Inspection Reports for Wheatridge Park Care Center
1501 S HOLLY DR, KS, 67901-
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 27, 2018 found no deficiencies and confirmed the facility was in compliance with all regulations surveyed. Earlier inspections showed a pattern of deficiencies primarily related to immunization documentation, resident care planning, medication management, food handling, and sanitation practices. Complaint investigations from 2014 and 2015 identified issues with fall prevention, medication oversight, and care plan updates, some of which were substantiated and addressed through plans of correction. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with repeated revisits confirming correction of prior deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
44 residents
Based on a July 2018 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 27, 2018
Visit Reason
An offsite revisit survey was conducted on 08/27/2018 for all previous deficiencies cited on 07/11/2018.
Findings
All deficiencies have been corrected as of the compliance date of 07/23/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 11, 2018
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection related to missing consent documentation for influenza and pneumococcal immunizations.
Findings
The facility identified missing consent documentation for influenza and pneumococcal immunizations and implemented corrective actions including resident assessments, audits, and nursing re-education to ensure proper documentation and compliance.
Deficiencies (1)
| Description |
|---|
| Missing consent documentation on influenza and pneumococcal immunizations |
Report Facts
Audit date: Jul 11, 2018
Plan completion date: Jul 21, 2018
Plan submission date: Jul 23, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marc Riley | Executive Director | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 1
Jul 11, 2018
Visit Reason
The inspection was a health resurvey to assess compliance with influenza and pneumococcal immunization requirements.
Findings
The facility failed to ensure that residents #17, 29, 40, and 46 were offered and/or received the pneumonia and annual influenza vaccines as required by CDC guidelines. Documentation of immunization or refusal was missing for these residents.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents #17, 29, 40, and 46 were offered and/or received pneumonia and influenza vaccines per CDC recommendations. | SS=E |
Report Facts
Facility census: 44
Residents reviewed: 5
Inspection Report
Plan of Correction
Deficiencies: 8
Aug 23, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report for Wheatridge Park CC dated 08/03/2016.
Findings
The Plan of Correction addresses multiple deficiencies including resident trust account management, care plan updates related to weight loss, medication errors, food handling practices, and housekeeping sanitation. Corrective actions include policy reviews, staff inservices, performance improvement projects (PIPs), and ongoing monitoring by the Quality Assurance Performance Improvement (QAPI) Committee.
Severity Breakdown
D: 6
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Resident trust accounts were not properly closed or reconciled within 30 days after death or discharge. | D |
| Care plans for residents were not updated to include interventions related to weight loss as recommended by the Consultant Dietician. | D |
| Consultant Dietician recommendations were not consistently forwarded to the physician or implemented/documented. | D |
| Medication discontinued by physician was not discontinued timely, resulting in a medication error. | D |
| Orders from the Dialysis Center were not always entered correctly into the electronic medical record. | D |
| Deficient food serving practices including improper sanitary methods for spreading condiments and handling glasses. | F |
| Medication regimen irregularities requiring audit and reconciliation. | D |
| Resident room cleaning practices deficient, requiring re-cleaning and staff inservice on disinfecting chemicals and contact times. | F |
Report Facts
Balance remitted: 13.84
Dates of medication discontinuation: Medication discontinued by physician on 2016-06-24 and actually discontinued on 2016-07-27 for Resident #23
Inservice completion date: Inservice for licensed nursing staff and other staff to be completed by 2016-08-23
Surface contact time: 10
Inspection Report
Follow-Up
Deficiencies: 0
Aug 23, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers were corrected as of the revisit date, with completion dates documented for each.
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 3, 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 the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Date of survey: Aug 3, 2016
Effective date of substantial compliance: Aug 23, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 6
Aug 3, 2016
Visit Reason
The inspection was a Health Resurvey to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to convey resident funds within 30 days of death, failure to revise care plans for weight loss and nutritional needs, medication errors involving duplicate phosphate binders, improper food handling practices, and inadequate infection control related to disinfectant contact times.
Severity Breakdown
SS=D: 4
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to convey resident's personal funds to the individual or estate within 30 days of death. | SS=D |
| Failure to revise care plans for residents regarding weight loss and dietitian recommendations. | SS=D |
| Failure to maintain nutritional status by not following dietitian recommendations and physician notification for weight loss. | SS=D |
| Failure to remain free of medication errors by not discontinuing Renvela as ordered and administering both Renvela and Phoslo. | SS=D |
| Failure to prepare and serve food under sanitary conditions including improper hand washing, glove use, and handling of glassware. | SS=F |
| Failure to ensure infection control by not following disinfectant manufacturer's directions for surface contact times. | SS=F |
Report Facts
Resident census: 46
Resident sample size: 13
Weight loss: 31.6
Weight loss percentage: 12.8
Medication administration period: 33
Disinfectant contact time: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff B | Interviewed regarding resident funds conveyance upon death | |
| Administrative staff A | Interviewed regarding resident funds policy and care plan revision guidance | |
| Administrative staff V | Administrative nursing staff | Interviewed regarding care plan revisions and physician recommendations |
| Administrative staff G | Administrative nursing staff | Interviewed regarding care plan expectations for weight loss and edema |
| Dietary staff K | Interviewed regarding dietitian recommendations and supplement orders | |
| Licensed nursing staff F | Interviewed regarding care plan updates, physician notifications, and medication administration | |
| Consultant dietitian Z | Consultant dietitian | Interviewed regarding dietitian recommendations and communication with nursing |
| Licensed nursing staff U | Reported on resident snack refusals | |
| Licensed nursing staff Q | Reported on resident meal intake and weight monitoring | |
| Dietary staff T | Reported on meal preparation and protein servings | |
| Dietary staff L | Reported on supplement documentation | |
| Dietary staff I | Reported on resident meal intake and refusals | |
| Dietary staff O | Reported on food handling and glove use training | |
| Housekeeping staff C | Observed and interviewed regarding disinfectant use and contact times | |
| Housekeeping staff X | Interviewed regarding disinfectant contact times | |
| Housekeeping supervisor D | Housekeeping supervisor | Interviewed regarding disinfectant contact times and staff training |
| Licensed nursing staff G | Administrative nursing staff | Interviewed regarding medication order process and weight loss notifications |
| Physician staff W | Physician | Interviewed regarding receipt of dietitian recommendations |
| Consultant pharmacist M | Consultant pharmacist | Interviewed regarding medication review and failure to identify duplicate therapy |
Inspection Report
Life Safety
Deficiencies: 1
Mar 11, 2016
Visit Reason
A Life Safety Code survey was conducted on March 11, 2016, by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level severity in Life Safety Code compliance | F |
Report Facts
Effective date for denial of payments: Jun 11, 2016
Provider agreement termination date: Sep 11, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in enforcement and certification context |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 10, 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
All previously reported deficiencies identified by regulation numbers 483.15(f)(1), 483.20(d)(3), 483.10(k)(2), 483.25, 483.25(c), 483.25(l), and 483.60(c) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Apr 10, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report, outlining corrective actions to address identified issues.
Findings
The plan details immediate actions taken for affected residents, identification of other residents potentially affected, actions and systems implemented to reduce future risk, and monitoring plans to ensure compliance and prevent recurrence of deficiencies.
Severity Breakdown
D: 4
E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide person-specific and meaningful 1:1 programming and updates to care plans for residents with lower cognitive function. | D |
| Inadequate nursing skin condition care plans and monitoring for residents. | D |
| Failure to properly assess and monitor non-pressure related skin conditions. | D |
| Inadequate repositioning and care for residents with pressure ulcers or at risk for pressure ulcers. | D |
| Failure to include names and warnings for medications with black box warnings in nursing care plans. | E |
| Consulting pharmacist did not adequately review resident charts or communicate black box warnings to nursing staff. | E |
Report Facts
Care plans reviewed weekly: 3
Care plans reviewed weekly: 4
Residents audited monthly: 2
Residents audited monthly: 1
Charts audited weekly: 3
Weeks audited: 6
Pharmacy recommendations audited monthly: 6
Pharmacy recommendations audited monthly: 8
Audit duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Durler | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 6
Mar 11, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS00079177 to assess compliance with regulatory requirements.
Findings
The facility failed to provide ongoing activities meeting residents' individual needs, failed to revise care plans for non-pressure related skin issues, failed to provide timely repositioning for pressure ulcer healing, and failed to include and act upon black box warning (BBW) information for medications in residents' care plans.
Complaint Details
The visit was triggered by a complaint investigation identified as #KS00079177.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide ongoing activities to meet the physical, mental, and psychosocial well-being for 3 sampled residents (#4, #19, and #20). | SS=D |
| Failed to revise resident #36's care plan related to non-pressure related skin issues including a pre-cancerous facial lesion. | SS=D |
| Failed to assess and monitor non-pressure related skin issues for resident #36. | SS=D |
| Failed to ensure timely repositioning of resident #27 with a pressure ulcer to promote healing and prevent new ulcers. | SS=D |
| Failed to ensure residents' drug regimens were free from unnecessary drugs and failed to include BBW information in care plans for residents #14, #18, #41, and #50. | SS=E |
| Failed to ensure consultant pharmacist identified irregularities related to medications with BBWs and the facility acted upon those recommendations for residents #14, #18, #41, and #50. | SS=E |
Report Facts
Residents sampled: 21
Residents reviewed for non-pressure skin issues: 3
Residents reviewed for unnecessary medications: 5
Residents with medication BBW issues: 4
Duration resident #27 remained repositioned: 176
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Consultant pharmacist L | Consultant Pharmacist | Verified monthly drug regimen reviews and identification of medications with black box warnings but did not review care plans for BBW information. |
| Administrative nurse B | Administrative Nurse | Confirmed lack of BBW information in nursing care plans and verified failure to act on pharmacist recommendations. |
| Licensed nurse M | Licensed Nurse | Provided information about resident #36's skin condition and weekly skin assessments. |
| Direct care staff K | Direct Care Staff | Provided observations about resident #36's skin condition and resident #27's pressure ulcer care. |
| Licensed nurse F | Licensed Nurse | Reported awareness of BBW medications for residents and provided information about resident #27's pressure ulcer care. |
Inspection Report
Deficiencies: 1
Mar 11, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services 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, resulting in a finding of substantial compliance effective April 10, 2015.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy | E |
Report Facts
Effective date of substantial compliance: Apr 10, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Life Safety
Deficiencies: 1
Nov 5, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Feb 5, 2015
Provider agreement termination date: May 5, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Durler | Administrator | Named as facility administrator |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Joe Ewert | Commissioner | Mentioned in copy of letter |
Inspection Report
Follow-Up
Deficiencies: 3
Jul 17, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies at Wheatridge Park Care Center.
Findings
The report documents that previously identified deficiencies under regulations 483.25(h), 483.25(l), and 483.60(c) were corrected by the dates indicated in July 2014.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 483.25(h) |
| Deficiency under regulation 483.25(l) |
| Deficiency under regulation 483.60(c) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 4
Jul 16, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Wheatridge Park facility.
Findings
The plan addresses deficiencies related to fall risk assessments, sleep assessments, and medication management for hypnotics and sedatives. Corrective actions include staff training, daily and monthly reviews, and ongoing monitoring by nursing management and quality assurance committees.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified by Event ID OX8Q11 and Complaint ID 061914.
Severity Breakdown
G: 1
D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to complete fall risk assessments and update care plans for residents #1, #2, and #3 | G |
| Failure to conduct sleep assessments and update care plans to reflect non-pharmacological interventions for Resident #2 | D |
| Failure to provide mandatory in-service education regarding hypnotics and sedatives policy | D |
| Failure to monitor monthly drug regimen reviews for residents on hypnotics/sedatives | D |
Report Facts
Records audited weekly: 6
Records audited weekly: 10
Records audited biweekly: 5
Records audited monthly: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Durler | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 3
Jun 19, 2014
Visit Reason
The inspection was conducted as a complaint investigation based on allegations related to falls and medication management at Wheatridge Park Care Center.
Findings
The facility failed to ensure adequate supervision and fall prevention strategies for three sampled residents, resulting in multiple falls including some requiring emergency treatment. Additionally, the facility failed to ensure resident #2's drug regimen was free from unnecessary medications, with excessive use and dosage of hypnotics without adequate assessment or indication. The consultant pharmacist failed to report these irregularities timely.
Complaint Details
The investigation was triggered by complaints identified as #KS00076003, KS00076020, and KS00076095 related to falls and medication management.
Severity Breakdown
SS=G: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 3 sampled residents received adequate supervision and assistive devices to prevent accidents, including failure to evaluate falls, implement prevention strategies, and follow care plans. | SS=G |
| Failed to ensure resident #2's drug regimen was free from unnecessary drugs, including excessive dose and duration of Temazepam and Halcion without adequate indication or monitoring. | SS=D |
| Failed to ensure the consultant pharmacist identified and reported drug irregularities related to resident #2's hypnotic medication use. | SS=D |
Report Facts
Resident census: 50
Number of falls for resident #1: 11
Number of falls for resident #2: 4
Number of falls for resident #3: 8
Temazepam dosage: 30
Halcion dosage: 0.25
Fall risk assessment scores: 26
Fall risk assessment scores: 20
Fall risk assessment scores: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Administrative Nurse | Verified failures in fall prevention follow-up and medication review for residents #1 and #2 |
| Nurse F | Licensed Nurse | Provided information on resident #1's restlessness and bed safety |
| Consultant Pharmacist G | Consultant Pharmacist | Reviewed drug regimen and reported irregularities related to resident #2's hypnotic use |
| Physician H | Physician | Confirmed resident #1's falls and medical conditions |
| Direct Care Staff C | Recalled resident #1's fall and described circumstances of the fall | |
| Direct Care Staff D | Assisted resident #3 and provided care observations | |
| Direct Care Staff I | Assisted resident #2 with transfers | |
| Direct Care Staff J | Assisted resident #2 with transfers | |
| Direct Care Staff K | Provided information on resident #3's fall risk and prevention |
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 15, 2014
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
The report confirms that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 02/15/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously reported |
Report Facts
Deficiency correction date: Feb 15, 2014
Inspection Report
Follow-Up
Deficiencies: 6
Feb 15, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-11-26.
Findings
All previously cited deficiencies identified by regulation numbers F0157, F0309, F0314, F0371, F0441, and F0520 were corrected as of the revisit date.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 7
Feb 15, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report. It outlines corrective actions taken and planned to resolve identified issues.
Findings
The plan details immediate actions taken for affected residents, identification of other residents potentially affected, systems put in place to reduce future risk, and monitoring plans to ensure deficiencies do not recur. Areas addressed include resident condition changes, fall assessments, wound care, dietary sanitation, housekeeping sanitation, quality assurance activities, and obtaining a certified CDM.
Deficiencies (7)
| Description |
|---|
| Failure to notify physician and sponsor of resident vomiting and condition change |
| Failure to provide and document nursing assessment following a fall |
| Failure to document wound assessments and repositioning for residents with pressure ulcers |
| Improper dietary sanitation practices including dish sanitizing and food handling |
| Improper housekeeping cleaning techniques and disinfectant use |
| Lack of ongoing quality assurance activities to ensure improvement and deficiency correction |
| Facility lacked a certified Certified Dietary Manager (CDM) |
Report Facts
Corrective action completion date: Feb 15, 2014
Chart audits: 5
Fall audits: 4
Wound audits: 2
Sanitation audits: 5
Housekeeping audits duration: 4
QA audit monitoring frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Lindsay Durler | Administrator | Administrator who submitted the Plan of Correction |
| Irina Strakhova | Person who added and modified the Plan of Correction | |
| Dietary Manager | Dietary Manager (DM) | In-serviced dietary staff on sanitation and food handling practices |
| Environmental services coordinator | Conducts random audits of housekeeping cleaning procedures | |
| Director of Nursing | Director of Nursing Services | Conducts audits and in-services related to nursing assessments, wound care, and falls |
| Administrator | Educates QAA committee members and monitors QA audits |
Inspection Report
Follow-Up
Deficiencies: 0
Jan 29, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date, January 29, 2014.
Report Facts
Deficiencies corrected: 9
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 6
Jan 29, 2014
Visit Reason
The inspection was a non-compliance revisit to verify correction of previously cited deficiencies related to resident care, pressure ulcer treatment, food service sanitation, infection control, and quality assurance.
Findings
The facility failed to immediately report a significant change in a resident's medical condition after a fall, failed to provide necessary nursing assessments post-fall, failed to ensure daily wound assessments and timely repositioning for residents with pressure ulcers, failed to properly sanitize dishware and thermometers in food service, and failed to maintain a sanitary environment in resident rooms. The Quality Assessment and Assurance (QAA) program failed to develop and implement effective action plans to address these deficiencies.
Severity Breakdown
SS=D: 3
SS=F: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to immediately report a significant change in medical condition (repeated vomiting after an unwitnessed fall) for Resident #63. | SS=D |
| Failed to provide necessary nursing assessments after a fall to maintain highest practicable well-being for Resident #33. | SS=D |
| Failed to ensure daily assessment/documentation of pressure ulcers and timely repositioning for Residents #26, #33, and #40. | SS=D |
| Failed to store, prepare, and serve food under sanitary conditions including improper sanitization of dishware and thermometers, and failure to consistently record food temperatures. | SS=F |
| Failed to maintain a sanitary environment to prevent infection transmission when staff failed to properly sanitize a resident's sink and room. | SS=F |
| Failed to develop and implement effective Quality Assessment and Assurance (QAA) action plans related to notification of change, pressure ulcer documentation, food service, and infection control. | SS=F |
Report Facts
Deficiencies cited: 6
Census: 32
Sanitizer ppm: 400
Days with missing cooked temperature documentation: 3
Days with missing cooked temperature documentation: 12
Days with missing cooked temperature documentation: 3
Days with missing serving temperature documentation: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported QAA meetings and deficiencies related to pressure ulcer documentation, food service, notification of change, and infection control. | |
| Administrative nursing staff B | Confirmed failures in immediate physician notification, pressure ulcer documentation, and infection control practices. | |
| Licensed nursing staff M | Licensed nursing staff | Confirmed failure to immediately notify physician of repeated vomiting after fall. |
| Licensed nursing staff I | Licensed nursing staff | Described post-fall assessment procedures and skin assessment practices. |
| Dietary staff D | Dietary staff | Verified improper sanitization of dishware and thermometers and improper glove use. |
| Dietary staff E | Dietary staff | Observed failing to remove contaminated gloves and sanitize thermometers properly. |
| Housekeeping staff G | Housekeeping staff | Observed improper sanitization of resident's sink and use of contaminated rag. |
| Housekeeping staff H | Housekeeping staff | Verified failure to leave sanitizer on surfaces for required time and improper rag use. |
Inspection Report
Plan of Correction
Deficiencies: 15
Dec 21, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, detailing corrective actions to address identified issues.
Findings
The plan outlines immediate actions taken for affected residents, identification of other residents potentially affected, systems put in place to reduce future risk, and monitoring plans to ensure compliance across multiple areas including Medicare non-coverage notices, weight loss notifications, bathing preferences, fall prevention, neurological checks, wound care, medication storage, food portion sizes, sanitation, and hand hygiene.
Severity Breakdown
D: 8
E: 2
F: 5
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to give notice of Medicare non-coverage and use of CMS form 10123 | D |
| Failure to notify physician or family of significant weight loss | D |
| Failure to assess and document bathing preferences and meal choices | D |
| Failure to update nursing fall prevention care plans | D |
| Failure to notify physician of dietitian recommendations and update care plans | D |
| Failure to provide and document neurological checks after unwitnessed falls | D |
| Failure to properly assess and document wound care | D |
| Failure to complete fall risk assessments and repair grab bars | E |
| Failure to complete and report laboratory tests ordered by physician | D |
| Failure to serve proper food portion sizes | E |
| Failure to maintain proper kitchen sanitation and ware washing | F |
| Failure to properly store medications requiring refrigeration | D |
| Failure to maintain proper temperature logs for medication refrigerators | F |
| Failure to maintain proper hand hygiene and sanitation practices | F |
| Dietary Manager not yet exam eligible | F |
Report Facts
Residents audited weekly for non-coverage notice: 2
Residents audited weekly for weight loss notification: 5
Months of monitoring bathing and meal choice practices: 3
Days of care plan review for fall prevention: 14
Weeks of neurological check audits: 4
Wounds audited per month: 2
Weeks of chart audits for fall incident reports: 6
Records audited weekly for lab testing: 10
Food preparation and service audits monthly: 4
Dietary sanitation audits weekly: 3
Medication refrigerator inspection duration: 3
Hand washing and laundry audits duration: 4
Dietary Manager exam eligibility target date: Mar 31, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Durler | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Dietary Manager | Involved in multiple corrective actions and trainings | |
| Director of Nursing Services | Responsible for education, monitoring, and audits related to nursing and medication practices | |
| Social Services Coordinator | Responsible for interviewing residents and reviewing procedures related to bathing preferences and Medicare notices | |
| Dietary Manager (DM) | Conducts audits and in-service trainings related to dietary and sanitation practices |
Inspection Report
Plan of Correction
Census: 50
Deficiencies: 1
Nov 26, 2013
Visit Reason
The document is a statement of deficiencies and plan of correction related to dietary services at Wheatridge Park Care Center, focusing on certification compliance of dietary services supervisory staff.
Findings
The facility failed to ensure that the dietary services supervisor was certified as a dietary manager, as dietary staff D, who worked as the supervisor, did not have the required certification.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure a certified dietary manager maintained supervisory responsibilities of the kitchen/food services. | SS=F |
Report Facts
Census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| dietary staff D | dietary services supervisor | Worked as the supervisor of dietary staff but lacked dietary manager certification |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 15, 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 have been corrected.
Findings
All previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 8
Jul 30, 2012
Visit Reason
This document is a Plan of Correction submitted by Wheatridge Park Care Center to address deficiencies identified in a prior inspection report dated 07/17/2012.
Findings
The plan outlines corrective actions for multiple deficiencies including abuse reporting, medication management, blood pressure parameter monitoring, influenza and pneumococcal vaccination consent and education, medication destruction, clean technique during medication administration, and sanitization of equipment. The facility describes measures to prevent recurrence and monitoring plans involving audits and staff education.
Severity Breakdown
C: 2
D: 4
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to assign a responsible individual for reporting abuse and failure to educate staff on abuse recognition and reporting. | C |
| Inadequate review and gradual dose reduction attempts of antipsychotic medications for Resident #12. | D |
| Failure to notify physician and monitor blood pressure parameters appropriately for Resident #12 and others. | D |
| Lack of appropriate diagnoses documented for medications ordered for Resident #48 and others. | D |
| Failure to obtain and document influenza vaccination consent and education for residents. | C |
| Failure to ensure destruction of expired medications and staff education on medication disposal. | D |
| Failure to maintain clean technique during medication administration through gastric tube for Resident #48. | F |
| Failure to properly sanitize equipment between resident uses including blood pressure machines and lifts. | F |
Report Facts
Days for corrective action completion: 90
Date of inspection visit: Jul 17, 2012
Date of Plan of Correction submission: Jul 30, 2012
Number of residents referenced: 4
Number of staff audits per week: 3
Number of resident charts audited weekly: 2
Number of residents audited weekly for blood pressure parameters: 3
Number of random weekly audits for expired medications: 1
Number of random audits for sanitization techniques: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Durler | Administrator | Assigned as the covered individual responsible for abuse reporting and submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 6
Jul 17, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies related to abuse/neglect policies, unnecessary drug use, immunization education, drug regimen review, drug storage and labeling, and infection control.
Findings
The facility failed to update abuse/neglect policies per federal requirements, failed to ensure residents did not receive unnecessary medications including lack of gradual dose reduction and monitoring, failed to provide education and documentation for influenza and pneumococcal immunizations, failed to ensure pharmacist reported medication irregularities, failed to dispose of expired medications, and failed to maintain infection control practices including cleaning of blood pressure cuffs, mechanical lifts, and maintaining clean technique during medication administration via gastric tube.
Severity Breakdown
SS=C: 2
SS=D: 3
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to update abuse, neglect, and exploitation policies to comply with Section 115-B of the Social Security Act. | SS=C |
| Failure to ensure residents did not receive unnecessary drugs including lack of gradual dose reduction for Xanax and inadequate monitoring of Lisinopril effectiveness. | SS=D |
| Failure to provide education and document benefits and side effects of influenza and pneumococcal immunizations for residents and/or legal representatives. | SS=C |
| Failure of pharmacist to report irregularities related to unnecessary medications and lack of indications for use to attending physician and director of nursing. | SS=D |
| Failure to dispose of expired medications in medication carts. | — |
| Failure to maintain infection control including cleaning blood pressure cuffs between residents, sanitizing mechanical lifts between use, and maintaining clean technique during medication administration via gastric tube. | SS=F |
Report Facts
Census: 45
Residents sampled for unnecessary medications: 10
Residents reviewed for immunizations: 5
Expired medications found: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Consultant C | Pharmacy Consultant | Reported lack of awareness of resident medication history and failure to report medication irregularities |
| Direct Care Staff H | Reported checking for expired medications monthly and identified expired medications in cart | |
| Direct Care Staff E | Observed failing to clean blood pressure cuffs between residents | |
| Direct Care Staff F | Observed failing to sanitize mechanical lift between resident use | |
| Licensed Nursing Staff D | Observed failing to maintain clean technique during medication administration via gastric tube | |
| Administrative Nursing Staff B | Administrative Nursing Staff | Confirmed lack of documentation and education for immunizations and medication monitoring failures |
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