Inspection Reports for Via Christi Village Pittsburg Ks LLC
1502 E CENTENNIAL DRIVE, KS, 66762
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 17, 2024, found no deficiencies, confirming that all prior issues cited in October 2024 were corrected by December 5, 2024. Earlier inspections showed a pattern of deficiencies primarily related to resident care planning, medication administration, hygiene assistance, equipment maintenance, and environmental cleanliness, with several complaint investigations substantiating these issues. Notable enforcement actions included denial of payment for new Medicare and Medicaid admissions at various times due to deficiencies posing actual harm or immediate jeopardy, and a substantiated complaint in 2015 involving failure to prevent sexual abuse that placed residents in immediate jeopardy. Most complaints were substantiated when investigated, especially those concerning care planning, medication errors, and resident safety, though some complaints were found unsubstantiated. The trend shows improvement with recent inspections free of deficiencies following corrective actions and monitoring, indicating progress in addressing prior concerns.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
30.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
403% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
74 residents
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 17, 2024
Visit Reason
An offsite revisit survey was conducted on 12/17/24 for all previous deficiencies cited on 10/21/24 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 12/05/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Renewal
Deficiencies: 0
Nov 6, 2024
Visit Reason
The licensure resurvey with attached complaint number 189934 was conducted on 11/04/24, 11/05/24, and 11/06/24 at the assisted living facility.
Findings
The inspection resulted in a finding of no deficiency citations.
Complaint Details
Complaint number 189934 was attached to the licensure resurvey; no deficiencies were found.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 4, 2024
Visit Reason
The licensure resurvey with attached complaint number 189934 was conducted on 11/04/24, 11/05/24, and 11/06/24 at the assisted living facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 10
Oct 21, 2024
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. in response to deficiencies cited in a prior survey conducted on 10/21/2024. The plan outlines corrective actions to address identified deficiencies and ensure ongoing compliance with state and federal regulations.
Findings
The plan details multiple assessments of residents showing no adverse effects, updates to care plans, re-education of staff, policy reviews, and ongoing monitoring through audits by various committees to prevent recurrence of deficient practices related to care planning, use of personal humidifiers, wheelchair foot rests, personal hygiene assistance, dialysis communication, medication parameter monitoring, antipsychotic medication assessments, wound care, toilet riser safety, and privacy curtain maintenance.
Severity Breakdown
E: 4
D: 6
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure resident participation or legal representative participation in care plan development and review. | E |
| Inadequate care plan updates related to personal humidifier use and family education. | D |
| Deficient care planning for wheelchair foot rest use and positioning. | D |
| Inadequate assistance with personal hygiene and grooming needs. | D |
| Failure to maintain dialysis communication sheets and documentation. | D |
| Failure to follow physician orders for medication administration parameters. | D |
| Failure to complete AIMS assessments for residents on antipsychotic medications. | D |
| Inadequate wound care management including hand hygiene and glove use. | D |
| Unsafe or unclean toilet risers in resident bathrooms. | E |
| Unsanitary or unsafe privacy curtains in shower rooms. | E |
Report Facts
Audit frequency: 3
Plan completion dates: 2024
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 12
Oct 21, 2024
Visit Reason
The inspection was conducted as a health survey and investigation of complaint #189939 regarding care plan meetings and other resident care concerns.
Findings
The facility failed to provide required care plan meetings for multiple residents, failed to complete comprehensive care plans including instructions for personal equipment, failed to review and revise care plans for wheelchair footrests, failed to provide grooming assistance to dependent residents, failed to properly position residents in wheelchairs, failed to properly clean and maintain a resident's humidifier, failed to assess and monitor a resident receiving dialysis, failed to administer medication within physician ordered parameters, failed to assess for adverse effects of antipsychotic medication, failed to perform proper hand hygiene during wound care, failed to maintain resident equipment in safe condition, and failed to maintain a clean environment regarding privacy curtains.
Complaint Details
The inspection was triggered by complaint #189939 regarding care plan meetings and resident care issues.
Severity Breakdown
SS=E: 3
SS=D: 8
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to provide care plan meetings for four residents as required. | SS=E |
| Failed to complete a comprehensive care plan for one resident regarding care and maintenance of personal humidifier. | SS=D |
| Failed to review and revise care plans for two residents regarding wheelchair footrests. | SS=D |
| Failed to ensure two residents received grooming assistance. | SS=D |
| Failed to properly position two residents in wheelchairs regarding footrests. | SS=D |
| Failed to properly clean and maintain a resident's humidifier. | SS=D |
| Failed to ensure assessment and monitoring for a resident receiving dialysis before and after treatment. | SS=D |
| Failed to administer Midodrine medication within physician ordered blood pressure parameters. | SS=D |
| Failed to assess a resident for adverse effects of antipsychotic medication using the AIMS tool every three months. | SS=D |
| Failed to perform proper hand hygiene while completing wound care for a resident. | SS=D |
| Failed to ensure all resident equipment was in clean, safe condition; noted a toilet seat riser with rust and cracks. | SS=E |
| Failed to ensure a clean environment regarding soiled, stained privacy curtains in a shower room. | SS=E |
Report Facts
Residents reviewed: 20
Resident census: 74
Stage II pressure ulcer size: 1.2
Stage II pressure ulcer size: 0.8
Midodrine doses administered: 12
BIMS scores: 8
BIMS scores: 12
BIMS scores: 1
BIMS scores: 5
BIMS scores: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Confirmed expectations for medication administration and care plan reviews; stated nurses responsible for humidifier care |
| Social Service Staff X | Interviewed regarding missing care plan meetings for multiple residents | |
| Certified Medication Aide R | CMA | Stated night shift staff responsible for humidifier care |
| Certified Medication Aide S | CMA | Uncertain who was responsible for humidifier care |
| Licensed Nurse G | LN | Stated expectation for footrest use on wheelchairs and proper medication administration |
| Certified Nurse Aide M | CNA | Observed propelling resident in wheelchair without footrests |
| Certified Nurse Aide N | CNA | Observed propelling resident in wheelchair without footrests |
| Licensed Nurse H | LN | Interviewed about resident cooperation with cares |
| Licensed Nurse I | LN | Interviewed about dialysis assessments and medication administration |
| Administrative Nurse D | Administrative Nurse | Interviewed about expectations for care plan meetings, personal hygiene, and dialysis assessments |
| Administrative Nurse F | Administrative Nurse | Observed wound care without proper hand hygiene |
| Housekeeping/Maintenance Staff U | Stated toilet seat riser needed replacement and privacy curtains needed cleaning |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 29, 2024
Visit Reason
An offsite revisit survey was conducted on 04/29/24 for all previous deficiencies cited on 03/07/24 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 03/23/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 7, 2024
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. in response to deficiencies cited in a prior inspection related to medication administration and documentation.
Findings
The plan addresses corrective actions for residents affected by deficient medication administration practices, including reassessment of residents, staff re-education, policy review, and ongoing audits to ensure compliance and prevent recurrence.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficient practice related to administration and documentation of PRN controlled medications. | D |
Report Facts
Date of resident assessment: Feb 28, 2024
Date of staff re-education completion: Mar 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlin Strawderman | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Mar 7, 2024
Visit Reason
The inspection was conducted as a complaint investigation for complaint numbers KS00186159 and KS00186315 regarding medication administration practices.
Findings
The facility failed to prevent a medication error when a licensed nurse administered an as-needed dose of oxycodone and failed to document it, resulting in a resident receiving two doses of oxycodone within two hours, contrary to physician orders requiring a six-hour interval between doses.
Complaint Details
The findings represent the results of complaint investigation #KS00186159 and KS00186315.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent a medication error when Licensed Nurse I administered oxycodone as needed and failed to document it, causing the resident to receive two doses within two hours. | SS=D |
Report Facts
Resident census: 83
Medication dose: 5
Time interval: 2
Pain rating: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse I | Administered undocumented as-needed oxycodone dose | |
| Licensed Nurse H | Administered scheduled oxycodone dose two hours after undocumented dose | |
| Administrative Nurse D | Reported on proper medication documentation procedures |
Inspection Report
Follow-Up
Deficiencies: 0
May 9, 2023
Visit Reason
An offsite revisit survey was conducted on 05/09/23 to verify correction of all previous deficiencies cited on 04/19/23.
Findings
All deficiencies have been corrected as of the compliance date of 05/01/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 2
Apr 19, 2023
Visit Reason
The visit was a resurvey with a complaint (#176351) at an Assisted Living facility conducted on 04/18/23 - 04/19/23.
Findings
The facility failed to ensure that resident R102 was informed both orally and in writing of the current rate for the level of care and services. Additionally, the facility failed to ensure the Negotiated Service Agreement for resident R104 identified who was responsible for the administration and management of selected medications that the resident self-administered.
Complaint Details
The resurvey was conducted following complaint #176351.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to inform resident R102 both orally and in writing of the current rate for the level of care and services to be provided. | SS=D |
| Failure to ensure the Negotiated Service Agreement for resident R104 identified who was responsible for administration and management of selected medications self-administered by the resident. | SS=D |
Report Facts
Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Stated no documentation of charges for resident R102. | |
| Licensed Nurse C | Stated resident R104 had prescribed eyedrops and could have them at bedside. | |
| Administrative Nurse B | Acknowledged resident R104 self-administered medications not identified in the NSA. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 18, 2023
Visit Reason
The document is a plan of correction related to a resurvey with a complaint #176351 conducted at an Assisted Living facility on 04/18/23 - 04/19/23.
Findings
The plan of correction addresses citations found during the resurvey related to the complaint investigation conducted on the specified dates.
Complaint Details
The visit was triggered by complaint #176351.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 27, 2023
Visit Reason
An offsite revisit survey was conducted on 02/27/2023 for all previous deficiencies cited on 12/29/2022.
Findings
All deficiencies have been corrected as of the compliance date of 01/05/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 27, 2023
Visit Reason
An offsite revisit survey was conducted on 02/27/2023 for all previous deficiencies cited on 12/19/2022 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 01/19/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 29, 2022
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a survey conducted on 12/29/2022.
Findings
The facility identified a deficiency related to expired code status documentation for resident #1 and implemented corrective actions including staff education, routine reviews, and mock code drills to ensure compliance and prevent recurrence.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Expired code status documentation for resident #1 as of 12/27/22. | D |
Report Facts
Date of expired code status: Dec 27, 2022
Date of community review: Dec 29, 2022
Date of staff education completion deadline: Jan 5, 2023
Monitoring period: 3
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 1
Dec 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation (#KS 177081) regarding the facility's failure to honor a resident's Do Not Resuscitate (DNR) order during an emergency.
Findings
The facility failed to ensure that one resident's wishes regarding CPR were respected, as staff initiated CPR despite a valid DNR order in the resident's medical record. Staff were unaware of the DNR status at the time of the emergency, leading to unnecessary CPR until EMS reviewed the DNR form and stopped resuscitation efforts.
Complaint Details
The complaint investigation #KS 177081 found that the facility did not honor the resident's DNR order, leading to inappropriate initiation of CPR.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide basic life support in accordance with the resident's DNR order, resulting in CPR being initiated contrary to the resident's wishes. | SS=D |
Report Facts
Census: 76
CPR duration: 10
CPR duration: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Performed CPR on the resident and was unaware of the DNR status at the time |
| Administrative staff A | Reported the nurse initiated CPR unaware of the resident's changed code status | |
| Director of Nursing | Director of Nursing | Assisted in locating the DNR orders in the electronic records during the emergency |
Inspection Report
Plan of Correction
Deficiencies: 8
Dec 19, 2022
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. in response to deficiencies cited during a survey conducted on 12/19/2022.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies related to resident care, safety, medication management, food storage, and other quality of life issues. The facility describes assessments of affected residents, re-education of staff, policy reviews, and ongoing monitoring plans to ensure compliance and prevent recurrence.
Severity Breakdown
D: 7
F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Deficiency related to Quality of Life policy and resident privacy during personal care | D |
| Deficiency related to accommodation of needs for residents requiring foot pedals for safety | D |
| Deficiency related to elopement prevention and care plans for residents with exit seeking behavior | D |
| Deficiency related to activities policy and use of activity baskets | D |
| Deficiency related to Resident Nursing- Range of Motion Program policy | D |
| Deficiency related to Pharmacy Services- Role of the Consultant Pharmacist policy and medication reviews | D |
| Deficiency related to Storage of Medication policy and expired insulin disposal | D |
| Deficiency related to Food Storage policy and walk-in refrigerator maintenance | F |
Report Facts
Deficiencies cited: 8
Dates for corrective action completion: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlin Strawderman | Executive Director | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 11
Dec 19, 2022
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for multiple complaint investigations identified by numbers KS00176330, KS00175970, and KS00174757.
Findings
The facility was found deficient in multiple areas including failure to provide dignity during care, failure to provide reasonable accommodations, failure to revise care plans for wandering residents, inadequate activity programs, failure to provide range of motion services, failure to prevent accidents including improper use of wheelchair seatbelts and monitoring of WanderGuard bracelets, failure to provide appropriate dementia care, failure to identify inappropriate antipsychotic medication use, failure to discard expired medications, and failure to maintain sanitary food storage.
Complaint Details
The inspection included complaint investigations #KS00176330, KS00175970, and KS00174757.
Severity Breakdown
SS=D: 10
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to provide Resident 5 with dignity during basic cares, including removing clothing without privacy or announcement. | SS=D |
| Failed to ensure foot pedals were provided for Resident 30's wheelchair to prevent feet dragging on the floor. | SS=D |
| Failed to revise care plan interventions related to Resident 26's ongoing exit seeking behaviors and need for a WanderGuard bracelet. | SS=D |
| Failed to provide Resident 30 with a meaningful activity program to address assessed needs. | SS=D |
| Failed to provide necessary services for Resident 6's multiple contractures to prevent further loss of range of motion and mobility. | SS=D |
| Failed to utilize Resident 5's wheelchair seatbelt resulting in a fall with injury; failed to monitor and check placement or function of Resident 26's WanderGuard bracelet. | SS=D |
| Failed to provide appropriate dementia care and treatment for Resident 76 who displayed wandering, agitation, confusion, and sundowning behaviors. | SS=D |
| Failed to ensure the Consultant Pharmacist identified and reported inappropriate indication for use of antipsychotic medication for Resident 30 with dementia. | SS=D |
| Failed to ensure appropriate indication for use of antipsychotic medication for Resident 30 with dementia, risking unnecessary psychotropic medication administration. | SS=D |
| Failed to discard an outdated individual insulin pen in medication cart, risking adverse consequences or ineffective treatment. | SS=D |
| Failed to maintain sanitary dietary standards related to food storage; air-conditioning unit in walk-in refrigerator was leaking onto stored food items. | SS=F |
Report Facts
Residents reviewed: 18
Medication carts: 10
Expired insulin pen date: 28
Resident census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nurses Aide | Named in dignity care deficiency and fall incident involving Resident 5 |
| CNA M | Certified Nurses Aide | Named in dignity care deficiency and fall incident involving Resident 5 |
| Administrative Nurse D | Administrative Nurse | Provided statements on privacy, care expectations, WanderGuard monitoring, restorative program, and fall investigation |
| Licensed Nurse J | Licensed Nurse | Provided statements on wheelchair safety, foot pedal use, and activity program |
| Licensed Nurse G | Licensed Nurse | Responded to fall incident involving Resident 5 |
| Certified Nurses Aide O | Certified Nurses Aide | Observed pushing Resident 30's wheelchair without foot pedals |
| Certified Nurses Aide P | Certified Nurses Aide | Provided statements on wheelchair foot pedal safety |
| Licensed Nurse I | Licensed Nurse | Provided statements on WanderGuard monitoring and activity program |
| Activity Director Z | Activity Director | Provided statements on activity scheduling and resident engagement |
| Licensed Nurse I | Licensed Nurse | Noted expired insulin pen and discarded it |
| Dietary Staff BB | Dietary Staff | Reported on food storage inspection and leak in walk-in refrigerator |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 28, 2021
Visit Reason
An offsite revisit survey was conducted on 10/28/2021 for all previous deficiencies cited on 09/13/2021 to verify correction of those deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 09/29/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 13, 2021
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. in response to deficiencies cited in a prior survey conducted on 9/13/2021.
Findings
The facility acknowledged deficiencies related to resident care plans and skin interventions, and outlined corrective actions including review and update of care plans, re-education of licensed nurses, and ongoing monitoring through clinical huddles and Quality Assurance Committee meetings.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency related to resident care plan and skin interventions | D |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Sep 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#165260) regarding the facility's failure to implement an intervention following an incident of extensive bruising to a resident caused by the assistive rail on her bed.
Findings
The facility failed to implement interventions to prevent further bruising to Resident 1, who sustained a large bruise on her upper extremity from contact with the bed's assistive rail. Multiple staff interviews and record reviews confirmed the lack of new interventions despite the resident's risk and documented bruising.
Complaint Details
The visit was triggered by complaint investigation #165260. The complaint involved failure to prevent injury from bed assistive rail bruising. The complaint was substantiated by findings.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement an intervention following bruising caused by the assistive rail on Resident 1's bed to prevent further injury. | SS=D |
Report Facts
Resident census: 80
Bruise size: 13
Bruise size: 22.5
Bruise size: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Assisted Resident 1 with transfers and provided information about resident's use of assistive rail and mobility. |
| CMA R | Certified Medication Aide | Provided resident care and described transfer assistance and bed mobility for Resident 1. |
| Administrative Nurse D | Administrative Nurse | Assessed bruising, participated in investigation, and stated lack of new interventions to prevent further bruising. |
| CNA N | Certified Nurse Aide | Reported unawareness of new interventions to prevent further bruising. |
| LN G | Licensed Nurse | Observed bruising and reported it to Administrative Nurse D; unaware of cause or new interventions. |
| Administrative Staff A | Administrative Staff | Expected intervention to prevent bruising and stated facility determined cause related to bed positioning handle. |
| CMA S | Certified Medication Aide | Assisted with resident care and described resident's bed positioning behavior. |
Inspection Report
Renewal
Deficiencies: 0
Aug 9, 2021
Visit Reason
The licensure resurvey was conducted on 08/05/2021 and 08/09/2021 at the assisted living facility to assess compliance for license renewal.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 21, 2021
Visit Reason
A revisit survey was conducted on 07/21/21 to verify correction of all previous deficiencies cited on 05/13/21.
Findings
All deficiencies cited in the previous inspection have been corrected as of 05/27/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 4
May 13, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation covering multiple complaint numbers (#152137, #160166, and #162242).
Findings
The facility failed to timely review and revise care plans following resident falls and skin tears, failed to implement adequate fall prevention interventions, failed to maintain nutritional status for a resident with weight loss, and failed to ensure proper infection control related to laundering of blood-soiled linens.
Complaint Details
The visit was complaint-related, investigating complaints #152137, #160166, and #162242.
Severity Breakdown
SS=E: 1
SS=G: 1
SS=D: 1
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to review and revise care plans for residents after falls and skin tears to prevent further incidents. | SS=E |
| Failure to ensure appropriate fall interventions by determining causal factors and preventing repeated falls, including a fall resulting in nasal fracture and lacerations. | SS=G |
| Failure to identify, plan, and implement timely interventions to maintain nutritional status for a resident with significant weight loss. | SS=D |
| Failure to ensure sanitary laundering of blood-soiled linen to prevent cross contamination with blood borne pathogens. | SS=F |
Report Facts
Resident census: 74
Residents in sample: 22
Weight loss: 11
Skin tear size: 6
Skin tear size: 4
Sutures: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Stated expectation that nurses immediately initiate fall interventions following falls; involved in fall and skin tear findings. |
| Licensed Nurse G | Licensed Nurse | Stated nurses initiate fall interventions immediately after falls. |
| Certified Nurse Aide Q | Certified Nurse Aide | Provided information about resident transfers and fall risks. |
| Therapy Consultant Staff II | Therapy Consultant | Provided assessment of resident's transfer safety and safety awareness. |
| Administrative Nurse E | Administrative Nurse | Confirmed lack of interventions and investigations for skin tears. |
| Consultant staff GG | Consultant Staff | Provided recommendations for nutritional interventions and weight loss notifications. |
| Certified Medication Aide R | Certified Medication Aide | Assisted resident with meals and provided information on feeding. |
| Dietary staff BB | Dietary Staff | Stated nurses notify her of resident weight loss. |
| Laundry staff U | Laundry Staff | Handled laundry with blood soiling using 'personal' cycle without confirmation of adequate disinfection. |
| Maintenance staff V | Maintenance Staff | Reported washer uses low temperature water and chemicals but no formula chart for cycles. |
| Chemical supplier staff JJ | Chemical Supplier Staff | Recommended 'Heavy Load' cycle for killing blood borne pathogens. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 13, 2021
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. in response to deficiencies cited in a prior survey conducted on 5/13/2021.
Findings
The plan outlines corrective actions taken for multiple residents related to fall interventions, skin interventions, nutrition and weight loss management, and laundry cycle compliance. The facility commits to ongoing monitoring and education to prevent recurrence of deficiencies.
Report Facts
Deficiency completion dates: 5
Resident IDs referenced: 5
Laundry cycle compliance monitoring duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlin Strawderman | Executive Director | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 16, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a COVID-19 survey conducted at the facility.
Findings
The facility was found to be deficiency free in the COVID-19 survey conducted on 09/16/2020.
Deficiencies (1)
| Description |
|---|
| DEFICIENCY FREE COVID 19 SURVEY. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 15, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Kansas Department for Aging and Disability Services on 09/15/2020 and 09/16/2020.
Findings
The facility was found to be in compliance with the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 14, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 7-14-2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 28, 2020
Visit Reason
An offsite revisit was conducted on 04/28/2020 for all previous deficiencies cited on 02/20/2020.
Findings
All deficiencies have been corrected as of the compliance date of 03/06/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 22, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a COVID-19 related survey conducted on 04/22/2020.
Findings
The facility was found to be deficiency free in the COVID-19 survey conducted on 04/22/2020.
Deficiencies (1)
| Description |
|---|
| Deficiency Free Covid survey |
Inspection Report
Routine
Deficiencies: 0
Apr 22, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Kansas Department for Aging and Disability Services.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 20, 2020
Visit Reason
This Plan of Correction is submitted in response to deficiencies cited during a prior inspection related to resident care and transportation safety.
Findings
The facility identified a deficiency involving transportation safety for resident #01, including an initial skin assessment and proper securing during transport. Corrective actions include re-education of drivers, competency evaluations, and ongoing monitoring by the transportation director and QAPI committee.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency related to transportation safety and resident care for resident #01 | D |
Report Facts
Date of initial skin assessment: Feb 4, 2020
Date of resident transport: Feb 20, 2020
Compliance date for corrective actions: Mar 6, 2020
Monitoring period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlin Strawderman | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Feb 20, 2020
Visit Reason
The inspection was conducted as a complaint investigation (#150063) following an incident where a resident's wheelchair became loose during transport in the facility van, causing injury.
Findings
The facility failed to ensure the safety of one resident during transportation when the wheelchair was not properly secured, resulting in the resident's leg hitting the seat in front and causing a large hematoma with an open area and bruising. The investigation found that the van staff did not properly secure the wheelchair straps or seatbelt, and the facility lacked a policy for securing residents in the van.
Complaint Details
The complaint investigation (#150063) substantiated that the resident's wheelchair was not properly secured in the van, leading to the resident's injury. The van driver was suspended and terminated following the incident.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment was free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents during transportation, resulting in injury to a resident. | SS=D |
Report Facts
Resident census: 71
Hematoma size: 10
Hematoma size: 13
Open area size: 2
Open area size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Transportation staff MM | Van driver who failed to properly secure the resident's wheelchair and was suspended and terminated following the incident | |
| Certified Nurse Aid O | CNA | Reported resident's increased assistance needs and knowledge of the fall in the van |
| Certified Medication Aide P | CMA | Observed and reported the resident's swollen leg to the nurse |
| Administrative Nurse D | Administrative Nurse | Reported suspension and termination of Transportation staff MM |
| Transportation staff LL | Observed securing the resident's wheelchair properly during a later transport | |
| Social services staff X | Social services staff | Interviewed the resident about the incident |
| Administrative Nurse E | Administrative Nurse | Evaluated van straps and seatbelt after the incident |
| Maintenance staff U | Maintenance staff | Inspected van straps and seatbelt and reported on their condition |
| Administrative staff A | Administrative staff | Reported the facility lacked a policy for securing residents in the van |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 23, 2019
Visit Reason
A revisit survey was conducted on 09/23/19 to verify correction of all previous deficiencies cited on 08/21/19.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 09/11/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 08/21/19 and corrected by 09/11/19
Inspection Report
Plan of Correction
Deficiencies: 17
Aug 12, 2019
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. in response to deficiencies cited during a survey conducted on 8/12/2019. The purpose is to outline corrective actions to address the cited deficiencies and ensure compliance with state and federal regulations.
Findings
The Plan of Correction details multiple deficiencies related to resident rights, weight loss monitoring, environmental maintenance, care plan updates, medication administration, infection control, and facility cleanliness. The facility outlines corrective actions including staff re-education, environmental repairs, routine monitoring, and reporting to the Quality Assurance/Performance Improvement (QAPI) committee over a three-month period.
Deficiencies (17)
| Description |
|---|
| Resident #20 identified jars of honey were returned to room prior to exit of surveyors on 8/12/2019, indicating potential issues with resident rights to personal property. |
| Resident #2 had significant weight loss; orders received and implemented, with ongoing monitoring and staff re-education planned. |
| Multiple environmental deficiencies including replacement of spa seats, shower chairs with rusty castors, ceiling tiles with brown spots, gouged walls, and maintenance of HVAC ducts. |
| Significant change MDS assessments not completed timely for resident #2 and others; re-education and monitoring planned. |
| Care plans for residents #20, #32, #15, #2, #60, and others were reviewed and updated to reflect current interventions and needs. |
| Discharge summaries for discharged residents not consistently completed; audit and re-education planned. |
| Assistance with facial grooming for resident #15 not consistently provided; re-education and monitoring planned. |
| Activity plans for resident #26 and others not consistently updated; education and routine reviews planned. |
| Wheelchair positioning for resident #60 and others not consistently monitored; education and routine reviews planned. |
| Fall interventions and investigations for residents #32, #2, #15 reviewed and updated; staff re-education and monitoring planned. |
| Infection control related to peri-care and UTI prevention for resident #219; re-education and routine observations planned. |
| Medication administration errors identified for resident #170; re-education and monitoring planned. |
| Pharmacy recommendations not always followed timely; re-education and follow-up procedures implemented. |
| Blood sugar monitoring and physician notification processes for resident #17 improved with re-education and monitoring. |
| Expired and discontinued medications not consistently removed; re-education and routine audits planned. |
| Food debris and grime found in kitchen and kitchenette areas; cleaning and maintenance actions taken with ongoing monitoring. |
| Equipment repairs including oven door spring replacement and faucet repair completed; staff re-education and monitoring planned. |
Report Facts
Deficiencies cited: 17
Monitoring period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Busby | Executive Director | Named as submitter of the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 19
Aug 12, 2019
Visit Reason
The inspection was a health resurvey and complaint investigation triggered by complaints #142344 and #143675.
Findings
The facility was found deficient in multiple areas including respect for resident rights, notification of significant changes, safe and clean environment, comprehensive assessments, care planning, fall prevention, medication administration, infection control, nutrition and hydration, respiratory care, food safety, equipment maintenance, and nurse staffing postings.
Complaint Details
The inspection was triggered by complaints #142344 and #143675.
Severity Breakdown
SS=D: 15
SS=E: 3
SS=C: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to ensure resident's right to retain and use personal possessions, specifically two Mason Jars of honey were removed without proper justification. | SS=D |
| Failed to notify physician of significant weight loss for Resident 2, resulting in lack of timely intervention. | SS=D |
| Failed to provide a safe, clean, comfortable, and homelike environment; multiple maintenance and housekeeping deficiencies noted in Courts A, B, D, F and elevators. | SS=E |
| Failed to complete a significant change Minimum Data Set (MDS) assessment for Resident 2 after significant changes in condition. | SS=D |
| Failed to develop and implement comprehensive care plans for residents, including failure to address CPAP use and cleaning, and failure to implement timely fall prevention interventions. | SS=D |
| Failed to review and revise care plans timely for residents with weight loss, falls, and positioning needs. | SS=D |
| Failed to provide individualized activity programs to meet interests and support physical, mental, and psychosocial well-being for a cognitively impaired resident. | SS=D |
| Failed to provide quality of care related to fall prevention and investigation, including lack of neuro checks and timely interventions. | SS=D |
| Failed to provide appropriate peri-care, use of PPE, and hand hygiene to prevent cross contamination and urinary tract infections for a resident on contact isolation. | SS=D |
| Failed to develop and implement timely nutritional interventions for residents with significant weight loss or gain. | SS=D |
| Failed to administer medications as ordered, specifically delayed administration of Januvia for Resident 170 due to medication unavailability. | SS=D |
| Failed to act timely on consultant pharmacist recommendations to discontinue Esomeprazole and start Pantoprazole for Resident 17. | SS=D |
| Failed to provide necessary respiratory care and services related to cleaning and storage of CPAP machine and distilled water for Resident 20; oxygen tanks stored in soiled laundry area risking contamination. | SS=D |
| Failed to post daily nurse staffing information including actual hours worked for Certified Nurses Aides. | SS=C |
| Failed to ensure staff administered medications as ordered by the physician for Resident 170. | SS=D |
| Failed to act timely upon consultant pharmacist recommendations for Resident 17 to prevent unnecessary drug usage. | SS=D |
| Failed to store medications properly; eight medication cards with expired medications found on Court B medication cart. | SS=D |
| Failed to store, prepare, distribute and serve food under sanitary conditions in multiple kitchenettes and main kitchen; issues included food particles, grime, expired foods, and maintenance concerns. | SS=E |
| Failed to maintain mechanical equipment in safe operating condition; oven door held closed with cardboard in main kitchen. | SS=E |
Report Facts
Residents present: 73
Weight loss: 17
Weight loss: 8
Weight loss: 8
Weight gain: 30
Missed medication doses: 2
Blood glucose elevated doses: 41
Expired medication cards: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Confirmed multiple findings including weight loss notification failure, environmental issues, respiratory care, and fall interventions |
| Administrative Nurse E | Administrative Nurse | Confirmed findings related to weight loss, respiratory care, environmental issues, and fall interventions |
| Licensed Nurse J | Licensed Nurse | Reported on weight loss protocol and fall interventions |
| Certified Dietary Manager CC | Certified Dietary Manager | Confirmed weight loss findings and nutritional interventions |
| Consultant Staff KK | Consultant Staff | Confirmed significant weight loss and lack of physician notification |
| Certified Medication Aide R | Certified Medication Aide | Reported medication administration and blood glucose monitoring practices |
| Licensed Nurse H | Licensed Nurse | Reported on weight loss and fall interventions |
| Certified Nursing Assistant UU | Certified Nursing Assistant | Reported on resident care and weight loss |
| Certified Nursing Assistant SS | Certified Nursing Assistant | Verified respiratory care observations |
| Maintenance Staff V | Maintenance Staff | Verified environmental and equipment maintenance issues |
| Certified Dietary Manager ZZ | Certified Dietary Manager | Verified kitchen sanitation issues |
| Consultant Pharmacist GG | Consultant Pharmacist | Reported on medication administration and follow-up |
| Consultant Pharmacist HH | Consultant Pharmacist | Reported on medication administration and follow-up |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 26, 2019
Visit Reason
An offsite revisit was conducted on 06/26/19 for all previous deficiencies cited on 05/22/19 to verify correction of prior deficiencies.
Findings
All deficiencies cited on 05/22/19 have been corrected as of the compliance date of 06/07/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
May 15, 2019
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a survey conducted on 5/15/2019.
Findings
The plan addresses medication administration deficiencies, including missed medications and order entry errors, with corrective actions such as staff re-education, monitoring of medication orders, and reporting procedures to ensure compliance and prevent recurrence.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #2 received Atropine eye drops as prescribed; medication delivery and monitoring procedures were deficient. | D |
| Resident #01 expired on 3/24/19; deficiencies related to missed medication processes and order entry errors were identified. | D |
Report Facts
Deficiencies cited: 2
Dates referenced: May 12, 2019
Dates referenced: Mar 24, 2019
Dates referenced: May 15, 2019
Dates referenced: May 16, 2019
Dates referenced: May 31, 2019
Duration: 3
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
May 15, 2019
Visit Reason
The inspection was conducted as a result of complaint investigations #139540, #139687, and #141147 focusing on medication administration and pharmacy services.
Findings
The facility failed to administer medications as ordered by the physician for 2 of 3 residents reviewed, including failure to administer Xarelto and Cardizem CD SR for 2 days to resident #01, contributing to the resident's death, and failure to administer Atropine eye drops as ordered to resident #02 following an eye injury.
Complaint Details
The visit was complaint-related involving investigations #139540, #139687, and #141147. The facility failed to administer medications as ordered, resulting in significant medication errors and contributing to a resident's death.
Severity Breakdown
Level D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to administer Xarelto and Cardizem CD SR as ordered for resident #01 for 2 days. | Level D |
| Failure to administer Atropine eye drops as ordered for resident #02 following eye injury. | Level D |
| Failure to ensure residents are free of significant medication errors, specifically for resident #01. | Level D |
Report Facts
Resident census: 68
Residents reviewed for medication: 3
Days medications not administered: 2
Date of resident #01 hip replacement: Mar 13, 2019
Date of resident #01 readmission: Mar 21, 2019
Date resident #01 expired: Mar 24, 2019
Date resident #02 admitted: Feb 15, 2018
Date of resident #02 eye injury: May 8, 2019
Date resident #02 returned from hospital: May 10, 2019
Date Atropine eye drops missed: May 11, 2019
Date Atropine eye drops missed: May 12, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse C | Licensed Nurse | Involved in investigation and interviews regarding medication administration failures |
| Licensed nurse D | Licensed Nurse | Transferred discharge medication orders to pharmacy and involved in investigation |
| Certified medication aide E | Certified Medication Aide | Reported missing medications and involved in medication administration issues |
| Licensed nurse B | Licensed Nurse | Verified failure to notify physician about missing medications |
| Licensed nurse F | Licensed Nurse | Noted resident's condition after eye injury |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 3, 2019
Visit Reason
A revisit survey was conducted on 04/03/19 to verify correction of all previous deficiencies cited on 02/27/19.
Findings
All deficiencies have been corrected as of the compliance date of 03/06/19 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 27, 2019
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. in response to deficiencies cited in a prior survey related to fall prevention interventions.
Findings
The facility acknowledged deficiencies related to fall prevention care plans and interventions for resident #01 and committed to re-educate staff, update care plans, and implement monitoring and review processes to ensure compliance and effectiveness.
Deficiencies (1)
| Description |
|---|
| Resident care plan and care guide were not updated to reflect current fall prevention interventions for resident #01. |
Report Facts
Deficiency completion date: Mar 6, 2019
Plan of Correction submission date: Mar 5, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Busby | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Feb 27, 2019
Visit Reason
The inspection was conducted as a result of complaint investigations #137855, #138300, and #137884.
Findings
The facility failed to ensure that one resident (#01) wore the planned non-slip socks in bed to prevent falls. The resident fell when getting out of bed, sustaining a fractured left elbow and a hematoma to the back of the head.
Complaint Details
The findings represent the results of complaint investigations #137855, #138300, and #137884.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure resident #01 wore planned non-slip socks in bed to prevent falls, resulting in a fall and fractured elbow. | SS=G |
Report Facts
Census: 73
BIMS score: 3
Fall incident date: Jan 30, 2019
Inspection Report
Abbreviated Survey
Deficiencies: 1
Feb 27, 2019
Visit Reason
An abbreviated survey was conducted on February 27, 2019, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the severity, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions effective March 16, 2019.
Severity Breakdown
Level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency at a level of actual harm that is not immediate jeopardy requiring corrections | Level of actual harm |
Report Facts
Denial of Payment Effective Date: Mar 16, 2019
Compliance Deadline: Aug 27, 2019
Civil Money Penalty Amount: 10483
IDR Submission Deadline: 10
Hearing Request Deadline: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to Informal Dispute Resolution process and contact for questions |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 10, 2019
Visit Reason
A desk review was performed for the deficiencies cited on 2018-11-15 to verify compliance.
Findings
The deficiencies cited on 2018-11-15 were found to be corrected and the facility was placed back into compliance as of 2018-12-14.
Report Facts
Deficiency citation date: Nov 15, 2018
Compliance date: Dec 14, 2018
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 4, 2018
Visit Reason
The visit was a resurvey of the assisted living facility conducted on December 3-4, 2018.
Findings
The resurvey resulted in no citations or deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 3
Nov 15, 2018
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. in response to deficiencies cited in a prior survey conducted on 11/15/2018. The plan outlines corrective actions to address identified issues related to resident activity assessments, skin integrity evaluations, and staffing patterns.
Findings
The plan addresses deficiencies involving updating residents' activity assessments and care plans, conducting skin assessments and treatment plan reviews for residents with wounds, and reviewing staffing patterns and ratios to meet resident needs. The facility commits to ongoing monitoring, education, and quality assurance reviews to ensure compliance.
Severity Breakdown
E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident activity assessments and care plans were outdated and required updating by the Activity Director. | E |
| Skin assessments and treatment plans for residents with wounds required evaluation and updates. | E |
| Staffing patterns and ratios needed review to ensure adequacy in meeting resident needs. | E |
Report Facts
Deficiencies cited: 3
Dates for corrective actions: Dec 14, 2018
Resident expiration date: Oct 23, 2018
Skin evaluations date: Nov 29, 2018
Staffing review deadline: Dec 10, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Busby | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Diana Melander | Added Plan of Correction | |
| Caryl Gill | Modified Plan of Correction |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 3
Nov 15, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about activities, pressure ulcer care, and staffing at the facility.
Findings
The facility failed to provide individualized activity programs for residents, failed to ensure proper care and healing of pressure ulcers for multiple residents, and failed to maintain sufficient staffing to meet residents' physical, mental, and psychosocial needs.
Complaint Details
The complaint investigation included allegations related to inadequate activities programming, improper pressure ulcer care, and insufficient staffing levels at the facility.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide an ongoing individualized activity program based on residents' interests and preferences for 4 of 6 residents reviewed. | SS=E |
| Failure to ensure proper treatment and services to prevent and heal pressure ulcers for 4 residents reviewed. | SS=E |
| Failure to provide sufficient nursing staff with appropriate competencies and skills to assure resident safety and well-being. | SS=E |
Report Facts
Residents reviewed for activities: 6
Residents failed to receive individualized activities: 4
Residents reviewed for pressure ulcers: 4
Residents failed to receive proper pressure ulcer care: 4
Facility census: 75
Neighborhoods open: 5
Neighborhoods closed: 1
Direct care staff per shift: 11
Direct care staff per night shift: 6
Licensed nurses per night shift: 2
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 15, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'E' level deficiency that constitutes no actual harm 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 December 14, 2018.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was a 'E' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signer of the report letter. |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 8, 2018
Visit Reason
An offsite revisit survey was conducted on 11/08/2018 for all previous deficiencies cited on 10/09/2018.
Findings
All deficiencies have been corrected as of the compliance date of 11/07/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 18
Oct 9, 2018
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a prior survey conducted on 2018-10-09. The plan outlines corrective actions to address cited deficiencies and ensure compliance with regulations.
Findings
The plan details corrective actions for multiple deficiencies including wheelchair and assistive device safety, grievance follow-up, abuse reporting, care plan updates, medication administration, infection prevention, environmental cleanliness, pest control, and staffing ratios. The facility commits to re-education, monitoring, and routine reviews with reporting to the Quality Assurance/Performance Improvement (QAPI) committee over a period of months.
Severity Breakdown
D: 7
E: 4
F: 5
Deficiencies (18)
| Description | Severity |
|---|---|
| Resident #56 wheelchair and cushion re-evaluated and alternative provided; clinical staff re-education on assistive devices. | D |
| Grievances follow-up process improved with re-education and monitoring. | E |
| Internal investigations on abuse allegations completed; staff re-educated on reporting. | D |
| Resident assessments (CAA) completed and monitored for timeliness. | D |
| Resident #58 under observational period for significant change assessment; staff re-educated on RAI requirements. | D |
| Care plans updated for multiple residents; staff re-educated and monitoring established. | E |
| Wheelchair ordered and placed in service; fall investigations and care plan updates completed. | D |
| Fall event investigation process re-education and monitoring. | F |
| Care plans reviewed and staffing ratios evaluated; resident interviews conducted. | F |
| Medication administration reviewed; missed medications investigated; staff re-educated. | D |
| Medication reviews and pharmacist recommendations followed up; monitoring of compliance. | D |
| Monitoring of blood sugar, weights, behaviors; MAR documentation process re-education. | D |
| Medication reviews for Risperdal and Haldol; drug review process monitored. | D |
| Outdated medications disposed; medication carts and rooms reviewed for labeling compliance. | E |
| Kitchen environment cleaned and maintained; dietary staff re-educated on sanitation and garbage disposal. | F |
| Trash dumpsters area cleaned; grounds reviewed; staff re-educated on garbage disposal process. | F |
| Antibiotic stewardship monitoring updated; infection tracking and trending implemented. | F |
| Pest control measures implemented; pest strips replaced; staff educated on pest reporting. | E |
Report Facts
Deficiencies cited: 16
Plan of Correction completion date: Nov 7, 2018
Survey date: Oct 9, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Busby | Executive Director | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 16
Oct 9, 2018
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation triggered by multiple complaint investigation numbers.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations for resident needs, failure to respond to grievances timely, failure to report alleged violations timely, failure to complete timely comprehensive assessments and care plan revisions, failure to ensure adequate supervision and assistive devices to prevent falls, failure to administer medications as ordered, failure to monitor drug regimens and psychotropic medication use appropriately, failure to label and store medications properly, failure to maintain sanitary food preparation and storage, failure to dispose of garbage properly, failure to maintain an effective infection control program, and failure to maintain an effective pest control program.
Complaint Details
The visit was complaint-related triggered by multiple complaint investigation numbers 131497, 133281, 133349 and 134095. The facility failed to report 4 incidents including 3 allegations of neglect and 1 allegation of staff to resident abuse.
Severity Breakdown
SS=D: 7
SS=E: 4
SS=F: 4
Deficiencies (16)
| Description | Severity |
|---|---|
| Failure to provide reasonable accommodations for resident #56 including appropriate sized wheelchair and cushion, resulting in repeated falls from wheelchair during transport. | SS=D |
| Failure to respond to resident grievances in a timely manner. | SS=E |
| Failure to report alleged violations including neglect and abuse to appropriate authorities timely. | SS=D |
| Failure to complete comprehensive assessments and care area assessments within required time frames for residents #41 and #1. | SS=D |
| Failure to complete significant change MDS assessment for resident #58 after change in condition. | SS=D |
| Failure to review and revise care plans timely and appropriately for residents #58, #56, #65, #1, and #25 to address changing needs and fall interventions. | SS=E |
| Failure to ensure adequate supervision and assistive devices to prevent falls for residents #56 and #58. | SS=D |
| Failure to provide sufficient nursing staff to ensure resident safety and care needs were met. | SS=F |
| Failure to administer scheduled pain and anxiety medications as ordered for resident #59. | SS=D |
| Failure of pharmacist to identify irregularities and act on unnecessary medications for residents #14 and #67 including lack of clinical rationale for antipsychotic use and failure to follow up on gradual dose reduction recommendation. | SS=D |
| Failure to ensure residents remained free from unnecessary psychotropic medications for residents #14 and #67. | SS=D |
| Failure to label and store medications properly including unlabeled multi-dose vials, expired vaccines, and medications of discharged residents found in medication carts. | SS=E |
| Failure to maintain sanitary food preparation and storage areas including rusty racks, dusty shelves, expired and undated beverages, and non-cleanable surfaces. | SS=F |
| Failure to properly dispose of garbage and refuse including uncovered dumpsters and debris around dumpsters. | SS=F |
| Failure to maintain an effective infection prevention and control program including inadequate tracking and trending of infections with missing resolution dates and incomplete documentation. | SS=F |
| Failure to maintain an effective pest control program resulting in insect infestations in resident rooms and lack of follow-up on insect traps. | SS=E |
Report Facts
Resident census: 76
Residents sampled: 21
Severity counts: 7
Severity counts: 4
Severity counts: 4
Fall risk score: 5
Wheelchair cushion thickness: 3
Distance to doctor's appointment: 125
Distance to doctor's appointment: 30
Medication doses missed: 10
Unlabeled hemorrhoidal suppositories: 16
Infections reported: 8
Infections reported: 6
Infections reported: 9
Infections reported: 18
Infections reported: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Transportation Staff | Witnessed resident #56 sliding out of wheelchair during transport and called 911 |
| Staff R | Licensed Therapy Staff | Evaluated resident #56 for appropriate wheelchair after falls |
| Staff K | Direct Care Staff | Described resident #56 wheelchair positioning and transfer needs |
| Staff O | Direct Care Staff | Assisted with resident #56 wheelchair positioning and transport |
| Staff L | Direct Care Staff | Assisted resident #56 with transfers and wheelchair positioning |
| Staff B | Administrative Nursing Staff | Brought gait belt for resident #56 and commented on fall reporting |
| Staff D | Licensed Nursing Staff | Discussed resident #56 wheelchair positioning and fall reporting |
| Staff I | Administrative Staff | Discussed resident #56 fall incident and wheelchair evaluation payment issues |
| Staff W | Direct Care Staff | Discussed care plan and fall interventions for resident #58 |
| Staff E | Licensed Nursing Staff | Described fall protocol and care plan update responsibilities |
| Staff FF | Direct Care Staff | Discussed behavior monitoring responsibilities |
| Staff P | Dietary Staff | Confirmed unsanitary kitchen conditions and garbage disposal issues |
| Staff Q | Maintenance Staff | Discussed pest control practices and insect trap follow-up |
Inspection Report
Re-Inspection
Deficiencies: 1
Oct 9, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-11-07.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a "F" level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure & Certification Enforcement Manager | Named as contact person regarding the survey and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 7, 2018
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. in response to deficiencies cited in a prior complaint-related survey.
Findings
The plan addresses deficiencies related to safe transfer practices for residents, including re-evaluation of transfer status, re-education of staff, and implementation of audits to ensure compliance with transfer policies.
Deficiencies (1)
| Description |
|---|
| Deficiency related to improper transfer assistance and failure to follow safe transfer policies. |
Report Facts
Date of re-evaluation: Sep 4, 2018
Date of care plan update: Sep 4, 2018
Date of staff re-education: Sep 5, 2018
Deadline for re-education and audits: Sep 7, 2018
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Aug 29, 2018
Visit Reason
The inspection was conducted as an investigation of complaint #0132658 regarding the facility's failure to provide a safe transfer for a resident, resulting in injury.
Findings
The facility failed to provide a safe transfer for one paraplegic resident, resulting in the resident's left leg/foot becoming trapped under a wheelchair and causing a fractured hip. Staff did not adequately control the resident's affected leg during transfer, despite the resident's care plan requiring extensive assistance from two staff members.
Complaint Details
Investigation of complaint #0132658 found the facility failed to prevent an accident during transfer of a paraplegic resident, leading to a fractured hip. The complaint was substantiated by observations, interviews, and record review.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a safe transfer for a resident, resulting in a fractured hip. | SS=G |
Report Facts
Census: 72
Residents reviewed for accidents: 3
Date of resident admission: Apr 9, 2016
Dates of MDS assessments: Feb 2, 2018
Dates of MDS assessments: Jul 19, 2018
Date of care plan: Aug 10, 2017
Date of incident: Aug 20, 2018
Date of x-ray: Aug 20, 2018
Date of policy: 201712
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff C | Assessed resident after incident and notified physician | |
| Licensed nursing staff B | Explained notification of physician about hip fracture | |
| Certified nursing staff D | Assisted in transfer and described incident details | |
| Certified staff E | Assisted in transfer and described incident details | |
| Licensed nursing staff G | Provided facility's safe lifting and moving policy | |
| Certified staff F | Provided care to resident post-incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 28, 2018
Visit Reason
A desk review was conducted for the deficiencies cited on June 20, 2018.
Findings
The deficiencies cited on June 20, 2018, were corrected as of the compliance date of August 1, 2018.
Report Facts
Deficiency compliance date: Aug 1, 2018
Inspection Report
Plan of Correction
Deficiencies: 2
Jul 20, 2018
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a complaint investigation survey conducted on 06/20/2018.
Findings
The facility was cited for deficiencies related to individualized care plans and behavior management for resident #1. The plan outlines corrective actions including updating care plans, re-educating staff, and monitoring through Quality Assurance committees to ensure compliance.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Complaint 06202018.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident care plan was updated to include new peri-care plan and behavioral interventions. | D |
| Resident care plan updated to include interventions for uncontrolled behaviors, pain management, and peri-care practices. | D |
Report Facts
Date of care plan update: Jun 22, 2018
Date of re-education deadline: Jul 19, 2018
Date of substantial compliance: Aug 1, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Busby | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Jun 20, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#KS00130178) focusing on care plan timing, revision, and behavioral health services for residents.
Findings
The facility failed to review and revise the care plan for one resident with severe cognitive impairment and behavioral issues, resulting in inconsistent care and lack of individualized interventions. The resident exhibited uncontrolled behaviors, including screaming and physical aggression, which disrupted the living environment and other residents. The facility also failed to provide adequate behavioral health services and psychiatric interventions despite documented needs and ongoing behaviors.
Complaint Details
Complaint investigation #KS00130178 focused on care plan timing, revision, and behavioral health services for one resident with severe cognitive impairment and behavioral issues.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to review and revise the care plan for one resident to ensure individualized care and consistent staff instruction. | SS=D |
| Failure to provide necessary behavioral health care and services to one resident to maintain the highest practicable physical, mental, and psychosocial well-being. | SS=D |
Report Facts
Census: 87
BIMS score: 3
Medication doses: 10
Medication doses: 20
Medication doses: 0.5
Care plan date: 2018
Behavior monitoring order date: 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 20, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective August 1, 2018.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 3
Jun 10, 2018
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. to address deficiencies cited in a prior survey related to resident notification, staffing adequacy, and medication administration.
Findings
The facility identified deficiencies including failure to notify resident representatives timely, inadequate staffing based on resident acuity, and medication administration errors involving Lasix orders. Corrective actions include staff re-education, use of staffing agencies, audits, and ongoing monitoring through Quality Assurance Committee meetings.
Severity Breakdown
D: 1
F: 1
G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify resident representative of incident and changes in resident status in a timely manner. | D |
| Inadequate staffing based on resident acuity requiring use of staffing agency and education on call light response times. | F |
| Medication administration errors related to Lasix orders and medication ordering procedures. | G |
Report Facts
Dates of corrective actions completion: Jun 10, 2018
Date of incident notification: May 24, 2018
Date of staffing agency utilization start: Jun 3, 2018
Date of medication aide re-education: May 30, 2018
Inspection Report
Plan of Correction
Deficiencies: 1
May 30, 2018
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg Inc. to address deficiencies cited in a prior survey related to medication administration for residents with dysphagia.
Findings
The facility identified a deficiency regarding the lack of physician orders to crush medications for residents diagnosed with dysphagia. The plan outlines corrective actions including obtaining physician orders, updating care plans, re-educating staff, and monitoring compliance.
Deficiencies (1)
| Description |
|---|
| Failure to obtain physician orders to crush medications for Resident #4 with dysphagia. |
Report Facts
Date physician orders obtained: May 30, 2018
Plan of correction completion date: Jun 1, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Busby | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 3
May 30, 2018
Visit Reason
The inspection was conducted as a result of complaint investigations #129818, #129831, and #129960.
Findings
The facility failed to notify the responsible party timely after a resident's fall requiring emergency treatment, failed to provide sufficient nursing staff to meet resident needs, and failed to administer prescribed medication (Lasix) to a resident for three consecutive days, resulting in exacerbation of congestive heart failure and emergency room treatment.
Complaint Details
The inspection findings represent the results of complaint investigations #129818, #129831, and #129960. The facility failed to notify the family of a resident's fall and emergency room transport in a timely manner, causing distress to the family.
Severity Breakdown
SS=D: 1
SS=F: 1
SS=G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify the resident's family/responsible party in a timely manner following a fall that required emergency room treatment. | SS=D |
| Failure to ensure adequate nursing staff to provide care as needed for the residents of the facility. | SS=F |
| Failure to administer Lasix 40 mg daily as ordered for 3 consecutive days, resulting in exacerbation of congestive heart failure and emergency room treatment. | SS=G |
Report Facts
Census: 81
Missed medication doses: 3
Residents sampled: 3
Staffing counts: 3
Staffing counts: 4
Staffing counts: 8
Staffing counts: 2
Staffing counts: 8
Staffing counts: 2
Staffing counts: 6
Resident weight: 134.4
Resident weight: 135
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
May 23, 2018
Visit Reason
The inspection was conducted as a result of complaint investigations #121567, #124285, and #122367.
Findings
The facility failed to administer medications to one resident as ordered by the physician, specifically crushing medications without a physician's order, contrary to facility policy and regulatory requirements.
Complaint Details
The findings represent the results of complaint investigations #121567, #124285, and #122367. The facility failed to follow physician orders regarding medication administration for resident #4.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to administer medications per physician's orders by crushing medications without a physician's order for resident #4. | SS=D |
Report Facts
Census: 79
Residents reviewed for medications: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Direct Care Staff | Prepared and administered crushed medications without physician order. |
| Staff B | Licensed Staff | Stated physician would send an order if medications needed to be crushed. |
| Staff A | Administrative Staff | Stated facility lacked orders to crush medications and staff should not crush medications without an order. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 28, 2018
Visit Reason
A complaint survey was conducted on 3/28/18 for complaint # KS00126487.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Complaint Details
Complaint # KS00126487 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 28, 2018
Visit Reason
A complaint survey was conducted on 3/28/18 for complaint # KS00126487.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint # KS00126487 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 28, 2018
Visit Reason
A complaint survey was conducted on 3/28/18 for complaint # KS 00126487.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint # KS 00126487 was investigated and found unsubstantiated with no noncompliance identified.
Inspection Report
Plan of Correction
Deficiencies: 3
Oct 12, 2017
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a revised complaint inspection conducted on 10/12/2017.
Findings
The plan addresses deficiencies related to resident code status documentation and identification, notification of reportable events including CPR provision, and bathing and oral care practices. The facility outlines corrective actions including staff education, audits, and ongoing quality assurance monitoring.
Deficiencies (3)
| Description |
|---|
| Failure to document and identify residents' desired code status and honor advance directives. |
| Failure to notify KDADS timely regarding CPR not provided to a resident who desired full code and failure to report abuse, neglect, or exploitation. |
| Inadequate bathing and oral care practices, including failure to document refusals and resident preferences. |
Report Facts
Audit dates: Audits completed on 09-30-17 and 10-02-17 for code status and notification processes.
Education completion date: Nursing staff education completed by 10-03-17.
Observation frequency: 4
Review period: 3
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 4
Oct 12, 2017
Visit Reason
The inspection was conducted as an investigation of complaints #121105 and #121768 regarding failure to initiate CPR and issues with advance directives documentation.
Findings
The facility failed to initiate CPR on a resident without a DNR order when the resident's heart stopped, failed to document advance directives upon admission/readmission, and failed to report the incident to the state agency in a timely manner. Additionally, the facility failed to provide adequate oral care and bathing to dependent residents, placing residents at risk.
Complaint Details
The investigation was triggered by complaints #121105 and #121768 concerning failure to initiate CPR on a resident without a DNR order and failure to report the incident timely to the state agency.
Severity Breakdown
E: 1
D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to initiate CPR on a resident without a DNR order when heart stopped and failure to document advance directives. | Immediate Jeopardy (E) |
| Failure to report incidents of neglect immediately to the state agency as required. | Severity D |
| Failure to provide adequate oral care for a resident with dementia and end stage Parkinson's. | Severity D |
| Failure to provide adequate bathing for two dependent residents. | Severity D |
Report Facts
Census: 75
Residents identified as full codes: 23
Days between incident and reporting: 11
Baths provided: 2
Days resident #03 stayed: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Licensed Nurse | Named in failure to initiate CPR and lack of knowledge of resident's advance directives |
| Administrative staff A | Administrator | Acknowledged delayed knowledge and reporting of CPR incident |
| Social service staff E | Explained intake person should have documented advance directives | |
| Administrative nurse B | Administrative Nurse | Provided notarized statement regarding CPR incident and reporting |
| Nurse F | Outside Agency Nurse | Performed oral care on resident #02 and reported lack of prior oral care |
| Direct care staff G | Reported inadequate oral care for resident #02 | |
| Direct care staff H | Reported inadequate bathing and oral care for residents #02 and #03 |
Inspection Report
Plan of Correction
Deficiencies: 5
Jul 14, 2017
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a complaint survey conducted on 06/30/2017.
Findings
The facility identified multiple deficiencies related to MDS quarterly assessments, inaccurate MDS documentation, care plan reviews and revisions, urinary incontinence management, and accident/fall reviews. The Plan of Correction outlines corrective actions including audits, staff education, interdisciplinary team reviews, and monitoring to achieve substantial compliance by mid to late July 2017.
Complaint Details
This Plan of Correction is in response to a complaint survey conducted on 06/30/2017 at Via Christi Pittsburg.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| MDS quarterly assessment was incomplete or late for Resident #2. | D |
| Inaccurate MDS documentation and incomplete toileting plans for Resident #3. | D |
| Care plans for Residents #2 and #4 required review and revision including bowel and bladder assessments and fall risk assessments. | D |
| Urinary incontinence care plans for Residents #2, #3, and #4 required review, revision, and staff re-education. | D |
| Falls and accident care plans for Residents #2, #3, and #4 required review and revision with root cause analysis and long term interventions. | D |
Report Facts
Dates for substantial compliance: Jul 14, 2017
Dates for substantial compliance: Jul 24, 2017
Audit frequency: 4
Care plan audits: 3
Audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armand | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Caryl Gill | Modified the Plan of Correction document |
Inspection Report
Follow-Up
Deficiencies: 5
Jul 14, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with completion dates documented for each regulation cited.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.20(c) |
| Deficiency related to regulation 483.20(g)-(j) |
| Deficiency related to regulations 483.10(c)(2)(i-ii,iv,v) and 483.21(b)(2) |
| Deficiency related to regulation 483.25(e)(1)-(3) |
| Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3) |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 5
Jun 30, 2017
Visit Reason
The inspection was conducted as a complaint investigation involving allegations related to quarterly assessments, care planning, urinary continence, fall prevention, and catheter use at the facility.
Findings
The facility failed to complete timely and accurate quarterly assessments, did not develop individualized toileting programs for incontinent residents, failed to ensure valid medical justification for urinary catheter use, and did not implement effective fall prevention interventions for residents with a history of falls. Documentation and follow-up on falls and care plans were inadequate.
Complaint Details
The report represents findings from complaint investigations #116151, #116996, and #116443.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to complete timely quarterly review assessments for residents. | SS=D |
| Failure to complete accurate quarterly Minimum Data Set (MDS) assessments related to individualized toileting programs. | SS=D |
| Failure to review and revise care plans including individualized toileting plans and fall prevention interventions. | SS=D |
| Failure to provide appropriate treatment and services to promote urinary continence and ensure valid medical justification for urinary catheter use. | SS=D |
| Failure to ensure resident environment free from accident hazards and to provide adequate supervision and interventions to prevent repeated falls. | SS=D |
Report Facts
Residents sampled: 4
Residents census: 82
Fall risk assessment score: 22
Fall risk assessment score: 13
BIMS score: 3
BIMS score: 8
Fall dates: 3
Fall dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff F | Administrative Licensed Nurse | Confirmed incomplete quarterly assessments and lack of individualized toileting program for resident #3. |
| Direct Care Staff U | Provided care to resident #4 and described toileting assistance and gait issues. | |
| Licensed Nursing Staff J | Described fall interventions and pain management for resident #4. | |
| Licensed Nursing Staff K | Discussed fall risk assessments and care plan interventions. | |
| Administrative Nursing Staff C | Reviewed care plans and fall investigations, noted failures in interventions and documentation. | |
| Social Service Staff T | Described therapy order process and delays for resident #2. | |
| Direct Care Staff R | Reported on toileting practices and resident care. | |
| Direct Care Staff V | Described resident transfers and toileting assistance. | |
| Direct Care Staff N | Unaware of bed unplugging intervention for resident #2. | |
| Licensed Nursing Staff H | Unaware of bed unplugging intervention and catheter orders. | |
| Administrative Nurse E | Verified fall log deficiencies and lack of root cause analysis. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 30, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies, indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction effective July 14, 2017.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'D' level indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person and complaint coordinator related to the survey findings. |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 22, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.25(g)(1)(3), 483.45(d)(e)(1)-(2), 483.45(c)(1)(3)-(5), and 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 4
Inspection Report
Re-Inspection
Census: 79
Deficiencies: 4
May 23, 2017
Visit Reason
The inspection was a noncompliant revisit from a prior health resurvey focusing on nutritional status, medication regimen, and quality assurance concerns.
Findings
The facility failed to ensure residents received fortified foods as ordered and follow-up on dietician recommendations for wound healing. Additionally, necessary medications were not adequately monitored, including inappropriate diagnoses for some medications and lack of blood glucose monitoring for a resident on insulin. The facility's quality assurance committee was ineffective in addressing these deficiencies.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure resident #136 received fortified foods as ordered and follow-up on dietician recommendations for residents #50 and #132 to receive additional calories and protein. | SS=D |
| Failed to ensure necessary medications with adequate monitoring for residents #136 and #161, including inappropriate diagnoses and lack of blood glucose monitoring. | SS=D |
| Consulting pharmacist failed to identify unnecessary medications and lack of monitoring for residents #136 and #161. | SS=D |
| Failed to maintain an effective quality assurance committee that develops and implements plans of action to correct quality deficiencies. | SS=F |
Report Facts
Census: 79
Units of insulin: 28
Number of residents sampled for nutritional status: 4
Number of residents sampled for medication review: 3
Number of quality assurance committee meetings: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Administrative Nursing Staff | Verified issues with fortified foods implementation and medication monitoring |
| Licensed nursing staff C | Licensed Nursing Staff | Reported resident meal assistance and dietary intake |
| Dietary aide staff H | Dietary Aide | Reported on provision of fortified foods and dietary practices |
| Direct care staff F | Direct Care Staff | Provided resident feeding assistance and reported on supplement administration |
| Consultant staff N | Consultant Pharmacist | Verified lack of appropriate diagnoses and monitoring for medications |
Inspection Report
Plan of Correction
Deficiencies: 4
May 23, 2017
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited during a revisit complaint inspection conducted on May 23, 2017.
Findings
The plan addresses deficiencies related to diet supplement orders and monitoring (F325-D), medication orders lacking adequate indications and monitoring (F329-D, F428-D), and includes systemic changes such as staff re-education, audits, and ongoing monitoring through the Quality Assurance Committee.
Complaint Details
This plan of correction is related to a revisit complaint inspection conducted on May 23, 2017, addressing deficiencies found during that complaint investigation.
Severity Breakdown
D: 3
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Orders for diet supplements and the yellow flag program were reviewed and updated; dietary staff re-educated on related policies. | D |
| Medications prescribed without adequate indications and monitoring; new systemic changes include daily review of orders and nurse re-education. | D |
| Pharmacy consultant and Director of Nurses to review medications for diagnosis and lab testing; re-education planned; second pharmacy review implemented. | D |
| Monthly QAPI meetings to be held for the next three months to monitor compliance. | F |
Report Facts
Date: May 23, 2017
Date: Jun 19, 2017
Percentage: 10
Timeframe: 3
Timeframe: 6
Timeframe: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Re-Inspection
Deficiencies: 1
May 23, 2017
Visit Reason
This document reports on a first revisit inspection conducted on May 23, 2017, following a March 17, 2017 health survey to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The revisit found the most serious deficiency to be an 'F' level deficiency, resulting in a denial of payment for new Medicare and Medicaid admissions effective April 9, 2017. The facility was advised that this denial will remain until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency | F |
Report Facts
Denial of payment effective date: Apr 9, 2017
Provider agreement termination recommendation date: Sep 17, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed letter and contact for questions concerning the instructions contained in the letter |
Inspection Report
Follow-Up
Deficiencies: 16
May 23, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from an earlier survey had been corrected and to confirm the date such corrective actions were accomplished.
Findings
All previously reported deficiencies were corrected as of the revisit date, with each deficiency fully identified by regulation or LSC provision number and marked as completed.
Deficiencies (16)
| Description |
|---|
| Deficiency identified by regulation 483.10(d)(3)(g)(1)(4)(5)(13)(16)(18) |
| Deficiency identified by regulation 483.10(g)(14) |
| Deficiency identified by regulation 483.12(a)(3)(4)(c)(1)-(4) |
| Deficiency identified by regulation 483.10(c)(2)(F)(ii,iv,v)(3),483.21(b)(2) |
| Deficiency identified by regulation 483.24, 483.25(k)(l) |
| Deficiency identified by regulation 483.25(b)(1) |
| Deficiency identified by regulation 483.25(d)(1)(2)(n)(1)-(3) |
| Deficiency identified by regulation 483.25(g)(2) |
| Deficiency identified by regulation 483.45(f)(2) |
| Deficiency identified by regulation 483.35(a)(1)-(4) |
| Deficiency identified by regulation 483.35(g)(1)-(4) |
| Deficiency identified by regulation 483.60(i)(1)-(3) |
| Deficiency identified by regulation 483.45(a)(b)(1) |
| Deficiency identified by regulation 483.80(a)(1)(2)(4)(e)(f) |
| Deficiency identified by regulation 483.90(i)(5) |
| Deficiency identified by regulation 483.70(i)(1)(5) |
Inspection Report
Re-Inspection
Deficiencies: 1
Apr 8, 2017
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.
Findings
The report confirms that the previously identified deficiency related to regulation 26-41-206 (e)(1) has been corrected as of 04/08/2017. No other deficiencies are listed.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-41-206 (e)(1) |
Inspection Report
Plan of Correction
Deficiencies: 19
Mar 17, 2017
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a prior survey conducted on March 17, 2017. The plan outlines corrective actions to address various regulatory compliance issues identified during the inspection.
Findings
The plan addresses multiple areas including timely Notices of Medicare Non-coverage, weight monitoring and reporting, medication administration and error prevention, care plan participation, pain management, skin integrity, fall risk assessments, hydration, medication review, infection control, maintenance, staffing, food sanitation, and quality assurance processes. Several residents mentioned had expired or been discharged, and no further interventions were indicated for them.
Severity Breakdown
C: 1
D: 7
E: 3
F: 5
G: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failure to provide timely and accurate Notices of Medicare Non-coverage to residents prior to discharge from Medicare Part A services. | D |
| Failure to notify primary care physician of significant weight loss or gain for residents. | D |
| Medication errors and failure to ensure medication administration as ordered. | D |
| Failure to ensure resident and family participation in care plans and timely implementation. | E |
| Failure to adequately assess and manage pain for residents with cognitive impairment. | D |
| Failure to complete reassessment and care planning for residents with wounds or skin integrity issues. | G |
| Failure to review and revise care plans for residents with fall risk or recent falls. | D |
| Failure to provide adequate hydration and assistance with fluids to residents. | D |
| Failure to ensure prescribed medications have diagnoses and follow-up on PRN medication effectiveness. | E |
| Failure to prevent significant medication errors and properly notify involved parties. | D |
| Failure to provide adequate nursing staff to meet resident needs. | F |
| Failure to maintain and post daily clinical staffing data sheet as required. | C |
| Failure to maintain sanitary food preparation and storage conditions. | F |
| Failure to ensure medications are administered per physician orders and document reasons for omissions. | D |
| Failure to ensure complete medication review by consulting pharmacist and medical director. | E |
| Failure to maintain an infection control program to prevent and control infections. | F |
| Failure to maintain a maintenance department ensuring a safe and sanitary environment. | F |
| Failure to maintain accurate and complete medical records and filing system. | F |
| Failure to maintain a Quality Assurance Process Improvement committee to identify and address resident needs and facility issues. | F |
Report Facts
Date: Mar 17, 2017
Date: Apr 8, 2017
Audit sample size: 3
Weight variance thresholds: 5
Weight variance percentages: 5
Fall risk score: 14
Staffing data retention: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Terri Baker | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 13
Mar 17, 2017
Visit Reason
The inspection was a health resurvey and complaint investigation triggered by complaint investigation numbers 108185 and 110846.
Findings
The facility was cited for multiple deficiencies including failure to timely notify residents of Medicare non-coverage, failure to notify physicians of significant weight loss, failure to report a medication error involving insulin administration to the wrong resident, failure to develop and revise care plans appropriately, failure to provide adequate pain management, failure to monitor unnecessary medication use, failure to maintain infection control surveillance logs, failure to maintain sanitary laundry rooms, failure to post accurate nurse staffing data, and failure to maintain accurate and accessible medical records.
Complaint Details
The inspection was triggered by complaint investigation numbers 108185 and 110846.
Severity Breakdown
SS=D: 7
SS=E: 4
SS=C: 1
SS=F: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to timely notify resident or responsible party of Medicare non-coverage and right to appeal. | SS=D |
| Failure to notify physician of significant weight loss for residents #127 and #50 in a timely manner. | SS=D |
| Failure to report to the state agency a significant medication error related to insulin administration to the wrong resident (#27). | SS=D |
| Failure to inform physician of resident's significant weight loss and failure to revise care plan accordingly. | SS=E |
| Failure to review and revise care plan for resident #27 after multiple falls, resulting in extensive facial ecchymosis and injury. | SS=E |
| Failure to provide adequate pain management for resident #27, including failure to administer pain medication prior to painful procedures. | SS=E |
| Failure to maintain adequate hydration for resident #27, including failure to offer fluids between meals and signs of dehydration. | SS=D |
| Failure to ensure medication orders have diagnoses, monitor effectiveness of PRN medications, monitor blood sugar and blood pressure as ordered, and include black box warnings for medications. | SS=D |
| Medication administration errors including failure to administer medications as ordered and failure to document reasons for omitted medications. | SS=D |
| Failure to post accurate daily nurse staffing schedule reflecting actual staff present. | SS=C |
| Failure to store, prepare and serve food under sanitary conditions including expired food items and unclean kitchenettes. | SS=E |
| Failure to maintain an infection control program with consistent tracking and trending of infections and antibiotic use. | SS=D |
| Failure to maintain a quality assurance committee that develops and implements appropriate plans of action to correct identified deficiencies. | SS=F |
Report Facts
Resident census: 84
Weight loss: 21
Weight loss: 20
Weight loss: 12
Fall risk score: 36
Number of infections: 20
Number of infections: 22
Number of infections: 12
Number of infections: 22
Number of infections: 10
Number of infections: 22
Number of infections: 21
Staffing: 7
Staffing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Named in medication error insulin administration to wrong resident and fall investigation |
| Staff C | Administrative Nursing Staff | Named in infection control surveillance and medication black box warning follow-up |
| Staff D | Administrative Nursing Staff | Named in weight loss monitoring and care plan review |
| Staff Q | Dietary Staff | Named in weight monitoring and nutrition care plan |
| Staff P | Physician Assistant | Named in weight loss and pain management discussion |
| Staff N | Licensed Nursing Staff | Named in wound care and medication monitoring |
| Staff E | Licensed Nursing Staff | Named in wound care and pain management |
| Staff MM | Licensed Nursing Staff | Named in staffing and fall response |
| Staff Y | Licensed Nursing Staff | Named in fall investigation and medication administration |
| Staff WW | Pharmacy Consultant | Named in medication regimen review |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 6
Mar 17, 2017
Visit Reason
The licensure survey was conducted to assess compliance with food storage and sanitary conditions at the assisted living facility.
Findings
The facility failed to store, prepare, and serve food under sanitary conditions, including multiple food items without expiration dates, dirty kitchen areas, and unlabeled frozen food items. Staff did not properly determine expiration dates from manufacturer codes, and cleaning schedules were inadequate.
Severity Breakdown
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Food items without expiration dates in main kitchen dry storage. | SS=F |
| Ice machine drainage tube positioned directly on floor drain with debris buildup. | — |
| Build-up of dirt on kitchenette floor perimeter and covebase. | — |
| Trash can contained dried food/liquid on the outside. | — |
| Frozen waffles, ice cream treats, and water bottle in kitchenette freezer undated and unlabeled. | — |
| Vent hood interior surface above stove contained dust. | — |
Report Facts
Census: 27
Frozen waffles: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Certified dietary staff | Interviewed regarding food expiration date coding and cleaning schedules |
| Staff WW | Dietary staff | Confirmed all food should be dated and labeled |
Inspection Report
Enforcement
Deficiencies: 1
Mar 17, 2017
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. The visit was triggered by deficiencies found in the current survey and a prior complaint survey.
Findings
The survey found serious deficiencies at a level of actual harm that is not immediate jeopardy. Due to the facility's history of noncompliance, no opportunity to correct deficiencies was given before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions effective April 9, 2017.
Complaint Details
The enforcement action was based on deficiencies found in the current survey and a complaint survey conducted on February 1, 2016.
Severity Breakdown
Level of actual harm (not immediate jeopardy): 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies related to pressure ulcers (F314) indicating noncompliance with prevention and care requirements | Level of actual harm (not immediate jeopardy) |
Report Facts
Denial of payment effective date: Apr 9, 2017
Noncompliance correction deadline: Sep 17, 2017
Civil Money Penalty minimum amount: 5000
Days to request hearing: 60
Days to submit IDR request: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the enforcement action |
Inspection Report
Follow-Up
Deficiencies: 4
Dec 15, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.20(g)-(j), 483.20(d), 483.20(k)(1), 483.25(h), and 483.30(a) were corrected as of the revisit date.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.20(g)-(j) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.30(a) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 4
Nov 15, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#107534) focusing on the facility's assessment accuracy, care planning, supervision, and staffing adequacy related to resident safety and elopement risks.
Findings
The facility failed to accurately assess and develop care plans for residents at risk of elopement, failed to provide adequate supervision and assistive devices to prevent elopement, and lacked sufficient nursing staff to ensure resident safety and care needs were met.
Complaint Details
The inspection was triggered by complaint investigation #107534 regarding concerns about resident assessments, care planning, supervision, and staffing adequacy related to elopement risks.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to accurately assess residents' wandering behaviors and develop appropriate plans of care to prevent elopement. | SS=D |
| Failed to develop comprehensive care plans for residents at high risk for elopement. | SS=D |
| Failed to ensure resident environment was free of accident hazards and provide adequate supervision to prevent elopement. | SS=D |
| Failed to maintain sufficient 24-hour nursing staff to provide necessary care and supervision to residents. | SS=F |
Report Facts
Census: 94
Deficiencies cited: 4
Elopement risk score: 7
Elopement risk score: 8
Elopement risk score: 4
Staffing: 1
Staffing: 2
Inspection Report
Plan of Correction
Deficiencies: 4
Nov 15, 2016
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a complaint investigation survey conducted on 2016-11-15.
Findings
The plan addresses deficiencies related to assessment accuracy, comprehensive care plans, accident hazards/supervision/devices, and nursing services staffing. It outlines corrective actions including retraining staff, auditing assessments and care plans, updating risk assessments, conducting elopement drills, and improving staffing practices.
Complaint Details
This Plan of Correction is in response to a complaint investigation survey conducted at Via Christi Pittsburg on 2016-11-15.
Severity Breakdown
D: 3
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Assessment Accuracy issues related to Section E / Behaviors and Wandering of the MDS for residents #1 and #2 | D |
| Failure to develop comprehensive and individualized care plans including wandering and elopement prevention for residents #1 and #2 | D |
| Failure to ensure residents are free of accident hazards and adequate supervision/devices to prevent elopement | D |
| Insufficient nursing services staffing to address elopement risk and resident care needs | F |
Report Facts
Audit frequency: 10
Audit duration: 3
Elopement drill frequency: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 15, 2016
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 deficiency to be 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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and coordinator related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 5
Oct 20, 2016
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a complaint survey conducted on October 10, 2016.
Findings
The facility identified deficiencies related to assessment accuracy, development of comprehensive care plans, maintenance and improvement of residents' range of motion, and ensuring residents are free from accident hazards related to supervision and use of assistive devices. The plan outlines corrective actions including audits, staff education, care plan revisions, and ongoing monitoring by the Quality Assurance Performance Improvement (QAPI) team.
Complaint Details
This Plan of Correction is in response to a complaint survey conducted on October 10, 2016, related to Via Christi Village Pittsburg.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Assessment accuracy related to functional limitation in range of motion coding (G0400). | D |
| Failure to develop individualized comprehensive care plans including instructions for resident care. | D |
| Failure to prevent reduction in range of motion unless unavoidable. | D |
| Failure to increase or prevent decrease in range of motion. | D |
| Failure to ensure residents are free of accident hazards related to supervision and use of assistive devices. | D |
Report Facts
Audit frequency: 10
Audit frequency: 3
Audit frequency: 3
Plan of Correction completion date: Most corrective actions to be completed by October 29, 2016.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Terri Baker | Executive Director | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Diana Melander | Modified the Plan of Correction on 02/21/2020. |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 5
Oct 10, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint citations (#105195, #96723, #103569, #103608, #103558, #103628, #103971, and #97965).
Findings
The facility failed to complete accurate comprehensive assessments, develop individualized comprehensive care plans, provide necessary restorative services to maintain or improve residents' range of motion, and ensure safe transfers using mechanical lifts. Specific failures were noted for residents #1, #2, #3, and #4 regarding assessment accuracy, care planning, restorative services, and safe transfer procedures.
Complaint Details
The inspection was triggered by multiple complaint investigations identified by citation numbers #105195, #96723, #103569, #103608, #103558, #103628, #103971, and #97965.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to complete an accurate comprehensive assessment for resident #4 related to functional limitations in range of motion. | SS=D |
| Failed to develop individualized comprehensive care plans for residents #1 and #2 regarding assistance needed for activities of daily living. | SS=D |
| Failed to provide necessary assistance to maintain restorative services for resident #3. | SS=D |
| Failed to provide restorative services to prevent further decline in range of motion for resident #4. | SS=D |
| Failed to provide safe transfers with a mechanical lift for resident #2, using only one staff member despite facility policy requiring two. | SS=D |
Report Facts
Residents sampled: 10
Census: 89
Restorative services frequency: 3
BIMS score: 15
BIMS score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing staff K | Interviewed regarding resident #4's functional ROM limitations and care plan completeness. | |
| Administrative nursing staff A | Interviewed regarding expectations for MDS coding, care plan completeness, restorative services, and restorative aide staffing. | |
| Direct care staff E | Observed transferring resident #2 using sit to stand lift and described transfer procedures. | |
| Direct care staff C | Reported restorative care practices and resident refusals. | |
| Direct care staff D | Described restorative plans and staff roles. | |
| Skilled therapy staff I | Discussed expectations for restorative aide adherence to plans. | |
| Nursing staff J | Responsible for entering restorative plans into electronic records and acknowledged documentation issues. | |
| Direct care staff F | Described use of sit to stand lift with resident #2. | |
| Nursing staff G | Confirmed use of one staff member for transfers with sit to stand lift and resident waiver. | |
| Administrative nursing staff B | Acknowledged existence of resident waiver for one staff transfer but unable to locate it. |
Inspection Report
Life Safety
Deficiencies: 1
Sep 20, 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 to be at '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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level with no harm but potential for more than minimal harm. | F |
Report Facts
Effective date for denial of payments: Dec 20, 2016
Provider agreement termination date: Mar 20, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and is responsible for licensure certification and enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for informal dispute resolution process. |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 12, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation at Via Christi Village Pittsburg.
Findings
The Plan of Correction addresses deficiencies related to free of accident hazards, supervision, and devices, specifically updating care plans and summaries for residents, conducting mandatory in-service training for clinical associates, and auditing processes to ensure compliance.
Complaint Details
This Plan of Correction is related to a complaint investigation at Via Christi Village Pittsburg dated 02/01/2016.
Deficiencies (1)
| Description |
|---|
| F 323 Free of Accident Hazards/Supervision/Devices |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christine Kuhn | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Feb 1, 2016
Visit Reason
The inspection was conducted as a result of complaint investigations #95513 and #96186 regarding the facility's failure to ensure safe transfer and ambulation of a resident with physician-ordered weight bearing restrictions.
Findings
The facility failed to follow physician's orders for toe touch weight bearing restrictions for one resident, resulting in the resident being ambulated improperly, which caused displacement of a femur fracture requiring surgical repair. The resident care summary assessment did not accurately reflect the weight bearing restrictions, leading to staff ambulating the resident unsafely.
Complaint Details
The citations represent findings from complaint investigations #95513 and #96186. The complaint was substantiated as the facility failed to follow physician orders and ensure safe ambulation of the resident.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to transfer and ambulate a resident with physician ordered toe touch weight bearing restrictions safely, resulting in fracture displacement and surgical repair. | SS=G |
Report Facts
Census: 92
Residents sampled: 5
Residents with weight bearing restrictions: 3
Residents with deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Direct Care Staff | Reported knowledge of resident care summary and ambulation practices |
| Staff D | Direct Care Staff | Ambulated resident against weight bearing restrictions |
| Staff E | Licensed Nursing Staff | Reported resident was TTWB on admission and explained care summary responsibilities |
| Staff B | Administrative Nursing Staff | Acknowledged inaccurate care summary assessment and responsibility issues |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Feb 1, 2016
Visit Reason
An abbreviated survey was conducted on February 1, 2016, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be at a "G" level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective May 1, 2016, until the facility achieves substantial compliance or the provider agreement is terminated.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found in the facility | G |
Report Facts
Denial of Payment effective date: May 1, 2016
Compliance deadline: Aug 1, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Follow-Up
Deficiencies: 12
Oct 13, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, indicating compliance with the required standards.
Deficiencies (12)
| Description |
|---|
| Deficiency related to regulation 483.15(c)(6) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(d)(3) and 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.30(a) |
| Deficiency related to regulation 483.30(e) |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(c)(2) |
| Deficiency related to regulation 483.75(l)(1) |
Report Facts
Deficiencies corrected: 12
Inspection Report
Plan of Correction
Deficiencies: 12
Sep 24, 2015
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a prior survey to comply with state and federal regulations.
Findings
The plan addresses multiple deficiencies including response to Resident Council concerns, housekeeping and maintenance issues, care plan revisions related to urinary incontinence, skin and wound care, nursing staff adequacy, medication storage, infection control, mechanical equipment maintenance, nurse staffing data, and clinical record documentation.
Severity Breakdown
E: 3
D: 4
F: 3
C: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to respond timely to Resident Council concerns | E |
| Housekeeping and maintenance deficiencies affecting sanitary environment | E |
| Inadequate review and revision of care plans related to urinary incontinence | D |
| Failure to provide necessary care and services including neuro checks, skin assessment, wound tracking, and hospice services | E |
| Inadequate treatment and services for monitoring pressure ulcers | D |
| Failure to provide individual toileting plans related to urinary incontinence | D |
| Inadequate nursing staff to meet resident needs | F |
| Failure to maintain and complete posted daily nurse staffing data | C |
| Failure to ensure secure storage of narcotic medication and proper dating of insulin | F |
| Failure to maintain an infection control program by not tracking and trending infection and antibiotic use | F |
| Failure to maintain essential mechanical, electrical, and patient care equipment in safe operating condition | C |
| Failure to maintain complete, accurate, and accessible clinical records | D |
Report Facts
Date of Resident Council meeting: Sep 24, 2015
Date of Activity Director in-service: Sep 15, 2015
Date of ice removal from freezer: Sep 14, 2015
Date of care plan revision for resident #124: Sep 22, 2015
Date of hospice care plan update for resident #60: Sep 30, 2015
Date of three day voiding assessment for resident #7: Sep 12, 2015
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 12
Sep 14, 2015
Visit Reason
The inspection was a Health Resurvey and complaint investigation triggered by complaints #90657 and 89127.
Findings
The facility failed to act on resident grievances, maintain housekeeping and maintenance, revise care plans for urinary incontinence and skin conditions, provide neurological checks after a fall, coordinate hospice care, maintain infection control, secure narcotics, maintain equipment, and keep complete clinical records.
Complaint Details
The visit was complaint-related as indicated by the Health Resurvey and complaint investigation #90657 and 89127.
Severity Breakdown
SS=E: 3
SS=D: 3
SS=F: 2
SS=C: 1
: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to act on grievances/recommendations of residents during resident council meetings. | SS=E |
| Failed to provide housekeeping and maintenance services in 9 resident rooms. | SS=E |
| Failed to review and revise plan of care for urinary incontinence for resident #124. | SS=D |
| Failed to provide necessary care and services to 5 residents including neurological checks after a fall, skin condition management, and hospice care coordination. | SS=E |
| Failed to provide individualized toileting plans for 2 residents with urinary incontinence. | — |
| Failed to provide necessary treatment and services for monitoring pressure ulcers for 2 residents. | SS=D |
| Failed to provide sufficient nursing staff to meet resident needs, as evidenced by resident council complaints and staff interviews. | SS=F |
| Failed to maintain posted daily nurse staffing data as required. | SS=C |
| Failed to ensure narcotic medications were secured and insulin vials were properly labeled and dated. | — |
| Failed to maintain an infection control program including tracking infections and sanitizing glucometer per manufacturer instructions. | SS=F |
| Failed to maintain dietary walk-in freezer in safe operating condition due to ice build-up. | — |
| Failed to maintain complete clinical records for 2 residents including missing blood sugar and blood pressure documentation. | SS=D |
Report Facts
Resident census: 83
Narcotic quantities: 27
Narcotic quantities: 21
Narcotic quantities: 18.5
Ice build-up: 5
Blood sugar omissions: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff W | Activities Staff | Reported resident concerns often not adequately addressed |
| Staff GG | Housekeeping/Maintenance Staff | Verified areas in need of painting, maintenance, and repairs |
| Staff H | Licensed Nursing Staff | Reported need for neurological checks after resident fall |
| Staff B | Licensed Administrative Staff | Verified failure to conduct neurological checks after resident fall |
| Staff S | Licensed Nursing Staff | Interviewed about resident incontinence and skin issues |
| Staff T | Administrative Nursing Staff | Interviewed about resident incontinence and skin issues |
| Staff DD | Licensed Nursing Staff | Reported staffing shortages and resident ulcers |
| Staff C | Direct Care Staff | Observed resident heel condition |
| Staff D | Licensed Nursing Staff | Reported resident heel condition and glucometer sanitization |
| Staff CC | Licensed Nursing Staff | Performed blood glucose testing and sanitization |
| Staff BB | Housekeeping Staff | Sanitized bathroom surfaces without proper dry time |
| Staff F | Licensed Administrative Staff | Verified missing daily staffing sheets |
| Staff A | Administrative Staff | Reported missing daily staffing sheets |
Inspection Report
Renewal
Deficiencies: 0
Sep 14, 2015
Visit Reason
The Health Licensure Resurvey was conducted as a renewal inspection of the facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 1
Sep 14, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, 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 October 13, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies found, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date of substantial compliance: Oct 13, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 3
Aug 5, 2015
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that deficiencies previously cited under regulations 483.13(b), 483.13(c)(1)(i), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), and 483.20(d)(3), 483.10(k)(2) were corrected by 07/08/2015.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 483.13(b), 483.13(c)(1)(i) |
| Deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency under regulation 483.20(d)(3), 483.10(k)(2) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Jun 23, 2015
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited during a complaint investigation related to allegations of abuse and neglect.
Findings
The facility was cited for deficiencies related to ensuring residents remain free of abuse, protecting residents from possible sexual abuse, and developing individualized care plans for residents displaying inappropriate sexual and other behaviors. The Plan of Correction outlines actions taken including 1:1 supervision of a resident, staff in-service training, ongoing monitoring, care plan updates, and grievance process revisions.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse and neglect involving resident #3, who exhibited increased inappropriate sexual behaviors and was transferred for psychological evaluation. The complaint was substantiated with findings of deficiencies in abuse prevention and care planning.
Severity Breakdown
K: 2
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents remain free of abuse. | K |
| Failure to protect residents from possible sexual abuse by reporting and investigating allegations. | K |
| Failure to develop, implement, review and revise individualized care plans for residents with inappropriate sexual behavior and other behaviors. | D |
Report Facts
Dates of staff in-service training: 6-17-2015 and 6-18-2015
Date of resident transfer: 6-19-2015
Date of care plan update: 6-17-2015
Date of Quality Assurance Performance Improvement Committee review: 7-16-2015
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Jun 23, 2015
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of sexual abuse and inappropriate behaviors by a resident towards other residents.
Findings
The facility failed to ensure two female residents remained free from sexual abuse by another resident, placing all female residents on the unit in immediate jeopardy. The facility also failed to thoroughly investigate and report the incidents of abuse and failed to revise the care plan to address the resident's inappropriate sexual and other behaviors.
Complaint Details
The complaint investigations #87919 and 87472 involved allegations that resident #03 sexually abused two female residents (#7 and #8). The facility failed to protect these residents and failed to investigate and report the incidents properly.
Severity Breakdown
Level K: 2
Level D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents were free from sexual abuse by another resident, placing residents in immediate jeopardy. | Level K |
| Failure to investigate and report allegations of abuse to the state agency and take corrective action. | Level K |
| Failure to review and revise the plan of care to address inappropriate sexual and other behaviors of a resident. | Level D |
Report Facts
Census: 88
Residents on unit: 14
Female residents on unit: 12
Days to abate immediate jeopardy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care nursing staff E | Reported and documented incidents of sexual abuse by resident #03. | |
| Licensed nursing staff B | Licensed nursing staff | Acknowledged administrative awareness of incidents and failure to investigate. |
| Administrative staff A | Was aware of incidents but failed to complete investigations; told staff abuse was inappropriate behavior and no action needed. | |
| Social services staff F | Acknowledged shredding of witness statement and administrative staff's dismissal of abuse. | |
| Licensed nursing staff D | Licensed nursing staff | Unaware of resident's inappropriate behaviors and had not revised care plan accordingly. |
| Licensed charge nurse C | Licensed charge nurse | Received reports of incidents from direct care nursing staff E. |
| Indirect care staff H | Documented concern about resident #03's aggressive behavior. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 23, 2015
Visit Reason
An Abbreviated survey was conducted on June 23, 2015, by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the facility was not in substantial compliance with participation requirements and conditions constituted immediate jeopardy to resident health or safety from April 27, 2015 through June 18, 2015. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed effective July 15, 2015.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F223, CFR 483.13(b) & (c)(1)(i) and F225, CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) constituting immediate jeopardy and substandard quality of care. | Immediate Jeopardy |
Report Facts
Denial of payment effective date: Jul 15, 2015
Provider agreement termination recommendation date: Dec 19, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions concerning the instructions contained in the letter |
Inspection Report
Life Safety
Deficiencies: 1
Jun 19, 2015
Visit Reason
A Life Safety Code survey was conducted on June 19, 2015, 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 to be 'F' level, widespread, with no harm but with potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required and enforcement remedies were recommended due to failure to achieve substantial compliance.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were 'F' level, widespread, with no harm but potential for more than minimal harm. | F |
Report Facts
Effective date for denial of payments: Sep 19, 2015
Provider agreement termination date: Dec 19, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for informal dispute resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 18, 2014
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit report confirms that the deficiency identified by regulation 28-39-255 with ID prefix S3400 was corrected as of 07/18/2014. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency previously reported under regulation 28-39-255 with ID prefix S3400 |
Report Facts
Deficiency correction date: Jul 18, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 18, 2014
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village of Pittsburg in response to deficiencies cited in a prior survey, aiming to assure correction and continued compliance with regulations.
Findings
The facility was found to have deficiencies related to the sanitary conditions of food storage, preparation, and service in the Assisted Living kitchenette. A revised cleaning schedule and additional staff education were implemented to address these issues.
Deficiencies (1)
| Description |
|---|
| Food storage, preparation, distribution, and service under sanitary conditions in the Assisted Living kitchenette were deficient. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Melinda Ewan | Executive Director | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 8
Jul 18, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.20(k)(3)(i) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 8
Jun 18, 2014
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a prior survey. It outlines corrective actions to address compliance issues identified during the inspection.
Findings
The plan addresses multiple deficiencies including individualized care plans for residents at risk for falls, admission documentation, accident prevention, nutritional care, medication regimen reviews, food sanitation, and infection control. The facility commits to staff education, monitoring, and ongoing compliance.
Severity Breakdown
D: 6
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to develop, implement, review and revise individualized care plans for residents at risk for falls. | D |
| Failure to develop and implement individualized care plans for residents on admission with proper documentation. | D |
| Failure to ensure resident environment is free of accidental hazards and provide adequate supervision and assistive devices to prevent accidents. | D |
| Failure to prevent significant unplanned weight loss or decreased protein level unless clinically unavoidable. | D |
| Failure to ensure residents' drug regimens are free from unnecessary drugs and proper admission documentation. | D |
| Failure to store, prepare, distribute, and serve food under sanitary conditions. | F |
| Failure to review drug regimen of each resident on admission and at least monthly by a licensed pharmacist. | D |
| Failure to establish and maintain an infection control program to provide a safe, sanitary, and comfortable environment. | F |
Report Facts
Weight loss: 7
Plan of Correction review dates: Quality Assurance Committee review on June 19, 2014 and July 24, 2014
Training dates: Staff training on June 18, 2014 and June 19, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Ewan | Executive Director | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 18, 2014
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious 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 the submitted plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator related to survey and plan of correction. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 6
Jun 18, 2014
Visit Reason
The inspection was a health resurvey and complaint investigation #74814 focusing on care plan revisions, fall prevention, nutrition monitoring, medication management, infection control, and sanitary conditions.
Findings
The facility failed to review and revise care plans for residents with repeated falls, failed to develop initial care plans timely, did not provide adequate nutritional monitoring for residents with weight loss, failed to monitor side effects of antipsychotic medications through AIMS assessments, and failed to maintain sanitary conditions in one kitchenette. Infection control logs lacked consistent tracking and trending of infections and antibiotic usage.
Complaint Details
The visit was triggered by complaint investigation #74814 focusing on care plan revisions, fall prevention, nutrition, medication monitoring, infection control, and sanitation.
Severity Breakdown
Level D: 4
Level F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to review and revise the plan of care for 2 residents (#118 and #34) with repeated falls and injuries. | Level D |
| Failed to develop an initial care plan for 2 residents (#64 and #139) upon admission. | Level D |
| Failed to provide adequate nutritional monitoring for 2 residents (#80 and #54) with significant weight loss. | Level D |
| Failed to monitor side effects of antipsychotic medication through AIMS assessments for resident #58. | Level F |
| Failed to store, prepare, distribute and serve food under sanitary conditions in 1 of 6 kitchenettes. | Level F |
| Failed to thoroughly track and trend infections in the facility to prevent spread of infection. | Level D |
Report Facts
Resident census: 84
Residents reviewed: 15
Weight loss: 11
Weight loss: 10
Weight loss: 9
Weight loss: 6
Weight loss: 7
Fall risk score: 12
Fall risk score: 10
Fall risk score: 22
AIMS score: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff LL | Direct Care Staff | Interviewed regarding resident #118 fall and alarm use |
| Staff VV | Direct Care Staff | Interviewed regarding resident #118 fall and alarm use |
| Staff DD | Direct Care Staff | Interviewed regarding resident #118 care summary and fall interventions |
| Staff Z | Licensed Nursing Staff | Interviewed regarding resident #118 care summary and fall interventions |
| Staff B | Administrative Nursing Staff | Interviewed regarding fall interventions and care plan responsibilities |
| Staff SS | Direct Care Staff | Interviewed regarding resident #64 care needs |
| Staff TT | Direct Care Staff | Interviewed regarding resident #64 decline |
| Staff BB | Licensed Nursing Staff | Interviewed regarding resident #64 care summary use |
| Staff D | Dietary Staff | Interviewed regarding resident #80 weight loss and meal monitoring |
| Staff RR | Direct Care Staff | Interviewed regarding resident #80 appetite and meal intake |
| Staff UU | Direct Care Staff | Interviewed regarding resident #54 meal monitoring |
| Staff WW | Dietary Staff | Interviewed regarding resident #54 meal intake documentation |
| Staff W | Licensed Nursing Staff | Interviewed regarding AIMS assessments for resident #58 |
| Staff Q | Consultant | Interviewed regarding monitoring of AIMS assessments |
| Staff NN | Direct Care Staff | Interviewed regarding resident #34 fall risk and interventions |
| Staff GG | Direct Care Staff | Interviewed regarding resident #34 fall risk and interventions |
| Staff HH | Direct Care Staff | Interviewed regarding resident #34 transfers and fall prevention |
| Staff X | Licensed Nursing Staff | Interviewed regarding resident #34 fall risk and care plan interventions |
| Staff V | Licensed Nursing Staff | Interviewed regarding resident #34 fall interventions and care summary |
| Staff P | Administrative Nursing Staff | Interviewed regarding fall committee and intervention process |
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 1
Jun 12, 2014
Visit Reason
The inspection was an Assisted Living Healthcare Licensure resurvey to assess compliance with sanitary meal preparation and service requirements in dietary areas.
Findings
The facility failed to maintain sanitary conditions in the dietary area, with observations including dust on the window sill, sticky gray discoloration on the microwave and refrigerator fronts, an ice machine drainage tube without an air gap, a plate warmer with dried residue, food particles on the floor and dining tables, and no improvement throughout the day.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to store and prepare food under sanitary conditions to prevent the spread of food borne illnesses. | SS=F |
Report Facts
Census: 32
Inspection Report
Follow-Up
Deficiencies: 5
May 3, 2013
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25(d), 483.25(h), 483.35(i), and 483.60(b), (d), (e) were corrected by the revisit date of 05/03/2013.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(b), (d), (e) |
Inspection Report
Plan of Correction
Deficiencies: 5
May 3, 2013
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg to address deficiencies cited in a prior survey and to demonstrate compliance with state and federal regulations.
Findings
The plan outlines corrective actions for deficiencies related to individualized care plans for residents at risk for falls, bladder incontinence care, accident hazard prevention, food sanitation, and medication management including expired medications.
Severity Breakdown
D: 3
F: 1
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Deficiency related to individualized care plans for residents at risk for falls. | D |
| Deficiency related to appropriate treatment and service for residents who are incontinent of bladder. | D |
| Deficiency related to ensuring the resident's environment remains free of accident hazards and prevention of elopement. | D |
| Deficiency related to food storage, preparation, and sanitation conditions. | F |
| Deficiency related to medication management including monitoring and removal of expired medications. | E |
Report Facts
Date of Plan of Correction completion: May 3, 2013
Resident references: 3
Dates of staff education: Apr 9, 2013
Dates of staff education: Apr 10, 2013
Date of cleaning: Apr 2, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Ewan | CEO/Administrator | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 5
Apr 4, 2013
Visit Reason
The inspection was a health resurvey and complaint investigation (#63975) focusing on care planning, fall prevention, urinary incontinence treatment, accident prevention, food sanitation, and medication management.
Findings
The facility failed to revise care plans to prevent repeated falls, provide appropriate urinary incontinence care, ensure adequate supervision to prevent elopement and accidents, maintain sanitary conditions in kitchenettes, and monitor and dispose of expired medications.
Complaint Details
The visit was triggered by complaint investigation #63975, which included concerns about care planning, fall prevention, urinary incontinence care, supervision to prevent elopement, food sanitation, and medication management.
Severity Breakdown
SS=D: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to review and revise care plans for residents #95 and #89 to prevent repeated falls. | SS=D |
| Failed to provide appropriate treatments and services to resident #28 to prevent urinary tract infections and restore bladder function. | SS=D |
| Failed to ensure adequate supervision to prevent elopement of resident #60 and failed to implement interventions to prevent accidents for resident #95. | SS=D |
| Failed to store and serve food under sanitary conditions in 6 court kitchenettes. | SS=E |
| Failed to monitor and dispose of expired medications in 1 medication room and 3 medication carts. | SS=E |
Report Facts
Residents reviewed for sample: 20
Residents reviewed for urinary incontinence: 3
Residents reviewed for accidents: 3
Resident census: 80
Fall risk score: 21
Elopement risk score: 6
Fall risk score: 19
Expired Tramadol doses: 29
Expired Ativan tablets: 53
Expired Acetaminophen tablets: 58
Expired Promethazine tablets: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Reported resident #95's pressure pad alarm was ineffective and reviewed care plan |
| Staff F | Licensed Nursing Staff | Reported resident #95 disliked pressure pad alarm and failed to document refusal |
| Staff G | Licensed Nursing Staff | Reported on resident #60 elopement and medication expiration monitoring |
| Staff J | Direct Care Staff | Assisted resident #28 with toileting and provided pericare |
| Staff M | Direct Care Staff | Reported resident #60 elopement incident and resident agitation |
| Staff N | Direct Care Staff | Found resident #60 outside during elopement incident |
| Staff Q | Direct Care Staff | Observed resident #95 transferring without pressure pad alarm |
| Staff R | Direct Care Staff | Assisted resident #95 with ambulation and noted lack of pressure pad alarm |
| Staff K | Direct Care Staff | Reported resident #95 required stand by assistance and lacked knowledge of pressure pad alarm |
| Staff L | Dietary Staff | Reported on unsanitary conditions in court kitchenettes |
| Staff T | Direct Care Staff | Reported resident #60's anxiety and use of pull pin alarm |
| Staff U | Direct Care Staff | Reported resident #60's mood swings and use of pull pin alarm |
Inspection Report
Renewal
Deficiencies: 0
Apr 2, 2013
Visit Reason
The licensure survey was conducted as a renewal inspection of the facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 4
N019013 POC 4QZQ11
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Pittsburg in response to deficiencies cited in a prior survey related to food labeling, sanitation, and kitchen cleanliness.
Findings
The facility identified deficiencies including unlabeled food items, improper positioning of the ice machine drain tube, buildup of dirt on kitchenette floors, and inadequate cleaning of trash cans. The plan outlines corrective actions such as staff education, cleaning schedules, audits, and monitoring to ensure compliance.
Severity Breakdown
F: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Food items not marked with expiration date in the main kitchen | F |
| Ice machine drain tube positioned on the floor drain | F |
| Kitchenette floor contained buildup of dirt | F |
| Trash cans not cleaned daily | F |
Report Facts
Plan of Correction completion date: Apr 8, 2017
Deep cleaning completion date: Mar 8, 2017
Trash cans cleaned date: Mar 20, 2017
Sanitation hood cleaning date: Apr 3, 2017
Mandatory in-service education date: Apr 1, 2017
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