Inspection Report Summary
The most recent inspection on November 13, 2018, found one deficiency related to the failure to conduct quarterly reviews of the facility’s emergency management plan with employees and residents. Earlier inspections showed a pattern of deficiencies primarily involving medication administration, reporting and investigation of incidents, resident supervision and safety, dietary services, and care planning. Several complaint investigations were substantiated, including issues with timely reporting of incidents, resident elopement risk, and mistreatment, with one incident resulting in resident death and enforcement actions such as denial of payment for new admissions imposed at times. Fines or license suspensions were not listed in the available reports, but enforcement remedies were noted for repeated noncompliance. The facility’s inspection history shows periods of improvement following plans of correction, though some issues recurred over time, indicating a mixed compliance trend.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
31 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
417% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
13 residents
Based on a November 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 13
Deficiencies: 1
Date: Nov 13, 2018
Visit Reason
The visit was a resurvey conducted on 11/13 and 11/14/2018 at an assisted living facility to assess compliance with disaster and emergency preparedness requirements.
Findings
The administrator failed to ensure disaster and emergency preparedness by not conducting quarterly reviews of the facility's emergency management plan with employees and residents as required.
Deficiencies (1)
Failure to ensure quarterly review of the facility's emergency management plan with employees and residents.
Report Facts
Census: 13
Sample size: 3
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 21, 2018
Visit Reason
An offsite revisit survey was conducted on 09/21/2018 for all previous deficiencies cited on 08/30/2018.
Findings
All deficiencies have been corrected as of the compliance date of 09/18/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 18, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies, outlining corrective actions to achieve substantial compliance with Federal Medicare and Medicaid requirements.
Findings
The Plan of Correction details updates to the Medication Administration Record to include pulse checks, training of the Medical Record clerk, removal of outdated medications, and ongoing monitoring responsibilities assigned to the Director of Nursing and consulting pharmacists.
Deficiencies (2)
Medication Administration Record updated with a box for checking the pulse and training provided to Medical Record clerk.
Removal of all outdated medication/stock vitamins and implementation of checks by licensed nurses and medication aides.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlotte Rathke | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 30, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found an isolated 'D' level deficiency that constitutes no actual harm but has potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility is found to be in substantial compliance effective 2018-09-18.
Deficiencies (1)
Isolated 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact and signatory related to enforcement and plan of correction acceptance. |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 2
Date: Aug 30, 2018
Visit Reason
This was a health resurvey inspection conducted to assess compliance with medication administration and drug storage regulations.
Findings
The facility failed to assess one resident's pulse prior to medication administration as ordered by the physician, and failed to discard expired medications including insulin and calcium tablets, placing residents at risk for physical decline and ineffective medication use.
Deficiencies (2)
Failed to assess Resident #25's pulse prior to medication administration as required by physician order.
Failed to discard expired insulin for Resident #26 and outdated oyster shell calcium on medication carts.
Report Facts
Census: 36
Sample size: 13
Residents reviewed for unnecessary medications: 6
Expired insulin expiration date: Aug 24, 2018
Expired calcium tablets expiration date: 201805
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Verified resident's pulse was not documented prior to medication administration and stated nurses should check expiration dates | |
| Licensed Nurse G | Licensed Nurse | Verified expired insulin administration and explained pulse measurement timing |
| Medication Aide M | Medication Aide | Verified expired calcium tablets and removed them from medication carts |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 13, 2018
Visit Reason
A revisit survey was conducted on 8/13/18 for all previous deficiencies cited on 6/19/18.
Findings
All deficiencies have been corrected as of the compliance date of 6/25/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 19, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the facility was not in substantial compliance and conditions constituted immediate jeopardy to resident health or safety related to F689, "J", CFR 483.25 (d)(1)(2). Enforcement remedies including denial of payment for new admissions were imposed without opportunity to correct.
Deficiencies (1)
Noncompliance with F689, "J", CFR 483.25 (d)(1)(2) constituting immediate jeopardy to resident health or safety
Report Facts
Denial of payment effective date: Jul 6, 2018
Recommended provider agreement termination date: Dec 19, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlotte Rathke | Administrator | Facility administrator named in the report |
| Caryl Gill | Complaint Coordinator | Named as contact for questions regarding the letter |
| Brad Fischer | Commissioner | Recipient of informal dispute resolution requests |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Date: Jun 19, 2018
Visit Reason
Partial extended survey conducted for complaint investigation #130370 regarding failure to report an incident involving a resident's wheelchair becoming unsecured in the facility van, resulting in a life-threatening situation and death.
Complaint Details
Complaint investigation #130370 regarding failure to report an incident where Resident #1's wheelchair became unsecured in the facility van, resulting in a life-threatening situation and death. The incident was not reported timely to the state agency due to ongoing police investigation. The facility investigation revealed inconsistent training and failure to secure wheelchairs properly.
Findings
The facility failed to report the incident in a timely manner and failed to provide thorough, consistent training to van drivers on securing residents in wheelchairs. The resident's wheelchair became unsecured on two occasions, with the last incident resulting in death. The facility lacked documentation of driver training and did not perform routine competency checks. Immediate jeopardy was abated after retraining drivers and removing the van from service.
Deficiencies (2)
Failure to report alleged violations involving abuse, neglect, or mistreatment in a timely manner.
Failure to ensure the resident environment was free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents, specifically failure to properly secure wheelchairs in the facility van.
Report Facts
Census: 41
Sample size: 3
Fall risk assessment score: 18
Date of incident: Jun 11, 2018
Date of survey completion: Jun 19, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide G | Van driver involved in incident | Transported Resident #1 in facility van during incident; transported to hospital for medical attention after incident |
| Nurse Aide M | Van driver and trainer | Provided training to other van drivers; involved in incident response; described securing procedures |
| Nurse Aide O | Van driver | Demonstrated loading and securing residents in wheelchair during survey |
| Nurse Aide P | Van driver | Described training and securing procedures for wheelchair transport |
| Nurse Aide Q | Van driver | Described training and securing procedures for wheelchair transport |
| Nurse Aide R | Van driver | Described training and securing procedures for wheelchair transport |
| Nurse Aide S | Van driver | Described training received for van driving and securing residents |
| Nurse Aide T | Van driver | Described training and securing procedures for wheelchair transport |
| Maintenance Staff U | Maintenance staff | Performed monthly van inspections and demonstrated use of van chair lift and seat belts |
| Administrative Staff A | Administrator | Did not report incident to state agency due to police investigation; gathered reports for facility investigation |
| Social Services Staff X | Van driver | Described training and securing procedures for wheelchair transport |
| Detective GG | Law enforcement | Verified staff had not reported consistent system of securing residents in wheelchairs |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 11, 2018
Visit Reason
This Plan of Correction addresses deficiencies related to an incident on 6/11/18 involving a wheelchair secured in a van and subsequent administrative and staff actions to ensure compliance with reporting and safety policies.
Findings
The administration timely reported the incident to law enforcement and the KDADS Complaint Hotline. No abuse, neglect, or mistreatment by staff was found. Retraining of van drivers was implemented, including competency audits and policy reviews, with ongoing compliance responsibilities assigned to the Director of Maintenance and Administrator.
Deficiencies (2)
Incident involving wheelchair securement in van and related administrative reporting and staff training
Van driver retraining and competency audits implemented following incident
Report Facts
Date of incident: Jun 11, 2018
Date of KDADS Complaint Hotline report: Jun 13, 2018
Number of van drivers retrained: 7
Number of van drivers designated current: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlotte Rathke | Administrator | Administrator involved in incident reporting and compliance oversight |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 29, 2018
Visit Reason
A complaint survey was conducted on 3/29/18 for complaint #127631.
Complaint Details
Complaint #127631 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 29, 2018
Visit Reason
A complaint survey was conducted on 3/29/18 for complaint #127631.
Complaint Details
Complaint #127631 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 16, 2017
Visit Reason
This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency with regulation number 28-39-158(a) was corrected as of 02/24/2017. No other deficiencies or findings are noted in this revisit report.
Deficiencies (1)
Deficiency previously cited under regulation 28-39-158(a) corrected
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 16, 2017
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 had been corrected.
Findings
All previously cited deficiencies were corrected as of 02/24/2017, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiency correction completion date: Feb 24, 2017
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Feb 24, 2017
Visit Reason
This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-206 (a)(b) and 26-41-206 (d) have been corrected as of 02/24/2017.
Deficiencies (2)
Deficiency related to regulation 26-41-206 (a)(b)
Deficiency related to regulation 26-41-206 (d)
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 24, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction addresses deficiencies related to dietary services and food preparation, including staff training and policy compliance regarding facial hair covering procedures.
Deficiencies (2)
Dietary services deficiency related to staff training in Certified Dietary Manager course.
Food preparation deficiency related to facial hair covering procedures and policy compliance.
Report Facts
Completion date: Feb 24, 2017
Scheduled inservice date: Feb 8, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Charlotte Rathke | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Feb 24, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to identified deficiencies from a prior inspection, outlining corrective actions to achieve substantial compliance with Federal Medicare and Medicaid requirements.
Findings
The Plan of Correction addresses multiple deficiencies including failure to report incidents timely, pressure sore treatment and prevention, accident hazard management, drug regimen issues, food storage and preparation, infection control, and dietary services. The facility outlines training, policy reviews, and quality assurance measures to ensure compliance.
Deficiencies (8)
Failure to timely report incidents to KDADS hotline
Inadequate treatment and prevention of pressure sores
Failure to maintain a safe environment free of accident hazards
Use of unnecessary drugs and medication administration issues
Improper food procurement, storage, preparation, and serving
Irregularities in drug regimen review and follow-up
Infection control deficiencies related to chemical labeling and storage
Dietary services staffing and training compliance
Report Facts
Date for substantial compliance: Feb 24, 2017
Date for Quality Assurance committee review: Feb 16, 2017
Date for staff meetings and inservices: Feb 8, 2017
Date for staff meetings and inservices: Feb 9, 2017
Date for staff meetings and inservices: Feb 21, 2017
Course completion date: 201709
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlotte Rathke | Administrator | Named as responsible for quality checks and submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Person who added and modified the Plan of Correction document |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jan 30, 2017
Visit Reason
A Health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs. The survey was prompted by deficiencies found in a prior abbreviated survey and resulted in enforcement actions.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy. Due to repeated noncompliance, the facility was denied payment for new Medicare and Medicaid admissions effective February 19, 2017, until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers, indicating avoidable pressure ulcers and inadequate care and services to prevent worsening of existing pressure ulcers.
Report Facts
Denial of payment effective date: Feb 19, 2017
Noncompliance period: 6
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person regarding the enforcement action and informal dispute resolution |
| Charlotte Rathke | Administrator | Facility administrator addressed in the report |
Inspection Report
Re-Inspection
Census: 13
Deficiencies: 2
Date: Jan 30, 2017
Visit Reason
The inspection was a licensure resurvey of an Assisted Living/Residential Healthcare facility to assess compliance with dietary service regulations.
Findings
The facility failed to provide a full-time certified dietary manager for its 13 residents and failed to maintain sanitary food preparation and serving conditions, placing residents at risk for inadequate nutrition and foodborne illness.
Deficiencies (2)
Failure to provide services of a full-time certified dietary manager for 13 residents.
Failure to store, prepare, distribute, and serve food under sanitary conditions, including dietary staff not wearing proper hair restraints.
Report Facts
Census: 13
Sample size: 3
Residents receiving pureed diets: 6
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 1
Date: Jan 30, 2017
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with dietary services regulations, specifically regarding the employment of a full-time certified dietary manager.
Findings
The facility failed to provide a full-time certified dietary manager for 40 of 41 residents receiving meals from the facility's kitchen, placing residents at risk of inadequate nutrition.
Deficiencies (1)
Failure to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee food ordering, preparation, and storage.
Report Facts
Census: 41
Sample size: 12
Residents receiving pureed diets: 6
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 21, 2016
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 deficiencies at the facility to be at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy.
Deficiencies (1)
Most serious deficiencies found at "F" level with no harm but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: 2017
Provider agreement termination date: 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned as responsible for enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 2, 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 had been corrected.
Findings
The revisit confirmed that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 10/01/2016. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Deficiency with ID Prefix F0323 related to regulation 483.25(h)
Report Facts
Deficiency correction date: Oct 1, 2016
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 21, 2016
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy for F323 "J", CFR 483.25(h). Deficiencies were cited that constituted a level of actual harm or above, leading to enforcement remedies including denial of payment for new admissions.
Deficiencies (1)
Noncompliance with F323 "J", CFR 483.25(h) related to substandard quality of care
Report Facts
Denial of payment effective date: Oct 13, 2016
Provider agreement termination recommended date: Mar 21, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter and contact for questions regarding the survey and enforcement action |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Sep 21, 2016
Visit Reason
The inspection was conducted as a partial extended survey and complaint investigation related to elopement risks and supervision concerns for residents at the facility.
Complaint Details
The complaint investigation #105429 and #105414 revealed that Resident #1, diagnosed with dementia and anxiety disorder, displayed exit-seeking behavior with 11 attempts to leave the facility in one day. The resident eloped without staff knowledge and was found 3 blocks away by an off-duty staff member. The Wanderguard alarm system was not functioning properly and staff failed to monitor it, leading to immediate jeopardy.
Findings
The facility failed to provide adequate supervision to prevent elopement for one cognitively impaired resident who attempted to leave the facility 11 times in one day and eventually left unnoticed, placing the resident in immediate jeopardy. The Wanderguard alarm system was found to be malfunctioning and staff failed to monitor it properly. The facility implemented corrective actions including staff training, 1:1 supervision, and policy changes to prevent recurrence.
Deficiencies (1)
Failure to provide adequate supervision to prevent elopement for a cognitively impaired resident who left the facility unnoticed.
Report Facts
Resident census: 34
Exit attempts: 11
Residents wearing Wanderguards: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Nurse on duty the day of the elopement | Reported staff did not inform him/her of the elopement until later and verified nurses were responsible for ensuring Wanderguard placement and function. |
| Medication Aide I | Medication Aide | Reported that Medication Administration Record included Wanderguard checks twice daily after the elopement. |
| Maintenance Staff G | Maintenance Staff | Verified weekly exit door alarm checks and lack of routine Wanderguard alarm checks. |
| Administrative Staff F | Administrative Staff | Observed resident's agitation and failure of Wanderguard alarm, instructed nurse aide to monitor resident closely. |
| Nurse Aide C | Nurse Aide | Found resident 3 blocks away and returned him/her to the facility. |
| Nurse Aide D | Nurse Aide | Verified resident was left unsupervised on assisted living side and Wanderguard alarm was not functioning. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 8, 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
The revisit confirmed that the identified deficiencies, specifically related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4), were corrected as of the revisit date.
Deficiencies (1)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Report Facts
Deficiency correction date: Sep 8, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 8, 2016
Visit Reason
This Plan of Correction addresses deficiencies identified related to a complaint incident on 09/08/2016 involving resident safety and elopement risk.
Complaint Details
Complaint investigation related to an incident on 09/08/2016 involving resident elopement risk.
Findings
The facility implemented multiple corrective actions including psychiatric evaluation and medication adjustments for the resident involved, enhanced monitoring of residents at risk for elopement, daily and weekly checks of door alarms and wanderguard systems, staff education on elopement prevention, and ongoing quality monitoring by designated staff.
Deficiencies (1)
Resident #1 remained safely in the building or attended outdoor walks by staff or family since the 9/8/16 incident; functional wrist wanderguard in place; psychiatric evaluation and medication adjustments completed; care plan updated with diversional activities; enhanced monitoring and checks of door alarms and wanderguard systems; staff education on elopement prevention and policy revisions; implementation of Behavior Based Ergonomic Therapy program.
Report Facts
Date of incident: Sep 8, 2016
Date of psychiatric evaluation: Sep 12, 2016
Date of Quality Assurance review: Sep 27, 2016
Plan of Correction completion date: Oct 1, 2016
Staff training completion deadline: Sep 30, 2016
Behavior Based Ergonomic Therapy program start date: Oct 7, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlotte Rathke | Administrator | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 17, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Deficiencies (1)
Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Aug 17, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#103426) regarding an alleged violation involving mistreatment and neglect when a certified medication aide (CMA) took the battery out of a resident's call light.
Complaint Details
Complaint investigation #103426 regarding failure to report mistreatment and neglect when a CMA removed the battery from Resident #1's call light. The violation was substantiated by observations, record review, and interviews.
Findings
The facility failed to immediately report the incident involving the removal of the call light battery by a CMA, which placed the resident at risk for isolation and injury. Multiple staff members knew about the incident but did not report it promptly, and the facility reported the incident to the state agency four days after it occurred.
Deficiencies (1)
Failure to immediately report an alleged violation involving mistreatment and neglect when a CMA took the battery out of a resident's call light.
Report Facts
Census: 36
Sample size: 3
Call light activations: 8
Delay in reporting: 4
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 19, 2016
Visit Reason
This Plan of Correction addresses a self-reported incident involving alleged abuse that occurred on 7/19/2016, which triggered a complaint investigation and subsequent corrective actions.
Complaint Details
The incident was self-reported to the KDADS hotline on 7/21/2016 following an event on 7/19/2016. The perpetrator was suspended and terminated. The complaint was investigated with disciplinary actions taken against involved employees and retraining scheduled.
Findings
The incident involved a perpetrator who was suspended and terminated following investigation. Three employees aware of the incident were disciplined and retrained on abuse, neglect, and exploitation (ANE) reporting. The facility has implemented measures including call light system checks and staff training to prevent recurrence.
Deficiencies (1)
Incident involving abuse reported and corrective actions taken including employee discipline and retraining on ANE reporting.
Report Facts
Incident date: Jul 19, 2016
Report date: Jul 21, 2016
Retraining date: Aug 25, 2016
Plan of Correction review date: Aug 30, 2016
Substantial compliance date: Sep 8, 2016
Inspection Report
Follow-Up
Deficiencies: 7
Date: May 25, 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 were corrected as of 05/11/2016, with completion dates documented for each regulation cited.
Deficiencies (7)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.13(c)(1)(i)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.13(c)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 7
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 13, 2016
Visit Reason
An Abbreviated Survey was conducted on April 13, 2016, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be a "G" level deficiency, isolated, with no actual harm but with potential for more than minimal harm that is not immediate jeopardy. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended due to failure to achieve substantial compliance.
Deficiencies (1)
"G" level deficiency, isolated, with no actual harm but potential for more than minimal harm that is not immediate jeopardy
Report Facts
Denial of Payment Effective Date: Jul 13, 2016
Termination Recommendation Date: Oct 13, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 7
Date: Apr 13, 2016
Visit Reason
Complaint investigations and partial extended survey were conducted due to multiple complaints regarding resident care, abuse allegations, infection control, and medication administration.
Complaint Details
The visit was triggered by multiple complaint investigations (#98098, #98422, #98743, #97460, #98857) involving failure to notify physicians, abuse allegations, infection control issues, and medication administration problems.
Findings
The facility failed to timely notify a resident's physician regarding antibiotic treatment for a UTI, failed to report and investigate allegations of abuse by staff, failed to implement abuse prevention policies, failed to provide comprehensive care plans for residents with specific needs, failed to provide timely medication leading to hospitalization, failed to monitor fall prevention plans resulting in injury, and failed to implement infection control procedures to prevent spread of scabies among residents and staff.
Deficiencies (7)
Failed to notify resident's physician timely after no antibiotic was ordered for a resident with UTI for 6 days and failed to notify physician of resident's refusal of antibiotic doses.
Failed to report and thoroughly investigate allegations of potential abuse by staff, and failed to protect residents by not suspending staff and timely reporting allegations.
Failed to implement abuse/neglect policies including failure to complete pre-employment screening and failure to investigate abuse allegations.
Failed to develop and implement comprehensive care plans addressing resident behaviors related to medication administration and care for scabies.
Failed to provide physician ordered medication timely to a resident with UTI, resulting in hospitalization for urosepsis.
Failed to monitor and follow fall prevention plan for a resident with history of falls, resulting in a fall with injury requiring sutures.
Failed to establish and maintain infection control program to prevent spread of scabies infection among residents and staff, including failure to follow CDC recommendations.
Report Facts
Residents treated for scabies: 8
Residents sampled: 11
Residents in facility: 35
Severity level D deficiencies: 3
Severity level F deficiencies: 3
Severity level G deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide H | Named in abuse allegations involving Resident #3 and Resident #2, including inappropriate behavior and failure to suspend after allegations. | |
| Nurse Aide K | Reported observation of Medication Aide H pulling up pants in resident's room, triggering investigation. | |
| Nurse J | Received abuse allegation report from resident's family and notified director of nursing. | |
| Administrative Nurse G | Verified failure to suspend Medication Aide H immediately and lack of investigation. | |
| Nurse C | Verified medication refusal notification practices and scabies treatment procedures. | |
| Nurse Aide B | Verified resident's multiple UTIs and care practices. | |
| Nurse Aide D | Verified resident decline and rash treatment. | |
| Medication Aide F | Reported rough treatment by Medication Aide H and resident fear. | |
| Medication Aide I | Witnessed Medication Aide H belittling resident and being short with residents. | |
| Housekeeper N | Described laundry and cleaning procedures for scabies. | |
| Administrative Staff O | Verified scabies outbreak details and treatment of residents and staff. | |
| KDHE Staff P | Provided expert opinion on scabies diagnosis and treatment recommendations. | |
| Nurse I | Verified resident fear of Medication Aide H after abuse allegations. | |
| Nurse L | Failed to notify administration of abuse allegation and did not suspend Medication Aide H. |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Apr 13, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Locust Grove Village.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Locust Grove Village dated 04/13/2016.
Findings
The Plan of Correction addresses multiple deficiencies related to notification of changes, investigation and reporting of allegations, abuse policies, comprehensive care plans, prevention of urinary tract infections, fall prevention, and infection control. The facility outlines corrective actions, staff training, policy reviews, and quality assurance measures to achieve substantial compliance by May 11, 2016.
Deficiencies (7)
F157 NOTIFY OF CHANGES - Failure to notify physician of changes in resident condition
F225 INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS - Failure to properly investigate and report incidents
F226 DEVELOP, IMPLEMENT ABUSE POLICIES - Incomplete abuse policies
F279 DEVELOP COMPREHENSIVE CARE PLANS - Care plans not updated or comprehensive
F315 NO CATHETER, PREVENT UTI, RESTORE BLADDER - Issues with medication refusal policy and follow-up
F323 FREE OF ACCIDENT HAZARDS/SUPERVISION/ DEVICES - Fall prevention and supervision deficiencies
F441 INFECTION CONTROL - Infection control policy and practice deficiencies
Report Facts
Compliance date: May 11, 2016
Background check date: Mar 29, 2016
Quality measure improvement: 78.4
Quality measure improvement: 62.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlotte Rathke | Administrator | Administrator responsible for quality checks and submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Dec 30, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies related to regulations 483.20(d)(3), 483.10(k)(2), 483.25, and 483.25(i) have been corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(l)
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Dec 30, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to cited deficiencies from a prior inspection, outlining corrective actions and timelines to achieve substantial compliance.
Findings
The Plan of Correction addresses multiple deficiencies including care planning participation, provision of care for highest well-being, maintenance of nutrition status, and ensuring the drug regimen is free from unnecessary drugs. The facility outlines training, audits, and ongoing compliance measures to correct these issues by December 30, 2015.
Deficiencies (4)
F280 RIGHT TO PARTICIPATE IN CARE PLANNING
F309 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
F325 MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE
F329 DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS
Report Facts
Complete Date: Dec 30, 2015
Quality Measure report date: Nov 30, 2015
Chart audit date: Dec 8, 2015
Training dates: Dec 15, 2015
Training date: Dec 23, 2015
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 10, 2015
Visit Reason
A first revisit was conducted on December 10, 2015, for the October 9, 2015 Health survey to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The revisit found the most serious deficiencies to be isolated 'D' level deficiencies, 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 submitted plan.
Deficiencies (1)
Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as the Enforcement Coordinator who signed the report and communicated findings. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 10, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The report indicates that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 11/07/2015. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Deficiency under regulation 28-39-158(a) previously cited
Report Facts
Correction completion date: Nov 7, 2015
Follow-up survey completion date: Oct 9, 2015
Inspection Report
Follow-Up
Deficiencies: 16
Date: Dec 10, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that all previously identified deficiencies, each referenced by regulation number and prefix code, were corrected by 11/07/2015 as verified by the state surveyor.
Deficiencies (16)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.15(f)(1)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(n)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.70(f)
Report Facts
Correction completion date: Nov 7, 2015
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Dec 10, 2015
Visit Reason
The inspection was conducted as a Noncompliant Revisit and Complaint Investigations #93447, #93002, and #92583 to assess compliance with care planning, provision of care, nutrition, and medication management.
Complaint Details
The visit was complaint-related, triggered by complaints #93447, #93002, and #92583, involving failures in care planning, neurological assessments, pain management, and nutrition.
Findings
The facility failed to review and revise care plans for residents after significant changes in condition or falls, failed to complete physician ordered neurological assessments and timely pain management after a fall, failed to administer a registered dietician recommended nutritional supplement, and failed to provide pain medication prior to restorative services as care planned.
Deficiencies (4)
Failed to review and revise care plans for 2 of 12 sampled residents after changes in functional and mental status or falls.
Failed to complete physician ordered neurological assessments and timely pain management for Resident #39 after a fall.
Failed to administer the registered dietician recommended supplement to Resident #43 whose weight fluctuated and albumin level was below normal.
Failed to provide pain medication prior to restorative services as care planned for Resident #43.
Report Facts
Residents sampled: 12
Facility census: 40
Fall risk score: 24
Neurological checks ordered: 8
Neurological checks completed: 4
Weight fluctuation: 11
Supplement dose: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Verified care plan updates were not made and pain medication was not administered as required |
| Administrative Nurse D | Administrative Nurse | Verified failures in care plan updates, neurological checks, pain management, and supplement administration |
| Nurse C | Nurse | Verified neurological checks were not completed as ordered |
| Nurse H | Nurse | Verified care plan was not updated after resident's status change |
| Nurse Aide F | Nurse Aide | Reported resident's assistance needs increased before death |
| Nurse Aide B | Nurse Aide | Reported resident was confused and did not use call light before fall |
| Medication Aide E | Medication Aide | Reported supplement was unavailable for resident for several months |
| Restorative Aide G | Restorative Aide | Provided range of motion exercises without resident receiving pain medication |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Nov 7, 2015
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit report confirms that the deficiencies identified in the prior survey were corrected as of the revisit date, with specific regulation citations noted for correction completion.
Deficiencies (2)
Deficiency related to regulation 28-39-158(a)
Deficiency related to regulation 26-43-206(d)
Inspection Report
Plan of Correction
Deficiencies: 20
Date: Nov 7, 2015
Visit Reason
This document is a Plan of Correction submitted by Locust Grove Village in response to cited deficiencies from a prior inspection, outlining corrective actions and compliance measures to address those deficiencies.
Findings
The Plan of Correction details multiple corrective actions including staff training, policy updates, care plan revisions, environmental maintenance, and quality assurance processes to achieve substantial compliance by November 7, 2015.
Deficiencies (20)
Incident reporting to KDADS hotline and staff training on ANE policy
Removal of inappropriate signage and staff retraining on resident rights and dignity
Resident bathing preferences reviewed and spa technician employed for bathing program
Review and revision of activity preferences and care plans
Cleaning of overhead lights and preventative maintenance program updated
Addition of comfort care plans and development of related policies
Review and update of care plans including medication reviews and fall procedures
Staff audits for proper lift usage and bathing protocol compliance
Wound management improvements and pressure ulcer prevention
Review of urinary incontinence care and auditing of caregiving staff
Security improvements with new lock on janitor door and fall injury investigations
Aspiration precautions and weight monitoring protocols implemented
Review of bowel movement protocols and diuretic medication monitoring
Immunization policy provided and consent forms sent to responsible parties
Cleaning of light fixtures and activity department refrigerator with new policies
Monthly drug regimen reviews by consultant pharmacist and notification procedures
Medication labeling improvements and monthly medication cart checks
Infection control training and housekeeping cleaning protocol updates
Preventative maintenance program for call light system and monitoring devices
Certified Dietary Manager course enrollment and training preceptor assignment
Report Facts
Date: Nov 7, 2015
Pressure ulcer quality measure improvement: 10.5
Pressure ulcer quality measure improvement: 5.9
Course completion date: 201512
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Charlotte Rathke | Administrator | Administrator submitting the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 20, 2015
Visit Reason
This Plan of Correction document serves as a written allegation of substantial compliance with Federal Medicare and Medicaid requirements, addressing deficiencies identified in a prior inspection.
Findings
The facility has taken corrective actions including enrolling a person in the Certified Dietary Manager course and cleaning overhead lights, with ongoing compliance ensured through a preventative maintenance program and oversight by the Director of Maintenance.
Deficiencies (2)
Dietary services deficiency addressed by enrolling a person in the Certified Dietary Manager course.
Food preparation deficiency addressed by cleaning overhead lights and updating the preventative maintenance schedule.
Report Facts
Completion date: Nov 7, 2015
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 9, 2015
Visit Reason
A health survey was conducted on October 9, 2015, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at an 'F' level, indicating significant noncompliance. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended.
Deficiencies (1)
Deficiencies found at 'F' level severity
Report Facts
Denial of Payment for New Admissions effective date: Jan 9, 2016
Timeframe for potential termination: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter related to enforcement and survey findings |
| Charlotte Rathke | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 19
Date: Oct 9, 2015
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation #91394 to investigate allegations related to resident care, dignity, falls, infection control, and other compliance issues.
Complaint Details
Complaint Investigation #91394 focused on allegations of abuse, neglect, dignity concerns, falls, infection control, medication management, and resident rights.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate and report incidents, maintain resident dignity, provide choice in care, implement activities, maintain housekeeping and maintenance, develop comprehensive care plans, provide appropriate care and services, maintain nutrition, ensure drug regimens are free from unnecessary drugs, maintain infection control, and ensure a working call system.
Deficiencies (19)
Failed to thoroughly investigate and report an incident with injury to the state agency for Resident #14.
Failed to promote care for Resident #11 in a manner that maintained or enhanced dignity, including failure to address strong urine odor and inappropriate signage outside rooms.
Failed to provide Resident #36 a choice of how many baths or showers the resident desired weekly.
Failed to provide an ongoing program of activities to meet the interests and well-being of Residents #43 and #14.
Failed to provide maintenance and housekeeping services necessary to maintain a sanitary and orderly environment, including dead bugs in overhead lights.
Failed to develop a comprehensive care plan for Resident #31 that included measurable objectives and timetables for end of life care and comfort care.
Failed to review and revise care plans with new interventions to prevent additional falls for Resident #15 after multiple falls including head injuries.
Failed to provide appropriate end of life comfort care for Resident #31 and failed to provide physician ordered continuous oxygen therapy for Resident #3.
Failed to provide necessary care and services in a safe manner for Residents #32 and #18 during transfers using mechanical lifts, and failed to provide good grooming and personal hygiene for Resident #14.
Failed to provide necessary treatment and services to prevent pressure ulcers for Residents #41 and #52, including delayed physician notification and treatment.
Failed to provide appropriate treatment and services to maintain as much normal urinary function as possible for Residents #11 and #14, including failure to provide proper pericare and manage incontinence.
Failed to provide supervision and assistance devices to prevent accidents for Residents #14 and #15, including bruises and skin tears of unknown origin and inadequate supervision to prevent falls.
Failed to maintain acceptable nutritional status for Resident #18, including failure to implement dietitian recommendations and monitor aspiration precautions.
Failed to ensure residents' drug regimens were free from unnecessary drugs, including failure to monitor bowel management for Resident #44 and failure to ensure daily weights for Resident #3.
Failed to ensure each resident's medication had a legible prescription label in the medication room refrigerator.
Failed to maintain infection control practices to prevent disease transmission, including improper hand hygiene, improper cleaning of equipment and environment, and improper handling of linens.
Failed to ensure a working call system for residents in 3 rooms and bathrooms on 2 halls, including non-functioning emergency call buttons and lack of policy.
Failed to properly store food in the activity room refrigerator, including expired and moldy food items, and lacked a food storage policy.
Failed to ensure medical record documentation of education and opportunity to accept or refuse influenza and pneumococcal immunizations for 5 residents.
Report Facts
Residents present: 44
Sample size: 18
Bruise measurement: 18
Bruise measurement: 15
Skin tear measurement: 8
Skin tear measurement: 4
Pressure ulcer measurement: 4.3
Pressure ulcer measurement: 5.2
Weight loss percentage: 23
Weight: 116
Weight: 92.4
Weight: 119.6
Weight: 138.5
Weight: 118.2
Weight: 115
Weight: 116.2
Weight: 107.2
Weight: 105
Weight: 104.4
Weight: 98.2
Weight: 99.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide J | Nurse Aide | Named in findings related to Resident #14 fall and incontinence care |
| Nurse Aide K | Nurse Aide | Named in findings related to Resident #14 incontinence care and transfer |
| Nurse Aide L | Nurse Aide | Named in findings related to Resident #14 incontinent care and transfer |
| Nurse Aide M | Nurse Aide | Named in findings related to Resident #14 incontinent care |
| Nurse Aide A | Nurse Aide | Named in findings related to Resident #11 incontinence care |
| Nurse D | Licensed Nurse | Named in findings related to Resident #36 bathing and Resident #15 fall care plan |
| Nurse E | Administrative Nurse | Named in findings related to Resident #14 dignity, Resident #3 oxygen therapy, and infection control |
| Nurse G | Nurse Aide | Named in findings related to Resident #18 transfer and Resident #14 incontinent care |
| Nurse O | Nurse Aide | Named in findings related to Resident #18 transfer and Resident #14 incontinent care |
| Nurse R | Nurse Aide | Named in findings related to Resident #44 bowel care |
| Nurse Staff P | Housekeeper | Named in findings related to infection control and cleaning |
| Administrative Staff Q | Administrative Staff | Named in findings related to immunization education and call system |
| Therapy Assistant C | Therapy Assistant | Named in findings related to Resident #36 bathing and Resident #15 fall care plan |
| Dietary Staff I | Dietary Staff | Named in findings related to Resident #18 nutrition |
| Administrative Nurse F | Administrative Nurse | Named in findings related to Resident #44 bowel care |
| Administrative Staff E | Administrative Nurse | Named in findings related to Resident #14 dignity, Resident #15 falls, Resident #3 oxygen therapy, Resident #18 nutrition, infection control |
| Administrative Staff A | Administrative Staff | Named in findings related to Resident #14 fall |
| Nurse Aide N | Nurse Aide | Named in findings related to infection control and Resident #1 care |
Inspection Report
Re-Inspection
Census: 6
Deficiencies: 2
Date: Oct 9, 2015
Visit Reason
The inspection was a resurvey of the Assisted Living/Residential Healthcare facility to assess compliance with prior citations.
Findings
The facility failed to employ a full-time certified dietary manager and failed to maintain sanitary conditions in the kitchen, including inadequate cleaning of overhead lights and presence of dead bugs, resulting in failure to prepare and serve food under sanitary conditions for the 6 residents.
Deficiencies (2)
Failed to employ a full-time certified dietary manager for the 6 residents receiving meals from the facility kitchen.
Failed to provide maintenance and housekeeping services necessary to maintain a sanitary and orderly environment in the facility kitchen.
Report Facts
Census: 6
Inspection Report
Follow-Up
Deficiencies: 3
Date: Sep 24, 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
The revisit confirmed that corrections were completed for deficiencies related to regulations 483.10(f)(2), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), and 483.25(h) as of 09/24/2015.
Deficiencies (3)
Deficiency related to regulation 483.10(f)(2)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 22, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Locust Grove facility.
Complaint Details
This Plan of Correction is related to a complaint investigation at Locust Grove, with deficiencies cited and addressed including incident reporting and resident fall precautions.
Findings
The plan addresses concerns related to family communication, incident reporting to the state hotline, and fall precautions for residents, with commitments to ongoing quality assurance and compliance by September 24, 2015.
Deficiencies (4)
Written allegation of substantial compliance with Federal Medicare and Medicaid requirements.
Concerns identified will be addressed to family via written communication or personal meeting; follow-up on resident concerns and grievance process.
Incident reported to KDADS hotline; review of incidents and falls for compliance with reporting requirements.
Resident fall precautions maintained; no injury resulted; staff education and audits planned.
Report Facts
Date of family meeting set by Board: Sep 24, 2015
Date incident reported to KDADS hotline: Sep 21, 2015
Date of Nursing Staff meeting for fall precautions review: Sep 18, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlotte Rathke | Administrator | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 10, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be "D" level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Deficiencies (1)
Deficiencies cited at "D" level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 3
Date: Sep 10, 2015
Visit Reason
The inspection was conducted as a result of Complaint Investigations #90928 and #90935 to evaluate grievances and allegations related to resident care and safety.
Complaint Details
The visit was complaint-related, involving grievances about staff care and failure to report incidents. The complaints were substantiated as the facility failed to maintain grievance logs, promptly resolve grievances, report incidents, and follow care plans.
Findings
The facility failed to promptly resolve grievances for a resident and maintain a grievance log. It also failed to report a fall incident involving a resident who sustained skin tears, and did not follow care plans to prevent falls for two residents, resulting in injuries and safety risks.
Deficiencies (3)
Failed to promptly resolve grievances for Resident #1 and provide outcome to the complainant.
Failed to report a fall for Resident #2 who required assistance of 2 staff with a mechanical lift and sustained 2 skin tears.
Failed to follow care plan and facility policy to prevent falls for Residents #1 and #2, resulting in falls and injuries.
Report Facts
Census: 44
Sample size: 3
Skin tears: 2
BIMS score: 2
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of grievance log, confirmed staff expectations for mechanical lift transfers, and acknowledged failure to report incidents. |
| Nurse A | Nurse | Verified transfer protocols requiring 2 staff and commented on fall prevention measures. |
| Nurse B | Nurse | Discussed fall prevention efforts and resident non-compliance. |
| Nurse Aide C | Nurse Aide | Verified resident refusal to wear gripper socks and fall prevention practices. |
| Nurse Aide E | Nurse Aide | Verified training on mechanical lift use with 2 staff and participated in resident transfer. |
| Nurse Aide F | Nurse Aide | Participated in resident transfer using mechanical lift. |
| Nurse Aide G | Nurse Aide | Reported difficulty working without a partner and sometimes transferring residents alone. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 26, 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 deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.
Deficiencies (1)
Most serious deficiencies found were 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Nov 26, 2014
Provider agreement termination date: Feb 26, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for informal dispute resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 22, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies identified by regulation numbers F0241, F0242, F0244, F0280, F0312, and F0323 were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jun 25, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior deficiency report, outlining corrective actions to address cited deficiencies.
Findings
The plan details corrective actions including staff training on resident dignity and bathing procedures, updates to care plans and documentation systems, replacement of unsafe equipment, and ongoing quality assurance audits to ensure compliance.
Deficiencies (6)
Staff to complete training on improving and maintaining resident quality of life, including dignity issues and resident rights.
All sampled residents have received bathing; bathing preferences reviewed and documented daily.
Resident council agenda to include follow-up on previous concerns with documented minutes and assigned follow-up.
Bathing preferences reviewed and care plans updated; staff trained on documentation and care plan access.
Staff training on assistance in dining room and monitoring residents; charge nurse ensures adequate assistance.
Unsafe bed replaced with newer bariatric bed; bedrail assessment updated and safety audits completed.
Report Facts
Complete Date: Jul 22, 2014
Inspection Report
Enforcement
Deficiencies: 1
Date: Jun 23, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, indicating no actual harm but 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 July 22, 2014.
Deficiencies (1)
Deficiencies at 'E' level, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 19, 2014
Visit Reason
The Assisted Living/Residential Healthcare resurvey of the facility was conducted to verify compliance and assess any deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 7
Date: Jun 17, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously identified deficiencies related to resident dignity, bathing services, care planning, assistance with dining, and safety measures.
Findings
The facility failed to provide dignity and respect during dining for some residents, did not provide scheduled bathing services as per care plans for multiple residents, failed to respond to resident grievances regarding bathing, did not assist a resident during meals as required, and failed to assess and provide safe side rails for a resident.
Deficiencies (7)
Failed to care for residents in a manner that maintains or enhances dignity during dining for 2 residents (#10, #45).
Failed to provide scheduled bathing services as chosen by 2 residents (#12, #16).
Failed to respond to resident concerns regarding showers discussed at resident council meetings.
Failed to provide scheduled bathing services as care planned for 4 residents (#26, #12, #16, #37) and assistance with dining for 1 resident (#10).
Failed to provide scheduled bathing services for 4 residents (#26, #12, #16, #37) and assistance with dining for 1 resident (#10).
Failed to assist and monitor Resident #10 during meals.
Failed to assess and provide side rails without unsafe gaps that extremities could easily pass through for Resident #24.
Report Facts
Census: 44
Sample size: 12
Days without shower: 11
Days without shower: 14
Days without shower: 13
Days without shower: 10
Days without shower: 14
Days without shower: 14
Days without shower: 7
Days without shower: 7
Days without shower: 11
Days without shower: 7
Days without bath: 10
Days without bath: 5
Days without bath: 14
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 20, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report documents that all previously reported deficiencies identified on the CMS-2567 have been corrected as of the revisit date.
Report Facts
Correction completion date: Dec 20, 2013
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Dec 20, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Complaint Details
This Plan of Correction is related to deficiencies cited during a complaint investigation at Locust Grove on November 21, 2013.
Findings
The plan outlines corrective actions including staff training on resident rights, skin assessment and care protocols, and competency in accessing electronic health records, with Quality Assurance oversight to ensure ongoing compliance.
Deficiencies (4)
Failure to comply with Federal Medicare and Medicaid requirements.
Staff training needed on Resident Rights.
Inadequate skin assessments and interventions.
Caregiving staff competency in accessing Plan of Care and related procedures.
Report Facts
Complete Date: Dec 20, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Charlotte Rathke | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 3
Date: Nov 21, 2013
Visit Reason
The inspection was conducted as a result of complaint investigations #KS00068462 and #KS00066058.
Complaint Details
The inspection was triggered by complaint investigations #KS00068462 and #KS00066058. The complaints involved dignity issues during incontinence care and failure to provide proper nursing assessments and incontinence care.
Findings
The facility failed to promote dignity and respect for one resident during incontinence care, failed to provide necessary nursing assessments related to skin issues for two residents, and failed to provide incontinence care as planned for one resident, resulting in a period of over 3 hours without care.
Deficiencies (3)
Failed to promote care for 1 of 4 sampled residents in a manner that enhanced dignity when staff provided incontinence care with the resident's entire body exposed.
Failed to provide necessary care (nursing assessments related to non-pressure related skin issues) to maintain 2 of 4 sampled residents' highest practicable physical well-being.
Failed to provide services (incontinence care as care planned) to maintain as much normal bladder function as possible for 1 of 3 residents sampled for incontinence.
Report Facts
Census: 42
Residents sampled: 4
Incontinence care delay: 190
Bruise size: 1.5
Bruise size: 3.5
Bruise size: 2
Skin tear size: 2.5
Skin tear size: 1.6
Wounds count: 3
Wound size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Licensed Nurse | Noted resident #12 was unclothed during incontinence care and acknowledged it was a dignity issue; also verified incontinence care should be provided every 2 hours. |
| Staff F | Direct Care Staff | Provided incontinence care to resident #12 without covering the resident; transferred resident #12 to geri chair and activity room; acknowledged should have covered resident during care. |
| Staff G | Direct Care Staff | Assisted with incontinence care and transfers of resident #12; did not realize resident went over 3 hours without care. |
| Nurse E | Licensed Nurse | Completed skin assessments weekly; unaware of current bruises on resident #12; verified resident #13 had a healing skin tear. |
| Nurse B | Administrative Nurse | Confirmed lack of documentation and monitoring of bruises and skin tears for residents #12 and #13. |
| Staff H | Direct Care Staff | Verified licensed nurses completed weekly skin assessments and confirmed use of full lift for resident #12. |
| Staff I | Direct Care Staff | Reported resident #13 occasionally had bruises and skin tears from transfers and used sit to stand lift. |
| Staff K | Direct Care Staff | Wheeled resident #12 back to living room area after evening meal. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 4, 2013
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been accomplished.
Findings
The report confirms that the previously identified deficiency with regulation number 26-40-305 (e)(1)(2) and ID prefix S1358 was corrected as of 04/04/2013.
Deficiencies (1)
Deficiency related to regulation 26-40-305 (e)(1)(2) previously cited under ID prefix S1358
Inspection Report
Follow-Up
Deficiencies: 8
Date: Apr 4, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-03-05.
Findings
All previously reported deficiencies identified on the CMS-2567 Statement of Deficiencies were corrected as of the revisit date 2013-04-04.
Deficiencies (8)
Deficiency with regulation 483.20(b)(1)
Deficiency with regulation 483.20(d), 483.20(k)(1)
Deficiency with regulation 483.25
Deficiency with regulation 483.25(l)
Deficiency with regulation 483.25(n)
Deficiency with regulation 483.35(i)
Deficiency with regulation 483.60(c)
Deficiency with regulation 483.65
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Mar 14, 2013
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection identifying deficiencies related to Medicare and Medicaid compliance, medication diagnosis documentation, discharge planning, infection control, and staff education.
Findings
The plan outlines corrective actions including education sessions, audits, documentation improvements, and ongoing compliance monitoring by the Director of Nursing and other staff to address deficiencies such as incomplete medication diagnoses, discharge planning, infection control practices, and equipment sanitation.
Deficiencies (8)
Annual or Significant change MDS assessments will be completed on cited residents within 30 days.
Discharge plan for cited resident #49 was completed in the care plan.
Resident #37 was assessed due to complaint of pain; care plan revised and staff educated on response to condition changes.
Diagnosis obtained for medications on cited residents (#37 Lomotil, #26 Bactrim, #26 Lasix, #29 Valproic Acid).
Education and audits related to infection control and equipment sanitation provided to staff.
A plumber will install a backflow valve on the south sink of the beauty shop.
Mandatory staff inservice for dietary personnel on food preparation and glove use.
Letter to responsible party with education related to influenza vaccine mailed and documented.
Report Facts
Date of Plan of Correction submission: 2013
Date of education sessions: 2013
Dates diagnosis obtained: 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlotte Rathke | Administrator | Submitted the Plan of Correction |
Inspection Report
Census: 44
Deficiencies: 1
Date: Mar 5, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with plumbing and piping system requirements in the facility.
Findings
The facility failed to have a backflow prevention valve on the south beauty shop sink, which is required to prevent contamination of the water supply system.
Deficiencies (1)
Facility failed to have a backflow prevention valve in one of the beauty shop sinks.
Report Facts
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff H | Confirmed the south sink in the beauty shop lacked a backflow valve |
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