours daily, seven days a week, placing all residents at risk of decreased quality of care.
F 0744: The facility failed to provide appropriate dementia care and services for Resident 22, who had dementia and behaviors, placing her at risk for abuse and decreased quality of life.
F 0801: The facility failed to employ a full-time certified dietary manager for 44 residents, placing residents at risk for inadequate nutrition.
F 0804: The facility kitchen staff failed to prepare all food items on the noon menu for residents on a pureed diet, placing residents at risk for impaired nutrition.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards, including improper glove use, uncovered food delivery, and inadequate temperature and sanitizer documentation, placing residents at risk for foodborne illness.
F 0851: The facility failed to submit complete and accurate Payroll Based Journal staffing data, misrepresenting licensed nurse coverage and placing residents at risk for unidentified inadequate staffing.
F 0883: The facility failed to offer Resident 9 the pneumococcal PCV20 vaccination or obtain a documented declination, placing the resident at risk for pneumococcal infection and complications.
Report Facts
Census: 44
PBJ missing RN coverage days: 7
PBJ missing RN coverage days: 7
PBJ missing RN coverage days: 6
PBJ missing RN coverage days: 8
PBJ missing RN coverage days: 6
PBJ missing RN coverage days: 6
PBJ missing RN coverage days: 8
PBJ missing RN coverage days: 4
PBJ missing RN coverage days: 4
PBJ missing RN coverage days: 4
PBJ missing RN coverage days: 4
PBJ missing RN coverage days: 4
PBJ missing RN coverage days: 8
PBJ missing RN coverage days: 8
PBJ missing RN coverage days: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified RN coverage issues, commented on dignity and respiratory care findings |
| Certified Nurse Aid M | Certified Nurse Aid | Named in dignity and respiratory care findings related to Resident 22 |
| Social Services X | Social Services | Unaware of notification requirements for hospital transfers |
| Licensed Nurse G | Licensed Nurse | Commented on respiratory care and dementia care findings |
| Dietary Staff BB | Dietary Staff | Not certified dietary manager, verified food preparation deficiencies |
| Dietary Staff CC | Dietary Staff | Observed preparing pureed diets improperly |
| Registered Dietitian CC | Registered Dietitian | Commented on pureed diet preparation and food safety |
| Administrative Staff A | Administrative Staff | Commented on PBJ submission issues |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Jun 3, 2024
Visit Reason
The inspection was conducted following a complaint related to a fall incident involving Resident 1 during a mechanical lift transfer.
Complaint Details
The investigation was triggered by a complaint regarding a fall on 05/22/24 when CNA M failed to properly attach the lift sling loops during a mechanical lift transfer, causing Resident 1 to fall and sustain a right comminuted distal femoral fracture. The complaint was substantiated with actual harm.
Findings
The facility failed to ensure Resident 1 remained free from accidents when staff improperly attached the lift sling harness loops, resulting in a fall with a right distal femoral fracture. The facility implemented corrective actions including staff education and a Triple Check System for lift use.
Deficiencies (1)
F 0689: The facility failed to ensure staff transferred Resident 1 safely during a mechanical lift transfer, resulting in a fall with injury. This deficient practice placed Resident 1 at risk for unnecessary injury and pain.
Report Facts
Resident census: 40
Fall Risk Evaluation score: 17
Fall Risk Evaluation score: 19
Date of incident: May 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in the finding for improper lift sling attachment causing Resident 1's fall |
| LN G | Licensed Nurse | Responded to the fall incident and called EMS |
| CNA N | Certified Nurse Aide | Assisted during the fall incident and stayed with Resident 1 |
| Consultant GG | Witnessed the fall incident and assisted Resident 1 | |
| Administrative Nurse D | Administrative Nurse | Provided statement regarding cause of incident and corrective actions |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 3
Date: Apr 1, 2024
Visit Reason
The inspection was conducted following complaints involving resident safety during transfers, medication availability, and psychotropic medication monitoring.
Complaint Details
The investigation was complaint-driven, focusing on incidents involving Resident 1's fall during transfer and Resident 2's medication errors including unavailable antibiotic and inadequate monitoring of psychotropic medication.
Findings
The facility failed to ensure Resident 1's safety during a mechanical lift transfer resulting in fractures. Resident 2 did not receive prescribed antibiotic medication for a urinary tract infection and lacked proper monitoring of psychotropic medication after a dosage increase.
Deficiencies (3)
F 0689: The facility failed to ensure Resident 1's safety during transfer with a full body lift, resulting in a fall and fractures to the left femur and fibula.
F 0755: The facility failed to ensure Resident 2's antibiotic for a urinary tract infection was available for administration, placing the resident at risk for worsening infection.
F 0758: The facility failed to monitor Resident 2's psychotropic medication after a trial dosage increase, risking inadequate oversight and ineffective dosing.
Report Facts
Resident census: 43
Fall risk score: 11
Weight: 267
Antibiotic dosage: 100
Psychotropic medication dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Involved in Resident 1's transfer and fall incident |
| LN G | Licensed Nurse | Responded to Resident 1's fall and performed assessments |
| CNA N | Certified Nurse Aide | Assisted during Resident 1's fall incident |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding incidents and corrective actions |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Date: Mar 4, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to develop and implement a comprehensive care plan for respiratory needs, provide appropriate respiratory care, ensure pain management, and prevent medication errors for Resident 1.
Complaint Details
The investigation was complaint-driven, focusing on Resident 1's respiratory care, pain management, and medication administration. The complaint was substantiated with findings of deficient care and medication errors.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 1's respiratory needs and equipment, failed to provide appropriate respiratory care with the Trilogy non-invasive ventilator, failed to ensure Resident 1 received pain medication as ordered, and failed to prevent medication errors, including missed doses due to unavailability and lack of physician notification.
Deficiencies (4)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, lacking documentation and direction regarding Resident 1's Trilogy non-invasive ventilator.
F 0695: The facility failed to provide safe and appropriate respiratory care for Resident 1, lacking physician orders and care plan directions for the Trilogy non-invasive ventilator, placing the resident at risk for respiratory failure.
F 0697: The facility failed to provide safe, appropriate pain management for Resident 1, who missed pain medications multiple times, causing risk of pain and emotional distress.
F 0760: The facility failed to ensure Resident 1 was free from significant medication errors, including missed doses of hydrocodone/acetaminophen, duloxetine, and potassium chloride due to medication unavailability and failure to notify the physician.
Report Facts
Residents reviewed for pain: 3
Medication missed days - hydrocodone/acetaminophen: 1
Medication missed days - duloxetine: 3
Medication missed days - potassium chloride: 24
Medication missed days - potassium chloride: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Verified no orders for Trilogy ventilator and discussed medication re-order process |
| Administrative Staff A | Administrative Staff | Unaware of missing orders for Trilogy ventilator and acknowledged medication re-order issues |
| Certified Medication Aide M | Certified Medication Aide | Responsible for writing medication re-order sheets and described medication re-order process |
| Certified Medication Aide N | Certified Medication Aide | Documented potassium administration and noted medication unavailability |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to identify fall risk and initiate fall interventions for Resident 1 upon admission.
Complaint Details
The complaint investigation found that Resident 1 was admitted with a history of frequent falls but the facility did not perform a fall risk assessment or implement fall interventions. Resident 1 fell on 11/09/23, sustaining fourth and fifth rib fractures. The complaint was substantiated with actual harm.
Findings
The facility failed to perform a fall risk assessment and implement fall prevention interventions for Resident 1 upon admission. Resident 1 subsequently fell, resulting in two rib fractures and severe pain, indicating actual harm.
Deficiencies (1)
F 0689: The facility failed to identify fall risk and initiate fall interventions for Resident 1 upon admission, resulting in a fall with rib fractures and severe pain.
Report Facts
Resident census: 44
Fall risk score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in witness statements related to Resident 1's fall and assessment |
| CNA M | Certified Nurse's Aide | Named in witness statements related to Resident 1's fall and assessment |
| CNA N | Certified Nurse's Aide | Named in witness statements related to Resident 1's care and fall |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding fall risk assessment policies and procedures |
| Administrative Nurse E | Administrative Nurse | Provided statements regarding admission checklist and fall risk assessment |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 14
Date: Aug 31, 2023
Visit Reason
The inspection was an annual survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility had multiple deficiencies including failure to notify physicians of significant resident conditions, inadequate care planning for falls and mental health needs, failure to provide ordered medications, improper food preparation, lack of proper equipment maintenance, and insufficient RN coverage.
Deficiencies (14)
F580: The facility failed to notify physicians timely of residents' significant conditions including suicidal ideations, elopement, and lack of bowel movements, placing residents at risk for delayed treatment.
F609: The facility failed to report an elopement as neglect and failed to investigate incidents of self-harm and leaving the facility unattended, placing the resident at risk for ongoing neglect.
F610: The facility failed to investigate incidents of tweezers in a resident's throat and elopement during winter weather, placing the resident at risk for ongoing neglect and unidentified care needs.
F657: The facility failed to revise care plans with meaningful, person-centered interventions after multiple falls for residents R31 and R34, placing them at risk for further falls and injury.
F684: The facility failed to provide appropriate pressure ulcer care and preventive interventions for resident R23, resulting in an unstageable pressure ulcer on the left heel.
F689: The facility failed to complete root cause analyses for multiple falls and failed to implement meaningful interventions for residents R31 and R34, and failed to prevent elopement of resident R27, placing residents at risk for further falls and injury.
F697: The facility failed to provide appropriate pain management for resident R16 after an incident with a sit to stand lift, placing the resident at risk for prolonged pain.
F727: The facility failed to provide registered nurse coverage eight consecutive hours a day, seven days a week, placing residents at risk of lack of assessments and inappropriate care.
F740: The facility failed to provide appropriate behavioral health treatment and services to resident R2 after reporting suicidal ideations, placing the resident at risk for unmet mental health care needs.
F745: The facility failed to provide medically-related social services to resident R23 who reported wanting to die, placing the resident at risk for further decline of emotional and mental well-being.
F757: The facility failed to ensure residents' drug regimens were free from unnecessary drugs by failing to provide physician ordered medications for resident R13's constipation and failing to notify the physician, placing the resident at risk for impaction.
F804: The facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance, including failure to follow recipes and serving food at incorrect temperatures, placing residents at risk for unmet dietary needs and foodborne illness.
F812: The facility failed to maintain food service safety by failing to change gloves appropriately, placing residents at risk for foodborne illness.
F908: The facility failed to ensure essential equipment, including sit to stand lifts, was maintained in safe operating condition, placing residents at risk for preventable accidents.
Report Facts
Residents present: 41
Consecutive days without bowel movement: 4
Consecutive days without bowel movement: 5
Fall risk assessments: 11
Pressure ulcer size: 4.1
Pressure ulcer size: 3.2
Pressure ulcer size: 0.1
Pressure ulcer size: 1.8
Pressure ulcer size: 5
Temperature of pureed beef steak: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of RN coverage, failure to notify physicians, and care plan deficiencies |
| Licensed Nurse G | Licensed Nurse | Verified medication administration issues and fall risks |
| Certified Nurse Aide M | Certified Nurse Aide | Documented bowel movement monitoring and assisted with sit to stand lift |
| Social Service X | Social Service | Reported lack of awareness of resident suicidal ideations |
| Dietary Staff CC | Dietary Staff | Failed to follow recipe and glove hygiene in food preparation |
| Dietary Staff DD | Dietary Staff | Failed to maintain proper food temperature and omit vegetable serving |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: May 9, 2023
Visit Reason
The inspection was conducted due to complaints regarding neglect and failure to follow care plans, specifically related to choking and aspiration incidents for Resident 1 and an injury to Resident 2 during transfer.
Complaint Details
The complaint investigation substantiated neglect related to Resident 1's aspiration and failure to follow up on speech therapy evaluation, and actual harm related to Resident 2's injury from improper transfer.
Findings
The facility failed to prevent neglect of Resident 1 by not following up on speech therapy evaluation requests after aspiration events, resulting in immediate jeopardy. The facility also failed to prevent Resident 2 from sustaining a closed fibula/tibia fracture due to improper transfer by staff not following the care plan.
Deficiencies (2)
F 0600: The facility failed to prevent neglect of Resident 1 by not obtaining speech therapy services after aspiration events and failed to respond adequately during an acute change in condition, placing Resident 1 in immediate jeopardy.
F 0689: The facility failed to ensure Resident 2 was transferred according to care plan, resulting in a closed fibula/tibia fracture and skin tear, causing actual harm.
Report Facts
Resident census: 43
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 3
Skin tear measurement: 6
Skin tear measurement: 3.5
Skin tear measurement: 6
Skin tear measurement: 4.2
Skin tear measurement: 3.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Assessed Resident 1 during choking episode and coordinated emergency transfer |
| CNA M | Certified Nurse Aide | Involved in feeding and transfer of Resident 1 and Resident 2; admitted not following care plan for Resident 2 transfer |
| CNA N | Certified Nurse Aide | Assisted with Resident 1 during choking episode |
| LN I | Licensed Nurse | Responded to Resident 2 injury and assessed wound |
| Administrative Nurse D | Administrative Nurse | Verified lack of follow-up on speech therapy for Resident 1 and educated staff on care plans |
Inspection Report
Census: 43
Deficiencies: 1
Date: Apr 5, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with safety standards related to accident hazards and supervision, specifically following an incident involving a resident's fall from an electric lift chair/recliner.
Findings
The facility failed to ensure the safety of Resident 1 when operating an electric lift chair/recliner by not performing timely evaluations to confirm the resident's capability to safely use the device. This failure resulted in a fall causing a right femur fracture requiring surgical repair and significant decline in the resident's condition.
Deficiencies (1)
F 0689: The facility failed to ensure that a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. This resulted in Resident 1 sustaining a right femur fracture after falling from an electric lift chair/recliner due to lack of timely safety evaluations.
Report Facts
Resident census: 43
Brief Interview for Mental Status (BIMS) score: 14
Brief Interview for Mental Status (BIMS) score: 10
Pain rating: 8
Date of fall incident: Mar 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse's Aide (CNA) M | Found Resident 1 on the floor after the fall | |
| Certified Medication Aide (CMA) R | Administered medications and reported Resident 1's decline in ability to perform activities of daily living | |
| Certified Nursing Assistant (CNA) N | Reported Resident 1's decline and depressive symptoms after injury | |
| Administrative Nurse D | Discussed policy and frequency of Recliner/Chair Evaluations |
Inspection Report
Routine
Census: 34
Deficiencies: 13
Date: Mar 17, 2022
Visit Reason
Routine inspection of Topside Manor Inc nursing home to assess compliance with regulatory standards including resident care, medication management, infection control, and facility safety.
Findings
The facility failed to provide dignified care, develop comprehensive care plans, prevent pressure ulcers, ensure safe transfers, provide adequate nutrition and pain management, properly store medications and equipment, and maintain infection control. Several residents were at risk due to these deficiencies.
Deficiencies (13)
F 0550: The facility failed to treat residents R3 and R1 with respect and dignity during care, placing them at risk for embarrassment and an undignified environment.
F 0656: The facility failed to develop a comprehensive care plan for diabetes mellitus for R3, placing the resident at risk for elevated blood sugars and adverse side effects.
F 0657: The facility failed to revise the care plan with interventions to prevent skin breakdown for R20, who had a Stage 2 pressure ulcer, placing the resident at risk for further skin breakdown.
F 0677: The facility failed to provide appropriate transfers to prevent shearing when repositioning R1, placing the resident at risk for skin injury.
F 0686: The facility failed to prevent development of a Stage 4 pressure ulcer for R1 and a Stage 2 pressure ulcer for R20, and failed to implement wound assessments, nutritional consults, and preventative measures, placing residents at risk for pain, infection, and further breakdown.
F 0689: The facility failed to provide a safe environment for R3 by not using a mechanical lift for transfers and not placing an alarm on his wheelchair, placing the resident at risk for further injury while recovering from a hip fracture.
F 0692: The facility failed to provide necessary nutritional assessments and treatment for weight loss for R31, placing the resident at risk for further weight loss and decline.
F 0695: The facility failed to provide necessary respiratory care by improperly storing uncovered nebulizer masks for residents R1, R5, R19, and R27, placing them at increased risk for respiratory infection.
F 0697: The facility failed to administer physician ordered pain medication in a timely manner for R1 during wound care and failed to assess and treat breakthrough pain, resulting in severe unrelieved pain.
F 0756: The facility failed to ensure the Consultant Pharmacist identified and reported irregularities regarding R3's antidiabetic medications and lack of blood sugar monitoring, placing R3 at risk for hypoglycemia.
F 0757: The facility failed to monitor blood sugar for R3 who received routine antidiabetic medications, placing the resident at risk for adverse medication side effects.
F 0812: The facility failed to store, prepare, and serve food in accordance with professional standards, including storing meat above eggs and expired cottage cheese, and poor kitchen sanitation, placing 34 residents at risk for foodborne illness.
F 0880: The facility failed to exercise adequate infection control measures during care for R3, including inadequate hand hygiene and failure to use gloves when administering insulin, placing residents at increased risk for infection.
Report Facts
Resident census: 34
Resident sample size: 12
Weight loss percent: 11.5
Pressure ulcer size: 4
Pressure ulcer size: 5
Pressure ulcer size: 4
Pressure ulcer size: 3.5
Fall risk score: 18
Braden Scale score: 17
Braden Scale score: 15
Braden Scale score: 13
Braden Scale score: 14
BIMS score: 14
BIMS score: 12
BIMS score: 15
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified dignity failures, wound care pain, hand hygiene failures, and improper nebulizer mask storage |
| Licensed Nurse G | Licensed Nurse | Verified medication administration, wound care observations, and lack of blood sugar monitoring |
| Consultant Pharmacist HH | Consultant Pharmacist | Verified no recommendations made regarding R3's antidiabetic medication monitoring |
| Certified Nurse Aide N | Certified Nurse Aide | Observed providing incontinent care with poor hand hygiene |
| Certified Nurse Aide O | Certified Nurse Aide | Observed providing incontinent care with poor hand hygiene |
| Certified Medication Aide R | Certified Medication Aide | Administered pain medication to R1 and assessed pain |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 5, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All deficiencies previously reported were corrected as of 12/30/2013, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Correction completion date: Dec 30, 2013
Follow-up survey date: Feb 5, 2014
Inspection Report
Plan of Correction
Deficiencies: 19
Date: 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. It outlines corrective actions to address identified compliance issues.
Findings
The plan details multiple corrective actions including staff education on medication policies, abuse reporting, fall prevention, wound care, food preparation, and maintenance repairs. Audits and monitoring activities are scheduled to ensure compliance and quality improvement.
Deficiencies (19)
F157-D: Medication aides and nurses will be educated on medication ordering policies and required documentation. Audits will monitor medications marked unavailable and notification procedures.
F225-D: Staff will be educated on reporting suspected mistreatment, neglect, or abuse and incident report procedures.
F253-E: Maintenance replaced cracked floor tiles, sealed holes, cleaned exhaust fans, and will conduct monthly audits of fans.
F280-D: Nurses will be educated on falls policy and care plan updates. Incident reports will be reviewed daily by the fall committee.
F309-D: Nurses will receive education on pressure ulcer assessment and prevention, with audits on skin assessments and wound documentation.
F314-D: Nurses will be educated on wound care documentation and protocols. Audits will ensure wounds are measured and documented regularly.
F323-E: Staff education on falls policy and care plan updates. Maintenance will audit and repair handrails and surge protectors monthly for one year.
F329-D: Nurses and medication aides will be educated on unnecessary medications and medication administration policies. Medication audits will be conducted weekly.
F353-F: Human Resources staff will be educated on tracking licenses and certifications for licensed and certified staff.
F354-F: A full-time Director of Nursing has been hired to ensure appropriate nursing coverage.
F364-E: Dietary staff will be educated on food preparation standards. The dietary director will audit portion sizes and food temperatures bi-monthly for one year.
F371-F: Kitchen staff will be educated on cleaning procedures and hand washing. Monthly food preparation audits will be completed.
F372-C: Staff will be educated to ensure dumpster lids remain closed at all times.
F425-E: Nurses and medication aides will be educated on unnecessary medications and medication administration. Weekly medication audits will be conducted.
F428-E: Nurses and medication aides will be educated on unnecessary medications and medication administration. The facility pharmacy consultant has been educated on deficiencies.
F441-F: Housekeeping staff will be educated on proper chemical use. Safety data sheets will be maintained by the maintenance director.
F468-E: Maintenance director fixed loose handrails and will audit all handrails monthly.
F499-F: Human Resources staff will be educated on tracking licenses and certifications for staff.
F520-F: The facility QA committee will use QA tools to identify quality issues and develop corrective plans.
Report Facts
Complete Date: Dec 30, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Haase | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 19
Date: Dec 11, 2013
Visit Reason
Health Resurvey and Complaint Investigation for multiple regulatory compliance issues including medication administration, resident care, and facility maintenance.
Complaint Details
The inspection was a Health Resurvey and Complaint Investigation triggered by complaints regarding medication administration, resident care, abuse allegations, and facility maintenance.
Findings
The facility failed to notify physicians of significant resident changes, failed to investigate and report abuse allegations, did not maintain sanitary conditions, failed to revise care plans after falls, did not provide necessary care to maintain resident well-being, failed to prevent accidents, administered unnecessary medications, lacked sufficient licensed nursing staff, failed to maintain food safety and sanitation, and failed to ensure proper infection control and facility maintenance.
Deficiencies (19)
F157: The facility failed to immediately notify physicians of significant changes in residents' status and omitted medication doses for residents #45, #56, and #9.
F225: The facility failed to thoroughly investigate and report verbal abuse allegations involving residents #16 and #46 to the state survey agency.
F253: The facility failed to provide necessary housekeeping and maintenance services, including repairing cracked floor tiles, holes in walls, and cleaning bathroom exhaust fans.
F280: The facility failed to review and revise nursing care plans after falls for residents #55 and #35.
F309: The facility failed to provide necessary care and services including weekly skin assessments and neurological checks after falls for residents #56 and #55.
F314: The facility failed to ensure resident #54 received necessary treatment and monitoring for a pressure ulcer to promote healing and prevent infection.
F323: The facility failed to maintain a safe environment free from accident hazards including uneven sidewalks, unsafe toilet risers, unsafe surge protector use, and failed to provide adequate supervision to prevent falls for residents #35 and #55.
F329: The facility failed to keep residents #56 and #35 free from unnecessary drugs by administering incorrect dosages and omitting medications as ordered.
F353: The facility failed to designate a licensed nurse as charge nurse when a nurse worked repeated shifts without a current license for 24 days.
F354: The facility failed to ensure registered nurse coverage for at least 8 consecutive hours a day, 7 days a week when a nurse worked without a current license for 24 days.
F364: The facility failed to prepare food that conserved nutritive value and serve food at proper temperatures for residents on ground and pureed diets.
F371: The facility failed to store, prepare, and serve food under sanitary conditions including failure to maintain equipment sanitation, monitor temperatures, change gloves, wash hands, and avoid contaminating dishes.
F372: The facility failed to properly dispose of garbage when 4 of 5 dumpster lids remained open.
F425: The facility failed to ensure accurate administration of medications due to unavailability and delayed physician orders for multiple residents (#45, #56, #51, #9).
F428: The facility failed to ensure the consultant pharmacist identified and reported drug irregularities related to omitted medications and incorrect dosages for residents #45, #56, #51, #9, and #35.
F441: The facility failed to maintain a safe and sanitary environment by using disinfectants that did not meet healthcare infection control standards.
F468: The facility failed to have firmly secured handrails on two of four hallways (100 and 300 hallways).
F499: The facility failed to ensure licensed nurse E maintained a current nursing license and worked as a registered nurse for 24 days after license expiration.
F520: The facility's Quality Assessment and Assurance committee failed to identify quality issues and implement plans of action to correct deficiencies.
Report Facts
Resident census: 52
Missed doses of Xopenex: 135
Missed doses of Nystatin: 69
Days nurse worked without license: 24
Vitamin D3 doses administered: 33
Vitamin D3 doses ordered: 16
Dumpster lids open: 4
Residents sampled for unnecessary medications: 9
Residents sampled for accidents: 6
Residents sampled for complaint investigation: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Nurse/Charge Nurse | Worked 24 days without current nursing license |
| Administrative staff A | Reported nurse E's license lapsed and facility's lack of license verification system | |
| Administrative nurse B | Confirmed failures in medication administration and care plan updates | |
| Licensed nursing staff I | Reported medication administration and care plan update failures | |
| Consultant Pharmacist G | Consultant Pharmacist | Failed to identify and report medication irregularities |
| Dietary staff O | Failed to follow recipe and contaminated plates | |
| Maintenance staff D | Unaware of facility maintenance issues | |
| Direct care staff K | Reported medication unavailability to charge nurse | |
| Administrative staff B | Confirmed medication administration failures and care plan issues |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 26, 2012
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency with regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) deficiency was corrected by the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 26, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date of 09/26/2012.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Sep 4, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection. It outlines corrective actions to address compliance issues.
Findings
The Plan of Correction details multiple areas of noncompliance including personal funds accounting, pressure sore prevention, chemical storage, medication monitoring, infection control, and nurse call system implementation. The facility commits to education, audits, and monitoring to achieve substantial compliance by specified dates in September and October 2012.
Deficiencies (7)
F160-D: The AR Specialist will ensure final accounting of personal funds and refunds within 30 days of resident death or discharge, with monthly audits and oversight to ensure timely distribution.
F314-D: Nursing staff will be educated to prevent pressure sores by timely repositioning residents at risk, with ongoing audits and reporting to QA.
F323-E: Staff will be educated on chemical storage in locked areas, with weekly safety inspections and monthly audits to ensure compliance.
F329-E: Medication regimens will be monitored monthly by pharmacists and staff, with education on documentation and audits to ensure adequate monitoring.
F428-D: Consultant pharmacist will monitor medication documentation and notify nursing leadership of deficiencies, with audits and QA reporting.
F441-E: Infection control program will ensure proper sanitization of whirlpool tubs and linen transport, with staff education and monthly audits.
S1166-C: A new nursing call system will be implemented with enunciator panels and portable devices, accompanied by staff education and compliance by October 31, 2012.
Report Facts
Plan of Correction completion date: Sep 14, 2012
Plan of Correction completion date: Sep 21, 2012
Plan of Correction completion date: Sep 26, 2012
Plan of Correction completion date: Oct 31, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheyenne George | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 1
Date: Aug 28, 2012
Visit Reason
The inspection was conducted to evaluate compliance with nursing facility emergency call system requirements and to identify deficiencies related to the facility's call system.
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 resident calls. The only enunciator panel was located in the main lobby, which does not meet regulatory requirements.
Deficiencies (1)
26-40-303 (b)(i)(ii)(iii)(iv)(c) Nursing facility support system requires an emergency call button or pull cord with an enunciator panel at nurses' stations. The facility lacked an enunciator panel in the LTCU and SCU nurses' stations to identify call locations.
Report Facts
Resident census: 52
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N091001 POC ILY211
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency records are found or detailed in this Plan of Correction document.
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