Inspection Report Summary
The most recent inspection on July 21, 2025, found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections showed multiple deficiencies primarily related to resident care, medication administration, infection control, and staff training, with issues such as inadequate supervision during meals, improper medication management, and lapses in hand hygiene. Complaint investigations included substantiated findings of medication administration errors that led to hospitalization for one resident, as well as concerns about resident dignity, fall prevention, and abuse reporting in earlier years. Enforcement actions such as immediate jeopardy findings and payment denials occurred in 2017 related to resident safety and supervision but were followed by corrective plans and subsequent compliance. The facility’s inspection history shows a pattern of addressing cited deficiencies with corrective actions, and the recent clean inspection suggests improvement over time.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
65 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 21, 2025
Visit Reason
An offsite revisit survey was conducted on 07/21/25 to verify correction of all previous deficiencies cited on 06/04/25.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 07/15/25, 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: 13
Jul 15, 2025
Visit Reason
This document is a Plan of Correction submitted by Village Shalom RS in response to deficiencies cited in a regulatory inspection, outlining corrective actions to address specific findings related to resident care, medication administration, infection control, and staff training.
Findings
The plan details multiple corrective actions including care plan updates, staff education, audits, and policy reviews addressing issues such as resident dignity and privacy, Medicare notification, antipsychotic medication use, mealtime assistance, weight monitoring, mattress settings, oxygen storage security, medication administration, food storage, hand hygiene, and nurse aide training compliance.
Severity Breakdown
D: 11
E: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Resident #31’s care plan lacked specific, person-centered interventions addressing undressing behaviors and privacy preferences. | D |
| Inadequate notification and documentation regarding Medicare coverage and non-coverage for Resident 165. | D |
| Incomplete clinical documentation and monitoring related to antipsychotic medication use for Residents #50 and #1. | D |
| Insufficient supervision and assistance during meals for Resident #19 and others dependent for eating. | D |
| Missed daily weight measurements for Resident #50 and other residents with physician orders. | D |
| Incorrect low air loss mattress pump settings and lack of proper monitoring for Resident #19 and others. | D |
| Unsecured oxygen storage areas and inadequate call light accessibility for Resident #19 and others. | E |
| Medication orders for Resident #50, including Midodrine, were not properly reviewed or updated. | D |
| Unattended, unlocked medication cart found; staff not compliant with securing medication carts. | D |
| Improper supplement administration timing and monitoring for Resident #19 and others. | D |
| Improper food storage practices including unsealed or undated frozen food packages and inadequate staff training. | D |
| Non-compliance with hand hygiene and equipment disinfection procedures among clinical staff. | E |
| Nurse aides non-compliant with required in-service training hours. | D |
Report Facts
Compliance deadline: Jul 15, 2025
Audit frequency: 5
Audit duration: 12
Audit duration: 4
Training deadline: Jul 8, 2025
In-service training date: Jun 19, 2025
Nurse aide training deadline: Jun 27, 2025
Nurse aide training audit period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Haley Tinch | Executive Assistant | Submitted the Plan of Correction to KDADS |
| Deb Harper | Modified the Plan of Correction document |
Inspection Report
Routine
Census: 65
Deficiencies: 13
Jun 4, 2025
Visit Reason
Routine health resurvey of Village Shalom Inc nursing facility to assess compliance with resident rights, medication management, care provision, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified care environment, failure to provide required Medicaid notices, inappropriate use of psychotropic medications without proper indication or physician rationale, failure to provide consistent assistance during meals, failure to follow physician orders for daily weights and medication administration, unsafe storage of oxygen tanks and chemicals, improper food safety practices, lapses in infection control including hand hygiene and equipment sanitation, and failure to provide required nurse aide in-service training.
Severity Breakdown
SS=D: 10
SS=E: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to ensure a dignified care environment for Resident 31, including exposure while sleeping and refusal of care. | SS=D |
| Failure to provide required Medicaid/Medicare coverage and liability notices to Resident 165. | SS=D |
| Failure to ensure appropriate indication and physician rationale for use of antipsychotic medications for Residents 50 and 1. | SS=D |
| Failure to provide consistent assistance and supervision during meals for Resident 19. | SS=D |
| Failure to follow physician order for daily weights for Resident 17 to monitor congestive heart failure. | SS=D |
| Failure to ensure pressure-reducing mattress settings were adjusted to resident's current weight for Resident 19. | SS=D |
| Failure to secure pressurized oxygen tanks and cleaning chemicals in locked areas and failure to provide consistent supervision and call light access for Resident 19. | SS=E |
| Failure to ensure medication carts were locked when unattended and failure to wear hairnets and maintain food safety practices in kitchen and serving areas. | SS=D |
| Failure to perform hand hygiene before glucose checks and IV medication administration and failure to sanitize mechanical lifts between residents. | SS=E |
| Failure to provide Ensure supplementation 30 minutes after meals as ordered for Resident 19. | SS=D |
| Failure to ensure monthly drug regimen review addressed pharmacist recommendations and physician documented rationale for antipsychotic use and medication administration for Residents 50 and 1. | SS=D |
| Failure to administer Midodrine medication per physician order for Resident 50, risking adverse effects and untreated hypotension. | SS=D |
| Failure to ensure nurse aides received required 12 hours of annual in-service training including dementia management and abuse prevention. | SS=D |
Report Facts
Residents reviewed: 16
Medication administration opportunities: 50
Weight of Resident 19: 122
Nurse aide in-service training hours: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements on care expectations, medication administration, infection control, and supervision |
| Licensed Nurse I | Licensed Nurse | Provided statements on medication indications and infection control |
| Licensed Nurse H | Licensed Nurse | Provided statements on medication administration and vital signs |
| Licensed Nurse G | Licensed Nurse | Observed not performing hand hygiene and medication cart left unlocked |
| Certified Nurse Aide N | Certified Nurse Aide | Observed serving food with thumb on plate lip and not performing hand hygiene |
| Certified Nurse Aide M | Certified Nurse Aide | Observed not sanitizing Hoyer lift between residents |
| Dietary Staff CC | Dietary Staff | Observed not wearing hairnet and improper food storage |
| Administrative Staff A | Administrative Staff | Provided statements on nurse aide in-service training responsibility |
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 4
Feb 8, 2024
Visit Reason
The inspection was a resurvey of an assisted living facility conducted on 02/07/24 and 02/08/24 to assess compliance with previously identified deficiencies.
Findings
The facility failed to ensure negotiated service agreements accurately described services for residents, failed to label over-the-counter medications with residents' full names, lacked documentation of quarterly emergency management plan reviews with staff and residents, and did not comply with tuberculosis testing guidelines for residents.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Negotiated Service Agreements for Residents 3 and 6 did not describe the services they received based on their Functional Capacity Screens. | SS=D |
| Licensed pharmacist or nurse failed to place full names of residents on original packages of eight over-the-counter medications in assisted living. | SS=E |
| Failed to provide evidence of quarterly reviews of the facility's emergency management plan with staff and residents. | SS=F |
| Failed to ensure compliance with tuberculosis guidelines including missing second-step TB skin tests and annual symptom screenings for residents. | SS=F |
Report Facts
Census: 71
OTC medications not labeled: 8
Residents included in sample: 6
Years since last TB symptom screen for Resident 4: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse G | Administrative Nurse | Confirmed deficiencies related to negotiated service agreements and tuberculosis testing |
| Certified Medication Aide D | Certified Medication Aide | Observed handling of unlabeled OTC medications |
| Certified Medication Aide E | Certified Medication Aide | Observed handling of unlabeled OTC medications |
| Administrative Nurse F | Administrative Nurse | Confirmed negotiated service agreement deficiencies for Resident 6 |
| Administrative Staff A | Administrative Staff | Confirmed lack of documentation for emergency management plan reviews |
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 4
Feb 8, 2024
Visit Reason
The inspection was a resurvey of the assisted living facility conducted on 02/07/24 and 02/08/24 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure negotiated service agreements accurately described services for residents, improper labeling of over-the-counter medications, lack of documentation for quarterly emergency management plan reviews, and non-compliance with tuberculosis screening guidelines.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Negotiated Service Agreements for Residents 3 and 6 failed to describe the services they received based on their Functional Capacity Screens. | SS=D |
| Licensed pharmacist or nurse failed to place full names of residents on original packages of eight over-the-counter medications. | SS=E |
| Failed to provide evidence of quarterly reviews of the facility's emergency management plan with staff and residents. | SS=F |
| Failed to ensure compliance with tuberculosis guidelines including missing second step TB skin tests and annual symptom screens for residents. | SS=F |
Report Facts
Census: 71
Residents in sample: 6
Over-the-counter medications without resident names: 8
Residents in assisted living: 48
Residents in memory care: 23
Vitamin D3 gummies: 60
Calcium with D3 gummies: 80
Centrum Silver Women 50+ tablets: 50
Osteo Bi-Flex joint health tablets: 200
Acetaminophen 500 mg caplets: 225
Acetaminophen 500 mg caplets: 150
Antacid tablets: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse G | Administrative Nurse | Confirmed deficiencies related to negotiated service agreements and tuberculosis testing |
| Certified Medication Aide D | Certified Medication Aide | Confirmed OTC medications on second-floor medication cart were not labeled with residents' full names |
| Certified Medication Aide E | Certified Medication Aide | Confirmed OTC medications on first-floor medication cart were not labeled with residents' full names |
| Administrative Nurse F | Administrative Nurse | Confirmed negotiated service agreement deficiencies for Resident 6 |
| Administrative Staff A | Administrative Staff | Confirmed lack of documentation for quarterly emergency management plan reviews |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 7, 2024
Visit Reason
The document represents the findings of a resurvey conducted for the assisted living facility on 02/07/24 and 02/08/24.
Findings
This document is a Plan of Correction submitted in response to the findings from the resurvey conducted on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 28, 2023
Visit Reason
A revisit survey was conducted on 11/28/23 to verify correction of all previous deficiencies cited on 10/19/23.
Findings
All deficiencies cited in the prior inspection have been corrected as of 11/20/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Health Resurvey And Complaint
Census: 66
Deficiencies: 11
Oct 19, 2023
Visit Reason
Health Resurvey and Complaint #KS00180119 to assess compliance with resident rights, care quality, safety, and medication management.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity, failure to act on resident council concerns, failure to report alleged abuse, inadequate ADL care, poor quality of care related to skin and pressure ulcers, inadequate fall prevention and supervision, improper medication management including psychotropic drugs, failure to submit accurate staffing data, lack of qualified infection preventionist, and failure to administer pneumococcal vaccinations.
Complaint Details
Complaint #KS00180119 triggered the health resurvey. The complaint involved issues related to resident dignity, care quality, reporting of abuse, and medication management.
Severity Breakdown
SS=D: 4
SS=E: 4
SS=G: 2
SS=F: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to promote dignity for residents during medication administration and meal service. | SS=D |
| Failure to act promptly upon resident council concerns regarding staffing and food service. | SS=E |
| Failure to report an unwitnessed fall with fracture to the State Agency. | SS=D |
| Failure to provide necessary ADL care including bathing for a resident. | SS=D |
| Failure to follow up on impaired skin and document treatment for a skin tear. | SS=D |
| Failure to implement interventions to prevent and treat facility acquired pressure ulcers for multiple residents. | SS=G |
| Failure to provide adequate supervision and safe environment to prevent falls resulting in fractures and injuries. | SS=G |
| Failure to ensure consultant pharmacist identified and reported inappropriate medication indications and lack of stop dates for psychotropic and antianxiety medications. | SS=E |
| Failure to submit accurate Payroll Based Journal staffing data to CMS for FY 2022 Q4. | SS=F |
| Failure to designate an Infection Preventionist with required education, training, experience, and certification. | SS=F |
| Failure to administer pneumococcal vaccinations to residents despite consent and orders. | SS=E |
Report Facts
Residents reviewed for dignity: 18
Residents reviewed for ADL: 6
Residents reviewed for pressure ulcers: 6
Residents reviewed for accidents: 5
Residents reviewed for pneumococcal vaccination: 5
Residents reviewed for medication management: 18
Residents with severe cognitive impairment: 3
Residents with fractures from falls: 2
Residents with pressure ulcers: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide R | Infection Preventionist | Designated Infection Preventionist without required qualifications |
| Licensed Nurse H | Licensed Nurse | Involved in medication administration and wound care |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding multiple findings including fall reporting and medication irregularities |
| Certified Nurse Aide M | Certified Nurse Aide | Observed providing care and involved in fall incident |
| Licensed Nurse K | Licensed Nurse | Observed providing wound care |
| Consultant GG | Consultant Pharmacist | Provided consultant pharmacist services and infection control support |
Inspection Report
Plan of Correction
Deficiencies: 11
Oct 19, 2023
Visit Reason
This document is a Plan of Correction submitted by Village Shalom RS in response to deficiencies identified during a regulatory inspection conducted on October 19, 2023.
Findings
The Plan of Correction addresses multiple deficiencies related to resident dignity during care, Resident Council engagement, abuse and neglect investigations, personal hygiene and bathing services, skin care and wound management, fall risk management, psychotropic medication use, PBJ reporting, infection prevention, and pneumococcal vaccination compliance. The facility outlines corrective actions including staff training, audits, policy reviews, and ongoing monitoring to achieve compliance by November 20, 2023.
Severity Breakdown
D: 4
E: 4
F: 2
G: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to honor resident dignity during medication administration via feeding tube and meal service. | D |
| Inadequate engagement and response to Resident Council concerns. | E |
| Incomplete investigation and reporting related to abuse, neglect, and exploitation incidents. | D |
| Insufficient personal hygiene and bathing services documentation and delivery. | D |
| Inadequate skin assessment, wound management, and documentation. | D |
| Lack of comprehensive skin assessments and preventive interventions for pressure ulcers. | G |
| Fall risk management deficiencies including visitor safety and resident fall risk assessments. | G |
| Inappropriate use and monitoring of psychotropic medications including lack of stop dates and informed consents. | E |
| Failure to ensure accurate and timely PBJ data submission. | F |
| Infection Preventionist role and infection prevention practices not fully implemented or monitored. | F |
| Incomplete pneumococcal vaccination administration and documentation. | E |
Report Facts
Compliance deadline: Nov 20, 2023
Training date: Nov 8, 2023
Incident date: Sep 30, 2023
Consultant pharmacist start date: Nov 6, 2023
Infection Preventionist appointment date: Nov 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Emily Kirkpatrick | Executive Assistant | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 8, 2023
Visit Reason
An offsite revisit survey was conducted on 09/08/23 for all previous deficiencies cited on 08/03/23 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/29/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Aug 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#KS00181449) focusing on quality of care concerns related to medication administration and monitoring for Resident 1.
Findings
The facility failed to ensure Resident 1's diuretic medication was properly administered, weights were monitored as ordered, and medication changes were clarified. This failure placed the resident at risk for complications related to heart failure and fluid overload.
Complaint Details
The complaint investigation #KS00181449 found that Resident 1 did not receive diuretic medication consistently, weights were not properly documented or monitored, and medication orders were unclear leading to confusion among nursing staff. Resident 1 was hospitalized for CHF exacerbation due to these issues.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer Resident 1's diuretic medication as ordered, monitor weights, and clarify medication changes. | SS=D |
Report Facts
Census: 65
Medication administration opportunities: 14
Weight measurements recorded: 10
Weight values (lbs): 312.2
Weight values (lbs): 319
Weight values (lbs): 320.6
Weight values (lbs): 316
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Consultant GG | Consultant | Entered medication orders and noted lack of clarification by nursing staff |
| LN G | Licensed Nurse | Reported Resident 1's increased shortness of breath and status leading to hospital transfer |
| Administrative Nurse D | Administrative Nurse | Commented on medication order entry issues and expectations for nurse notifications |
| Administrative Nurse E | Administrative Nurse | Reported on charge nurse's lack of awareness of medication order and documentation process |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 3, 2023
Visit Reason
This document is a Plan of Correction submitted by Village Shalom in response to deficiencies cited in a prior inspection report dated August 3, 2023.
Findings
The plan addresses issues related to weight monitoring accuracy, communication of new or changed medication/treatment orders, and staff education and auditing processes to ensure compliance with regulatory requirements.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident R1's orders were clarified with physician notification and timing for weight monitoring was changed; documentation and audit processes were updated to ensure accurate weight recording. | D |
Report Facts
Weeks of weekly reporting: 12
Months of monthly reporting: 3
Education completion date: Aug 29, 2023
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 1, 2023
Visit Reason
The abbreviated survey was conducted in response to complaints numbered 181648 and 180545 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Complaint Details
The visit was complaint-related for complaints #181648 and #180545 and resulted in no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 1, 2023
Visit Reason
The document is a plan of correction related to an abbreviated survey conducted for complaints numbered 181648 and 180545 on 07/31/23 and 08/01/23 at an assisted living facility.
Findings
The abbreviated survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 7, 2023
Visit Reason
An abbreviated survey was conducted for complaints #178632, #178634, and #178377 at the facility.
Findings
The abbreviated survey resulted in no deficiency citations.
Complaint Details
The survey was complaint-related for complaints #178632, #178634, and #178377 and resulted in no deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 7, 2023
Visit Reason
An abbreviated survey was conducted on 03/07/23 for complaints #178632, #178634, and #178377 at the facility.
Findings
The abbreviated survey resulted in no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 5
Nov 1, 2022
Visit Reason
This report is a revisit conducted by a State surveyor to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date, November 1, 2022.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-201 (a) (b) |
| Deficiency related to regulation 26-41-202 (a) |
| Deficiency related to regulation 26-41-204 (d) |
| Deficiency related to regulation 26-41-102 (d) |
| Deficiency related to regulation 26-41-207 (b) (5-6) (c) |
Inspection Report
Follow-Up
Deficiencies: 5
Nov 1, 2022
Visit Reason
This revisit report documents the completion of corrective actions for deficiencies previously reported during an earlier survey.
Findings
All previously identified deficiencies related to life safety code provisions were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-201 (a) (b) |
| Deficiency related to regulation 26-41-202 (a) |
| Deficiency related to regulation 26-41-204 (d) |
| Deficiency related to regulation 26-41-102 (d) |
| Deficiency related to regulation 26-41-207 (b) (5-6) (c) |
Inspection Report
Re-Inspection
Deficiencies: 5
Nov 1, 2022
Visit Reason
This is a revisit report completed by a State surveyor to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date, November 1, 2022.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-201 (a) (b) |
| Deficiency related to regulation 26-41-202 (a) |
| Deficiency related to regulation 26-41-204 (d) |
| Deficiency related to regulation 26-41-102 (d) |
| Deficiency related to regulation 26-41-207 (b) (5-6) (c) |
Inspection Report
Re-Inspection
Deficiencies: 5
Nov 1, 2022
Visit Reason
This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions have been corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-201 (a) (b) |
| Deficiency related to regulation 26-41-202 (a) |
| Deficiency related to regulation 26-41-204 (d) |
| Deficiency related to regulation 26-41-102 (d) |
| Deficiency related to regulation 26-41-207 (b) (5-6) (c) |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 5
Sep 27, 2022
Visit Reason
The inspection was a licensure resurvey with complaint investigations for complaint numbers 174462, 174463, 173752, and 171792 conducted on 09/26/22, 09/27/22, and 09/28/22.
Findings
The facility failed to complete and document the Functional Capacity Screen (FCS) for resident R112, including cognitive impairment. The Negotiated Service Agreement (NSA) and Health Care Service Plan (HSP) lacked required descriptions of services and the name of the licensed nurse responsible for supervision for multiple residents. Employee records lacked required documentation from the Kansas nurse aide registry for a newly hired Certified Medication Aide (CMA A). The facility also failed to comply with tuberculosis (TB) testing guidelines for residents and newly hired personnel.
Complaint Details
The inspection was conducted as a licensure resurvey with complaint investigations for complaint numbers 174462, 174463, 173752, and 171792.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to complete and document Functional Capacity Screen (FCS) for resident R112 including cognitive impairment. | SS=D |
| Negotiated Service Agreement (NSA) and Health Care Service Plan (HSP) lacked description of services required for resident R112 with impaired cognitive status. | SS=D |
| NSA did not contain the name of the licensed nurse responsible for supervision and implementation of the Health Care Service Plan for residents R112, R116, R118, and R120. | SS=F |
| Employee records lacked documentation from the Kansas nurse aide registry that newly hired Certified Medication Aide (CMA A) did not have findings of abuse, neglect, or exploitation. | SS=D |
| Facility failed to comply with tuberculosis (TB) guidelines for adult care homes for resident R112 and newly hired personnel CMA A, Licensed Nurse C, and Certified Nurse Aide D. | SS=D |
Report Facts
Census: 71
Number of sampled residents: 5
Number of newly hired employees reviewed: 5
Admission date: Aug 29, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Interviewed and confirmed deficiencies related to documentation and compliance | |
| Certified Medication Aide A | Certified Medication Aide | Newly hired employee lacking required nurse aide registry documentation and TB testing |
| Licensed Nurse C | Licensed Nurse | Newly hired employee lacking required TB testing documentation |
| Certified Nurse Aide D | Certified Nurse Aide | Newly hired employee lacking required TB testing documentation |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 23, 2022
Visit Reason
An offsite revisit survey was conducted on 03/23/22 for all previous deficiencies cited on 02/07/22 to verify correction of deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 03/07/22, 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
Census: 47
Deficiencies: 4
Feb 7, 2022
Visit Reason
The inspection was a Health Resurvey conducted to evaluate compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to include residents and their representatives in care planning, failure to accommodate resident needs such as appropriate dining table height, failure to maintain a safe environment by leaving hazardous chemicals accessible, and failure to provide timely Registered Dietician assessments for residents with special nutritional needs.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to include residents and their representatives in the development and planning of care plans for Residents 26 and 27. | SS=D |
| Failure to accommodate the needs of Resident 2 by providing a dining table of appropriate height to facilitate comfort and ease of independent eating. | SS=D |
| Failure to provide an environment free of accident hazards when staff left chemicals in an unlocked cabinet accessible to cognitively impaired residents. | SS=E |
| Failure to provide a Registered Dietician assessment in a timely manner after admission of Resident 93, placing the resident at risk for unmet special nutritional needs. | SS=D |
Report Facts
Census: 47
Sample size: 12
Volume of nail polish remover: 6
Volume of adhesive spray: 10
Days delay for RD assessment: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified expectations regarding care plan meetings, chemical storage, and Registered Dietician assessments. |
| Social Service Designee X | Social Service Designee | Reported on care conference scheduling and documentation. |
| Licensed Nurse G | Licensed Nurse | Commented on Resident 2's dining table height and resident complaints. |
| Activity Staff Z | Activity Staff | Verified unlocking of cabinet containing hazardous chemicals. |
| Licensed Nurse H | Licensed Nurse | Provided information about Resident 93's dialysis schedule and diet. |
Inspection Report
Plan of Correction
Deficiencies: 4
Feb 1, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report, addressing corrective actions to be taken for compliance with Federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions for deficiencies including care plan meeting documentation, dining accommodations, hazardous chemical storage, and nutritional risk assessments, with timelines for completion and ongoing monitoring by facility leadership.
Severity Breakdown
D: 3
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Lack of signature sheets for care plan meetings and resident/representative involvement | D |
| Failure to provide dining accommodations to meet resident needs | D |
| Improper storage of hazardous chemicals | E |
| Incomplete nutritional risk assessments by Registered Dietician | D |
Report Facts
Complete Date: Mar 7, 2022
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 21, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 21, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS) on 12/21/20.
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
Abbreviated Survey
Deficiencies: 0
Sep 9, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS).
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: 0
Sep 9, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS) on 9/9/2020.
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
Routine
Deficiencies: 0
Aug 3, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 2020-08-03.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 27, 2020
Visit Reason
A revisit survey was conducted on 7/27/20 for all previous deficiencies cited on 3/16/20 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 4/14/20, 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: 0
Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS) on 06/23/2020.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Inspection Report
Routine
Census: 40
Deficiencies: 0
Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS).
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the COVID-19 focused infection control survey.
Report Facts
Sample Size: 5
Supplemental: 0
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 13
Mar 16, 2020
Visit Reason
The inspection was conducted as a Health Resurvey, partial extended survey, and complaint investigation triggered by allegations of resident to resident sexual abuse and failure to protect residents.
Findings
The facility failed to prevent resident to resident sexual abuse by Resident 9 against cognitively impaired female residents, failed to report abuse allegations timely to state and law enforcement agencies, and failed to implement effective interventions to protect residents during the investigation. Additional deficiencies included failure to transmit MDS data timely, failure to provide incontinence care as per care plan, failure to properly store and date oxygen tubing, failure to communicate with dialysis center, failure to complete annual CNA performance reviews, failure to provide adequate psychosocial care to Resident 9 related to anxiety and depression, failure to ensure medications were available and administered as ordered, and failure to ensure drug regimen review identified medication administration irregularities.
Complaint Details
The complaint investigation was triggered by allegations of resident to resident sexual abuse involving Resident 9 and cognitively impaired female residents. The facility failed to prevent abuse, failed to report timely to state and law enforcement, and failed to protect residents during investigation.
Severity Breakdown
Immediate Jeopardy: 1
G: 1
F: 1
E: 1
D: 7
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to prevent resident to resident sexual abuse by Resident 9 against cognitively impaired female residents. | Immediate Jeopardy |
| Failure to report allegations and/or suspicions of resident to resident sexual abuse to the appropriate state and law enforcement agencies within the required timeframe. | D |
| Failure to protect residents from abuse while investigating episodes of resident to resident sexual abuse. | E |
| Failure to electronically transmit completed Minimum Data Set (MDS) data to CMS within 14 days after completion for two residents. | D |
| Failure to provide incontinence care as directed by comprehensive care plan for one resident. | D |
| Failure to provide necessary respiratory care and services including proper storage and dating of oxygen tubing and nebulizer equipment for one resident. | D |
| Failure to utilize a system for communication between the facility and dialysis center for one resident. | D |
| Failure to complete annual performance reviews for Certified Nurse Aides (CNAs). | F |
| Failure to provide appropriate treatment and services to maintain highest practicable psychosocial well-being for Resident 9 related to increased anxiety and depression after involuntary discharge notice. | G |
| Failure to ensure medications were available and administered as ordered by the physician for Resident 9 and Resident 10. | D |
| Failure to ensure Consultant Pharmacist identified medications not administered as ordered by the physician for Resident 10. | D |
| Failure to ensure drug regimen was free from unnecessary drugs for Resident 10 due to lack of documentation of medication administration and monitoring. | D |
| Failure to establish and maintain an infection prevention and control program including proper storage and handling of supplemental oxygen tubing for one resident. | D |
Report Facts
Census: 44
Deficiencies cited: 12
MDS completion delay: 2
Medication administration misses: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Administrator | Named in investigation and reporting failures related to resident to resident sexual abuse |
| Administrative Nurse D | Administrative Nurse | Named in investigation, reporting, and medication availability failures |
| Social Service X | Social Service | Named in psychosocial care and investigation of resident to resident sexual abuse |
| Certified Nurse Aid O | CNA | Witnessed resident to resident sexual abuse incident |
| Certified Medication Aide R | CMA | Provided medication administration and reported mood changes |
| Licensed Nurse G | LN | Provided care and observations related to oxygen tubing and resident care |
| Licensed Nurse H | LN | Provided information on medication administration and oxygen tubing |
| Certified Nurse Aide N | CNA | Provided care and observations related to resident behavior and medication administration |
| Social Service LL | Social Service | Investigated resident to resident sexual abuse |
| Certified Medication Aid S | CMA | Witnessed resident to resident sexual abuse incident |
| Licensed Nurse I | LN | Provided information on resident behavior and medication administration |
| Vice President Healthcare Services | VP | Involved in resident to resident sexual abuse investigation |
Inspection Report
Plan of Correction
Deficiencies: 13
Mar 16, 2020
Visit Reason
This document is a Plan of Correction submitted by Village Shalom following a survey conducted on March 16, 2020, addressing multiple deficiencies identified during the inspection.
Findings
The facility was found deficient in several areas including failure to prevent resident-to-resident abuse, failure to report allegations of abuse timely, failure to protect residents during abuse investigations, failure to transmit MDS data timely, failure to provide incontinence care as directed, failure to properly maintain respiratory equipment, failure to communicate with dialysis centers, failure to complete annual CNA performance reviews, failure to provide person-centered mental health interventions, failure to ensure medication availability and administration as ordered, and failure to ensure infection prevention and control related to oxygen tubing.
Deficiencies (13)
| Description |
|---|
| Facility failed to prevent resident to resident abuse. |
| Facility failed to report allegations and/or suspicions of resident to resident sexual abuse within required timeframe. |
| Facility failed to protect residents from abuse while investigating episodes of resident to resident sexual abuse. |
| Facility failed to electronically transmit completed Minimum Data Set (MDS) data within 14 days after completion for two residents. |
| Facility failed to provide incontinence care as the comprehensive care plan directed for one resident. |
| Facility failed to replace, date, and store oxygen tubing and nebulizer equipment properly. |
| Facility failed to utilize a system for communication to the dialysis center. |
| Facility failed to complete annual performance reviews for Certified Nurse Aides (CNAs). |
| Facility failed to provide person centered interventions to alleviate acute stress, anxiety and depression. |
| Facility failed to ensure medications were available for administration as ordered by physician. |
| Facility failed to ensure the Consultant Pharmacist identified medication not administered as ordered and failed to ensure care plan identified missed medications. |
| Facility failed to ensure that medication were administered as ordered by physician. |
| Facility failed to ensure the use of standard infection precautions for the proper storage and handling of supplemental oxygen tubing. |
Report Facts
Residents affected: 2
Completion Date: Apr 14, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Wheeler | VP of Healthcare | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction on 05/03/2019 | |
| Lori Mouak | Modified Plan of Correction on 02/26/2021 |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 16, 2020
Visit Reason
A revisit survey was conducted on 1/16/2020 for all previous deficiencies cited on 11/26/19 to verify correction of cited deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 12/13/19, 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
Nov 26, 2019
Visit Reason
The Plan of Correction addresses allegations that the facility improperly issued an involuntary discharge notice to a resident without clinical record validation.
Findings
The surveyor alleged that the facility issued an involuntary discharge notice to Resident 1 without proper clinical justification. The facility submitted a Plan of Correction outlining corrective actions, policy review, and monitoring plans to prevent recurrence.
Deficiencies (1)
| Description |
|---|
| Improper issuance of involuntary discharge notice without clinical record validation |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Wheeler | VP of Healthcare | Submitted the Plan of Correction |
| Felicia Majewski | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Nov 26, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint investigations (#KS00147811, KS00147387, KS00148028, and KS00147663).
Findings
The facility inappropriately issued an involuntary discharge notice to Resident 1 without sufficient clinical or physician documentation to support the discharge. The resident's clinical record did not validate the alleged inappropriate sexual conduct or danger to others, and the facility lacked investigative or incident reports to substantiate the claims.
Complaint Details
The investigation was based on complaints alleging inappropriate sexual conduct by Resident 1 and endangerment of others. The facility failed to provide evidence or documentation supporting these allegations, and the discharge notice was deemed inappropriate.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility issued an involuntary discharge notice to Resident 1 without proper documentation or physician validation that the resident's needs could not be met or that the resident endangered others. | SS=D |
Report Facts
Census: 47
Complaint investigations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided statements regarding Resident 1's discharge related to inappropriate actions towards staff | |
| Administrative Staff B | Stated discharge was based solely on inappropriate actions with staff | |
| Certified Nurse Aide (CNA) M | Reported never witnessing inappropriate behavior by Resident 1 | |
| Administrative Nurse D | Discussed Interdisciplinary Team review and lack of documentation in Resident 1's chart |
Inspection Report
Re-Inspection
Deficiencies: 0
May 28, 2019
Visit Reason
An offsite revisit survey was conducted on 05/28/2019 for all previous deficiencies cited on 04/25/2019.
Findings
All deficiencies have been corrected as of the compliance date of 05/24/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 5
Apr 25, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to allegations concerning resident care and facility compliance.
Findings
The facility failed to provide written notification of hospitalization to a resident and/or family, failed to revise care plans and implement interventions to prevent falls for a high-risk resident, failed to ensure adequate supervision to prevent accidents, and failed to ensure proper drug regimen review and monitoring, including inconsistent blood sugar monitoring and failure to notify physicians of abnormal results. Additionally, the facility failed to obtain physician-ordered daily weights for residents with specific conditions.
Complaint Details
The visit was triggered by complaints regarding failure to provide written notification of hospitalization, inadequate care planning and fall prevention, and medication monitoring issues.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure resident/responsible party was provided written notification of the reason for hospitalization. | SS=D |
| Failed to review and revise the care plan to direct care aimed at preventing falls for resident #30. | SS=D |
| Failed to identify and implement appropriate interventions aimed to prevent falls for resident #30. | SS=D |
| Failed to ensure the consultant pharmacist identified and reported inconsistent blood sugar monitoring for resident #11. | SS=D |
| Failed to notify the physician for blood sugars outside of ordered parameters for resident #11 and failed to obtain consistent physician ordered weights for residents #35 and #41. | SS=D |
Report Facts
Census: 48
Sample size: 27
Blood sugar monitoring failures: 5
Weight documentation missing days: 5
Weight documentation missing days: 5
Inspection Report
Plan of Correction
Deficiencies: 5
Apr 25, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during the annual inspection conducted on April 25, 2019.
Findings
The facility was found deficient in multiple areas including failure to provide written notification of hospitalization reasons, failure to review and revise care plans to prevent falls, failure to implement appropriate fall prevention interventions, and failure to ensure consultant pharmacist identified and reported inconsistent blood sugar monitoring and physician notifications related to medication use and resident weights.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure resident/responsible party was provided written notification of the reason for hospitalization. | D |
| Failed to review and revise the plan of care to direct care aimed at preventing falls for resident #30. | D |
| Failed to identify and implement appropriate interventions aimed to prevent falls for resident #30. | D |
| Failed to ensure the consultant pharmacist identified and reported inconsistent blood sugar monitoring for resident #11. | D |
| Failed to notify the physician for blood sugars outside ordered parameters and failed to obtain consistent physician ordered weights for residents #11, #35, and #41. | D |
Report Facts
Residents sampled for unnecessary medication use: 5
Residents with inconsistent physician ordered weights: 2
Resident discharged: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Wheeler | VP of Health Care Services | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | Listed as contact for assistance |
| Lanae Workman | Added Plan of Correction on 08/15/2018 | |
| Lacey Hunter | Modified Plan of Correction on 06/25/2019 |
Inspection Report
Renewal
Census: 68
Deficiencies: 1
Aug 14, 2018
Visit Reason
The inspection was conducted as a survey for re-licensure of the assisted living facility in Overland Park, KS on 8/9/18, 8/13/18, and 8/14/18.
Findings
The administrator failed to ensure disaster and emergency preparedness by not conducting quarterly reviews of the facility's emergency management plan with staff and residents, despite conducting monthly fire drills and evacuation drills annually.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure quarterly review of the facility's emergency management plan with staff and residents. | SS=F |
Report Facts
Residents present: 68
Sample residents reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff #A interviewed regarding disaster preparedness |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 9, 2018
Visit Reason
A revisit survey was conducted on 8/9/18 for all previous deficiencies cited on 6/21/18.
Findings
All deficiencies have been corrected as of the compliance date of 7/16/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 8
Jun 21, 2018
Visit Reason
The inspection was conducted as a Health Facility Resurvey and complaint investigation KS#121778.
Findings
The facility was found deficient in multiple areas including failure to adequately manage pain for a resident, failure to monitor and report blood sugar levels for another resident, improper storage of medications, unsanitary food preparation conditions, inadequate infection prevention and control practices, and lack of an antibiotic stewardship program.
Complaint Details
The visit was complaint-related as it included a complaint investigation KS#121778.
Severity Breakdown
SS=D: 2
SS=G: 1
SS=E: 1
SS=F: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to review and revise the care plan to ensure adequate pain management for resident #10 experiencing pain with movement of the left arm. | SS=D |
| Failure to provide adequate pain management interventions for resident #10, including non-pharmacological interventions and proper documentation of pain assessments. | SS=G |
| Failure to monitor and report blood sugar levels outside physician ordered parameters for resident #47, risking unnecessary medication use. | SS=D |
| Failure to properly store medications separate from food items in the medication refrigerator on unit #1. | SS=E |
| Failure to maintain sanitary conditions in the kitchen including dirty baking sheets, pots, rolling cart, and stove buildup. | SS=F |
| Failure to ensure nebulizer equipment was stored and sanitized properly and resident laundry areas were clean to prevent infection spread. | SS=F |
| Failure to track pneumococcal vaccinations for residents, risking infection control. | SS=F |
| Failure to establish an antibiotic stewardship program that includes monitoring and trending of infections, culture and sensitivity correlation, and infection resolution. | SS=F |
Report Facts
Resident census: 53
Residents sampled for review: 18
Residents reviewed for unnecessary medications: 5
Blood sugar readings above 300: 12
Residents on unit #1: 15
Baking sheets requiring replacement: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Restorative Staff | Named in pain management deficiency for resident #10, stopped exercises due to resident pain. |
| Staff H | Direct Care Staff | Named in pain management deficiency for resident #10, assisted resident with dressing despite pain complaints. |
| Staff D | Licensed Nursing Staff | Named in pain management deficiency for resident #10, explained documentation practices and pain reporting. |
| Staff B | Administrative Licensed Nursing Staff | Verified failure to review and revise resident #10's care plan for pain management. |
| Staff C | Licensed Staff | Confirmed improper storage of food in medication refrigerator on unit #1. |
| Staff G | Dietary Staff | Confirmed kitchen equipment required cleaning and replacement. |
| Staff I | Direct Care Staff | Observed handling of nebulizer equipment in unsanitary manner. |
| Staff J | Licensed Nursing Staff | Noted nebulizer equipment storage practices. |
| Staff L | Environmental Services Staff | Responsible for laundry area cleanliness, confirmed observations of unclean laundry areas. |
| Staff A | Licensed Nursing Administrative Staff | Confirmed lack of pneumococcal vaccination tracking and antibiotic stewardship program deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 7
Jun 21, 2018
Visit Reason
This document is a Plan of Correction submitted in response to an annual inspection conducted on June 21, 2018, addressing multiple deficiencies identified during the survey.
Findings
The facility was found deficient in several areas including inadequate pain management for a resident, failure to monitor blood sugar levels properly, improper storage of medications, unsanitary food preparation and storage conditions, inadequate infection prevention and control practices, and failure to establish an antibiotic stewardship program. Corrective actions and systemic changes were planned to address these deficiencies.
Severity Breakdown
D: 2
E: 1
F: 3
G: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to review and revise the plan of care to ensure adequate pain management for Resident 10. | D |
| Failure to ensure adequate pain management for Resident 10, including inadequate interventions to reduce pain during movement. | G |
| Failure to monitor and report Resident 47’s blood sugars within physician ordered parameters to avoid unnecessary medications. | D |
| Failure to properly store medications separate from food items in the medication refrigerator. | E |
| Failure to store, prepare, and serve food under sanitary conditions. | F |
| Failure to ensure nebulizer equipment was stored in a sanitary manner and maintain clean resident laundry areas. | F |
| Failure to establish an antibiotic stewardship program to track and trend infections through monitoring culture and sensitivity results. | F |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 15
Residents affected: 4
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Wheeler | VP of Health Care Services | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 3
Aug 3, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#KS00118449) and partial extended survey focusing on resident care planning and safety.
Findings
The facility failed to revise the care plan timely to prevent elopement of a cognitively impaired resident who eloped and sustained a compression fracture. The facility also failed to provide adequate supervision and timely interventions to prevent the elopement and fall. Additionally, the facility did not retain daily nurse staffing records for the required 18 months.
Complaint Details
Complaint investigation #KS00118449 focused on resident elopement and care planning deficiencies.
Severity Breakdown
SS=D: 1
SS=J: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to revise the care plan with timely interventions to prevent elopement of a resident with dementia and impaired cognition. | SS=D |
| Failed to provide adequate supervision and implement timely interventions to prevent elopement and fall with injury for a cognitively impaired resident. | SS=J |
| Failed to post and retain daily nurse staffing information for a minimum of 18 months. | SS=F |
Report Facts
Resident census: 77
Elopement risk score: 14
Days of missing nurse staffing records: 90
Date of resident admission: Jul 28, 2016
Date of resident elopement and fall: Jul 9, 2017
Date of immediate jeopardy abatement: Jul 25, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff H | Documented resident found outside after elopement and assisted with care. | |
| Licensed nursing staff I | Provided statements regarding elopement risk assessment and care plan requirements. | |
| Administrative nursing staff D | Provided statements on elopement risk, staffing records, and immediate jeopardy abatement. | |
| Direct care staff O | Provided care to resident on night of elopement. | |
| Direct care staff P | Provided care to resident and interviewed regarding events on elopement date. | |
| Direct care staff Q | Witnessed resident on ground after fall and assisted licensed nursing staff. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 3, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not to be in substantial compliance, with conditions constituting immediate jeopardy to resident health or safety related to F323, "J", CFR 483.25(d)(1)(2)(n)(1)-(3). Enforcement remedies including denial of payment for new admissions were imposed.
Severity Breakdown
immediate jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F323, "J", CFR 483.25(d)(1)(2)(n)(1)-(3) constituting immediate jeopardy to resident health or safety | immediate jeopardy |
Report Facts
Denial of payment effective date: Aug 24, 2017
Recommended provider agreement termination date: Feb 3, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter as Complaint Coordinator for Survey, Certification, and Credentialing Commission |
Inspection Report
Plan of Correction
Deficiencies: 3
Aug 3, 2017
Visit Reason
This Plan of Correction document responds to a complaint survey conducted on August 3, 2017, regarding deficiencies cited related to resident care and facility practices.
Findings
The facility failed to revise care plans timely to prevent elopement of a resident, failed to provide adequate supervision to prevent elopement and a fall with injury, and failed to retain daily nurse staffing information for 18 months. Corrective actions and quality assurance plans were outlined to address these deficiencies.
Complaint Details
The visit was complaint-related, triggered by allegations that the facility failed to revise care plans to prevent elopement, failed to provide adequate supervision leading to a resident's elopement and fall with injury, and failed to retain nurse staffing records. The resident eloped on 7/9/17 and was found after falling in the driveway, placing the resident in immediate jeopardy.
Severity Breakdown
D: 1
J: 1
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to revise the care plan with timely interventions to prevent the elopement of one resident. | D |
| Failure to provide adequate supervision and implement timely interventions to prevent elopement and a fall with injury for one resident. | J |
| Failure to retain daily nurse staffing information for a period of 18 months. | F |
Report Facts
Residents assessed for elopement risk: 5
Weeks of audits: 6
Daily 24 Hour Reports audited: 3
Nursing staff quizzed: 10
Weeks of CNA worksheet checks: 2
Months of elopement drills: 6
Logs audited per week: 3
Months of nurse staffing data retention: 18
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 15, 2016
Visit Reason
The health survey was conducted as a routine annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 15, 2016
Visit Reason
The Assisted Living/Residential Healthcare resurvey was conducted to assess compliance and verify correction of previous deficiencies.
Findings
The resurvey at the facility resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 15, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a health survey inspection for the facility Village Shalom conducted on 06/15/2016.
Findings
The health survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 15, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection, indicating the facility's corrective actions.
Findings
The resurvey resulted in a finding of no deficiency citations as of 06/15/2016.
Deficiencies (1)
| Description |
|---|
| No deficiency citations found upon resurvey. |
Inspection Report
Plan of Correction
Deficiencies: 3
Feb 13, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection.
Findings
The plan addresses deficiencies related to individualized and accurate resident care plans, dining service management including hair restraint and glove usage policies, and medication regimen review policies with physician notification and documentation.
Deficiencies (3)
| Description |
|---|
| Deficiency in individualizing and accuracy of resident care plans. |
| Deficiency in dining service management regarding proper use of hair restraints and glove usage. |
| Deficiency related to medication regimen review policy, including physician notification and documentation. |
Inspection Report
Follow-Up
Deficiencies: 3
Feb 13, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers F0279, F0371, and F0428 were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency identified under regulation 483.20(d), 483.20(k)(1) (F0279) |
| Deficiency identified under regulation 483.35(i) (F0371) |
| Deficiency identified under regulation 483.60(c) (F0428) |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 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 an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter regarding acceptance of plan of correction and enforcement decision. |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Jan 14, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS000079733 to assess compliance with care plan development, food sanitation, drug regimen review, and follow-up on pharmacy recommendations.
Findings
The facility failed to develop accurate and individualized care plans for residents, failed to serve food in a sanitary manner, and failed to follow up on pharmacy recommendations for multiple residents, resulting in unnecessary medication use and lack of documentation of follow-up actions.
Complaint Details
The visit was complaint-related as indicated by the Health Resurvey and Complaint Investigation #KS000079733.
Severity Breakdown
SS=D: 1
SS=F: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to develop individualized and accurate care plans for residents #131 and #52. | SS=D |
| Failure to serve food in a sanitary manner, including improper hair net use and glove use by dietary staff. | SS=F |
| Failure to follow up on pharmacy recommendations for residents #1, #43, #47, and #52, resulting in unnecessary medication use and lack of documentation. | SS=E |
Report Facts
Census: 72
Sample size: 10
Pharmacy recommendations not followed up: 4
Number of kitchenettes: 3
Number of days observed for kitchenettes: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Direct Care Staff | Mentioned in relation to care plan worksheets and behavior charting. |
| Staff J | Licensed Nursing Staff | Responsible for care plans and behavior charting. |
| Staff K | Licensed Nursing Staff | Responsible for care plans and documentation of pharmacy follow-up. |
| Staff D | Administrative Nursing Staff | Oversaw care plan accuracy and pharmacy recommendation follow-up. |
| Staff E | Administrative Nursing Staff | Responsible for ensuring care plan accuracy and pharmacy follow-up. |
| Staff DD | Dietary Worker | Observed not wearing gloves properly while serving food. |
| Staff EE | Dietary Staff | Provided information on infection control training. |
| Staff FF | Dietary Staff | Provided information on hair net usage. |
| Staff S | Direct Care Staff | Mentioned reassuring resident when scared. |
| Staff O | Direct Care Staff | Mentioned redirecting resident during behaviors. |
Inspection Report
Life Safety
Deficiencies: 1
Jun 4, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Sep 4, 2014
Effective date for provider agreement termination: Dec 4, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 7
Oct 18, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.15(b), 483.20(d), 483.20(k)(1), 483.25(a)(3), 483.25(i), 483.35(i), 483.35(i)(3), and 483.65 were corrected as of the revisit date.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 483.15(b) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.35(i)(3) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 7
Sep 25, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements related to resident rights, care planning, ADL care, nutrition, sanitation, garbage disposal, and infection control.
Findings
The facility failed to provide resident choice in bathing frequency, develop individualized comprehensive care plans for residents on psychoactive medications, provide equal bathing services to hospice residents, timely intervene for weight loss, maintain sanitary food preparation and garbage disposal areas, and prevent cross-contamination during room cleaning.
Severity Breakdown
SS=D: 5
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide choice in bathing frequency for one resident. | SS=D |
| Failed to develop individualized comprehensive care plans for three residents receiving antipsychotic medication. | SS=D |
| Failed to provide equal bathing/showering services to a hospice resident compared to non-hospice residents. | SS=D |
| Failed to provide timely nutritional interventions and document intake for a resident experiencing weight loss. | SS=D |
| Failed to prepare and serve food in a sanitary manner; missing paint and hair not fully contained by hats in kitchen. | SS=F |
| Failed to properly contain garbage in the garbage collection container; trash and food on ground around dumpster. | SS=F |
| Failed to prevent cross contamination and follow manufacturer guidelines during room cleaning; improper glove use and disinfectant contact time. | SS=D |
Report Facts
Census: 71
Sample size: 19
Resident weight loss: 5
Resident weight: 147
Resident weight: 125
Disinfectant contact time: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| House keeper X | Named in infection control deficiency for improper glove use and cleaning procedure | |
| licensed nurse J | Licensed Nurse | Interviewed regarding resident bathing preferences |
| direct care staff R | Interviewed regarding resident behavior and care | |
| direct care staff S | Interviewed regarding resident behavior and care | |
| licensed staff H | Licensed Staff | Interviewed regarding resident behavior and care |
| licensed staff I | Licensed Staff | Interviewed regarding resident behavior and care |
| direct care staff O | Interviewed regarding resident behavior and care | |
| direct care staff T | Interviewed regarding resident behavior and care | |
| licensed nursing staff K | Licensed Nursing Staff | Interviewed regarding resident behavior and care |
| administrative licensed staff E | Administrative Licensed Staff | Acknowledged care plan deficiencies |
| hospice licensed nurse KK | Hospice Licensed Nurse | Interviewed regarding hospice bathing schedule |
| direct care staff P | Interviewed regarding hospice bathing schedule | |
| direct care staff Q | Interviewed regarding hospice bathing schedule | |
| administrative nursing staff D | Administrative Nursing Staff | Interviewed regarding hospice bathing and infection control |
| dietary staff DD | Dietary Staff | Interviewed regarding nutritional supplement and kitchen sanitation |
| administrative nursing staff E | Administrative Nursing Staff | Interviewed regarding nutritional documentation |
| Housekeeping/maninence staff Y | Interviewed regarding disinfectant use |
Inspection Report
Renewal
Deficiencies: 0
Sep 25, 2013
Visit Reason
The Licensure Resurvey of the facility was conducted to assess compliance and determine if any deficiencies were present.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Aug 7, 2013
Visit Reason
The inspection was conducted as a result of complaint investigations #KS 63510, 66815, 67078 to assess compliance with regulations related to resident supervision and care.
Findings
The facility failed to provide adequate supervision to prevent elopement for two residents in the adult day care program, placing them in immediate jeopardy. Additionally, the facility failed to provide effective supervision to prevent multiple falls with head injury for one cognitively impaired resident, resulting in serious harm including an intracranial bleed.
Complaint Details
The inspection was triggered by complaints #KS 63510, 66815, 67078. The facility was found to have immediate jeopardy related to elopement risks and deficiencies in supervision and fall prevention.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to have a system in place to provide adequate supervision to prevent elopement for 2 residents in the adult day care program, placing residents in immediate jeopardy. | Immediate Jeopardy |
| Failed to provide effective supervision for one resident to prevent multiple falls with head injury, including lack of timely investigations and notification to medical director. | — |
Report Facts
Census - Assisted Living Facility: 63
Census - Adult Day Care: 10
Residents Sampled: 3
Falls: 12
Temperature: 82
Wind Speed: 16
Wind Speed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Staff G | Reported residents at risk for elopement and described elopement incidents. | |
| Licensed Nursing Staff A | Confirmed resident left facility unattended and described resident behavior. | |
| Social Services Staff D | Reported on resident elopement and typical dementia behaviors. | |
| Dietary Staff N | Observed resident walking outside and helped return resident to building. | |
| Therapy Staff E | Reported on resident's therapy history and fall incidents. | |
| Licensed Nursing Staff C | Reported resident's confusion, falls, and communication with primary care physician. | |
| Administrative Staff B | Reported on resident's medication administration issues and facility's response to safety concerns. |
Inspection Report
Follow-Up
Deficiencies: 3
Jul 2, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.20(d), 483.20(k)(1), 483.25(h), and 483.25(l) were corrected as of 07/02/2012.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 3
Jun 12, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously identified deficiencies and overall facility regulatory requirements.
Findings
The facility failed to develop comprehensive care plans for residents including dental and side rail care plans, failed to maintain a safe environment by not monitoring hot water temperatures in unlocked utility rooms, and failed to ensure drug regimens were free from unnecessary drugs including lack of Black Box Warning documentation and inadequate monitoring of medication side effects.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop a dental plan of care for resident #113 and failed to develop a side rail plan of care for resident #161. | SS=D |
| Failed to ensure the resident environment remained free of accident hazards by not monitoring hot water temperatures in two unlocked utility rooms. | SS=E |
| Failed to ensure drug regimens were free from unnecessary drugs, including failure to provide Black Box Warning side effects for Seroquel and failure to monitor side effects of medication for resident #98. | SS=D |
Report Facts
Census: 65
Residents sampled: 19
Residents sampled for unnecessary drugs: 10
Hot water temperature: 136.9
Hot water temperature: 138
Hot water temperature: 128.3
Hot water temperature: 127.2
Pulse: 43
Pulse: 40
Medication dose: 25
Document
Deficiencies: 0
N046054 POC ICJN11
Visit Reason
The document intended to provide details related to a plan of correction or inspection report, but the page is not available due to a rendering error.
Findings
No findings or content are available as the page failed to render and display the report details.
Document
Deficiencies: 0
N046054 POC 2TQM11
Visit Reason
The document intended to provide details related to a plan of correction or inspection report, but the page is not available due to a rendering error.
Findings
No findings or content are available as the page failed to render.
Loading inspection reports...
