Inspection Reports for
Village Shalom Inc
5500 W 123RD STREET, OVERLAND PARK, KS, 66209
Back to Facility ProfileDeficiencies (last 13 years)
Deficiencies (over 13 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
112% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
98% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 21, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-06-04.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 2025-07-15, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2025-06-04, all corrected by 2025-07-15
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Jul 15, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection, outlining corrective actions to address specific regulatory findings.
Findings
The Plan of Correction details multiple corrective actions including care plan updates, staff education, audits, and policy reviews to address issues such as resident dignity and privacy, Medicare notification compliance, antipsychotic medication use, mealtime assistance, daily weight monitoring, mattress settings, oxygen storage security, medication administration, food storage, hand hygiene, and nurse aide training compliance.
Deficiencies (15)
F550-D: Resident #31’s care plan was updated to address undressing behaviors and privacy preferences with staff education on dignity and respect.
F582-D: Resident 165’s Medicare notification was reviewed with counseling provided; facility policies and staff training on Medicare coverage notifications were updated.
F605-D: Clinical records for Residents #50 and #1 were reviewed for antipsychotic use with updated care plans and staff education on medication use and monitoring.
F677-D: Nursing staff re-educated on supervision during meals; audits and a Meal Assistance Review Team were implemented to ensure mealtime ADL needs are met.
F684-D: Missed daily weights were addressed with physician notification, audits, staff re-education, and monitoring protocols.
F686-D: Low air loss mattress settings were audited and staff re-educated on proper use and documentation to prevent pressure ulcers.
F689-E: Oxygen storage areas were secured and audited; resident call light accessibility and mealtime assistance care plans were reviewed and updated.
F756-D: Consultant Pharmacist recommendations for Resident 50’s medication were reviewed with updated orders and staff education on documentation requirements.
F757-D: Resident #50’s medication orders were reviewed and updated; staff re-educated on administration guidelines and audits initiated.
F760-D: Medication orders with specific parameters were reviewed facility-wide; staff re-educated on medication error definitions and procedures.
F761-D: Unattended, unlocked medication cart was secured immediately; audits and staff training on medication cart security were implemented.
F808-D: Supplement schedules were revised based on resident preferences; staff re-educated and audits initiated to ensure compliance with orders.
F812-F: Food storage procedures were reviewed and updated; staff re-educated on proper storage, hygiene, and contamination prevention with audits planned.
F880-E: Staff re-educated on hand hygiene and equipment disinfection; updated competencies and audits implemented to ensure compliance.
F947-D: Nurse aides non-compliant with in-service training were given deadlines to complete hours; audits and tracking systems implemented for ongoing compliance.
Report Facts
Resident care plans audited weekly: 5
Audit duration for psychotropic medication orders: 12
Audit duration for medication cart observations: 4
Audit duration for hand hygiene audits: 5
Nurse aide in-service training deadline: 2025
Compliance achievement date: 2025
Inspection Report
Routine
Census: 65
Deficiencies: 15
Date: Jun 4, 2025
Visit Reason
Routine health resurvey of Village Shalom Inc nursing facility to assess compliance with resident rights, medication management, care quality, 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, inconsistent assistance with activities of daily living, failure to follow physician orders for daily weights and medication administration, unsafe storage of oxygen tanks and chemicals, inadequate infection control practices, improper food handling and serving practices, and incomplete nurse aide in-service training.
Deficiencies (15)
F 550 Resident Rights: The facility failed to ensure a dignified care environment for Resident 31 who was found naked and exposed in his room, visible from hallway and outside, despite cognitive impairment and care refusal behaviors.
F 582 Medicaid/Medicare Coverage: The facility failed to provide required Medicare non-coverage notices to Resident 165, placing the resident at risk for uninformed treatment decisions and unexpected costs.
F 605 Chemical Restraints: The facility failed to ensure appropriate indication and physician rationale for continued use of antipsychotic medications for Residents 50 and 1 with dementia, risking unnecessary medication use and side effects.
F 677 ADL Care: The facility failed to provide consistent assistance and supervision to Resident 19 during meals, risking impaired nutrition and weight loss.
F 684 Quality of Care: The facility failed to follow physician orders for daily weights for Resident 17 with congestive heart failure, risking delayed treatment of fluid overload.
F 686 Pressure Ulcer Prevention: The facility failed to ensure Resident 19's low air-loss mattress was set to her current weight, risking skin breakdown and pressure ulcers.
F 689 Accident Hazards: The facility failed to secure pressurized oxygen tanks and cleaning chemicals in locked areas and failed to provide Resident 19 with consistent supervision during meals and ensure call light accessibility.
F 756 Drug Regimen Review: The facility failed to address consultant pharmacist recommendations and ensure physician documentation for irregularities related to unnecessary medications for Residents 50 and 1.
F 757 Unnecessary Drugs: The facility failed to administer Resident 50's hypotension medication per physician orders, risking unnecessary medication use and adverse effects.
F 760 Medication Errors: Resident 50 was at risk for medication errors due to failure to follow physician-ordered parameters for Midodrine administration.
F 761 Drug Storage: Medication carts were left unlocked and unattended, risking unauthorized access and medication errors.
F 808 Therapeutic Diet: The facility failed to follow Resident 19's order to provide Ensure supplementation 30 minutes after meals, risking impaired nutrition and weight loss.
F 812 Food Safety: The facility failed to ensure opened frozen food packages were sealed and labeled, staff wore hairnets, served food in a sanitary manner, and performed hand hygiene after serving, risking foodborne illness.
F 880 Infection Control: Staff failed to perform hand hygiene before glucose checks and IV medication administration and failed to sanitize shared equipment between residents, risking infection transmission.
F 947 Nurse Aide Training: The facility failed to ensure direct care staff completed the required 12 hours of annual in-service training, risking impaired care quality.
Report Facts
Resident census: 65
Deficiency sample size: 16
Medication review period: 12
Missed daily weights: 9
Missed Midodrine administration: 49
Opened frozen food packages without label: 3
Oxygen cylinders unsecured: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements on resident rights, medication orders, infection control, and supervision expectations |
| Licensed Nurse I | Licensed Nurse | Interviewed regarding medication indications and infection control practices |
| Licensed Nurse H | Licensed Nurse | Discussed medication administration responsibilities and vital sign monitoring |
| Licensed Nurse G | Licensed Nurse | Observed not performing hand hygiene and discussed medication administration |
| Certified Nurse Aide N | Certified Nurse Aide | Discussed care plan adherence and supervision during meals |
| Certified Nurse Aide M | Certified Nurse Aide | Observed not sanitizing Hoyer lift and discussed lift cleaning practices |
| Dietary Staff CC | Dietary Staff | Observed not wearing hairnet and discussed food handling practices |
| Dietary Services BB | Dietary Services | Discussed hairnet use and food storage policies |
| Administrative Staff A | Administrative Staff | Discussed nurse aide in-service training responsibilities |
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 4
Date: 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, and did not comply with tuberculosis screening guidelines for residents.
Deficiencies (4)
KAR 26-41-202(a)(1)(2) The administrator failed to ensure negotiated service agreements for residents 3 and 6 described the services they received based on their functional capacity screens.
KAR 26-41-205(g)(3) The administrator failed to ensure licensed staff placed residents' full names on original packages of eight over-the-counter medications in assisted living.
KAR 26-41-104(d)(3) The administrator failed to provide evidence that quarterly reviews of the emergency management plan with staff and residents were completed in 2023.
KAR 26-41-207(c) The administrator failed to ensure compliance with tuberculosis guidelines, including missing second-step TB skin tests and annual symptom screenings for three residents.
Report Facts
Resident census: 71
Residents in sample: 6
OTC medications without resident names: 8
Residents in assisted living: 48
Residents in memory care: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse G | Administrative Nurse | Confirmed services not described in negotiated service agreements and missing TB test documentation |
| Administrative Nurse F | Administrative Nurse | Confirmed negotiated service agreement deficiencies for resident 6 |
| Certified Medication Aide D | Certified Medication Aide | Confirmed unlabeled OTC medications on second-floor medication cart |
| Certified Medication Aide E | Certified Medication Aide | Confirmed unlabeled OTC medications on first-floor medication cart |
| Administrative Staff A | Administrative Staff | Confirmed lack of documentation for quarterly emergency plan reviews |
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 4
Date: Feb 8, 2024
Visit Reason
The inspection was a resurvey of an assisted living facility conducted to verify 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, and did not comply with tuberculosis screening guidelines for residents.
Deficiencies (4)
KAR 26-41-202(a)(1)(2) The administrator failed to ensure negotiated service agreements for residents 3 and 6 described the services they received based on their functional capacity screens.
KAR 26-41-205(g)(3) The administrator failed to ensure licensed staff placed residents' full names on original packages of eight over-the-counter medications in assisted living.
KAR 26-41-104(d)(3) The administrator failed to provide evidence of quarterly reviews of the emergency management plan with staff and residents for 2023.
KAR 26-41-207(c) The administrator failed to ensure compliance with tuberculosis guidelines, including missing second-step TB tests and annual symptom screenings for three residents.
Report Facts
Census: 71
Census: 48
Census: 23
Over-the-counter medications not labeled: 8
Residents included in sample: 6
OTC medications not labeled on second floor: 4
OTC medications not labeled on first floor: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse G | Administrative Nurse | Confirmed negotiated service agreement and tuberculosis testing deficiencies |
| Administrative Nurse F | Administrative Nurse | Confirmed negotiated service agreement deficiency for resident 6 |
| Certified Medication Aide D | Certified Medication Aide | Observed unlabeled OTC medications on second-floor medication cart |
| Certified Medication Aide E | Certified Medication Aide | Observed unlabeled OTC medications on first-floor medication cart |
| Administrative Staff A | Administrative Staff | Confirmed lack of documentation for emergency management plan quarterly reviews |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
The document represents a plan of correction submitted following a resurvey of an assisted living facility conducted on February 7 and 8, 2024.
Findings
The plan of correction addresses findings from the resurvey conducted on the specified dates. No specific deficiencies or findings are detailed in this document.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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 have been corrected as of the compliance date of 11/20/23 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Oct 19, 2023
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during the inspection conducted on October 19, 2023.
Findings
The Plan of Correction addresses multiple areas including resident dignity during care and meal service, engagement with the Resident Council, abuse and neglect policies, 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 has implemented training, audits, policy reviews, and ongoing monitoring to achieve compliance by November 20, 2023.
Deficiencies (12)
F550-D: Resident dignity concerns were identified related to medication administration via feeding tube and meal service, including kosher meal availability and resident preferences.
F565-E: Resident Council engagement and response to concerns required improvement, including timely communication and follow-up on resident issues.
F609-D: A thorough investigation was conducted regarding an incident on 9/30/2023, and abuse, neglect, and exploitation policies were reviewed and reinforced with staff training.
F677-D: Personal hygiene and bathing services were not consistently documented or aligned with resident preferences; a manual recordkeeping process was implemented.
F684-D: Skin impairment was investigated and treated; skin assessments and wound management training were implemented with ongoing audits.
F686-G: Comprehensive skin assessments and interventions were completed for identified residents; ongoing audits and staff training were conducted.
F689-G: Fall risk assessments and interventions were updated; staff training on fall management and visitor education on safety hazards were conducted.
F756-E: Psychotropic medication orders were reviewed and updated with appropriate stop dates; staff and physicians received education on medication use and monitoring.
F758-E: Medication lists were reviewed and updated to ensure appropriate stop dates and informed consents for psychotropic medications.
F851-F: PBJ reporting protocols were reviewed and staff trained to ensure accurate and timely data submission with ongoing audits.
F882-F: A Licensed Nurse Infection Preventionist was appointed; infection prevention policies were reviewed and staff trained with ongoing audits planned.
F883-E: Pneumococcal vaccinations were administered per physician orders and consents; staff training and audits were implemented to ensure compliance.
Report Facts
Compliance deadline: Nov 20, 2023
Training date: Nov 8, 2023
Incident date: Sep 30, 2023
Infection Preventionist appointment date: Nov 3, 2023
Pharmacist consultant start date: Nov 6, 2023
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 12
Date: Oct 19, 2023
Visit Reason
Health Resurvey and Complaint #KS00180119 investigation including review of resident rights, care quality, reporting of alleged violations, ADL care, pressure ulcers, medication regimen, staffing, infection prevention, and immunizations.
Complaint Details
The inspection was triggered by Complaint #KS00180119 and included a health resurvey.
Findings
The facility had multiple deficiencies including failure to promote resident dignity, failure to act on resident council concerns, failure to report an unwitnessed fall with injury, inadequate ADL care, failure to prevent and treat pressure ulcers, inadequate supervision leading to resident falls, failure to identify and report medication irregularities, failure to submit accurate staffing data, failure to ensure qualified infection preventionist, and failure to provide pneumococcal vaccinations.
Deficiencies (12)
F550 Resident Rights. The facility failed to promote dignity for residents during medication administration and meal service, exposing residents to undignified care.
F565 Resident/Family Group. The facility failed to act promptly on resident council concerns about staffing, food quality, and call light response, risking decreased quality of care.
F609 Reporting of Alleged Violations. The facility failed to report an unwitnessed fall with fracture and injuries for a resident to the State Agency within required timeframes.
F677 ADL Care. The facility failed to provide necessary bathing services for a resident, placing them at risk for poor hygiene and infection.
F684 Quality of Care. The facility failed to follow up and document treatment for a resident's skin tear and failed to prevent and treat pressure ulcers for multiple residents.
F686 Treatment to Prevent/Heal Pressure Ulcer. The facility failed to implement interventions to prevent and adequately treat pressure ulcers and deep tissue injuries for multiple residents.
F689 Free of Accident Hazards/Supervision. The facility failed to provide adequate supervision and a safe environment, resulting in falls with fractures and injuries for two residents.
F756 Drug Regimen Review. The facility failed to ensure the consultant pharmacist identified and reported medication irregularities including lack of indications and stop dates for psychotropic and antianxiety medications for multiple residents.
F758 Free from Unnecessary Psychotropic Medications. The facility failed to ensure appropriate indications, physician rationale, and stop dates for psychotropic and PRN antianxiety medications for multiple residents.
F851 Payroll Based Journal. The facility failed to submit accurate direct care staffing information to CMS for FY 2022 Quarter 4, risking unidentified and ongoing inadequate nurse staffing.
F882 Infection Preventionist Qualifications. The facility failed to ensure the designated Infection Preventionist possessed required education, training, experience, and certification.
F883 Influenza and Pneumococcal Immunizations. The facility failed to ensure four residents received pneumococcal vaccinations as consented, risking disease spread and complications.
Report Facts
Resident census: 66
Deficiencies cited: 12
Fall incidents: 5
Medication administration dates: 5
Days without shower: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Certified Medication Aide | Designated Infection Preventionist and involved in medication administration and infection control |
| LN H | Licensed Nurse | Involved in wound care and medication administration |
| Administrative Nurse D | Provided multiple statements regarding fall investigations, medication irregularities, and immunization status | |
| Consultant GG | Consultant | Consultant supporting Infection Preventionist role |
| LN J | Licensed Nurse | Wound nurse and infection control support |
| CMA M | Certified Nurse Aide | Involved in resident care and fall supervision |
| LN K | Licensed Nurse | Involved in wound care and medication administration |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 8, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-08-03.
Findings
All deficiencies have been corrected as of the compliance date of 2023-08-29, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation identified by complaint investigation #KS00181449.
Complaint Details
The findings represent the results of complaint investigation #KS00181449. The complaint was substantiated as evidenced by the cited deficiency.
Findings
The facility failed to ensure Resident 1's diuretic medication was properly administered, weights were monitored, and medication changes were clarified. This failure placed the resident at risk for complications related to heart failure and fluid overload.
Deficiencies (1)
F684 Quality of Care: The facility failed to administer Resident 1's diuretic medication as ordered, monitor weights, and clarify medication changes. This placed the resident at risk for heart failure complications and fluid overload.
Report Facts
Resident census: 65
Medication administration opportunities: 14
Medication administration opportunities: 6
Weight measurements: 10
Weight measurements: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant GG | Consultant | Entered medication orders and noted failure to clarify dosage; expected nurses to clarify orders and obtain daily weights. |
| LN G | Licensed Nurse | Reported resident's increased shortness of breath, called 911, and provided information about medication orders and weight monitoring. |
| Administrative Nurse D | Administrative Nurse | Reported on medication order entry issues and expectations for nurses to notify physicians of order clarifications and weight changes. |
| Administrative Nurse E | Administrative Nurse | Reported on charge nurse's lack of awareness of medication orders and documentation procedures for weights. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
This document is a Plan of Correction submitted by Village Shalom in response to deficiencies cited during a prior inspection on August 3, 2023.
Findings
The plan addresses issues related to weight monitoring accuracy and medication/treatment order communication processes. The facility outlines corrective actions including staff education, updated documentation procedures, and ongoing audits to ensure compliance.
Deficiencies (1)
F684-D: Resident weight monitoring orders were clarified and timing changed. The Electronic Health Record and reporting sheets were updated to ensure accurate weight documentation.
Report Facts
Weeks of audit reporting: 12
Months of QA Committee reporting: 3
Plan of Correction completion date: 2023
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
The abbreviated survey was conducted in response to complaints numbered 181648 and 180545 at the assisted living facility.
Complaint Details
The survey was complaint-related for complaints #181648 and #180545 and found no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
The visit was an abbreviated survey conducted on 07/31/23 and 08/01/23 related to complaints #181648 and #180545 at the assisted living facility.
Findings
The abbreviated survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
An abbreviated survey was conducted in response to complaints #178632, #178634, and #178377.
Findings
The survey resulted in no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
An abbreviated survey was conducted for complaints #178632, #178634, and #178377 on 03/07/23 at the facility.
Findings
The abbreviated survey resulted in no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Nov 1, 2022
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-201(a)(b), 26-41-202(a), 26-41-204(d), 26-41-102(d), and 26-41-207(b)(5-6)(c) were corrected as of the revisit date.
Deficiencies (5)
Regulation 26-41-201(a)(b) deficiency was corrected as of 11/01/2022.
Regulation 26-41-202(a) deficiency was corrected as of 11/01/2022.
Regulation 26-41-204(d) deficiency was corrected as of 11/01/2022.
Regulation 26-41-102(d) deficiency was corrected as of 11/01/2022.
Regulation 26-41-207(b)(5-6)(c) deficiency was corrected as of 11/01/2022.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies.
Findings
All previously reported deficiencies have been corrected as of the revisit date. The report documents completion of corrective actions for multiple regulatory citations.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
All previously cited deficiencies listed with regulation numbers 26-41-201(a)(b), 26-41-202(a), 26-41-204(d), 26-41-102(d), and 26-41-207(b)(5-6)(c) were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the date 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.
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 5
Date: Sep 27, 2022
Visit Reason
The inspection was a licensure resurvey with complaint investigations for complaint numbers 174462, 174463, 173752, and 171792 conducted over 09/26/22 to 09/28/22.
Complaint Details
The inspection was conducted as a licensure resurvey with complaint investigations for complaint numbers 174462, 174463, 173752, and 171792.
Findings
The facility failed to complete and document the Functional Capacity Screen (FCS) properly for resident R112, including cognitive impairment. The Negotiated Service Agreement (NSA) and Health Care Service Plan (HSP) lacked required details such as management of wandering behaviors, assistance with decision making, and the name of the licensed nurse responsible for supervision for multiple residents. Employee records lacked required documentation from the Kansas nurse aide registry and tuberculosis (TB) testing compliance was not met for several employees and resident R112.
Deficiencies (5)
K.A.R. 26-41-201 (a) The facility failed to ensure the Functional Capacity Screen for resident R112 was completed and documented cognitive impairment at or prior to admission to the locked memory care unit.
K.A.R. 26-41-202 (a) The facility failed to ensure the Negotiated Service Agreement for resident R112 included a description of services required based on cognitive impairment prior to admission to the locked memory care unit.
K.A.R. 26-41-204 (d) The facility failed to include the name of the licensed nurse responsible for supervision and implementation of the Health Care Service Plan for residents R112, R116, R118, and R120.
K.A.R. 26-41-102 (d) The facility failed to have supporting documentation from the Kansas nurse aide registry that newly hired Certified Medication Aide (CMA) A did not have findings of abuse, neglect, or exploitation.
K.A.R. 26-41-207 (b)(5-6) (c) The facility failed to comply with tuberculosis guidelines for adult care homes for resident R112 and newly hired personnel CMA A, Licensed Nurse C, and Certified Nurse Aide D, lacking required two-step TB test documentation.
Report Facts
Census: 71
Residents sampled: 5
Newly hired employees sampled: 5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 23, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-02-07.
Findings
All deficiencies have been corrected as of the compliance date of 2022-03-07, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 4
Date: Feb 7, 2022
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with previously identified deficiencies.
Findings
The facility failed to include residents and their representatives in care planning, failed to accommodate resident needs such as appropriate dining table height, left hazardous chemicals unsecured in a memory care unit, and did not provide a timely Registered Dietician assessment for a resident on dialysis.
Deficiencies (4)
F553: The facility failed to include residents R26 and R27 and their representatives in the development and planning of their care plans, risking unmet needs.
F558: The facility failed to provide Resident R2 with a dining table of appropriate height to facilitate comfort and ease of independent eating, risking discomfort during meals.
F689: The facility failed to maintain a safe environment by leaving flammable chemicals in an unlocked cabinet on the memory care unit, placing five cognitively impaired residents at risk of harm.
F692: The facility failed to provide a Registered Dietician assessment within 24 hours of admission for Resident R93 on dialysis, risking unmet nutritional needs.
Report Facts
Resident census: 47
Sample size: 12
Days until RD assessment: 11
Volume of nail polish remover: 6
Volume of adhesive spray: 10
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Feb 7, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including care plan meeting documentation, dining accommodations, hazardous chemical storage, and nutritional risk assessments. Corrective actions and monitoring plans are outlined with completion dates.
Deficiencies (4)
F553-D: A signature sheet for all care plan meetings has been implemented to ensure resident and representative involvement. Review of other resident records will be conducted to verify care plan participation.
F558-D: Resident R2 was provided an adjustable table to meet dining needs. Dining observations will be conducted to ensure accommodations and preferences are met.
F689-E: Hazardous chemicals in the identified area were locked upon notification. Staff will receive re-education on proper chemical storage with ongoing compliance monitoring.
F692-D: A nutritional risk assessment for Resident R93 was completed by the Registered Dietician. Audits will ensure timely nutritional assessments for all residents per policy.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 21, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of CMS to assess the facility's compliance with recommended COVID-19 practices.
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
Date: 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
Plan of Correction
Deficiencies: 0
Date: Sep 9, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of CMS on 9/9/2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 9, 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. No deficiencies were cited in this survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 3, 2020
Visit Reason
The facility underwent a special infection control survey for COVID-19 conducted on August 3, 2020.
Findings
The survey resulted in findings of no deficiency citations related to infection control.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 27, 2020
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2020-03-16.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2020-04-14. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Routine
Census: 40
Deficiencies: 0
Date: 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.
Report Facts
Sample Size: 5
Supplemental: 0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
A COVID-19 Focused Infection Control survey was conducted on 06/23/2020. The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 13
Date: 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.
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 was found not in substantial compliance with 42 CFR 483 subpart B and immediate jeopardy was identified due to failure to prevent abuse and protect residents during the investigation.
Findings
The facility failed to prevent resident to resident sexual abuse by Resident 9 towards cognitively impaired female residents. The facility also failed to report the abuse allegations timely and failed to protect residents during the investigation. Additional deficiencies were found related to medication administration, infection control, respiratory care, dialysis communication, CNA performance reviews, and psychosocial care.
Deficiencies (13)
F600: The facility failed to prevent resident to resident sexual abuse by Resident 9 towards cognitively impaired female residents on 01/23/20 and 02/23/20, placing residents in immediate jeopardy until corrective measures were implemented on 03/12/20.
F609: The facility failed to report allegations and/or suspicions of resident to resident sexual abuse to the appropriate state and law enforcement agencies within the required timeframe.
F610: The facility failed to protect residents from abuse while investigating episodes of resident to resident sexual abuse and failed to implement effective interventions to protect cognitively impaired female residents during the investigation.
F640: The facility failed to electronically transmit completed Minimum Data Set (MDS) data to CMS within 14 days after completion for two residents.
F677: The facility failed to provide incontinence care as directed by the comprehensive care plan for one resident, risking urinary tract infections, skin breakdown, and discomfort.
F695: The facility failed to date and properly store oxygen tubing and nebulizer equipment for one resident, risking transmission of infections.
F698: The facility failed to utilize a system for communication between the facility and the dialysis center for one resident, risking ineffective communication and unrecognized complications.
F730: The facility failed to complete annual performance reviews for Certified Nurse Aides, risking competent care provision.
F742: The facility failed to provide individualized care and interventions to respond to Resident 9's mental health needs, resulting in increased anxiety, depression, and impaired psychosocial well-being.
F755: The facility failed to ensure medications were available and administered as ordered by the physician for Resident 9, risking unwarranted and unrecognized medical complications.
F756: The facility failed to ensure the consultant pharmacist identified medications not administered as ordered by the physician for Resident 10.
F757: The facility failed to ensure medications were administered as ordered by the physician for Resident 10, risking unnecessary medication administration and possible harmful side effects.
F880: The facility failed to ensure the use of standard infection precautions for the proper storage and handling of supplemental oxygen tubing for one resident.
Report Facts
Resident census: 44
Deficiency counts: 12
MDS completion delay: 2
Medication non-administration: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Involved in investigation and reporting of resident to resident sexual abuse | |
| Administrative Nurse D | Involved in investigation, reporting, and medication administration oversight | |
| Social Service X | Provided psychosocial support and investigation follow-up for Resident 9 | |
| Certified Nurse Aid O | CNA | Witnessed and reported resident to resident sexual abuse incident |
| Certified Medication Aid R | CMA | Provided medication administration and reported mood changes |
| Licensed Nurse G | LN | Provided care and observations related to oxygen tubing and resident care |
| Certified Nurse Aide M | CNA | Provided care and observations related to incontinence care |
| Licensed Nurse H | LN | Provided care and observations related to medication administration and oxygen tubing |
| Certified Nurse Aide N | CNA | Provided care and observations related to resident behavior and medication administration |
| Licensed Nurse I | LN | Provided care and observations related to resident behavior and medication administration |
| Social Service LL | Involved in investigation of resident to resident sexual abuse | |
| Certified Medication Aid S | CMA | Witnessed and reported resident to resident sexual abuse incident |
| Certified Nurse Aide P | CNA | Received complaint from resident and representative about sexual abuse incident |
| Licensed Nurse J | LN | Provided care and observations related to resident behavior and abuse investigation |
| Vice President Healthcare Services | Involved in investigation of resident to resident sexual abuse |
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Mar 16, 2020
Visit Reason
This document is a Plan of Correction responding to deficiencies identified during a facility inspection conducted on March 16, 2020. It addresses multiple allegations of noncompliance related to resident abuse, reporting, investigation, care practices, medication administration, infection control, and other regulatory requirements.
Findings
The facility was found deficient in preventing resident-to-resident abuse, timely reporting of abuse allegations, protecting residents during investigations, timely transmission of MDS data, providing incontinence care, maintaining respiratory equipment, communication with dialysis centers, completing nurse aide performance reviews, addressing mental health needs, ensuring medication availability and administration, and infection prevention related to oxygen tubing.
Deficiencies (13)
F600 The facility failed to prevent resident to resident abuse.
F609 The facility failed to report allegations and/or suspicions of resident to resident sexual abuse to the appropriate state and law enforcement agencies within the required timeframe.
F610 The facility failed to protect residents from abuse while investigating episodes of resident to resident sexual abuse.
F640 The facility failed to electronically transmit completed Minimum Data Set (MDS) data to CMS within 14 days after completion for two residents.
F677 The facility failed to provide incontinence care as the comprehensive care plan directed for one resident.
F695 The facility failed to replace, date, and store oxygen tubing and nebulizer equipment.
F698 The facility failed to utilize a system for communication to the dialysis center.
F730 The facility failed to complete annual performance reviews for the Certified Nurse Aides (CNAs).
F742 The facility failed to provide person centered interventions to alleviate acute stress, anxiety and depression.
F755 The facility failed to ensure medications were available for administration as ordered by physician.
F756 The facility failed to ensure the Consultant Pharmacist identified medication not administered as ordered by the physician and failed to ensure the care plan identified medications were not administered as ordered by physician.
F757 The facility failed to ensure that medication were administered as ordered by physician.
F880 The 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. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 16, 2020
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-11-26.
Findings
All deficiencies had been corrected as of the compliance date 2019-12-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Nov 26, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint investigations identified by numbers KS00147811, KS00147387, KS00148028, and KS00147663.
Complaint Details
The investigation was triggered by complaints identified as KS00147811, KS00147387, KS00148028, and KS00147663. The facility's discharge of Resident 1 was found to be unsupported by clinical or physician documentation, placing the resident at risk for involuntary discharge without proper cause.
Findings
The facility inappropriately issued an involuntary discharge notice to Resident 1 without sufficient clinical or physician documentation to justify the discharge. The facility failed to provide evidence that the resident endangered others or that the resident's needs could not be met at the facility.
Deficiencies (1)
F622 Transfer and Discharge Requirements: The facility issued a 30-day involuntary discharge notice to Resident 1 without documentation validating the reason for discharge, including lack of physician documentation or evidence of resident endangering others or unmet needs.
Report Facts
Resident census: 47
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided statements regarding Resident 1's discharge related to inappropriate actions towards staff | |
| Administrative Staff B | Confirmed discharge was based on actions towards staff, not residents | |
| Certified Nurse Aide M | Certified Nurse Aide | Reported no observed inappropriate behavior by Resident 1 towards residents or staff |
| Administrative Nurse D | Administrative Nurse | Reported Interdisciplinary Team review and lack of documentation in clinical chart |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 26, 2019
Visit Reason
The Plan of Correction addresses allegations of improper issuance of an involuntary discharge notice to a resident without clinical record validation.
Findings
The facility was found to have improperly issued an involuntary discharge notice to Resident 1 without proper clinical justification as per the surveyor's allegations.
Deficiencies (1)
F622 – Transfer and Discharge Requirements: The facility improperly issued an involuntary discharge notice to Resident 1 though the clinical record did not validate the reason for the discharge.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 28, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-04-25.
Findings
All deficiencies have been corrected as of the compliance date of 2019-05-24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 5
Date: Apr 25, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for facility compliance with regulatory requirements.
Complaint Details
The inspection included a complaint investigation identified by complaint numbers #KS00140062 and #KS00134790.
Findings
The facility failed to provide written notification of hospitalization to a resident and/or responsible party, failed to timely revise care plans and implement fall prevention interventions for a high-risk resident, and failed to ensure adequate drug regimen review and monitoring, including inconsistent blood sugar monitoring and failure to notify physicians of out-of-range blood sugar levels. Additionally, the facility failed to obtain consistent physician-ordered daily weights for residents with specific medical conditions.
Deficiencies (5)
F623: The facility failed to provide written notification of the reason for hospitalization to resident #55 or their responsible party.
F657: The facility failed to review and revise the care plan to direct care aimed at preventing falls for resident #30 who was at high risk for falls.
F689: The facility failed to identify and implement appropriate interventions to prevent falls for resident #30 who had a history of falls.
F756: The facility failed to ensure the consultant pharmacist identified and reported inconsistent blood sugar monitoring for resident #11 and failed to notify the physician of blood sugar levels outside ordered parameters.
F757: The facility failed to notify the physician for blood sugars outside ordered parameters for resident #11 and failed to obtain consistent physician-ordered daily weights for residents #35 and #41.
Report Facts
Resident census: 48
Sample size: 27
Blood sugar monitoring days missed: 5
Weight documentation days missed for resident #35: 5
Weight documentation days missed for resident #41: 5
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Apr 25, 2019
Visit Reason
This document is a Plan of Correction submitted in response to an annual inspection conducted on April 25, 2019, addressing deficiencies identified during the survey.
Findings
The facility failed to provide written notification of hospitalization reasons to residents or their representatives, failed to review and revise care plans to prevent falls, failed to implement appropriate fall prevention interventions, and failed to ensure consultant pharmacist identified and reported inconsistent blood sugar monitoring and physician notifications for abnormal blood sugars and weights.
Deficiencies (5)
F623: The facility failed to ensure resident/responsible party was provided written notification of the reason for hospitalization.
F657: The facility failed to review and revise the plan of care to direct care aimed at preventing falls for resident #30.
F689: The facility failed to identify and implement appropriate interventions aimed to prevent falls for resident #30.
F756: The facility failed to ensure the consultant pharmacist identified and reported inconsistent blood sugar monitoring for 1 of 5 residents sampled.
F757: The facility failed to notify the physician for blood sugars outside ordered parameters for 1 of 5 residents and failed to obtain consistent physician ordered weights for 2 residents.
Report Facts
Residents sampled for unnecessary medication use: 5
Residents with blood sugar parameter orders: 1
Residents with weight orders: 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 |
Inspection Report
Renewal
Census: 68
Deficiencies: 1
Date: Aug 14, 2018
Visit Reason
The inspection was conducted for re-licensure of the assisted living facility.
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. Records lacked documentation of disaster/emergency preparedness in-services and reviews with staff and residents.
Deficiencies (1)
26-41-104(d)(3) Disaster and Emergency Preparedness: The administrator failed to ensure quarterly review of the facility's emergency management plan with staff and residents. Records lacked documentation of disaster/emergency preparedness in-services and reviews.
Report Facts
Resident census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff #A interviewed regarding disaster preparedness |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 9, 2018
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-06-21.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2018-07-16, 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: 53
Deficiencies: 7
Date: Jun 21, 2018
Visit Reason
The inspection was a Health Facility Resurvey and complaint investigation KS#121778 at Village Shalom Inc.
Complaint Details
The inspection included a complaint investigation KS#121778 related to pain management and other care concerns.
Findings
The facility failed to adequately manage pain for a resident with chronic pain, failed to monitor and report blood sugars for a diabetic resident, improperly stored medications with food, failed to maintain sanitary food preparation and laundry areas, failed to properly sanitize nebulizer equipment, lacked a pneumococcal vaccination tracking system, and did not have an effective antibiotic stewardship program.
Deficiencies (7)
F 657 Care Plan Timing and Revision: The facility failed to review and revise the care plan for resident #10 to ensure adequate pain management during movement of the left arm.
F 697 Pain Management: The facility failed to provide adequate pain management for resident #10, who experienced severe pain with movement and refused care due to pain.
F 757 Drug Regimen is Free from Unnecessary Drugs: The facility failed to monitor and report blood sugars outside physician-ordered parameters for resident #47 to prevent unnecessary medications.
F 761 Label/Store Drugs and Biologicals: The facility failed to properly store medications separate from food items in the medication refrigerator on one unit.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary conditions in the kitchen, including dirty baking sheets, pots, and equipment.
F 880 Infection Prevention & Control: The facility failed to ensure nebulizer equipment was stored sanitarily, maintain clean resident laundry areas, track pneumococcal vaccinations, and prevent infection spread.
F 881 Antibiotic Stewardship Program: The facility failed to establish an antibiotic stewardship program that included tracking and trending infections, culture and sensitivity correlation, and infection resolution data.
Report Facts
Resident census: 53
Residents sampled: 18
Residents reviewed for unnecessary medications: 5
Blood sugar readings above 300: 11
Residents on unit #1: 15
Baking sheets observed: 15
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Jun 21, 2018
Visit Reason
The 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 pain management, drug regimen monitoring, medication storage, food sanitation, infection prevention and control, and antibiotic stewardship. Corrective actions and systemic changes were planned to address these deficiencies and ensure ongoing compliance.
Deficiencies (7)
42 C.F.R. § 483.21(b)(2)(i)-(iii) – The facility failed to review and revise the plan of care for Resident 10 to ensure adequate pain management to prevent or reduce pain with movement of the left arm.
42 C.F.R. § 483.25(K) – The facility failed to ensure adequate pain management for Resident 10, who experienced severe pain during assistance with dressing and range of motion services.
42 C.F.R. § 483.45(d)(1)-(6) – The facility failed to monitor and report Resident 47’s blood sugars within physician-ordered parameters to ensure freedom from unnecessary medications.
42 C.F.R. § 483.45(g)(h)(1)(2) – The facility failed to properly store medications separate from food items in the refrigerator of one unit with 15 residents.
42 C.F.R. § 483.60(i)(1)(2) – The facility failed to store, prepare, and serve food under sanitary conditions to residents.
42 C.F.R. § 483.80(a)(1)(2)(4)(e)(f) – The facility failed to ensure nebulizer equipment was stored in a sanitary manner and resident laundry areas were clean to ensure sanitary processing.
42 C.F.R. § 483.80(a)(3) – The facility failed to establish an antibiotic stewardship program to track and trend infections through monitoring culture and sensitivity results and infection resolution.
Report Facts
Residents affected by medication storage deficiency: 15
Residents with nebulizer equipment removed: 3
Residents reviewed for pain management: 1
Resident reviewed for blood sugar monitoring: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Wheeler | VP of Health Care Services | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 in substantial compliance with participation requirements, 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.
Deficiencies (1)
F323, "J", CFR 483.25(d)(1)(2)(n)(1)-(3) was cited for substandard quality of care constituting immediate jeopardy to resident health or safety.
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 | Named as contact for questions regarding the enforcement action and instructions |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 3
Date: Aug 3, 2017
Visit Reason
Complaint investigation #KS00118449 and partial extended survey were conducted to assess compliance with care planning, supervision, and nurse staffing requirements.
Complaint Details
Complaint investigation #KS00118449 was conducted due to concerns about care planning and supervision related to resident elopement and safety.
Findings
The facility failed to revise the care plan timely to prevent elopement of a cognitively impaired resident, failed to provide adequate supervision leading to the resident's elopement and fall with injury, and failed to retain daily nurse staffing records for 18 months as required.
Deficiencies (3)
F280: The facility failed to revise the care plan with timely interventions to prevent elopement of a resident with dementia and impaired cognition who exhibited exit-seeking behaviors.
F323: The facility failed to provide adequate supervision and timely interventions to prevent elopement and a fall with injury for a cognitively impaired resident, placing the resident in immediate jeopardy.
F356: The facility failed to retain daily nurse staffing information for a period of 18 months as required by regulation.
Report Facts
Resident census: 77
Elopement Risk Score: 14
Days of missing nurse staffing records: 90
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Aug 3, 2017
Visit Reason
This Plan of Correction document responds to a complaint survey conducted on August 3, 2017, regarding deficiencies related to resident care and facility practices.
Complaint Details
This Plan of Correction addresses deficiencies cited from a complaint survey alleging failure to revise care plans to prevent elopement, inadequate supervision leading to elopement and injury, and failure to retain nurse staffing records.
Findings
The facility failed to revise care plans timely to prevent elopement, provide adequate supervision to prevent elopement and injury, and retain daily nurse staffing information for 18 months. Corrective actions and quality assurance plans were implemented to address these issues.
Deficiencies (3)
F280: The facility failed to revise the care plan with timely interventions to prevent the elopement of one resident.
F323: The facility failed to provide adequate supervision and timely interventions to prevent the elopement and fall with injury of one resident, placing the resident in immediate jeopardy.
F356: The facility failed to retain daily nurse staffing information for a period of 18 months, potentially affecting all residents.
Report Facts
Deficiencies cited: 3
Resident affected: 1
Audit duration: 6
Audit duration: 6
Number of residents audited: 5
Number of nursing staff quizzed: 10
Elopement incident date: Jul 9, 2017
Retention period: 18
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 15, 2016
Visit Reason
The visit was an Assisted Living/Residential Healthcare resurvey to verify compliance and check for deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 15, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection to address deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Deficiencies (1)
The resurvey found no deficiency citations.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 15, 2016
Visit Reason
The health survey was conducted as an 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
Plan of Correction
Deficiencies: 0
Date: Jun 15, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a health survey inspection.
Findings
The health survey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 13, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously reported deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.35(i), and 483.60(c) were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Feb 13, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.
Findings
The plan outlines corrective actions including staff training on individualized care plans, dining service sanitation policies, and medication regimen review procedures to ensure compliance and accuracy.
Deficiencies (4)
F0000 The Statement of deficiencies will be taken to the next QAPI meeting.
F279-D Current resident care plans will be reviewed and corrected for individualization and accuracy by 2/9/15, with mandatory staff training on care plan accuracy and individualization.
F371-F Dining Service Management provided in-service training on hair restraint and glove usage policies, with ongoing audits and monitoring to ensure sanitation compliance.
F428-E A policy for Medication Regimen Reviews will be drafted and implemented, including physician notification and documentation, with mandatory staff education and monthly audits for compliance.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Date: Jan 14, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS000079733.
Complaint Details
The visit was triggered by a complaint investigation identified as #KS000079733.
Findings
The facility failed to develop individualized and accurate care plans for residents, failed to serve food in a sanitary manner, and failed to follow up on pharmacy recommendations for multiple residents.
Deficiencies (3)
F279: The facility failed to develop individualized and accurate comprehensive care plans for residents #131 and #52 that reflected their care needs.
F371: The facility failed to serve and store food in a sanitary manner, including improper hair net use and glove use by dietary staff.
F428: The facility failed to follow up on pharmacy recommendations for 4 of 5 residents reviewed, lacking documentation of physician notification and monitoring.
Report Facts
Resident census: 72
Sample size: 10
Number of kitchenettes: 3
Days of observation: 5
Pharmacy recommendations not followed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Direct care staff who revealed care 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 physician notification. |
| Staff D | Administrative nursing staff | Responsible for oversight of care plans and pharmacy recommendation follow-up. |
| Staff E | Administrative nursing staff | Responsible for ensuring care plans were accurate and individualized and pharmacy follow-up. |
| 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 | Reassured resident when scared. |
| Staff O | Direct care staff | Described redirection of resident during dining. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 14, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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 is found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 4, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for 'F' level deficiencies indicating widespread noncompliance with Life Safety Code requirements. These deficiencies posed no immediate jeopardy but had potential for more than minimal harm.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Sep 4, 2014
Provider agreement termination date: Dec 4, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 18, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
All deficiencies previously cited on the CMS-2567 have been corrected as of the revisit date 10/18/2013.
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 25, 2013
Visit Reason
The visit was a licensure resurvey to assess compliance for renewal of the facility's license.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 7
Date: Sep 25, 2013
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to provide resident choice in bathing frequency, failure to develop individualized comprehensive care plans for residents on psychoactive medications, inadequate ADL care for hospice residents, failure to provide timely nutritional interventions for weight loss, unsanitary food preparation practices, improper garbage disposal, and inadequate infection control practices including cross contamination and improper cleaning procedures.
Deficiencies (7)
F242: The facility failed to provide a bathing choice for resident #173, who preferred daily showers but was only offered three times a week.
F279: The facility failed to develop individualized comprehensive care plans with measurable goals and specific interventions for three residents (#13, #72, #97) receiving antipsychotic medications.
F312: The facility failed to offer the same bathing/showering services to resident #71 receiving hospice benefits as provided to other residents.
F325: The facility failed to provide timely nutritional interventions and consistently document meal and supplement intake for resident #34 who experienced weight loss.
F371: The facility failed to prepare and serve food in a sanitary manner, including missing paint on kitchen walls and staff not properly containing hair under hats.
F372: The facility failed to maintain a clean area around the garbage collection container, with trash and food observed on the ground around the dumpster.
F441: The facility failed to prevent cross contamination and follow manufacturer guidelines during room cleaning, including failure to change gloves after trash removal and improper disinfectant contact time.
Report Facts
Census: 71
Residents sampled: 19
Weight loss: 5
Med Pass volume: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| House keeper X | Named in infection control deficiency for failure to change gloves and cross contamination | |
| licensed nurse J | Licensed Nurse | Interviewed regarding bathing preferences for resident #173 |
| licensed staff H | Licensed Staff | Interviewed regarding behaviors of resident #13 |
| licensed staff I | Licensed Staff | Interviewed regarding behaviors of resident #13 |
| direct care staff R | Direct Care Staff | Interviewed regarding behaviors of resident #13 |
| direct care staff S | Direct Care Staff | Interviewed regarding behaviors of resident #13 |
| direct care staff O | Direct Care Staff | Interviewed regarding behaviors of resident #13 and hospice bathing for resident #71 |
| direct care staff Q | Direct Care Staff | Interviewed regarding hospice bathing for resident #71 |
| licensed nursing staff K | Licensed Nursing Staff | Interviewed regarding behaviors of resident #97 |
| licensed nursing staff HS | Licensed Staff | Interviewed regarding behaviors of resident #13 |
| administrative licensed staff E | Administrative Licensed Staff | Acknowledged care plan deficiencies for resident #13 |
| administrative nursing staff D | Administrative Nursing Staff | Interviewed regarding hospice bathing and infection control expectations |
| dietary staff DD | Dietary Staff | Interviewed regarding nutritional interventions and kitchen sanitation |
| Housekeeping/maintenance staff Y | Housekeeping/Maintenance Staff | Interviewed regarding disinfectant use |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 25, 2013
Visit Reason
This document is a plan of correction related to a prior deficiency report for Village Shalom ALF.
Findings
No deficiency details or findings are included in this document; it only references the plan of correction status and contact information.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Date: Aug 7, 2013
Visit Reason
The inspection was conducted as a result of complaint investigations #KS 63510, 66815, 67078 regarding resident safety and care concerns.
Complaint Details
The inspection was triggered by complaints alleging inadequate supervision leading to resident elopement and failure to prevent falls resulting in injury.
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 and timely interventions for a cognitively impaired resident who experienced multiple falls resulting in a head injury and intracranial bleed.
Deficiencies (2)
K.A.R. 26-41-101(f)(1)(B) Staff Treatment of Residents: The facility failed to have a system in place to provide adequate supervision to prevent elopement for two residents in the adult day care program, placing them in immediate jeopardy.
26-41-204(a) Health Care Services: The facility failed to provide effective supervision and timely interventions for one resident to prevent multiple falls with head injury and intracranial bleed.
Report Facts
Resident census: 63
Resident census: 10
Number of falls: 12
Bruise size: 10
Bruise size: 11.4
Bruise size: 15
Bruise size: 2
Bruise size: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff G | Reported resident elopement incidents and supervision failures. | |
| Licensed nursing staff A | Confirmed resident elopement and reported resident behavior. | |
| Licensed nursing staff C | Reported resident's confusion, fall with head injury, and communication with primary care physician. | |
| Therapy staff E | Reported resident's therapy history and fall incidents. | |
| Administrative staff B | Reported resident medication administration issues and facility's response to falls. | |
| Social services staff D | Reported resident behaviors and care status. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 2, 2012
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.25(h), and 483.25(l) were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 3
Date: Jun 12, 2012
Visit Reason
The visit was a health resurvey to assess compliance with previously identified deficiencies and to verify corrective actions.
Findings
The facility failed to develop comprehensive care plans for residents, ensure a safe environment free of accident hazards, and maintain drug regimens free from unnecessary drugs. Specific issues included lack of dental care plans, failure to monitor hot water temperatures, and inadequate monitoring of medication side effects.
Deficiencies (3)
F279: The facility failed to develop a dental care plan for resident #113 and failed to develop a side rail plan of care for resident #161.
F323: The facility failed to ensure the resident environment was free of accident hazards by not monitoring hot water temperatures in two unlocked utility rooms, exposing residents to scalding risk.
F329: The facility failed to provide Black Box Warning side effects for Seroquel for resident #165 and failed to monitor for side effects of Metoprolol for resident #98, resulting in inadequate assessment and monitoring of medication-related risks.
Report Facts
Deficiencies cited: 3
Resident census: 65
Residents ambulating independently: 9
Residents on unit: 22
Hot water temperature: 136.9
Hot water temperature: 138
Hot water temperature: 128.3
Hot water temperature: 127.2
Pulse rate: 43
Pulse rate: 40
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046054 POC X4ZE11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Document
Deficiencies: 0
Date: N046054 POC 2TQM11
Visit Reason
The document could not be rendered and no inspection or visit information is available.
Findings
No findings or content are available due to the rendering error.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046054 POC 4F2C11
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for the facility.
Findings
No specific findings are detailed in this document; it serves as a record of the Plan of Correction submission and modification dates.
Document
Deficiencies: 0
Date: N046054 POC 4GBK11
Visit Reason
The document could not be accessed or reviewed due to a rendering error, preventing determination of the visit reason.
Findings
No findings or content are available as the document page failed to render.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046054 POC TEP511
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or record for the Plan of Correction submission.
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