Inspection Reports for Wesley Towers Inc
700 MONTEREY PL, HUTCHINSON, KS, 67502-2248
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 24, 2018, found no deficiencies and confirmed the facility was in compliance with all regulations. Earlier inspections showed a pattern of deficiencies primarily related to infection control, sanitary kitchen conditions, medication management, and resident dignity and care planning. Complaint investigations substantiated issues with food safety, hand hygiene, and infection control, while other reports noted concerns about hazardous chemical storage and fall prevention. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed prior deficiencies effectively, demonstrating improvement over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
200% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
78 residents
Based on a June 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 24, 2018
Visit Reason
An offsite revisit survey was conducted on 07/24/2018 for all previous deficiencies cited on 06/14/2018.
Findings
All deficiencies have been corrected as of the compliance date of 07/11/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 14, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 07/11/2018.
Deficiencies (1)
Facility had a 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Report Facts
Deficiency level: F level deficiency cited in the survey
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure & Certification Enforcement Manager | Contact person for questions concerning the information in the letter |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 14, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a QIS survey conducted at Wesley Towers on June 14, 2018.
Findings
The plan addresses deficiencies related to maintaining a sanitary kitchen environment, ensuring appropriate hand hygiene and cleaning responsibilities, and effective infection control in housekeeping, particularly disinfection of isolation rooms with proper sanitizer wet times.
Deficiencies (2)
Failure to maintain a sanitary kitchen environment including hand hygiene and cleaning responsibilities in kitchenettes.
Failure to maintain effective infection control in housekeeping, especially regarding disinfection cleaning of isolation rooms and ensuring sanitizers remain wet the recommended period.
Report Facts
Plan of Correction completion date: Jul 11, 2018
Survey date: Jun 14, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Wagner | VP Health Services/Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 4
Date: Jun 14, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #102100, #100764, and #102610 to assess compliance with food safety and infection control regulations.
Complaint Details
The visit was complaint-related, involving Health Resurvey and Complaint Investigations #102100, #100764, and #102610.
Findings
The facility failed to maintain a sanitary kitchen environment in 2 of the 7 kitchenettes and did not maintain adequate hand hygiene practices in the main kitchen. Additionally, housekeeping failed to properly sanitize a resident's isolation room, not allowing adequate wet time for disinfectant, risking infection spread.
Deficiencies (4)
Failed to maintain a sanitary kitchen environment in 2 of the 7 kitchenettes serving food to residents.
Failed to maintain adequate hand hygiene practices in the main kitchen, including lack of paper towels and inability to properly turn off faucets without recontaminating hands.
Failed to ensure drawers of 2 kitchenettes were maintained in a sanitary manner to prevent spread of food borne infections.
Failed to maintain an effective infection control program when housekeeping failed to properly sanitize a resident's isolation room, not allowing adequate wet time of disinfectant.
Report Facts
Census: 78
Number of kitchenettes: 7
Number of kitchenettes with sanitary issues: 2
Disinfectant wet time required: 10
Disinfectant wet time observed: 3
Disinfectant wet time observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff D | Verified failure to turn off water in kitchen handwashing sink without recontaminating hands | |
| Dietary staff A | Observed pulling steam pans, checking food temperatures, and placing food into warmed carts | |
| Dietary staff B | Entered kitchen without washing hands, handled food items during inspection | |
| Dietary staff C | Entered kitchen without washing hands, handled pickles and utensils | |
| Administrative assistant staff E | Observed entering and exiting kitchen without washing hands, handled food and utensils | |
| Housekeeping staff G | Provided housekeeping services in resident's isolation room, failed to allow adequate disinfectant wet time | |
| Administrative staff F | Confirmed expectation for disinfectant wet time of 10 minutes |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 1, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously reported deficiencies were corrected as of the revisit date, with corrections completed for multiple regulatory requirements including 483.25(h), 483.35(i), 483.60(b),(d),(e), and 483.65.
Report Facts
Deficiencies corrected: 4
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 2, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, 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 plan of correction.
Deficiencies (1)
Most serious deficiencies found were 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to the survey findings and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Mar 2, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a QIS survey conducted at Wesley Towers on March 2, 2016.
Findings
The plan addresses multiple deficiencies related to chemical safety in the beauty shop, sanitary handling of drinks, medication management including dating and disposal of medications, and adherence to manufacturer recommendations for cleaning chemicals to maintain a sanitary environment.
Deficiencies (4)
Chemicals in the beauty shop area were not maintained in a safe manner.
Drinks were not served in a sanitary manner.
Medications were not dated when opened and not removed when expired.
Manufacturer's recommendations for use of cleaning chemicals were not followed.
Report Facts
Plan of Correction completion date: Apr 1, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Wineland | Administrator | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 4
Date: Feb 24, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #85346 to assess compliance with safety, sanitary, medication, and infection control regulations.
Complaint Details
The visit was triggered by a complaint investigation #85346. The findings included unsafe chemical storage, unsanitary food handling, medication labeling and expiration issues, and infection control lapses.
Findings
The facility was found deficient in maintaining a safe environment due to unlocked hazardous chemicals, improper sanitary handling of drinkware, failure to label and date medications properly, failure to remove expired medications, and inadequate infection control practices related to disinfectant wet times.
Deficiencies (4)
Failure to ensure the resident environment remained free of accident hazards related to unlocked chemicals accessible to residents.
Failure to serve drinks in a sanitary manner by handling drinkware by the drinking surface in 1 of 8 dining rooms.
Failure to label and date medications when opened and failure to remove expired medications from medication carts on multiple halls.
Failure to maintain a clean and sanitary environment by not following manufacturer's recommended wet times for disinfectant use in resident rooms.
Report Facts
Facility census: 90
Residents cognitively impaired and independently mobile: 7
Medication carts with expired medications: 4
Disinfectant wet time recommended by manufacturer: 10
Disinfectant wet time expected by facility staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Beauty Shop Contractor Staff | Left beauty shop door open and did not lock chemical closet |
| Staff D | Administrator Staff | Confirmed chemicals needed to be locked or room door locked |
| Staff A | Dietary Staff | Handled drinkware improperly by touching drinking surfaces |
| Staff B | Dietary Staff | Reported training on proper drinkware handling |
| Nurse G | Licensed Nurse | Confirmed medications in cart were not dated when opened |
| Nurse H | Administrative Nurse | Confirmed policy requiring dating of medications when opened |
| Nurse I | Licensed Nurse | Reported medication carts were to be checked weekly for outdated medications |
| Nurse J | Licensed Nurse | Reported weekly checks and removal of expired medications from medication carts |
| Nurse K | Licensed Nurse | Reported need to check medication carts on both shifts and remove expired medications |
| Staff E | Housekeeping Staff | Failed to follow manufacturer's disinfectant wet time recommendations during cleaning |
| Staff F | Housekeeping Supervisor | Reported disinfectant wet time as 2 minutes and described cleaning expectations |
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 16, 2015
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 deficiency to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
Most serious deficiency found at 'F' level with no harm but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Feb 16, 2016
Provider agreement termination date: May 16, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report and is the Enforcement Coordinator at the Kansas Department for Aging and Disability Services. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 8, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that the deficiencies identified under regulations 483.15(a) and 483.25(h) were corrected as of 05/08/2015.
Deficiencies (2)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 2
Follow-up survey date: Apr 10, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 10, 2015
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'D' level, indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective May 8, 2015.
Deficiencies (1)
Deficiencies cited at 'D' level indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and letter. |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 2
Date: Apr 10, 2015
Visit Reason
Complaint survey #84447 was conducted to investigate concerns related to resident care, dignity, respect, and fall prevention.
Complaint Details
The complaint survey #84447 focused on dignity and respect issues and fall prevention failures for residents #1, #2, and #3.
Findings
The facility failed to maintain resident dignity and respect, failed to prevent accidents by not thoroughly investigating falls or updating care plans for three residents, and did not timely update comprehensive care plans with new interventions to prevent further falls.
Deficiencies (2)
Failure to provide care in a manner that maintains resident dignity and respect, including toileting and staff arguing in front of resident #2.
Failure to ensure resident environment remained free of accident hazards and failure to investigate falls and revise care plans for residents #1, #2, and #3.
Report Facts
Facility census: 113
Residents in sample: 3
Falls: 4
Minutes of therapy: 330
Minutes of therapy: 340
Minutes of group therapy: 135
Minutes of group therapy: 135
BIMS score: 5
BIMS score: 3
BIMS score: 12
BIMS score: 13
BIMS score: 10
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff D | Interviewed regarding dignity and fall risk for resident #2 and #1. | |
| Licensed nursing staff E | Interviewed regarding dignity expectations and fall investigations. | |
| Licensed nursing staff I | Interviewed regarding dignity and fall investigations. | |
| Administrative staff F | Interviewed regarding dignity expectations and fall investigation process. | |
| Direct care staff H | Interviewed regarding fall risk and resident monitoring. | |
| Direct care staff K | Interviewed regarding fall prevention interventions. | |
| Licensed nursing staff L | Interviewed regarding fall risk and investigation process. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 9, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at Wesley Towers.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Wesley Towers, addressing alleged deficiencies related to resident care and communication.
Findings
The plan addresses deficiencies related to dignity and respect in resident care, fall management policies, and communication with residents and families. It outlines corrective actions including staff training, policy review, and ongoing quality assurance monitoring.
Deficiencies (3)
Facility-wide system to assure correction and continued compliance with regulations.
Issues related to dignity and respect, including communication with resident/family and staff counseling.
Fall management policy deficiencies including root cause identification and care plan updates after falls.
Report Facts
Complete Date: May 8, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Wineland | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 9, 2015
Visit Reason
This revisit report documents the correction of deficiencies previously reported during a prior survey, verifying that corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency identified by regulation 28-39-256 with prefix code S3420 was corrected as of 01/09/2015.
Deficiencies (1)
Deficiency identified under regulation 28-39-256 with prefix code S3420
Report Facts
Deficiency correction date: Jan 9, 2015
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 9, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a QIS survey at Wesley Towers ALF.
Findings
The plan addresses water temperature concerns where no harm was caused to residents; corrective actions include routine monthly water temperature checks, staff retraining, and ongoing monitoring reviewed by the Quality Assurance Committee.
Deficiencies (1)
Water temperature concerns identified and corrected immediately by maintenance staff.
Report Facts
Plan of Correction completion date: Jan 9, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Wineland | Administrator | Submitted the Plan of Correction |
Inspection Report
Census: 19
Deficiencies: 1
Date: Jan 8, 2015
Visit Reason
The licensure survey of the assisted living facility was conducted to assess compliance with mechanical requirements including heating, air conditioning, plumbing, and electrical systems.
Findings
The facility failed to maintain hot water temperatures between 98 and 120 degrees Fahrenheit in common areas accessible to residents, with observed temperatures exceeding the acceptable range. Maintenance staff adjusted the water heater setting during the survey and staff confirmed the temperatures were too hot.
Deficiencies (1)
Failed to maintain water temperatures between 98 and 120 degrees Fahrenheit in common areas accessible to residents.
Report Facts
Water temperature: 130.2
Water temperature: 125.4
Water temperature: 125.8
Water temperature: 125
Water heater setting: 125
Water heater setting: 119
Facility census: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Maintenance Staff | Verified water temperature requirements and adjusted water heater setting |
| Staff H | Licensed Nursing Staff | Confirmed hot water temperatures were too hot during interview |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 12, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited with various regulation numbers were corrected as of the revisit date, 12/12/2014.
Report Facts
Deficiencies corrected: 11
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Dec 12, 2014
Visit Reason
This document is a Plan of Correction responding to deficiencies cited during a QIS survey at the facility.
Findings
The plan outlines corrective actions for multiple deficiencies including catheter care, care plan completeness, fall prevention, staffing, food handling, medication management, and resident dining preferences. The facility commits to policy revisions, staff education, competency checks, monitoring, and quality assurance reviews to ensure compliance and improve resident care.
Deficiencies (11)
Dignity of residents using catheter bags ensured by use of bags with attached covers.
Ensuring residents receive necessary services outside the facility with revised policy and monitoring.
Care plans to be complete and reflect specifics on weight loss prevention and catheter care.
Care plans to include prevention and post-fall care plan revisions with ongoing review.
Catheter care policies revised; staff trained and competencies checked regularly.
Proper assessment and medication administration of tube feeding ensured by policy revision and nurse training.
Care plans current with fall prevention revisions; hazardous chemicals secured; lift chair use policy revised.
Necessary staffing ensured with ongoing hiring and staff training programs.
Food properly labeled, stored, handled, and expired food discarded timely with staff retraining.
Medication properly labeled and stored; expired medications destroyed; staff retrained on dispensing.
Residents encouraged to sit where they choose in dining room; extra dining space and furnishings provided.
Report Facts
Competency checks: 3
Frequency of food handling observations: 8
C.N.A. training sessions: 4
Monitor period for lift chair assessments: 3
Date for Quality Assurance Committee review: Jan 29, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Wineland | Administrator | Submitted the Plan of Correction to KDADS. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 12, 2014
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 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 effective December 12, 2014.
Deficiencies (1)
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.
Inspection Report
Routine
Census: 121
Deficiencies: 11
Date: Nov 12, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including dignity and respect for residents, provision of medically related social services, development and revision of comprehensive care plans, urinary catheter care, fall prevention and supervision, staffing sufficiency, food safety and handling, medication management, and dining room adequacy.
Deficiencies (11)
Failed to ensure resident dignity by keeping catheter drainage bag covered at all times.
Failed to provide medically related social services to assist resident with timely dental appointments.
Failed to develop comprehensive care plans related to nutrition and urinary catheter care.
Failed to revise care plan for falls to include new interventions and resident preferences.
Failed to provide appropriate urinary catheter care including irrigation and monitoring urine output.
Failed to ensure proper assessment and care when administering medications and tube feedings via PEG tube.
Failed to provide interventions to prevent falls and accidents for multiple residents and secure hazardous chemicals.
Failed to ensure sufficient nursing staff to provide necessary care and supervision to prevent falls and meet resident needs.
Failed to safely handle ready-to-eat foods, discard expired foods, ensure residents did not receive expired foods, and properly label foods.
Failed to discard expired medication and safely label and store medications prepared in advance for administration.
Failed to provide adequate space in dining room to accommodate all residents and dining activities.
Report Facts
Residents receiving pureed diets: 15
Residents receiving tube feedings: 3
Call light response time: 17
Call light response time: 13
Call light response time: 19
Call light response time: 15
Call light response time: 11
Call light response time: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Administrative Nurse | Expected staff to have dignity bags on catheter bags, expected catheter care every shift, expected medication checks, and staffing management. |
| Licensed nursing staff FF | Licensed Nurse | Formed care plans for residents on Hester unit and confirmed catheter care training. |
| Licensed nursing staff DD | Licensed Nurse | Reported catheter care practices and documentation. |
| Licensed nursing staff EE | Licensed Nurse | Administered PEG tube feeding and medications, described proper tube feeding procedures. |
| Licensed nursing staff W | Licensed Nurse | Described fall packet procedures and documentation. |
| Licensed nursing staff G | Licensed Nurse | Reported lack of system for checking outdated medications. |
| Licensed nursing staff F | Licensed Nurse | Removed expired Lantus insulin from medication cart. |
| Licensed nurse UU | Licensed Nurse | Confirmed chemicals in shower room should be locked. |
| Housekeeping staff VV | Housekeeping Staff | Confirmed housekeeping closet should be locked. |
| Activities staff WW | Activities Staff | Reported activities room cabinet containing chemicals should be locked. |
| Maintenance staff YY | Maintenance Staff | Verified chemicals should not be accessible to residents. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 12, 2014
Visit Reason
A Life Safety Code survey was conducted on March 12, 2014, by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm, not constituting 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.
Deficiencies (1)
Most serious deficiencies found to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Jun 12, 2014
Provider agreement termination date: Sep 12, 2014
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Veh | Administrator | Facility administrator named in the report header. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator for Kansas Department for Aging and Disability Services. |
Inspection Report
Follow-Up
Deficiencies: 13
Date: Aug 18, 2013
Visit Reason
This is a post-certification revisit 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 listed with their regulation numbers were corrected as of the revisit date 08/18/2013.
Deficiencies (13)
Deficiency related to Reg. # 483.10(e), 483.75(l)(4)
Deficiency related to Reg. # 483.13(c)(1)(ii)-(iii), (c)(2) - (4)
Deficiency related to Reg. # 483.20(d)(3), 483.10(k)(2)
Deficiency related to Reg. # 483.25
Deficiency related to Reg. # 483.25(c)
Deficiency related to Reg. # 483.25(h)
Deficiency related to Reg. # 483.25(l)
Deficiency related to Reg. # 483.25(n)
Deficiency related to Reg. # 483.35(i)
Deficiency related to Reg. # 483.60(a),(b)
Deficiency related to Reg. # 483.60(c)
Deficiency related to Reg. # 483.60(b), (d), (e)
Deficiency related to Reg. # 483.75(o)(1)
Report Facts
Deficiencies corrected: 13
Inspection Report
Follow-Up
Deficiencies: 2
Date: Aug 18, 2013
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiencies under regulations 26-40-302 (b)(c) and 26-40-305 (c)(1)(2) were corrected as of 08/18/2013.
Deficiencies (2)
Deficiency under regulation 26-40-302 (b)(c)
Deficiency under regulation 26-40-305 (c)(1)(2)
Report Facts
Deficiencies corrected: 2
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 18, 2013
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey and confirms the dates when corrective actions were completed.
Findings
The report indicates that the previously identified deficiency with regulation KSA 39-970(d) was corrected as of 08/18/2013. No other deficiencies or issues are noted.
Deficiencies (1)
Deficiency related to regulation KSA 39-970(d)
Report Facts
Date of Revisit: Aug 18, 2013
Followup to Survey Completed on: Jul 19, 2013
Inspection Report
Plan of Correction
Deficiencies: 16
Date: Aug 18, 2013
Visit Reason
This document is a Plan of Correction submitted by Wesley Towers in response to deficiencies cited during a QIS survey.
Findings
The plan outlines corrective actions for multiple deficiencies including privacy of electronic records, abuse reporting, care plan updates, medication management, food safety, environmental safety, and quality assurance processes. Each deficiency is addressed with specific corrective measures, staff education, and ongoing monitoring responsibilities.
Deficiencies (16)
Privacy of electronic records to prevent unauthorized access
Reporting and investigation of allegations of abuse
Updating care plans to reflect changes in resident status
Ensuring necessary care and services to maintain resident well-being
Implementation of dietary recommendations for pressure ulcer healing
Maintaining an environment free of accident hazards including secure storage of chemicals and medications
Ensuring medication regimens are free of unnecessary medications
Education regarding pneumococcal vaccination benefits and effects
Sanitary preparation and serving of food
Pharmaceutical services to ensure accurate medication administration
Pharmaceutical services to ensure physician notification of medication irregularities
Medication storage in locked compartments with proper labeling and removal of expired medications
Effective quality assessment and assurance system
Completion of background checks on new employees
Electrical monitoring system on designated doors remains activated
Exhaust fans in beauty shop functioning to meet ventilation requirements
Report Facts
Date of plan completion: Aug 18, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Veh | VP of Health Services | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction |
Inspection Report
Annual Inspection
Census: 125
Deficiencies: 12
Date: Jul 19, 2013
Visit Reason
Annual resurvey and complaint investigation to assess compliance with health and safety regulations in the facility.
Findings
The facility had multiple deficiencies including failure to ensure privacy of electronic resident records, failure to report and investigate abuse allegations, failure to revise care plans to reflect resident status changes, inadequate monitoring of fluid restrictions, failure to monitor and treat skin conditions properly, improper medication management including failure to clarify orders and monitor black box warnings, unsanitary food handling practices, unsecured hazardous chemicals, unlocked medication carts and rooms, and ineffective quality assurance monitoring.
Deficiencies (12)
Failed to ensure privacy of electronic resident records on multiple halls with unattended medication cart computers displaying resident information.
Failed to report all allegations of abuse to the State survey and certification agency and perform thorough investigations.
Failed to revise care plans to reflect changes in resident status including fluid restrictions, skin tears, and discharge plans.
Failed to monitor and coordinate fluid restrictions leading to residents exceeding ordered fluid limits.
Failed to monitor and treat resident bruising and skin tears properly, including documentation and care plan updates.
Failed to follow dietitian recommendation for high protein supplementation to promote healing of pressure ulcer.
Failed to maintain a safe environment by leaving hazardous chemicals unsecured and accessible to residents.
Unsanitary food handling practices including failure to wear hairnets, improper glove use, and improper handling of utensils and plates.
Failed to ensure accurate pharmaceutical services including clarifying incomplete medication orders, monitoring black box warnings, and performing gradual dose reductions.
Failed to store medications in locked compartments and failed to remove expired or unlabeled medications.
Failed to ensure pneumococcal vaccine education was provided to residents or legal representatives prior to immunization.
Failed to develop and implement an effective Quality Assessment and Assurance (QAA) program to address multiple systemic issues including medication management, abuse reporting, infection control, and resident care.
Report Facts
Facility census: 125
Residents affected by privacy breach: 61
Residents affected by abuse reporting failure: 43
Residents affected by medication cart unlocked: 11
Residents affected by hazardous chemical access: 16
Residents affected by insulin labeling issues: 10
Residents on pureed diet: 16
Residents sampled for medication review: 10
Residents reviewed for vaccination: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Nursing Staff | Reported expectations for abuse reporting, medication order clarifications, and monitoring fluid restrictions |
| Staff M | Administrative Nursing Staff | Reported expectations for abuse reporting, medication cart locking, and fluid restriction monitoring |
| Staff YY | Consultant Pharmacist | Reported pharmacy recommendations process and physician response issues |
| Staff KKK | Nurse Practitioner | Discussed hesitancy to perform gradual dose reduction of Seroquel |
| Staff NN | Administrative Nurse | Reported medication cart locking policy and expired medication handling |
| Staff OO | Dietary Staff | Reported expectations for glove use, hairnets, and food handling |
| Staff JJ | Licensed Nursing Staff | Reported medication monitoring and communication processes |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Apr 26, 2012
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 had been corrected.
Findings
The report shows that all previously cited deficiencies identified by their regulation numbers (483.15(a), 483.20(g)-(j), 483.25(c), and 483.25(h)) were corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.20(g)-(j)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Apr 3, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a QIS survey of the facility.
Findings
The plan outlines corrective actions to address deficiencies related to resident dignity and respect, incontinence care, pressure ulcer assessment and treatment, and maintaining a safe resident environment free of accident hazards.
Deficiencies (4)
Failure to maintain or enhance each resident's dignity and respect, particularly regarding incontinence care.
Inaccurate assessments reflecting resident status regarding pressure ulcers and inconsistent coding between CAAs and MDS 3.0.
Failure to provide necessary treatment and services to promote healing and prevent infection of pressure ulcers, including proper measuring and dressing changes.
Failure to ensure the resident environment remains free of accident hazards, including safe storage of chemicals.
Report Facts
Complete Date: Apr 3, 2012
Complete Date: Apr 26, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Veh | VP of Health Services | Submitted the Plan of Correction to KDADS |
Inspection Report
Re-Inspection
Census: 116
Deficiencies: 4
Date: Mar 27, 2012
Visit Reason
The visit was a resurvey to assess compliance following a prior inspection, focusing on deficiencies related to resident dignity, assessment accuracy, pressure ulcer care, and safety hazards.
Findings
The facility failed to promote dignity for residents in the special care unit by leaving incontinent pads on chairs, failed to accurately assess and document pressure ulcers including staging and treatment, and failed to maintain a safe environment by not securing hazardous chemicals in the beauty shop.
Deficiencies (4)
Failure to promote dignified care by leaving incontinent pads on chairs in the special care unit.
Failure to ensure assessments accurately reflected resident's status regarding pressure ulcers, including incorrect staging.
Failure to provide necessary treatment and services to promote healing and prevent infection of a stage 3 pressure ulcer, including improper wound measurement and glove use.
Failure to ensure resident environment was free from accident hazards by not securing hazardous chemicals in the beauty shop.
Report Facts
Census: 116
Residents in special care unit: 11
Residents in sample: 22
Residents cognitively impaired and independently mobile: 7
Pressure ulcer measurements: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Nurse | Verified incontinent pads remained on chairs and confirmed undignified practice |
| Nurse G | Nurse | Verified incontinent pads remained on chairs and confirmed undignified practice |
| Nurse F | Nurse | Verified undignified practice of pads on empty chairs and confirmed expectations for wound care and notification |
| Administrative Nursing staff I | Administrative Nursing Staff | Confirmed incorrect pressure ulcer staging in assessments |
| Administrative Nursing staff F | Administrative Nursing Staff | Confirmed pressure ulcer staging and expectations for wound care and glove use |
| Licensed Nursing staff H | Licensed Nursing Staff | Observed removing dressing and measuring wound depth |
| Licensed Nursing staff K | Licensed Nursing Staff | Observed changing dressing with improper glove use |
| Nurse A | Nurse | Verified beauty shop door should be locked |
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