4 Reports
Inspection Report — May 28, 2025
Routine CMS
Date: May 28, 2025
Visit Reason
Routine inspection of Wichita Presbyterian Manor to assess compliance with healthcare regulations including medication administration, resident care, infection control, and staff training.
Findings
The facility had multiple deficiencies including failure to inform residents about psychotropic medication risks, improper medication self-administration assessments, inadequate monitoring of antipsychotic side effects, failure to provide activities of daily living assistance, unsanitary respiratory care, incomplete pharmacist medication reviews, improper drug storage and labeling, inadequate infection control practices, and insufficient nurse aide training hours.
Deficiencies (10)
F 0552: The facility failed to inform Resident 37 or his representative about risks related to psychotropic medications, lacking documented informed consent and education.
F 0554: The facility failed to assess Resident 22 for clinical appropriateness to self-administer medications left at bedside, risking medication errors.
F 0605: The facility failed to perform assessments for side effects related to ongoing antipsychotic use for Resident 37, risking adverse reactions.
F 0677: The facility failed to provide Resident 10 with activities of daily living assistance including shaving, risking poor hygiene and quality of life.
F 0695: The facility failed to provide sanitary respiratory care by not cleaning the nebulizer after each use for Resident 45, risking infection.
F 0756: The facility's pharmacist failed to identify and report irregularities in monitoring Resident 18's pulse as ordered, risking unnecessary medication side effects.
F 0757: The facility failed to monitor effectiveness and side effects of antihypertensive and pain medications for Resident 18, risking unnecessary medications and side effects.
F 0761: The facility failed to ensure drugs and biologicals were labeled, stored in locked compartments, and insulin pens were dated, risking medication errors and diversions.
F 0880: The facility failed to disinfect shared sit-to-stand lifts between residents and did not follow proper respiratory infection control, risking resident infections.
F 0947: The facility failed to ensure all Certified Nurse Aides received the required minimum 12 hours of annual in-service training, risking decreased quality of care.
Report Facts
Residents sampled: 12
Medication refrigerator temperature missing days: 83
Training hours: 10.5
Bowel movement gaps: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed regarding medication consent, medication storage, infection control, and nurse aide training |
| Licensed Nurse H | Licensed Nurse | Interviewed about psychotropic medication monitoring and medication self-administration |
| Certified Medication Aide S | Certified Medication Aide | Interviewed about medication administration and documentation |
| Consultant GG | Consultant Pharmacist | Reviewed medication regimen and confirmed monitoring deficiencies |
| Licensed Nurse I | Licensed Nurse | Interviewed about medication monitoring and documentation |
| Certified Nurse Aide N | Certified Nurse Aide | Identified as lacking required annual training hours |
Inspection Report — Feb 19, 2024
Annual Inspection CMS
Date: Feb 19, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Wichita Presbyterian Manor.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Sep 14, 2023
Annual Inspection CMS
Date: Sep 14, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with healthcare regulations and standards at Wichita Presbyterian Manor.
Findings
The facility failed to provide appropriate respiratory care related to nebulizer use and cleaning, failed to ensure a resident's medication regimen was free from unnecessary drugs due to inadequate monitoring, and failed to maintain sanitary food preparation and storage practices. These deficiencies posed risks of respiratory complications, adverse medication effects, and potential foodborne illness.
Deficiencies (4)
F 0695: The facility failed to provide safe and appropriate respiratory care for Resident 2, including improper use and cleaning of nebulizer equipment.
F 0757: The facility failed to ensure Resident 7's medication regimen was free from unnecessary drugs due to inadequate monitoring of constipation related to laxative use.
F 0812: The facility failed to provide sanitary food preparation and storage, including expired and improperly stored food items, risking foodborne illness.
F 0880: The facility failed to properly clean and store nebulizer equipment for Resident 2, risking respiratory complications and contamination.
Report Facts
Residents sampled: 14
Residents reviewed for respiratory care: 2
Residents reviewed for unnecessary medications: 5
Expired shredded coconut: 1
Expired white baking chips: 1
Uncovered dessert trays: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide D | Certified Medication Aide | Reported nurses administer nebulized medications and CMA staff do not manipulate nebulizer equipment |
| Licensed Nurse E | Licensed Nurse | Described proper nebulizer cleaning procedures and confirmed nebulizer was not disassembled prior to medication administration |
| Licensed Nurse F | Licensed Nurse | Reported on nebulizer cleaning and resident medication refusal; unable to recall cleaning solution used |
| Administrative Nurse B | Administrative Nurse | Stated expectations for nebulizer cleaning and drying after medication administration |
| Administrative Nurse G | Administrative Nurse | Expressed infection control concerns about nebulizer equipment cleaning and storage |
Inspection Report — Dec 6, 2021
Complaint Investigation CMS
Date: Dec 6, 2021
Visit Reason
The inspection was conducted to investigate complaints related to failure to provide bed hold policy notification, failure to update a resident's care plan related to wander guard use, insufficient supervision leading to resident elopement, and improper food storage practices.
Complaint Details
The complaint investigation revealed failures in notification of bed hold policy, care plan updates for wander guard use, supervision leading to resident elopement, and food safety violations. The elopement incident was substantiated and resulted in immediate jeopardy findings.
Findings
The facility failed to provide written notification of bed hold policy to a resident or representative during hospitalization, failed to update a resident's care plan timely to include wander guard interventions, failed to provide adequate supervision resulting in a resident eloping for approximately eight minutes near dangerous traffic areas, and failed to store food properly by keeping expired items and undated thawed nutritional shakes.
Deficiencies (4)
F 0625: The facility failed to notify Resident 45 or her representative in writing about the bed hold policy during her hospitalization on 09/11/21.
F 0657: The facility failed to update Resident 22's care plan in a timely manner to include interventions related to the use of a wander guard.
F 0689: The facility failed to provide sufficient supervision to Resident 22 who eloped for approximately eight minutes near busy roads and railroad tracks, placing him in immediate jeopardy.
F 0812: The facility failed to store food in accordance with professional standards, with expired food items and undated thawed nutritional shakes found in the kitchen.
Report Facts
Residents sampled: 16
Elopement duration: 8
Expired food items: 9
Undated thawed nutritional shakes: 154
Elopement risk score: 12
Residents at risk with wander guards: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director J | Social Services Director | Interviewed regarding bed hold policy notification for Resident 45 |
| Licensed Nurse I | Licensed Nurse | Revealed placement date of wander guard on Resident 22 |
| Licensed Nurse F | Licensed Nurse | Reported Resident 22 was an elopement risk with wander guard checked every shift |
| Administrative Nurse B | Administrative Nurse | Expected staff to recognize wander guard and update care plan for Resident 22 |
| Certified Dietary Manager L | Certified Dietary Manager | Interviewed about expired food and thawed nutritional shakes in kitchen |
| Employee C | Allowed Resident 22 to exit through alarmed door unaware of wander guard | |
| Certified Nurse Aide D | Certified Nurse Aide | Responded to wander guard alarm and redirected Resident 22 |
| Licensed Nurse H | Licensed Nurse | Interviewed about Resident 22's wandering and elopement incident |
| Concierge Staff E | Encountered Resident 22 after elopement and assisted in locating him | |
| Administrative Staff A | Described Resident 22's movements during elopement |
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