Inspection Reports for
Wheatridge Park Care Center
1501 S HOLLY DR, LIBERAL, KS, 67901-
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 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
80
60
40
20
0
Occupancy
Latest occupancy rate
89% occupied
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 40
Deficiencies: 20
Date: Sep 16, 2024
Visit Reason
Routine inspection of Wheatridge Park Care Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to provide dignified care, incomplete advanced directives, inadequate notification of hospitalizations, failure to provide bed hold notices, incomplete care area assessments, inaccurate MDS completion, unsafe storage of chemicals and sharp objects, improper respiratory care, lack of annual CNA performance reviews, incomplete nurse staffing postings, unsafe medication cart security, unsanitary food storage and preparation, uncovered trash dumpsters, and failure to use proper infection control precautions.
Deficiencies (20)
F 0550: The facility failed to provide Resident R10 dignified care during colostomy care, leaving him exposed and uncovered for 40 minutes with the door open.
F 0567: The facility failed to ensure Resident R7 received his monthly benefits timely, causing potential negative effects on his well-being.
F 0578: The facility failed to ensure accurate and complete advanced directives for four residents, including missing required signatures.
F 0582: The facility failed to issue correct and complete Beneficiary Protection Notification forms to Resident R146 prior to discharge.
F 0623: The facility failed to provide timely notification to residents' representatives and the Long-Term Care Ombudsman upon resident hospitalizations.
F 0625: The facility failed to provide written bed hold notices to residents R2, R10, R21, and R26 at the time of hospital transfers.
F 0636: The facility failed to complete accurate Care Area Assessments and MDS for residents R7, R8, R21, and R144, placing residents at risk for uncommunicated care needs.
F 0641: The facility failed to ensure accurate assessments for residents R7, R8, R21, and R144, including incomplete fall investigations and inappropriate use of powered lift chairs.
F 0657: The facility failed to implement appropriate interventions after multiple falls for residents R8 and R22, resulting in actual harm including fractures and hospitalization for R8.
F 0686: The facility failed to provide pressure ulcer care for Resident R2, who developed two preventable stage 3 pressure injuries due to lack of proper interventions and equipment.
F 0689: The facility failed to maintain an environment free of accident hazards by improper storage of hazardous chemicals and failure to secure sharp objects from Resident R26.
F 0730: The facility failed to complete annual performance reviews for five Certified Nurse Aides to ensure adequate care provision.
F 0732: The facility failed to display accurate and identifiable daily nurse staffing information including facility name and resident census.
F 0761: The facility failed to ensure medication and treatment carts containing controlled substances and topical medications remained locked when unattended.
F 0812: The facility failed to provide sanitary food storage and preparation, including uncovered food items, uncleanable cutting boards, and improper sanitizer concentration.
F 0814: The facility failed to maintain garbage dumpsters with lids closed or covered, risking pest harborage.
F 0880: The facility failed to implement Enhanced Barrier Precautions for Residents R39 and R26 during wound and catheter care, increasing infection risk.
F 0883: The facility failed to provide proper documentation of COVID-19 and pneumococcal vaccinations or declinations for Resident R2.
F 0908: The facility failed to maintain the kitchen's double-door oven in safe operating condition, requiring a folding chair to hold doors closed.
F 0947: The facility failed to develop, implement, and maintain an in-service training program for CNAs with required topics and minimum hours.
Report Facts
Residents sampled: 12
Facility census: 40
Sanitizer concentration checks: 124
Sanitizer checks missing: 56
Refrigerator temperature checks missing: 26
Fall risk score R8: 25
Fall risk score R22: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Named in multiple findings related to care plan, infection control, respiratory care, and fall investigations |
| Licensed Nurse G | Licensed Nurse | Named in respiratory care and wound care findings |
| Dietary Manager L | Dietary Manager | Named in food safety and kitchen equipment findings |
| Administrative Staff A | Administrative Staff | Named in staffing and discharge planning findings |
| Consultant Nurse J | Consultant Nurse | Named in MDS completion and care area assessment findings |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 23
Date: Sep 16, 2024
Visit Reason
Annual inspection of Wheatridge Park Care Center to assess compliance with healthcare regulations including resident care, safety, and facility operations.
Findings
The facility had multiple deficiencies including failure to provide dignified care during colostomy care, incomplete care plan meetings, delayed resident benefits, incomplete advanced directives, inadequate discharge planning, pressure ulcer care deficiencies, unsafe storage of chemicals, unsecured treatment cart, improper respiratory care, incomplete staff training, inaccurate staffing postings, unsafe kitchen equipment, unsanitary food storage, improper garbage disposal, and failure to use enhanced barrier precautions.
Deficiencies (23)
The facility failed to provide Resident R10 care in a dignified manner during colostomy care, leaving him exposed for 40 minutes without a colostomy bag covering his stoma.
The facility failed to include Resident R7 in care plan meetings, risking inadequate care and uncommunicated needs.
The facility failed to ensure Resident R7 received his monthly benefits timely, potentially affecting his well-being.
The facility failed to ensure accurate and complete advanced directives for four residents, including missing signatures on DNR orders.
The facility failed to provide correct and complete Beneficiary Protection Notification forms to Resident R146 before discharge.
The facility failed to notify representatives and the Long-Term Care Ombudsman of hospitalizations for multiple residents, risking impaired rights and uninformed care choices.
The facility failed to provide written bed hold notices to residents and/or representatives specifying duration at time of hospital transfer.
The facility failed to complete Care Area Assessments addressing causes and risk factors for residents R7, R21, R8, and R144, including inaccurate documentation of resident R8 as deceased.
The facility failed to accurately complete Minimum Data Sets for residents R7 and R8 related to falls and dentition, risking uncommunicated care needs.
The facility failed to review and revise care plans with appropriate interventions for residents R20, R2, R22, and R8, resulting in uncommunicated care needs.
The facility failed to implement a discharge plan involving Resident R144, placing him at risk for decreased psychosocial well-being and uncommunicated needs.
The facility failed to provide pressure reducing devices for Resident R2, resulting in reopening of a stage three pressure injury.
The facility failed to maintain an environment free of accident hazards, including unsecured chemicals and allowing Resident R26 to carry scissors, risking injury.
The facility failed to investigate, develop, and implement appropriate interventions to prevent multiple falls for Residents R22 and R8, resulting in fractures and hospitalization for R8.
The facility failed to properly clean, label, and store nebulizer and oxygen supplies for Residents R7, R21, R22, and R144, risking respiratory care deficiencies.
The facility failed to complete annual performance reviews for five Certified Nurse Aides, risking inadequate care and services.
The facility failed to display accurate and identifiable daily nurse staffing information including facility name and census.
The facility failed to ensure a nurse treatment cart containing insulin, topical ointments, creams, and narcotics remained locked when unattended and accessible to residents.
The facility failed to provide sanitary food storage and dishwashing conditions, including uncovered food, undated items, and improper sanitizer concentration.
The facility failed to maintain and dispose of garbage and refuse properly, with uncovered dumpsters and broken lids, risking pest harborage.
The facility failed to maintain the kitchen's double-door oven in safe operating condition, requiring a folding chair to hold doors closed.
The facility failed to use Enhanced Barrier Precautions for Residents R39 during wound care and R26 during urinary catheter care, risking infection.
The facility failed to provide proper documentation of vaccination or declination for COVID-19 and pneumococcal vaccines for Resident R2.
Report Facts
Residents sampled: 12
Facility census: 40
CNAs lacking annual review: 5
CNAs with insufficient training hours: 2
CNAs lacking required training topics: 2
Sanitizer concentration check failures: 56
Refrigerator temperature check failures: 26
Refrigerator temperature above safe limit: 35
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Jan 4, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident-to-resident sexual abuse occurring on 12/10/2023.
Complaint Details
The complaint investigation substantiated that resident-to-resident sexual abuse occurred on 12/10/23. The facility failed to provide adequate supervision and timely notification to family and physician. The deficient practice placed a resident in immediate jeopardy.
Findings
The facility failed to provide adequate supervision to prevent resident-to-resident sexual abuse between two residents, one cognitively intact and one severely impaired. The facility lacked sufficient interventions and staff education to prevent further incidents, placing a resident in immediate jeopardy.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse, including sexual abuse, when staff did not provide adequate supervision to prevent resident-to-resident sexual abuse on 12/10/23. Staff found one resident with his hand inside another resident's shirt and the other resident with her hand inside his pants while kissing.
Report Facts
Resident census: 41
Cognitively impaired females: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide R | Reported the sexual abuse incident to the nurse and assisted in separating the residents | |
| Licensed Nurse G | Assisted in separating the residents during the sexual abuse incident | |
| Administrative Nurse D | Administrative Nurse | Reported expectations for staff regarding safety, notification, and education; confirmed failure to provide additional education after the incident |
Inspection Report
Routine
Census: 36
Deficiencies: 8
Date: Oct 27, 2022
Visit Reason
Routine inspection of Wheatridge Park Care Center to assess compliance with regulatory requirements including resident privacy, care planning, accident prevention, catheter care, nutrition, and staffing.
Findings
The facility failed to provide adequate privacy for residents during care, did not develop or revise comprehensive care plans timely, failed to ensure resident safety in wheelchair use and fall prevention, did not maintain sanitary catheter care, failed to monitor resident weight as ordered, and did not post accurate nurse staffing information daily.
Deficiencies (8)
F 0583: The facility failed to provide privacy for two residents during care, including exposing residents due to open doors and lack of privacy curtains.
F 0656: The facility failed to develop a comprehensive care plan including urinary catheter use for one resident.
F 0657: The facility failed to review and revise care plans timely for five residents, including fall interventions and shaving assistance.
F 0677: The facility failed to provide appropriate assistance with shaving for two dependent residents.
F 0689: The facility failed to ensure safety to prevent accidents for four residents, including inadequate foot support in wheelchairs and failure to implement timely fall interventions.
F 0690: The facility failed to ensure sanitary care of urinary catheters for two residents, including tubing and collection bags lying on the floor.
F 0692: The facility failed to obtain weekly weights as ordered to monitor one resident for weight loss.
F 0732: The facility failed to post accurate daily nurse staffing information including resident census and actual hours worked.
Report Facts
Resident census: 36
Residents sampled: 18
Weight loss: 14.6
Weight loss: 0.6
Fall incident date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements on privacy, catheter care, wheelchair safety, and shaving policies. |
| Administrative Nurse D | Administrative Nurse | Provided statements on privacy, care plan updates, catheter care, fall monitoring, and staffing. |
| Certified Nurse Aide N | Certified Nurse Aide | Observed and commented on privacy issues and shaving assistance. |
| Certified Nurse Aide O | Certified Nurse Aide | Observed and commented on privacy issues. |
| Certified Nurse Aide M | Certified Nurse Aide | Observed privacy breach and shaving assistance failure. |
| Certified Nurse Aide NN | Certified Nurse Aide | Observed wheelchair safety issues and catheter tubing placement. |
| Licensed Nurse H | Licensed Nurse | Discussed fall incidents and documentation. |
| Consulting Hospice Nurse GG | Consulting Hospice Nurse | Provided hospice care expectations and fall monitoring. |
| Certified Medication Aide R | Certified Medication Aide | Assisted resident with meal consumption. |
| Dietary Staff BB | Dietary Staff | Discussed weight monitoring procedures. |
| Certified Nurse Aide Q | Certified Nurse Aide | Observed shaving assistance failure. |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Date: May 4, 2021
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide adequate bathing assistance to residents, specifically Resident 21 and Resident 5.
Complaint Details
The investigation was complaint-driven based on resident reports and interviews indicating insufficient bathing assistance due to staffing shortages. The complaints were substantiated by observations and record reviews.
Findings
The facility failed to provide bathing care to Resident 21 and Resident 5 as required, resulting in inadequate grooming and personal hygiene. Staffing shortages were cited as a reason for the inability to complete bathing tasks as scheduled.
Deficiencies (2)
F 0677: The facility failed to provide Resident 21 with bathing care to maintain good grooming and personal hygiene. Resident 21 received baths only on 3 days in the 30-day review period despite requiring assistance.
F 0677: The facility failed to provide Resident 5 with bathing care to maintain good grooming and personal hygiene. Resident 5 received only one bath per week instead of the required two, and shaving assistance was also lacking.
Report Facts
Census: 45
Bathing frequency: 3
Bathing frequency: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 27, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 07/11/2018.
Findings
All deficiencies cited in the previous inspection have been corrected as 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
Date: Jul 11, 2018
Visit Reason
The document is a plan of correction submitted in response to deficiencies related to missing consent documentation for influenza and pneumococcal immunizations identified during a prior inspection.
Findings
The facility identified missing consent documentation for influenza and pneumococcal immunizations and implemented corrective actions including resident assessments, audits, and nursing in-services to ensure proper documentation and compliance.
Deficiencies (1)
F883-E: Missing consent documentation for influenza and pneumococcal immunizations was identified and addressed through resident assessments and nursing education.
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 1
Date: 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 according to CDC guidelines. Documentation of immunization or refusal was missing for these residents.
Deficiencies (1)
F 883 Influenza and pneumococcal immunizations: The facility failed to ensure residents #17, 29, 40, and 46 were offered or received the pneumonia vaccine per CDC recommendations. Documentation of education, immunization, or refusal was missing in the medical records.
Report Facts
Facility census: 44
Residents reviewed: 5
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 listed with their regulation numbers were marked as corrected and completed as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Aug 23, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The Plan 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, audits, and performance improvement projects monitored by the Quality Assurance Performance Improvement Committee.
Deficiencies (7)
F-160: Resident trust accounts were improperly managed with balances remaining after death or discharge. The account for Resident #16 was closed and balance remitted to the estate.
F-280: Care plans for Residents #4 and #14 lacked interventions for weight loss. Care plans were updated and dietary recommendations reviewed.
F-325: Consultant dietician recommendations for Residents #4 and #14 were not fully implemented. Recommendations were forwarded to the physician and care planned.
F-332: Medication discontinued by physician for Resident #23 was not discontinued timely. Medication was discontinued and physician and pharmacy notified.
F-371: Deficient food serving practices were identified affecting Resident #31 and others. Staff were instructed on proper sanitary methods and inservice education planned.
F-428: Medication errors identified related to Resident #23. Consultant pharmacist to audit medication regimens and staff inservice planned.
F-441: Housekeeping staff did not follow proper disinfecting procedures. Room was recleaned and staff inservice planned on disinfecting chemicals and contact times.
Report Facts
Balance remitted: 13.84
Plan of Correction completion date: Aug 23, 2016
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 3, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be '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.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated findings and compliance status. |
Inspection Report
Re-Inspection
Census: 46
Deficiencies: 7
Date: Aug 3, 2016
Visit Reason
The inspection was a health resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to convey resident funds upon death within required timeframes, failure to revise care plans for residents with weight loss and follow dietitian recommendations, medication errors involving duplicate phosphate binders, improper food handling practices, and inadequate infection control related to disinfectant contact times.
Deficiencies (7)
483.10(c)(6) The facility failed to convey 1 of 2 sampled residents' personal funds to the resident's estate within 30 days of death.
483.20(d)(3), 483.10(k)(2) The facility failed to revise care plans for residents #4 and #14 to reflect significant weight loss and dietitian recommendations.
483.25(i) The facility failed to ensure staff followed up on dietitian recommendations and implemented interventions to prevent weight loss for 2 of 4 residents reviewed for nutrition.
483.25(m)(1) The facility failed to ensure resident #23 remained free from medication errors by not discontinuing Renvela as ordered by the physician.
483.35(i) The facility failed to prepare and serve food under sanitary conditions by improper hand washing, glove use, and handling of glassware and straws.
483.65 The facility failed to ensure housekeeping staff followed manufacturer's directions for disinfectant contact times, risking spread of infection.
483.60(c) The facility's pharmacist failed to identify a medication error involving duplicate phosphate binders for resident #23.
Report Facts
Resident census: 46
Resident weight loss: 31.6
Resident weight loss percentage: 12.8
Medication error rate: 1
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 11, 2016
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 at the facility to be at 'F' level, indicating no harm but with 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.
Deficiencies (1)
The facility was cited for deficiencies at the 'F' level under the Life Safety Code survey, indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
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 context |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 10, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory requirements.
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 11, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility is 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 but with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the plan of correction. |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 6
Date: Mar 11, 2015
Visit Reason
Health Resurvey and Complaint Investigation #KS00079177 conducted to assess compliance with regulatory requirements.
Complaint Details
The inspection was triggered by a complaint investigation #KS00079177.
Findings
The facility failed to provide ongoing activities meeting residents' individual needs for 3 sampled residents. Care plans were not revised for non-pressure related skin issues for 1 resident. One resident with a pressure ulcer was not repositioned timely. Several residents' care plans lacked specific black box warning (BBW) information for medications, and the consultant pharmacist did not ensure BBW irregularities were acted upon.
Deficiencies (6)
F248: Facility failed to provide ongoing activities meeting the physical, mental, and psychosocial well-being for 3 sampled residents (#4, #19, #20).
F280: Facility failed to revise resident #36's care plan related to non-pressure related pre-cancerous skin condition on face.
F309: Facility failed to assess and monitor resident #36's pre-cancerous facial skin lesion.
F314: Facility failed to reposition resident #27 with a pressure ulcer timely, remaining in same position for 2 hours and 56 minutes without repositioning.
F329: Facility failed to include specific black box warning information in care plans for 4 residents (#14, #18, #41, #50) receiving medications with BBWs.
F428: Facility failed to ensure consultant pharmacist identified irregularities related to BBWs and failed to act upon those for 4 residents (#14, #18, #41, #50).
Report Facts
Resident census: 49
Residents sampled: 21
Residents reviewed for non-pressure skin issues: 3
Residents reviewed for unnecessary medications: 5
Repositioning interval: 176
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant pharmacist L | Consultant Pharmacist | Verified monthly drug regimen reviews and identification of medications with BBW but did not review care plans for BBW information. |
| Administrative nurse B | Administrative Nurse | Confirmed lack of BBW information in nursing care plans and awareness of BBW medications. |
| Licensed nurse M | Licensed Nurse | Provided information on skin assessments and resident conditions. |
| Direct care staff K | Interviewed regarding resident #36's skin condition and care. | |
| Direct care staff Q | Interviewed regarding resident #27's pressure ulcer care. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 5, 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 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 to address these deficiencies.
Deficiencies (1)
The facility was cited with an 'F' level deficiency that was widespread, indicating noncompliance with Life Safety Code requirements. The deficiency posed no immediate jeopardy but had potential for more than minimal harm.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Feb 5, 2015
Provider agreement termination date: May 5, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Durler | Administrator | Named as facility administrator in the report header. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Joe Ewert | Commissioner | Copied on the letter as KDADS Commissioner. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 17, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that all previously cited deficiencies identified by regulation numbers 483.25(h), 483.25(l), and 483.60(c) were corrected by the revisit dates of 07/16/2014 and 07/17/2014.
Deficiencies (3)
Regulation 483.25(h): Previously cited deficiency corrected as of 07/16/2014.
Regulation 483.25(l): Previously cited deficiency corrected as of 07/17/2014.
Regulation 483.60(c): Previously cited deficiency corrected as of 07/17/2014.
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 16, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at the facility.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by Complaint ID Wheatridge Park 061914.
Findings
The plan addresses issues related to fall risk assessments, sleep assessments, and medication management for hypnotics and sedatives. Corrective actions include staff education, monitoring of care plans, and ongoing audits to ensure compliance.
Deficiencies (3)
F323-G: The facility failed to complete fall risk assessments and update care plans for residents identified at risk. Licensed nursing staff will attend in-service training and daily reviews of falls will be conducted to ensure safety interventions.
F329-D: The facility failed to perform sleep assessments and update care plans for residents on hypnotics and sedatives. Mandatory staff education on medication policy was implemented and monitoring of sleep assessments will be conducted.
F428-D: The facility failed to identify irregularities in hypnotic/sedative medication use during monthly reviews. A consultant pharmacist will review medications monthly and audits will be performed to ensure compliance.
Report Facts
Records audited per week: 10
Records audited every two weeks: 5
Records audited per month: 5
Weeks of weekly chart audits: 6
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: 50
Deficiencies: 3
Date: Jun 19, 2014
Visit Reason
The inspection was conducted as a complaint investigation related to multiple allegations of inadequate supervision and fall prevention at Wheatridge Park Care Center.
Complaint Details
The complaint investigations #KS00076003, KS00076020, and KS00076095 focused on fall prevention failures and medication management concerns at the facility.
Findings
The facility failed to ensure adequate supervision and fall prevention strategies for three sampled residents, resulting in multiple falls, some requiring emergency treatment. The facility also failed to ensure appropriate medication management for one resident receiving excessive doses and duration of hypnotic medications without adequate assessment.
Deficiencies (3)
F 323: The facility 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. Resident #1 sustained multiple falls with injuries requiring emergency treatment.
F 329: The facility failed to ensure resident #2 did not receive unnecessary drugs, including excessive dose of Temazepam and excessive duration of Halcion without adequate indication or sleep assessment.
F 428: The facility failed to ensure the consultant pharmacist identified drug irregularities related to resident #2's use of hypnotics and reported these to the director of nursing and physician for action.
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 dose: 30
Halcion dose: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Administrative Nurse | Confirmed failures in fall prevention follow-up and medication review for Resident #2. |
| Nurse F | Licensed Nurse | Confirmed Resident #2 received hypnotic medications and was not oversedated. |
| Consultant Pharmacist G | Consultant Pharmacist | Identified irregularities in Resident #2's medication regimen and reported to director of nursing and physician. |
| Physician H | Physician | Confirmed Resident #1 sustained falls requiring emergency treatment. |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Feb 15, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.
Findings
The plan outlines immediate actions taken for affected residents, identification of other residents potentially affected, actions to reduce future risk, and monitoring procedures to ensure deficiencies do not recur.
Deficiencies (7)
F157-D: Resident #63's physician and sponsor were notified of vomiting and change in condition. A mandatory in-service education program will be conducted for licensed nursing staff on notification requirements.
F309-D: Licensed nurses will attend mandatory in-service training on providing and documenting nursing assessments following a fall. Weekly audits of residents who fall will be conducted for four weeks.
F314-D: Staff will document daily wound assessments for residents #33, #40, and #26, and reposition resident #26 every two hours. Nursing staff will attend mandatory in-service on wound care standards.
F371-F: Dietary staff were in-serviced on proper sanitizing and food handling procedures. Random sanitation audits will be conducted five times weekly.
F441-F: Housekeeping staff will be in-serviced on cleaning techniques and disinfectant use. Random audits of cleaning procedures will be conducted weekly for four weeks.
F520-F: The facility will continue Quality Assurance and Improvement activities to ensure improvement and deficiency correction. The administrator will educate QAA committee members on QA standards and monitor documentation.
S0600-F: The facility has obtained a certified Certified Dietary Manager (CDM) effective 2/10/2014. Audit results will be reviewed by the Risk Management/Quality Assurance Committee.
Report Facts
Audit frequency: 5
Audit frequency: 2
Audit frequency: 1
Audit frequency: 4
Audit frequency: 5
Audit frequency: 4
Audit frequency: 1
Audit frequency: 2
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 15, 2014
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 02/15/2014.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 02/15/2014.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Feb 15, 2014
Visit Reason
This visit was conducted as 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)
Regulation 483.10(b)(11) deficiency was corrected by 2014-02-15.
Regulation 483.25 deficiency was corrected by 2014-02-15.
Regulation 483.25(c) deficiency was corrected by 2014-02-15.
Regulation 483.35(i) deficiency was corrected by 2014-02-15.
Regulation 483.65 deficiency was corrected by 2014-02-15.
Regulation 483.75(o)(1) deficiency was corrected by 2014-02-15.
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 6
Date: Jan 29, 2014
Visit Reason
The inspection was conducted as part of the annual resurvey to assess compliance with federal regulations related to resident care, food service, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to immediately report significant changes in resident condition, inadequate nursing assessments after falls, insufficient treatment and documentation of pressure ulcers, unsanitary food preparation practices, failure to properly sanitize resident rooms, and ineffective quality assurance processes.
Deficiencies (6)
483.10(b)(11) The facility failed to immediately report a significant change in medical condition for 1 of 7 sampled residents after an unwitnessed fall and repeated vomiting episodes.
483.25 The facility failed to provide necessary care and services, including nursing assessments after a fall, to maintain the highest practicable physical well-being for 1 of 3 residents sampled for accidents.
483.25(c) The facility failed to ensure 3 of 4 residents with pressure ulcers received necessary treatment and daily assessments to promote healing and prevent infections.
483.35(i) The facility failed to store, prepare, and serve food under sanitary conditions, including improper sanitization of dishware and thermometers and inconsistent recording of food temperatures.
483.65 The facility failed to maintain a sanitary environment by improperly sanitizing a resident's sink and room, risking disease transmission.
483.75(o)(1) The facility failed to develop and implement an effective quality assessment and assurance program to ensure corrective action plans for notification of change, pressure ulcer documentation, food service, and infection control.
Report Facts
Resident census: 32
Deficiencies cited: 6
Sanitizer ppm: 400
Sanitizer ppm required: 200
Food temperature range: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported on QAA meetings and deficiencies | |
| Administrative nursing staff B | Confirmed failure to notify physician and pressure ulcer documentation issues | |
| Licensed nursing staff M | Confirmed failure to notify physician immediately after resident vomiting | |
| Dietary staff D | Verified improper sanitization of dishware and thermometers | |
| Dietary staff E | Observed failing to remove contaminated gloves and sanitize thermometer | |
| Housekeeping staff G | Observed improper sanitization of resident room surfaces | |
| Housekeeping staff H | Verified improper sanitization practices with cleaning rags |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 29, 2014
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 on the CMS-2567 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Dec 21, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.
Findings
The plan outlines immediate actions taken for affected residents, identification of other potentially affected residents, actions and systems implemented to reduce future risk, and monitoring plans to ensure compliance across multiple areas including Medicare non-coverage notices, significant weight loss notifications, resident bathing and meal preferences, fall prevention, neurological checks, wound care, medication lab testing, dietary portion sizes, kitchen sanitation, medication refrigeration, hand hygiene, and staff training.
Deficiencies (15)
F156-D: Procedures for giving notice of Medicare non-coverage and use of CMS form 10123 were reviewed and corrective education provided to therapy and social services staff.
F157-D: Significant weight loss notifications were addressed with physician and sponsor, and nursing and dietary staff received education on notification requirements.
F242-D: Bathing preferences and meal choices for residents on pureed diets were assessed and documented, with staff education and monitoring implemented.
F280-D: Nursing fall prevention care plans were updated and staff received in-service training on fall prevention policies.
F281-D: Physician notified of dietitian recommendations and care plans updated; staff educated on care plan development and monitoring.
F309-D: Licensed nurses received mandatory training on neurological checks following unwitnessed falls, with audits planned to ensure compliance.
F314-D: Wound assessments documented daily after dressing changes; nursing staff trained on pressure ulcer care and monitoring implemented.
F323-E: Fall risk assessments completed, grab bars repaired, and staff trained on accident policies with ongoing incident review and audits.
F329-D: Laboratory tests ordered and reported promptly; staff educated on physician order transcription and lab requisitioning with monitoring.
F363-E: Proper serving sizes and scoop sizes ensured for all residents; dietary staff trained and audits conducted to maintain compliance.
F371-F: Dietary staff in-serviced on ware washing and kitchen sanitation; random audits scheduled to ensure adherence to procedures.
F428-D: Lab results related to medications included in monthly reviews; drug regimen reviews audited monthly with discrepancies reported.
F431-F: Medication refrigerator temperature logs implemented and staff trained on proper medication storage; ongoing inspections planned.
F441-F: Resident room cleaned and sanitized; staff trained on hand hygiene and laundry sanitation with random audits to ensure compliance.
S600-F: Dietary Manager enrolled in CDM course and will be exam eligible by 2014-03-31; progress monitored by Quality Assurance Committee.
Report Facts
Corrective action completion date: Dec 21, 2013
Audit frequency: 2
Audit frequency: 5
Audit frequency: 4
Audit frequency: 3
Audit frequency: 6
Audit frequency: 10
Audit frequency: 3
Audit frequency: 4
Inspection Report
Census: 50
Deficiencies: 1
Date: Nov 26, 2013
Visit Reason
The inspection was conducted to assess compliance with dietary services regulations, specifically to verify that the dietary services supervisor met certification requirements.
Findings
The facility failed to ensure that the dietary services supervisor was certified as a dietary manager. Dietary staff D, who worked as the dietary supervisor, did not have the required dietary manager certification.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to ensure the dietary services supervisor was certified as a dietary manager as required. Dietary staff D confirmed lack of certification during interview.
Report Facts
Resident census: 50
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 15, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers F0226, F0329, F0334, F0428, F0431, and F0441 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: 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.
Findings
The plan outlines corrective actions for multiple deficiencies including abuse reporting, medication management, vaccination consent and administration, blood pressure monitoring, medication destruction, and proper sanitization techniques. The facility describes measures to prevent recurrence and monitoring plans for each deficiency.
Deficiencies (7)
F226-C: The facility assigned the manager as the responsible individual for timely reporting of suspected abuse and posted employee rights notices. Staff will be educated on abuse recognition and reporting.
F329-D: A review and gradual dose reduction of antipsychotic medications for Resident #12 will be conducted. Pharmacy consultant will meet monthly with staff to review medications and document results.
F334-C: Residents #12, 17, 18, and 38 received influenza vaccination consent and education; all residents will be offered annual influenza immunization per policy.
F428-D: Physician notified of blood pressure parameters and medication diagnoses for Residents #12 and #48; orders without diagnoses will be returned for correction.
F431-D: Expired medications were destroyed and staff educated on medication destruction policies. Audits will monitor expired medications monthly.
F441-F: Licensed nursing staff will be in-serviced on clean technique during medication administration via gastric tube; audits will monitor compliance.
Direct Care Staff were in-serviced on sanitization techniques for equipment including blood pressure machines and lifts; audits will monitor disinfection practices.
Report Facts
Complete Date: Aug 15, 2012
Audit frequency: 90
Medication doses: 12
Residents referenced: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Durler | Administrator | Named as the manager responsible for abuse reporting and submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 6
Date: Jul 17, 2012
Visit Reason
The inspection was a health resurvey to assess compliance with federal regulations related to abuse/neglect policies, drug regimen, immunizations, drug regimen review, drug records, and infection control.
Findings
The facility was found deficient in multiple areas including failure to update abuse/neglect policies, failure to ensure residents did not receive unnecessary medications, failure to provide education and documentation for influenza and pneumococcal immunizations, failure of the pharmacist to report medication irregularities, failure to dispose of expired medications, and failure to maintain infection control practices such as cleaning equipment between resident use.
Deficiencies (6)
F226: The facility failed to update abuse, neglect, and exploitation policies to comply with Section 115-B of the Social Security Act regarding reporting reasonable suspicion of a crime in long-term care facilities.
F329: The facility failed to ensure residents did not receive unnecessary medications, including failure to attempt gradual dose reduction for Xanax and failure to monitor effectiveness of Lisinopril for resident #12, and failure to provide indications for multiple medications for resident #48.
F334: The facility failed to provide education and document education regarding benefits and potential side effects of influenza and pneumococcal immunizations for 4 of 5 residents reviewed.
F428: The pharmacist consultant failed to report irregularities to the attending physician and director of nursing related to unnecessary medications and lack of indications for use for residents #12 and #48.
F431: The facility failed to dispose of expired medications found in one of two medication carts, affecting resident #41.
F441: The facility failed to maintain infection control by not cleaning blood pressure cuffs between residents, not sanitizing mechanical lifts between use, and failing to maintain clean technique during medication administration through a gastric tube for resident #48.
Report Facts
Census: 45
Residents sampled for unnecessary medications: 10
Residents reviewed for immunizations: 5
Expired Vitamin E stock bottle: 1
Expired Enteric Coat Aspirin stock bottle: 1
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N088002 POC 2SFJ11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan outlines corrective actions taken for multiple deficiencies related to resident care, including psychosocial programming, skin condition care plans, pressure ulcer prevention, and medication black box warning documentation. The facility describes education, monitoring, and auditing processes to ensure compliance and prevent recurrence.
Deficiencies (6)
F248-D: The facility failed to provide person-specific 1:1 programming and updates to care plans for residents with lower cognitive function.
F280-D: The facility failed to update nursing skin condition care plans and monitoring sheets appropriately for residents.
F309-D: The facility failed to properly assess and monitor non-pressure related skin conditions in residents.
F314-D: The facility failed to follow policy for repositioning residents dependent on care to prevent pressure ulcers.
F329-E: The facility failed to include names and warnings for medications with black box warnings in nursing care plans.
F428-E: The facility failed to ensure consultant pharmacist reviews included black box warning information in drug regimen reviews.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N088002 POC CYUQ11
Visit Reason
This document is a plan of correction related to a prior inspection event identified as CYUQ11 for facility with State ID N088002.
Findings
No deficiencies or findings are detailed in this document. It serves solely as a record of the plan of correction submission.
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