Inspection Reports for
Wesley Towers Inc
700 MONTEREY PL, HUTCHINSON, KS, 67502-2248
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
81% occupied
Based on a May 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 42
Deficiencies: 2
Date: May 8, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication administration procedures and staffing qualifications related to dietary management at the facility.
Findings
The facility failed to ensure medication error rates were 5 percent or less due to staff not priming insulin KwikPens before administration, resulting in a 6.06% error rate. Additionally, the facility failed to employ a full-time Certified Dietary Manager, placing residents at risk for inadequate nutrition.
Deficiencies (2)
F 0759: The facility failed to ensure insulin KwikPens were primed prior to administration, resulting in a medication error rate of 6.06% and placing residents at risk for medication errors.
F 0801: The facility failed to employ a full-time Certified Dietary Manager for the 42 residents, placing residents at risk for inadequate nutrition.
Report Facts
Medication error rate: 6.06
Resident census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication error finding for failure to prime insulin KwikPens |
| DS BB | Dietary Staff | Reported as dietary manager enrolled in Certified Dietary Manager course |
| Administrative Nurse D | Administrative Nurse | Stated expectation that nurses prime insulin KwikPens before administration |
Inspection Report
Routine
Census: 42
Deficiencies: 2
Date: May 8, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication administration procedures and staffing qualifications related to dietary management at the nursing home.
Findings
The facility failed to ensure insulin KwikPens were primed before administration, resulting in a medication error rate of 6.06%, and failed to employ a full-time Certified Dietary Manager, placing residents at risk for medication errors and inadequate nutrition.
Deficiencies (2)
F 0759: The facility failed to ensure insulin KwikPens were primed prior to administration, resulting in a medication error rate of 6.06% and placing residents at risk for medication errors.
F 0801: The facility failed to employ a full-time Certified Dietary Manager for the 42 residents, placing residents at risk for inadequate nutrition.
Report Facts
Medication error rate: 6.06
Resident census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication error finding for failure to prime insulin KwikPens |
| DS BB | Dietary Staff | Reported as dietary manager enrolled in Certified Dietary Manager course |
| Administrative Nurse D | Administrative Nurse | Stated expectation that nurses prime insulin KwikPens before administration |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 4
Date: Nov 21, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident assessments, care planning, hospice documentation, incontinence care, and food safety.
Findings
The facility failed to complete required Care Area Assessments (CAA) for all residents, resulting in incomplete comprehensive assessments. The facility also failed to accurately document hospice services for a resident, provide appropriate perineal care increasing risk of urinary tract infections, and maintain sanitary food storage and preparation conditions.
Deficiencies (4)
F 0636: The facility failed to complete Care Area Assessments (CAA) and analysis of triggered care areas for 32 residents, including Residents 4, 6, 8, 9, 11, and 14, as required by federal regulations.
F 0641: The facility failed to accurately document hospice or comfort care services for Resident 14 in the Minimum Data Set (MDS), despite physician orders admitting the resident to hospice.
F 0690: The facility failed to provide appropriate perineal care for Resident 6 during incontinence care, using the same washcloth for multiple swipes, increasing risk for urinary tract infections.
F 0812: The facility failed to store, prepare, and serve food under sanitary conditions, including open and undated food items, discolored food with obscured use-by dates, and improper air gaps on sinks and ice machine drains.
Report Facts
Resident census: 32
Residents sampled: 12
Residents affected: 32
Residents affected: 14
Residents affected: 6
Residents affected: 4
Residents affected: 8
Residents affected: 9
Residents affected: 11
Inspection Report
Census: 32
Deficiencies: 1
Date: Mar 11, 2021
Visit Reason
The inspection was conducted to evaluate food storage and safety practices in the facility's kitchen.
Findings
The facility failed to store food under sanitary conditions by having undated and expired food items in the kitchen, posing a risk for foodborne illness.
Deficiencies (1)
F0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food according to professional standards. Expired and undated food items were found in the main and staging kitchens during the inspection.
Report Facts
Resident census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| dietary staff A | Interviewed about expired food items and disposal procedures |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 24, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-06-14.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2018-07-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 24, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-06-14.
Findings
All deficiencies have been corrected as of the compliance date of 2018-07-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 2
Date: Jun 14, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #102100, #100764, and #102610.
Complaint Details
The inspection was triggered by complaint investigations #102100, #100764, and #102610.
Findings
The facility failed to maintain sanitary kitchen environments and adequate hand hygiene practices in the main kitchen and two kitchenettes. Additionally, the facility failed to maintain an effective infection control program related to sanitizing a resident's isolation room, specifically failing to ensure adequate wet time of disinfectant.
Deficiencies (2)
F812 Food safety requirements. The facility failed to maintain a sanitary kitchen environment in 2 of the 7 kitchenettes and failed to maintain adequate hand hygiene practices in the main kitchen to ensure sanitary food preparation and service.
F880 Infection Control. The facility failed to maintain an effective infection control program when housekeeping failed to properly sanitize a resident's isolation room, not allowing adequate disinfectant wet time to prevent infection spread.
Report Facts
Resident 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
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 14, 2018
Visit Reason
The Health survey was conducted to determine if the facility complies 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, 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 07/11/2018.
Deficiencies (1)
The facility had a widespread 'F' level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
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: 1
Date: Jan 11, 2017
Visit Reason
The plan of correction addresses deficiencies cited during a QIS survey related to water temperature issues in the facility.
Findings
The survey found that water temperature at certain sinks was out of range, potentially putting all residents at risk of harm. Corrective actions included adjusting water temperatures, replacing the water heater, revising policies, staff training, and ongoing monitoring.
Deficiencies (1)
S3420-L: Water heater temperature was out of range affecting the private dining room sink and kitchen lavatory, posing a risk to residents. Immediate adjustments were made and the water heater was replaced with a system that restricts temperature to prevent hot water hazards.
Report Facts
Training times: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Wineland | Administrator | Submitted the plan of correction |
Inspection Report
Re-Inspection
Census: 23
Deficiencies: 1
Date: Jan 11, 2017
Visit Reason
This inspection was a licensure resurvey of an Assisted Living Healthcare facility to assess compliance with mechanical requirements, specifically monitoring of water temperatures accessible to residents.
Findings
The facility failed to maintain a system to monitor water temperatures in resident and common areas, including a private dining room accessible to all residents. Water temperatures reached unsafe levels up to 149.1°F, placing residents at immediate risk of third degree burns. The facility had multiple instances of elevated water temperatures over the past year without effective correction or monitoring.
Deficiencies (1)
28-39-256 Mechanical requirements: The facility failed to monitor water temperatures in the private dining room and common areas, resulting in water temperatures reaching 149.1°F, posing immediate jeopardy to residents.
Report Facts
Facility census: 23
Water temperature: 149.1
Elevated temperature occurrences: 8
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 21, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a self-reported incident QIS survey related to a complaint.
Complaint Details
This Plan of Correction is related to a revised complaint investigation dated 10/18/2016.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, including care plan reviews for residents identified through fall logs, education for nursing staff on fall management policies, and revised fall investigation processes.
Deficiencies (2)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations following deficiencies cited during the self-reported incident QIS survey.
F323-G: The alert resident reported satisfaction with care after safety improvements; care plans for residents identified via fall logs will be reviewed and revised as needed with oversight by Care Coordinators and Risk Review meetings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Wineland | Administrator | Administrator who submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Irina Strakhova | Modified the Plan of Correction on 11/28/2016. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Date: Oct 18, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#104727) regarding resident safety and supervision related to repeated falls.
Complaint Details
The complaint investigation #104727 found the facility failed to provide adequate supervision to a resident with a history of multiple falls, leading to serious injuries including a fractured scapula and laceration.
Findings
The facility failed to ensure adequate supervision of a high fall-risk resident while toileting, resulting in multiple falls including a fractured scapula and forehead laceration. The care plan interventions were not fully implemented, and staff confusion about supervision requirements contributed to the incidents.
Deficiencies (1)
483.25(h) The facility failed to ensure staff stayed with a resident while on the toilet as care planned, resulting in repeated falls causing abrasions, a laceration requiring sutures, and a fractured scapula.
Report Facts
Resident census: 104
Total falls for resident #1: 6
Falls since last assessment: 4
Medication changes: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff B | Assisted resident on 8/23/16 when resident fell from toilet after being left alone | |
| Direct care staff A | Provided care and assisted resident during toileting on 10/11/16; reported resident disliked floor mat and bed lowered | |
| Licensed nurse D | Licensed Nurse | Reported not knowing staff needed to stay with resident on toilet and documented fall time |
| Licensed nurse G | Licensed Nurse | Responded to call light and found resident on floor with no staff present |
| Administrative nurse F | Administrative Nurse | Reported expectations for staff to stay close to resident while toileting and reviewed fall reports |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 1, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies identified by regulation numbers 483.25(h), 483.35(i), 483.60(b),(d),(e), and 483.65 were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 1, 2016
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.25(h), 483.35(i), 483.60(b),(d),(e), and 483.65 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 2, 2016
Visit Reason
The visit was a Health survey 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 '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.
Deficiencies (1)
The facility had 'E' level deficiencies 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 letter regarding the plan of correction acceptance. |
Inspection Report
Plan of Correction
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 with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Deficiencies (1)
The facility had 'E' level deficiencies 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 letter regarding the plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 5
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 the facility.
Findings
The plan addresses multiple deficiencies including chemical safety in the beauty shop, sanitary handling of drinks, medication dating and disposal, and proper use of cleaning chemicals to maintain infection control.
Deficiencies (5)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations. A complete deficiency list will be reviewed by the Quality Assurance Committee by April 28, 2016.
F323-E: Chemicals in the beauty shop will be maintained safely and kept locked unless under direct cosmetologist observation. Weekly monitoring by the Administrator will occur for one month.
F371-E: Drinks will be served in a sanitary manner with orientation and training for dining staff. Weekly monitoring by dining supervisors will continue for two months, then monthly if compliant.
F431-E: Medications will be dated when opened and disposed of when expired. Policy on Medication Management will be reviewed and staff trained accordingly with monthly supervision of monitors.
F441-E: Manufacturer recommendations for cleaning chemicals will be followed. Staff will be trained and monitored on proper chemical use, with observations in unusual cleaning situations monthly.
Report Facts
Plan of Correction completion date: Apr 1, 2016
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 inspection was triggered by a complaint investigation #85346. The findings were substantiated as evidenced by multiple deficiencies related to safety hazards, sanitary violations, medication management, and infection control.
Findings
The facility failed to maintain a safe environment due to unlocked hazardous chemicals accessible to residents, improper sanitary handling of drinkware, failure to date and remove expired medications on multiple medication carts, and inadequate infection control practices related to disinfectant wet times in resident rooms.
Deficiencies (4)
F 323: The facility failed to ensure the environment remained free of accident hazards related to unlocked chemicals accessible to residents.
F 371: The facility failed to serve drinks in a sanitary manner by handling drinkware by the drinking surface in 1 of 8 dining rooms.
F 431: The facility failed to establish a system to ensure medications were dated when opened and expired medications were removed on 4 of 8 medication carts.
F 441: The facility failed to maintain a clean and sanitary environment by not following manufacturer's recommended 10 minute wet time for disinfectant, using only 2 minutes, in resident rooms on 1 of 2 units.
Report Facts
Facility census: 90
Residents cognitively impaired and independently mobile: 7
Medication carts with expired medications: 4
Dining rooms observed: 8
Dining rooms with sanitary violation: 1
Units in facility: 2
Units with infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beauty shop contractor staff C | Interviewed regarding unlocked chemicals in beauty shop | |
| Administrator staff D | Confirmed chemicals needed to be locked or room locked | |
| Nurse G | Licensed nurse | Confirmed medications in cart were not dated when opened |
| Administrative nurse H | Administrative nurse | Confirmed facility policy on dating medications |
| Nurse I | Licensed nurse | Reported medication carts checked weekly for expired meds |
| Nurse J | Licensed nurse | Reported medication carts checked weekly and expired meds removed |
| Nurse K | Licensed nurse | Reported need to check medication carts on both shifts and remove expired meds |
| Dietary staff A | Observed handling drinkware improperly | |
| Dietary staff B | Reported training on proper drinkware handling | |
| Housekeeping staff E | Observed cleaning with disinfectant and interviewed about wet time | |
| Housekeeping supervisor staff F | Interviewed about disinfectant use and wet time procedures |
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 complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at the facility to be at 'F' level, indicating no harm but with potential for more than minimal harm, and not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited with deficiencies at the 'F' severity level related to Life Safety Code compliance. These deficiencies indicate no harm but potential for more than minimal harm without immediate jeopardy.
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 enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
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 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 '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)
The facility was cited with deficiencies at the 'F' severity level, indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
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 enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: May 8, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a QIS survey related to a complaint investigation at Wesley Towers.
Findings
The plan addresses deficiencies including development of a facility-wide correction system, communication and dignity policies with family involvement, and revisions to the Fall Management policy with staff training and ongoing quality assurance reviews.
Deficiencies (3)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations. A complete deficiency list will be reviewed by the Quality Assurance Committee by July 29, 2015.
F241-D: Family member was interviewed and expressed satisfaction with care. Staff were counseled on dignity policies and communication. Annual training on abuse prevention is conducted and satisfaction surveys are reviewed regularly.
F323-D: Two residents had significant change reassessments; one resident expired. The Fall Management policy will be revised to better identify root causes and staff will be trained on policy revisions and documentation procedures.
Report Facts
Plan of Correction completion date: May 8, 2015
Quality Assurance Committee review date: Jul 29, 2015
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 8, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report confirms that deficiencies previously cited under regulations 483.15(a) and 483.25(h) were corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 2
Date: Apr 10, 2015
Visit Reason
The inspection was conducted as a complaint survey (#84447) to investigate allegations related to resident care and safety.
Complaint Details
The survey was complaint-driven, investigating issues raised in complaint survey #84447.
Findings
The facility failed to maintain resident dignity by allowing staff to argue in front of a resident and not toileting the resident when requested. The facility also failed to thoroughly investigate the causes of falls and update comprehensive care plans with new interventions for three residents reviewed.
Deficiencies (2)
F241: The facility failed to maintain resident #2's dignity by allowing staff to argue in front of the resident and not toileting the resident when requested.
F323: The facility failed to ensure a safe environment by not thoroughly investigating fall causes and not updating care plans with new interventions for residents #1, #2, and #3.
Report Facts
Resident census: 113
Residents in sample: 3
Falls: 4
Therapy minutes: 330
Therapy minutes: 135
Therapy minutes: 340
Therapy minutes: 135
Falls: 2
Falls: 2
Falls: 1
Falls: 1
Falls: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 10, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 9, 2015
Visit Reason
This is a follow-up visit to verify correction of previously reported deficiencies at Wesley Towers Inc.
Findings
The report documents that previously cited deficiencies have been corrected as of the revisit date. No uncorrected deficiencies remain.
Deficiencies (1)
Regulation 28-39-256 deficiency was corrected by 2015-01-09.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 9, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a QIS survey at the facility.
Findings
The facility identified water temperature concerns but no harm was caused to residents. Maintenance staff corrected the issue and implemented routine monthly water temperature checks with ongoing monitoring and Quality Assurance reviews.
Deficiencies (2)
S0000: The facility developed and implemented a system to assure correction and continued compliance with regulations following the cited deficiency. A copy of the deficiency report will be reviewed by the Quality Assurance Committee by January 29, 2015.
S3420-F: Water temperature concerns were identified with no resident harm. Maintenance staff corrected the issue and will perform monthly water temperature checks recorded on a log, with ongoing monitoring by the operator or administrator.
Inspection Report
Census: 19
Deficiencies: 1
Date: Jan 8, 2015
Visit Reason
The inspection was a licensure survey of the assisted living facility to assess compliance with mechanical requirements and other regulatory standards.
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.
Deficiencies (1)
KAR 28-39-256(c)(2)(B) Mechanical requirements. The facility failed to maintain hot water temperatures between 98 and 120 degrees Fahrenheit in common areas accessible to residents.
Report Facts
Facility census: 19
Water temperature: 130.2
Water temperature: 125.8
Water temperature: 125.4
Water temperature: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff G | Verified water temperature settings and adjusted main water heater | |
| Licensed nursing staff H | Confirmed hot water temperatures were too hot |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Dec 12, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a QIS survey inspection.
Findings
The facility identified multiple deficiencies related to resident dignity, catheter care, care plan completeness, fall prevention, staffing, food safety, medication management, and resident satisfaction. The plan outlines corrective actions including policy revisions, staff education, competency checks, and monitoring through Quality Assurance and Risk meetings.
Deficiencies (12)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations. A complete deficiency list will be reviewed by the Quality Assurance Committee.
F241-D: The facility will ensure dignity for residents using catheter bags by using bags with attached covers and educating staff on the new product.
F250-D: The facility resolved a service issue for a resident and will revise policy to monitor timely external services with staff education and weekly Risk meeting reviews.
F279-D: Care plans will be complete and reflect specifics on weight loss prevention and catheter care, with weekly monitoring and staff training on new policies and competencies.
F280-D: Care plans will be current with prevention and post-fall revisions, reviewed by staff and new hires, with ongoing fall investigations reviewed in Risk and Quality Assurance meetings.
F315-D: Catheter care policies will be revised, staff trained, and competencies completed with monitoring of documentation completeness through medical records reports.
F322-D: The facility will revise policy and train nurses on tube feeding assessment and medication administration with competency checks and quarterly Quality Assurance reviews.
F323-E: Care plans will include fall prevention updates, hazardous chemicals secured, lift chair use policy revised, staff trained, and monitoring of new admissions for compliance.
F353-F: The facility will ensure adequate staffing by hiring to fill budgeted positions, providing CNA training programs, strengthening orientation, and revising staffing policies based on census and acuity.
F371-E: Food will be properly labeled, stored, handled, and expired food discarded timely with revised policies, staff retraining, and competency observations conducted multiple times monthly.
F431-E: Medications will be properly labeled and stored with revised policies, staff training, monthly pharmacy consultant checks, and nursing documentation reviewed in Risk meetings.
F464-D: Residents will be encouraged to choose seating in the dining room with staff orientation on seating flexibility and monitoring of resident satisfaction in monthly Resident Council meetings.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 12, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory citations.
Inspection Report
Enforcement
Deficiencies: 1
Date: Nov 12, 2014
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 programs.
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, resulting in a finding of substantial 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 that was not immediate jeopardy.
Inspection Report
Annual Inspection
Census: 121
Deficiencies: 11
Date: Nov 12, 2014
Visit Reason
Annual health resurvey of Wesley Towers Inc nursing facility to assess compliance with federal regulations.
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, staffing sufficiency, food safety, medication management, and dining room adequacy.
Deficiencies (11)
F241: The facility failed to ensure resident #118's catheter drainage bag was kept in a dignity bag at all times to maintain privacy.
F250: The facility failed to assist resident #20 in making timely dental appointments and providing medically related social services.
F279: The facility failed to develop comprehensive care plans for residents #48 related to nutrition and #52 related to urinary catheter care.
F280: The facility failed to revise the care plan for resident #91 to include interventions for multiple falls and changes in chair type.
F315: The facility failed to provide appropriate urinary catheter care for resident #52 including catheter irrigation and monitoring urine output.
F322: The facility failed to ensure resident #9 had proper assessment and care when administering medications and tube feedings via PEG tube.
F323: The facility failed to provide adequate fall prevention interventions for residents #167, #91, and #191 and failed to secure hazardous chemicals on one neighborhood.
F353: The facility failed to provide sufficient nursing staff to meet resident needs and ensure timely response to call lights and supervision to prevent falls.
F371: The facility failed to safely handle ready-to-eat foods, discard expired foods, ensure residents did not receive expired foods, and properly label foods not in original containers.
F431: The facility failed to discard expired insulin and failed to safely label and store medications prepared in advance for administration.
F464: The facility failed to provide adequate space in the Thorne assisted dining room to accommodate all residents and dining activities.
Report Facts
Residents receiving pureed diets: 15
Residents receiving tube feedings: 3
Expired insulin vial: 1
Call light response times: 17
Call light response times: 13
Call light response times: 19
Call light response times: 15
Call light response times: 11
Call light response times: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Administrative Nurse | Named in multiple interviews regarding care plan expectations, catheter care, fall prevention, and staffing |
| Licensed nursing staff FF | Licensed Nurse | Formed care plans for residents on Hester unit, confirmed catheter care protocol |
| Licensed nursing staff DD | Licensed Nurse | Provided catheter care for resident #52, described catheter irrigation and documentation |
| Licensed nursing staff JJ | Licensed Nurse | Administered tube feeding and medications to resident #9, failed to check tube placement properly |
| Licensed nursing staff W | Licensed Nurse | Described fall packet procedures and documentation |
| Licensed nursing staff G | Licensed Nurse | Reported lack of system to check for outdated medications |
| Licensed nursing staff F | Licensed Nurse | Removed expired Lantus insulin vial from medication cart |
| Licensed nurse LL | Licensed Nurse | Described fall risk assessment and fall packet use |
| Direct care staff T | Direct Care Staff | Reported staffing shortages and care challenges |
| Direct care staff N | Direct Care Staff | Reported staffing shortages and fall prevention practices |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 12, 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 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 to address these deficiencies.
Deficiencies (1)
The facility was cited for an 'F' level deficiency that was widespread with no harm but potential for more than minimal harm, not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jun 12, 2014
Provider agreement termination date: Sep 12, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 18, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-07-19.
Findings
All previously reported deficiencies identified by regulation numbers and prefix codes were corrected as of the revisit date 2013-08-18.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 18, 2013
Visit Reason
This is a follow-up revisit to verify correction of previously reported deficiencies at Wesley Towers Inc.
Findings
The report confirms that the deficiencies previously cited under regulations 26-40-302 (b)(c) and 26-40-305 (c)(1)(2) have been corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 18, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency under regulation KSA 39-970(d) was corrected as of the revisit date.
Deficiencies (1)
Regulation KSA 39-970(d) deficiency was corrected on 2013-08-18 as verified during the revisit.
Inspection Report
Plan of Correction
Deficiencies: 17
Date: Aug 18, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a QIS survey inspection.
Findings
The plan addresses multiple deficiencies related to privacy of electronic records, abuse reporting, care plan updates, medication management, dietary recommendations, environmental safety, immunization education, food preparation, pharmaceutical services, quality assessment, background checks, electrical monitoring, and ventilation.
Deficiencies (17)
F0000 For the deficiencies cited during this QIS survey, the facility will develop and implement a system to assure correction and continued compliance with regulations.
F164-E The facility will ensure privacy of electronic records by implementing policies including automatic logout, privacy screens, and staff education.
F225-E The facility will ensure all allegations of abuse are reported and investigated according to policies, with staff education and ongoing monitoring.
F280-E The facility will update care plans to reflect changes in resident status and educate staff on notification processes.
F309-E The facility will ensure residents receive necessary care to maintain well-being, including monitoring bruises and fluid restrictions, with staff education.
F314-D The facility will implement dietary recommendations to promote healing of pressure ulcers and educate staff on wound care.
F323-E The facility will maintain an environment free of accident hazards, including secure storage of chemicals and medications, with staff re-education.
F329-D The facility will ensure medication regimens are free of unnecessary medications, with audits and staff education.
F334-E The facility will ensure education on pneumococcal vaccination benefits is provided and documented, with staff re-education.
F371-F The facility will ensure food is prepared and served sanitarily, including proper hair restraint and hand hygiene, with staff education.
F425-D The facility will provide pharmaceutical services to ensure accurate medication administration and clarify orders, with staff education.
F428-D The facility and pharmacy consultant will provide pharmaceutical services according to clinical standards, including physician notification of medication irregularities.
F431-E The facility will store medications in locked compartments with proper labeling and remove expired medications, with staff education.
F520-F The facility will implement an effective quality assessment and assurance system to address identified deficiencies through audits and evaluations.
R0102-E The facility will ensure background checks are completed on all new employees, with ongoing monitoring.
S0976-E The facility will ensure the electrical monitoring system on designated doors remains activated until manually reset, with staff re-education.
S1354-E The facility will ensure exhaust fans in the beauty shop function properly to meet ventilation requirements, with ongoing maintenance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Veh | VP of Health Services | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 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 previously cited deficiencies listed by regulation numbers were corrected by the revisit date of 08/18/2013.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Aug 18, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report documents that the previously identified deficiencies under regulations 26-40-302 (b)(c) and 26-40-305 (c)(1)(2) were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-40-302 (b)(c): Previously cited deficiency has been corrected as of 08/18/2013.
Regulation 26-40-305 (c)(1)(2): Previously cited deficiency has been corrected as of 08/18/2013.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 18, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously identified deficiency under regulation KSA 39-970(d) was corrected as of the revisit date.
Deficiencies (1)
Regulation KSA 39-970(d) deficiency was corrected on 2013-08-18.
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 for Wesley Towers Inc nursing 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, failure to monitor fluid restrictions and skin conditions, failure to provide education for vaccinations, failure to maintain sanitary food service practices, medication regimen issues including lack of order clarifications and monitoring, and failure to secure medications and hazardous chemicals.
Deficiencies (12)
F164: Facility failed to ensure privacy of electronic resident records on multiple halls with unattended medication cart computers displaying resident information.
F225: Facility failed to report and thoroughly investigate an allegation of rough treatment of a resident by staff, affecting residents on two halls.
F280: Facility failed to revise care plans to reflect changes in resident status including fluid restrictions, skin tears, and mobility needs for multiple residents.
F309: Facility failed to assess and monitor bruising for residents and failed to implement and monitor fluid restrictions as ordered.
F314: Facility failed to follow dietitian recommendation for high protein supplementation to promote healing of a pressure ulcer for a resident.
F323: Facility failed to secure hazardous chemicals from cognitively impaired, independently mobile residents, creating accident hazards.
F329: Facility failed to ensure medication regimens were free of unnecessary drugs including failure to clarify medication orders, monitor acetaminophen dosage limits, and implement gradual dose reductions for antipsychotics.
F334: Facility failed to provide education regarding benefits and side effects of pneumococcal immunization to residents or legal representatives before administration.
F371: Facility failed to prepare and serve food in a sanitary manner including failure to restrain hair, proper glove use, proper handling of utensils and dishware, and hand hygiene.
F425: Facility failed to ensure accurate pharmaceutical services including proper medication administration, labeling, storage, and monitoring.
F431: Facility failed to ensure medication carts and medication rooms remained locked and secure, and failed to remove expired and unlabeled medications.
F520: Facility failed to develop and implement an effective Quality Assessment and Assurance program to monitor and address multiple quality deficiencies including medication management, abuse reporting, vaccination education, food sanitation, and environmental safety.
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 receiving pureed diet: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Nursing Staff | Named in multiple findings including abuse reporting, medication order clarifications, and QAA program failures |
| Staff M | Administrative Nurse | Named in medication cart locking and fluid restriction monitoring findings |
| Staff YY | Consultant Pharmacist | Named in medication regimen review and pharmacy communication findings |
| Staff KKK | Nurse Practitioner | Named in gradual dose reduction and psychiatric medication findings |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Apr 26, 2012
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 identified deficiencies have been corrected as of the revisit date.
Deficiencies (4)
Regulation 483.15(a): Deficiency identified under tag F0241 was corrected by 04/26/2012.
Regulation 483.20(g)-(j): Deficiency identified under tag F0278 was corrected by 04/26/2012.
Regulation 483.25(c): Deficiency identified under tag F0314 was corrected by 04/26/2012.
Regulation 483.25(h): Deficiency identified under tag F0323 was corrected by 04/26/2012.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Apr 26, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the Plan of Correction.
Findings
The report shows that all previously identified deficiencies were corrected by the revisit date of 04/26/2012.
Deficiencies (4)
Regulation 483.15(a) deficiency was corrected by 04/26/2012.
Regulation 483.20(g)-(j) deficiency was corrected by 04/26/2012.
Regulation 483.25(c) deficiency was corrected by 04/26/2012.
Regulation 483.25(h) deficiency was corrected by 04/26/2012.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Apr 3, 2012
Visit Reason
This document is a plan of correction submitted by the facility in response to deficiencies cited during a QIS survey.
Findings
The plan addresses deficiencies related to resident dignity and respect, incontinence care, pressure ulcer assessment and treatment, infection control during dressing changes, and maintaining a safe resident environment free of accident hazards.
Deficiencies (5)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations. A deficiency list will be reviewed by the continuous service improvement team.
F241-E: The facility will provide care that maintains or enhances resident dignity and respect, including policies on incontinence care and staff education.
F278-D: The facility will complete assessments accurately reflecting residents' pressure ulcer status and ensure consistency between coding and descriptions.
F314-D: The facility will provide treatment to promote healing and prevent infection of pressure ulcers, including proper measuring, dressing changes, and infection control.
F323-E: The facility will ensure the resident environment is free of accident hazards, with reviewed policies and staff education on safe chemical storage.
Inspection Report
Re-Inspection
Census: 116
Deficiencies: 4
Date: Mar 27, 2012
Visit Reason
The visit was a resurvey to assess compliance with previously cited deficiencies at Wesley Towers Inc.
Findings
The facility failed to promote dignity and respect for residents in the special care unit by leaving incontinent pads on chairs. The facility also failed to accurately assess and treat pressure ulcers, including improper staging and inadequate wound care. Additionally, the facility did not secure hazardous chemicals in the beauty shop, posing accident hazards to cognitively impaired residents.
Deficiencies (4)
F241: The facility failed to promote dignity and respect for 11 residents in the special care unit by consistently leaving incontinent pads on all chairs in the living room.
F278: The facility failed to ensure 1 sampled resident's pressure ulcer assessment accurately reflected the resident's current status, including incorrect staging and documentation.
F314: The facility failed to provide necessary treatment and services to promote healing and prevent infection of a stage 3 pressure ulcer, including failure to measure wound depth, change dressings as planned, and change gloves properly.
F323: The facility failed to provide an environment free from accident hazards by not securing hazardous chemicals in the beauty shop accessible to cognitively impaired residents.
Report Facts
Census: 116
Residents in special care unit: 11
Residents in Hester Care Center: 7
Sampled residents for pressure ulcer review: 1
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 glove use |
| Staff H | Licensed Nursing Staff | Removed dressing revealing wound depth and confirmed wound condition |
| Staff K | Licensed Nursing Staff | Performed dressing change with improper glove use and failed to measure wound depth |
| Administrative Nursing Staff I | Administrative Nursing Staff | Confirmed wound staging errors and assessment inaccuracies |
| Administrative Nursing Staff F | Administrative Nursing Staff | Confirmed wound staging, expected glove changes, and lack of treatment notification |
| Nurse A | Nurse | Verified beauty shop door should be locked |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N078010 POC S0CK11
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 ensure a sanitary kitchen environment and effective infection control in housekeeping, including staff education, policy revisions, and ongoing monitoring.
Deficiencies (3)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations, with review by the Quality Assurance Committee.
F812-F: The facility will maintain a sanitary kitchen environment by practicing appropriate hand hygiene and clarifying cleaning responsibilities, with staff education and weekly monitoring.
F880-F: The facility will maintain effective infection control in housekeeping by ensuring proper disinfection of isolation rooms, staff education, and weekly monitoring of compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078010 POC QJPF11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
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