Inspection Reports for Lone Tree Retirement Community, LLC
801 E GRANT, KS, 67864
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2025 found no deficiencies and confirmed the facility was in compliance with all regulations. Earlier inspections showed multiple deficiencies primarily related to resident dignity and privacy, discharge documentation, assessment accuracy, food safety and sanitation, garbage disposal, staffing data reporting, and infection prevention and control practices. Complaint investigations included substantiated issues such as failure to provide adequate nursing assessment after an elopement and inadequate supervision related to malfunctioning door alarms, as well as staff-to-resident abuse resulting in immediate jeopardy and enforcement actions in 2017. Enforcement actions included civil monetary penalties and potential termination threats in past years, but no fines or license suspensions were listed in the available reports for recent inspections. The facility appears to have addressed prior deficiencies effectively, with the most recent surveys showing full compliance and correction of earlier issues.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
13.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
33 residents
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/21/25.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 10/01/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 8
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as a Health Recertification Survey and complaint survey regarding allegations in KS00194531.
Complaint Details
The inspection included a complaint survey regarding allegations identified as KS00194531.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and privacy, failure to provide a written discharge summary, inaccurate resident assessments, unsanitary food storage and preparation practices, improper disposal of garbage, incomplete payroll-based journal staffing data, inadequate infection prevention and control practices including failure to use enhanced barrier precautions and hand hygiene, and lack of a qualified infection preventionist.
Deficiencies (8)
Failure to treat residents in a dignified manner with privacy during care involving mechanical lifts.
Failure to provide a written discharge summary or recapitulation of stay for a discharged resident.
Failure to accurately complete Minimum Data Set (MDS) assessments for multiple residents regarding alarms, pressure ulcers, medications, dental status, and diet.
Failure to prepare and serve food under sanitary conditions, including improper food storage, unsealed and unlabeled food items, and dirty kitchen equipment.
Failure to properly maintain and dispose of kitchen garbage and refuse, including uncovered garbage cans.
Failure to submit complete and accurate staffing information to Payroll-Based Journaling (PBJ), including inaccurate reporting of licensed nursing coverage.
Failure to utilize Enhanced Barrier Precautions and adequate hand hygiene during care of residents with infections, and failure to deliver food in a sanitary manner.
Failure to designate a qualified Infection Preventionist with specialized training in infection prevention and control.
Report Facts
Deficiencies cited: 8
Resident census: 33
Dates with no licensed nursing coverage reported in PBJ: 12
Date of survey completion: Aug 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Infection Preventionist | Named as facility IP without health-related degrees; responsible for infection control program. |
| Administrative Nurse D | Administrative Nurse | Assisted with infection prevention tasks; confirmed deficiencies in privacy, discharge summary, assessments, and infection control. |
| Certified Nurse Aide M | CNA | Observed failing to provide privacy during mechanical lift use and inadequate hand hygiene. |
| Certified Nurse Aide S | CNA | Observed failing to perform hand hygiene and use gowns during care of infected resident. |
| Consultant Staff GG | Consultant | Provided input on infection control expectations and IP qualifications. |
| Certified Dietary Manager BB | Certified Dietary Manager | Reported on food storage and sanitation deficiencies. |
| Licensed Nurse G | Licensed Nurse | Confirmed infection control deficiencies and PPE requirements. |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Aug 19, 2025
Visit Reason
The document is a Plan of Correction submitted by Lone Tree Retirement Community in response to an Annual and Complaint Survey conducted from August 19, 2025 to August 21, 2025.
Findings
The Plan of Correction addresses multiple deficiencies identified during the survey, including resident rights, discharge process, accuracy of assessments, food procurement and sanitation, garbage disposal, payroll based journal accuracy, infection prevention and control, and infection preventionist qualifications. The facility outlines immediate corrective actions, staff education, audits, and monitoring plans to ensure compliance and prevent recurrence.
Deficiencies (8)
Resident Rights/Exercise of Rights
Discharge Process
Accuracy of Assessments
Food Procurement, Store/Prepare/Serve-Sanitary
Dispose Garbage and Refuse Property
Payroll Based Journal
Infection Prevention & Control
Infection Preventionist Qualifications Role
Report Facts
Survey dates: Annual and Complaint Survey conducted from 8/19/2025 to 8/21/2025
Date of compliance: 2025
Number of residents with corrected MDS: 5
Missing PBJ days corrected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Casandra Mittlieder | LNHA | Submitted the Plan of Correction to KDADS |
| Felicia Majewski | Modified the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
An offsite revisit survey was conducted on 10/03/23 for all previous deficiencies cited on 08/30/23.
Findings
All deficiencies have been corrected as of the compliance date of 09/26/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 5
Date: Aug 30, 2023
Visit Reason
The inspection was a Health Resurvey to evaluate the facility's compliance with respiratory care, food safety, staffing reporting, infection control, and equipment maintenance requirements.
Findings
The facility failed to provide proper respiratory care and cleaning of nebulizer equipment for residents, failed to maintain food safety and sanitization practices in the kitchen, failed to submit complete and accurate staffing information, failed to maintain infection prevention and control including hand hygiene during incontinent care, and failed to maintain a functioning dish machine.
Deficiencies (5)
Failure to provide necessary respiratory care consistent with professional standards regarding nebulizer use and cleaning for Residents 26 and 27.
Failure to store foods safely and ensure proper sanitization and food handling practices to prevent foodborne illnesses.
Failure to submit complete and accurate staffing information to CMS through Payroll Based Journaling (PBJ).
Failure to establish and maintain an infection prevention and control program, including failure to clean nebulizer equipment and failure to perform proper hand hygiene during incontinent care.
Failure to maintain mechanical, electrical, and patient care equipment in safe operating condition due to a non-functioning dish machine since 08/08/23.
Report Facts
Resident census: 27
Residents in sample: 12
Sanitizing sink chlorine concentration: 100
Dishwasher non-functioning since: Aug 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | Certified Nurse Aide | Reported nebulizer machine remained on Resident 26's bed |
| Licensed Nurse G | Licensed Nurse | Reported staff should rinse out nebulizers after each use and cleanse with vinegar water |
| Administrative Nurse D | Administrative Nurse | Expected nursing staff to rinse nebulizers after each treatment and soak overnight; reported nursing staff do not monitor nebulizer treatment effectiveness |
| Dietary Staff CC | Dietary Staff | Washed dishes manually due to broken dishwasher; unsure how to test chlorine levels |
| Dietary Supervisor BB | Dietary Supervisor | Instructed dietary staff on chlorine testing; reported no log or schedule for chlorine testing |
| Certified Nursing Assistant N | Certified Nursing Assistant | Failed to remove soiled gloves and perform hand hygiene during incontinent care of Resident 16 |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Aug 30, 2023
Visit Reason
This document is a Plan of Correction submitted by Meade District Hospital LTCU in response to deficiencies cited during the inspection on 8/30/2023.
Findings
The Plan of Correction addresses multiple deficiencies including nebulizer treatment policies, food storage and safety, staffing information reporting, infection control education, and dishwasher sanitization procedures. Each corrective action includes timelines and responsible parties.
Deficiencies (5)
Updated policy for Nebulizer treatments including cleaning, storage, and oxygen saturation assessment before and after treatments.
Food services must maintain clean food storage areas, inspect food upon delivery, store non-refrigerated food in designated dry storage, cover and date refrigerated foods, and monitor refrigerator temperatures.
Policy for mandatory submission of uniform format staffing information reviewed; Director of Nursing responsible for timely reporting of PBJ information.
Direct care nursing staff provided education on infection control, peri-care, and hand hygiene with annual training and check-offs.
Dishwasher parts installed; chemical concentration for sanitization to be logged in place of water temperature when using three-sink method.
Report Facts
Deficiency completion dates: Sep 26, 2023
Meeting dates: Sep 6, 2023
Meeting dates: Sep 12, 2023
Meeting dates: Sep 29, 2023
Training completion date: Sep 30, 2023
Dishwasher installation date: Aug 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Blehm | Infection Control and Risk Manager | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 5, 2022
Visit Reason
A revisit survey was conducted on 01/05/22 for all previous deficiencies cited on 11/16/21.
Findings
All deficiencies have been corrected as of the compliance date of 12/11/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Dec 11, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions related to bed hold policies, oxygen use orders, and equipment cleaning and storage procedures to ensure compliance with regulatory requirements.
Deficiencies (3)
Failure to provide proper notification and documentation regarding bed hold policies to residents, representatives, and DPOAs.
Failure to update resident care plans with current oxygen use orders and proper documentation.
Inadequate policy for cleaning and storage of oxygen delivery equipment including tubing and nebulizer treatment equipment.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Date: Nov 16, 2021
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation for Meade District Hosp LTCU DBA Lone Tree Retirement.
Complaint Details
The inspection included a complaint investigation identified by KS00156100.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with dignity by not providing a privacy bag for an indwelling catheter, failure to provide bed-hold policy notice upon hospital transfer, failure to revise care plans to include oxygen care for residents receiving oxygen, and failure to properly clean, store, and change oxygen and nebulizer tubing for several residents.
Deficiencies (4)
Failed to ensure Resident 6 was treated with dignity by not providing a privacy bag for an indwelling catheter bag.
Failed to provide Resident 26 or representative with bed-hold policy upon hospital transfer.
Failed to revise care plans for Residents 9 and 28 to include care of oxygen received.
Failed to ensure proper respiratory care including routine changing and sanitary storage of oxygen and nebulizer tubing for Residents 9, 17, 25, and 28.
Report Facts
Census: 33
Residents in sample: 12
Deficiency count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Interviewed regarding catheter bag privacy, oxygen care, and nebulizer cleaning |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding catheter bag privacy, bed-hold policy, care plan expectations, and nebulizer cleaning |
| Certified Nurse Aide E | Certified Nurse Aide | Interviewed regarding catheter bag privacy policy |
| Certified Nurse Aide G | Certified Nurse Aide | Interviewed regarding oxygen use and storage |
| Certified Medication Aide I | Certified Medication Aide | Interviewed regarding nebulizer cleaning and medication administration |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
A revisit survey was conducted on 11/18/20 and 11/19/20 for all previous deficiencies cited on 10/13/20.
Findings
All deficiencies have been corrected as of the compliance date of 10/30/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 20, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior survey, focusing on fall prevention and resident safety.
Findings
The facility identified deficiencies related to fall prevention, including lack of staff adherence to resident care plans and environmental risks. Corrective actions include staff education, updated care plans for residents at high risk of falls, and ongoing assessments to prevent future incidents.
Deficiencies (1)
Facility failed to ensure a safe environment free from accident hazards and adequate supervision to prevent falls.
Report Facts
Date of QAPI meeting: Oct 28, 2020
Date of incident review: Oct 20, 2020
Plan of Correction completion date: Oct 30, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dr. Schowengardt | Medical Director | Attended QAPI meeting reviewing deficiencies |
| Sharon Blehm | Risk Management Director | Submitted the Plan of Correction to KDADS |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Oct 13, 2020
Visit Reason
The inspection was conducted as a complaint investigation involving multiple complaint numbers related to resident falls and supervision issues at the facility.
Complaint Details
The visit was triggered by multiple complaints (#KS00156602, KS00155347, KS00156388, KS00155716, KS00156617, KS00156616, and KS00156729) regarding falls and supervision failures.
Findings
The facility failed to adequately supervise residents and thoroughly investigate falls for residents R6, R7, R8, and R10, resulting in serious injuries including fractures. The investigations and interventions were delayed or inadequate, and staffing shortages contributed to the failures in supervision and timely care.
Deficiencies (1)
Failed to thoroughly investigate resident falls for R6, R7, R8, and R10 to determine root causes and tailor interventions to prevent avoidable accidents.
Report Facts
Facility census: 33
Fall investigation delay: 6
Staff on night shift: 3
Fall distance: 150
Voiding diary delay: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nursing Assistant | Named in fall incident involving R6 where resident was left unattended leading to fracture |
| Administrative Nurse A | Administrative Nurse | Reviewed fall video for R6 and identified staff failures; involved in fall investigations and interventions |
| LN D | Licensed Nurse | Involved in fall investigation and care of R6; failed to complete vital signs and fall report timely |
| CNA B | Certified Nursing Assistant | Provided care and described fall interventions for R6 and R8 |
| CNA C | Certified Nursing Assistant | Reported staffing concerns and described fall interventions for R6 and R7 |
| CNA P | Certified Nursing Assistant | Reported staffing shortages and fall concerns |
| LN M | Licensed Nurse | Reported staffing difficulties on evening shifts |
| LN H | Licensed Nurse | Notified about R8's pain after fall |
| CNA I | Certified Nursing Assistant | Described toileting and fall interventions for R8 and R10 |
| CNA O | Certified Nursing Assistant | Reported lack of communication about resident toileting needs |
| LN J | Licensed Nurse | Described fall interventions and resident condition for R10 |
| LN K | Licensed Nurse | Described toileting diaries and interventions for R10 |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 9, 2020
Visit Reason
The health survey was conducted as a regulatory inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 9, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Deficiencies (1)
No deficiency citations found in the health survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 17, 2019
Visit Reason
The health survey was conducted as a regulatory inspection of the long term care facility to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B.
Findings
The survey resulted in a finding of no deficiency citations with respect to applicable regulations for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 17, 2019
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 17, 2017
Visit Reason
This document is a Plan of Correction related to a prior inspection at Meade District Hosp LTCU DBA Lone Tree Retirement.
Findings
The document does not contain specific findings or deficiencies; it is a form intended for the provider's plan of correction following an inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 17, 2017
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a regulatory inspection of the facility.
Findings
No specific deficiencies or findings are detailed in the provided document; it appears to be a template or cover page for the plan of correction.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 13, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection, aiming to ensure a safe and sustained environment for residents.
Findings
The facility plans to address medication errors, food safety and storage, narcotics security, and call system maintenance through updated policies, staff education, and monitoring reported at QAPI meetings.
Deficiencies (4)
Medication Error Rate to be less than 5% by clarifying conflicting orders and updating medication administration policy.
Foods procured from approved sources and stored, prepared, distributed, and served under sanitary conditions with proper labeling and temperature control.
Narcotics secured in separately locked permanently affixed compartments with a double lock system.
Weekly preventative maintenance of the call system to verify functionality with logs maintained.
Inspection Report
Renewal
Census: 35
Deficiencies: 1
Date: Aug 21, 2017
Visit Reason
The inspection was a licensure resurvey to assess compliance with nursing facility regulations.
Findings
The facility failed to ensure weekly testing of the call light system, performing only monthly checks, which could affect all 35 residents. Additionally, the facility did not provide a policy regarding call light preventative maintenance.
Deficiencies (1)
Failure to perform weekly preventative maintenance on the call light system to verify functionality.
Report Facts
Residents present: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| J | Maintenance staff | Interviewed regarding call light system testing frequency |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Jun 27, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were corrected as of 05/03/2017, with corrective actions completed and verified during this revisit.
Deficiencies (7)
Deficiency related to regulation 483.10(h)(1)(3)(i); 483.70(i)(2)
Deficiency related to regulation 483.12(a)(1)
Deficiency related to regulation 483.12(a)(3)(4)(c)(1)-(4)
Deficiency related to regulation 483.12(b)(1)-(3), 483.95(c)(1)-(3)
Deficiency related to regulation 483.40(d)
Deficiency related to regulation 483.10(c)(2)(i-ii,iv,v)(3), 483.21(b)(2)
Deficiency related to regulation 483.35(d)(4)-(6)
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 3, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior compliant inspection.
Findings
The Plan of Correction outlines multiple corrective actions including staff education on confidentiality, abuse prevention, reporting procedures, investigation protocols, and competency verification for Nurse Aides. It emphasizes immediate suspension of staff suspected of abuse and ongoing monitoring and support for affected residents.
Deficiencies (7)
Failure to treat resident information confidentially and safeguard protected health information.
Inadequate staff education on Policy and Procedure for Abuse, Neglect and Exploitation (ANE).
Failure to thoroughly investigate reports of abuse, neglect or injuries of unknown sources.
Failure to suspend employees immediately pending investigation of suspected or witnessed abuse.
Lack of psychosocial support and monitoring for residents involved in abuse allegations.
Failure to communicate interventions and update resident care plans following incidents.
Failure to verify Nurse Aide registry and competency evaluation prior to employment.
Report Facts
Complete Date: May 3, 2017
QAPI team meeting date: May 11, 2017
Frequency: 3
Education frequency: 2
State agency reporting timeframe: 2
State report completion timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Blehm | Risk Management Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 8
Date: Apr 26, 2017
Visit Reason
Complaint investigation triggered by allegations of staff-to-resident abuse and resident-to-resident altercation, including a partially extended survey.
Complaint Details
The complaint investigation involved multiple allegations of staff-to-resident abuse including physical abuse and verbal mistreatment by direct care staff G and H, and resident-to-resident altercation involving resident #2 and resident #7. The investigation found credible evidence supporting abuse allegations leading to termination of staff. The facility failed to immediately report and investigate some allegations and failed to protect residents during investigations, placing all residents in immediate jeopardy.
Findings
The facility failed to protect residents from abuse by staff, failed to immediately report and investigate abuse allegations, failed to provide social services after abuse incidents, failed to revise care plans after resident-to-resident altercations, and failed to verify nurse aide registry prior to employment. Several staff were terminated following substantiated abuse incidents. Immediate jeopardy was identified and abated with staff education and suspensions.
Deficiencies (8)
Failed to protect resident #1's confidentiality when staff text-messaged details of alleged mistreatment including the resident's name.
Failed to provide an environment free from abuse when staff G and H abused resident #1 and other residents, including physical abuse and verbal mistreatment.
Failed to protect residents from abuse by allowing alleged perpetrators to continue working after abuse allegations until suspension.
Failed to report a resident-to-resident altercation between resident #2 and resident #7 that occurred on 1/3/17.
Failed to develop and implement written policies and procedures to prohibit and prevent abuse and to investigate allegations, including protection of residents during investigations.
Failed to provide medically-related social services to resident #1 following an incident of staff-to-resident abuse to ensure psychosocial well-being.
Failed to revise care plan for resident #2 following a resident-to-resident altercation/behavior to prevent future occurrences.
Failed to document verification of nurse aide registry prior to employment for 4 nurse aides.
Report Facts
Residents sampled for abuse: 6
Facility census: 42
Nurse aide files reviewed: 4
Nurse aides lacking documented registry verification: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff G | Direct Care Staff | Named in findings of abuse involving resident #1 and termination following investigation. |
| Direct care staff H | Direct Care Staff | Named in findings of abuse involving residents #1, #4, #5, and #6 and termination following investigation. |
| Direct care staff D | Direct Care Staff | Witnessed abuse incident involving resident #1 and reported details via text message. |
| Administrative nurse K | Administrative Nurse | Received abuse reports, directed text communication, and managed investigation and suspensions. |
| Licensed nurse F | Licensed Nurse | Received reports of staff behavior concerns and documented resident #4's complaint of hair pulling. |
| Direct care staff C | Direct Care Staff | Reported verbal and physical abuse by staff H towards residents #5 and #6. |
| Administrative nurse Q | Administrative Nurse | Did not report resident-to-resident altercation to State agency and confirmed lack of investigation. |
| Social service staff U | Social Service Staff | Had not provided social service follow-up to resident #1 after abuse incident. |
| Administrative staff S | Administrative Staff | Confirmed policy gaps and registry verification issues. |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Apr 26, 2017
Visit Reason
An abbreviated survey was conducted on April 26, 2017, 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 the most serious deficiencies at the facility to be F223, K", CFR 483.12(a)(1), F225, "L", CFR 483.12(a)(3)(4)(c)(1)-(4), which was determined to be immediate jeopardy, resulting in enforcement remedies including a civil monetary penalty and potential denial of payment and termination if substantial compliance is not achieved.
Deficiencies (3)
Deficiency F223, K", CFR 483.12(a)(1)
Deficiency F225, "L", CFR 483.12(a)(3)(4)(c)(1)-(4)
Deficiency F226 "F", CFR 483.12(b)(1)(2)
Report Facts
Civil Monetary Penalty: 7000
Effective date for denial of payment: 2017
Effective date for termination: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Brown | Administrator | Named as facility administrator in relation to the survey and deficiencies |
| Caryl Gill | RN, BSN, Complaint coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 11, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies have been corrected as indicated in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.24 and 483.25(d)(1)(2)(n)(1)-(3) were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.24, 483.25(k)(l)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3)
Report Facts
Deficiencies corrected: 2
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 12, 2017
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services 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 F523, an 'E' level deficiency indicating 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, resulting in a finding of substantial compliance effective February 11, 2017.
Deficiencies (1)
Deficiency F523, 'E' level deficiency indicating 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 contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Date: Jan 1, 2017
Visit Reason
The inspection was conducted as a complaint investigation (KS0010330) focusing on the facility's failure to provide necessary care and services to maintain residents' highest well-being, specifically related to nursing assessment after an elopement and supervision to prevent accidents.
Complaint Details
The complaint investigation (KS0010330) found substantiated deficiencies related to failure in nursing assessment after elopement and inadequate supervision to prevent accidents due to malfunctioning or disabled door alarms and unsecured exit doors.
Findings
The facility failed to provide a thorough nursing assessment following an elopement of a cognitively impaired resident in cold weather, and failed to provide adequate supervision and functional door alarms to prevent accidents for 8 cognitively impaired and independently mobile residents. Multiple door alarms were malfunctioning or disabled without proper checks, and an unalarmed door led to an enclosed courtyard accessible to residents.
Deficiencies (2)
Failed to provide necessary nursing assessment following an elopement to maintain resident's highest practicable physical well-being.
Failed to provide adequate supervision and assistive devices to prevent accidents related to malfunctioning door alarms and unalarmed exit door.
Report Facts
Census: 41
Residents selected for sample: 3
Residents identified as cognitively impaired and independently mobile: 8
Months door alarm malfunctioned: 2.5
Temperature at time of elopement: 33.8
Wind chill: 25.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff E | Reported witnessing resident elopement and described resident's clothing and conditions | |
| Direct Care Staff F | Reported witnessing resident elopement and described resident's clothing | |
| Direct Care Staff C | Reported witnessing resident elopement and silencing door alarm without checking door | |
| Administrative Nurse B | Administrative Nurse | Confirmed failure to complete thorough nursing assessment after elopement |
| Maintenance/Housekeeping Staff G | Reported door alarm malfunction and lack of alarm on courtyard door | |
| Maintenance Staff H | Confirmed door alarm malfunction and failure to call for repair | |
| Administrative Staff A | Administrative Staff | Reported staff should not reset door alarms without checking door |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Nov 23, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies at the facility.
Findings
The report shows that previously identified deficiencies under regulations 483.25(c) and 483.60(a),(b) were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.60(a),(b)
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 23, 2015
Visit Reason
This document is a Plan of Correction submitted by Meade District Hospital LTCU in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to skin assessments and pharmaceutical services, including procedures to prevent skin issues and ensure accurate medication administration and documentation.
Deficiencies (2)
Failure to prevent development of skin issues; lack of proper skin assessments and monitoring.
Inadequate pharmaceutical services including medication administration timing and documentation.
Report Facts
Plan of Correction completion date: Nov 23, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Brown | Director | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 2
Date: Nov 2, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements, including treatment and services to prevent and heal pressure sores and pharmaceutical services.
Findings
The facility failed to provide necessary services to prevent one resident from developing a stage 2 pressure ulcer and failed to ensure medications were administered as ordered to another resident.
Deficiencies (2)
Failed to provide services necessary to prevent a resident from developing a stage 2 pressure ulcer.
Failed to ensure medications were administered as ordered to resident #39.
Report Facts
Census: 45
Residents in sample: 9
Weight loss percentage: 14.6
Weight loss percentage: 8.8
Pressure ulcer wound size: 0.5
Medication doses missed: 17
Medication doses missed: 2
Medication doses missed: 2
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 2, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies that constituted no actual harm but had potential for more than minimal harm without 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)
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 | Signed the enforcement decision letter. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 18, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be '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 remedies including denial of payment for new admissions and termination of provider agreement were outlined if substantial compliance was not achieved.
Deficiencies (1)
"F" level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: Nov 18, 2015
Termination effective date: Feb 18, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report and is the enforcement coordinator for the Survey, Certification and Credentialing Commission. |
Inspection Report
Follow-Up
Deficiencies: 14
Date: Oct 13, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously identified deficiencies were corrected by 08/29/2014 as indicated by the correction completion dates for each cited regulation.
Deficiencies (14)
Deficiency related to regulation 483.15(e)(1)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(b)(2)(i)
Deficiency related to regulation 483.20(g) - (j)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(b)
Deficiency related to regulation 483.35(d)(1)-(2)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Report Facts
Deficiencies corrected: 14
Inspection Report
Renewal
Deficiencies: 1
Date: Aug 1, 2014
Visit Reason
A Health recertification 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 most serious deficiency to be a 'G' level deficiency, isolated, with no actual harm but potential for more than minimal harm that is not immediate jeopardy. Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were outlined.
Deficiencies (1)
Most serious deficiency found was a 'G' level deficiency, isolated, with no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Civil Money Penalty minimum amount: 5000
Denial of payment effective date: Nov 1, 2014
Termination effective date: Feb 1, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Brown | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the letter |
| Joe Ewert | Commissioner of Survey, Certification and Credentialing Commission | Official signing the letter and overseeing survey |
| Carol Schiffelbein | Regional Manager | KDADS staff mentioned |
| Audrey Sunderraj | Director | KDADS staff mentioned |
| Sharon Dabzadeh | KDADS staff mentioned |
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 14
Date: Jul 25, 2014
Visit Reason
This document is a Plan of Correction submitted by Meade District LTCU in response to deficiencies cited during a prior survey inspection.
Findings
The plan addresses multiple deficiencies including maintenance of call lights, housekeeping sanitation, timely completion of admission assessments, accuracy of MDS entries, comprehensive care planning, skin care and pressure ulcer prevention, fall prevention, medication management including black box warnings, dietary staffing and food service quality.
Deficiencies (14)
Call lights were not properly maintained and placed within resident reach.
Housekeeping services failed to maintain a sanitary, orderly, and comfortable interior.
Admission assessment process was not completed within 14 days of admission.
Miss mark on MDS not discovered until survey process; unintentional entry error.
Comprehensive care plans were not developed or updated timely for all residents.
Care plans were not reviewed and revised to include necessary services and resident rights.
Skin care assessments and documentation were inadequate.
Residents entering the facility developed pressure ulcers due to inadequate skin assessments.
Unsafe environment due to inadequate fall prevention measures and follow-up.
Black box warnings were not included on all care plans.
Insufficient dietary personnel employed.
Meals were not palatable in texture, flavor, and variety.
Food was not stored, prepared, distributed, and served under sanitary conditions.
Consultant pharmacist did not adequately identify drug irregularities related to black box warnings.
Report Facts
Potential residents affected: 45
Dates for corrective actions: Aug 29, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Sheila Brown | Director | Submitted the Plan of Correction |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 14
Date: Jul 23, 2014
Visit Reason
Annual health resurvey of Meade District Hosp LTCU DBA Lone Tree Retirement to assess compliance with health and safety regulations.
Findings
The facility had multiple deficiencies including failure to maintain call lights accessible, inadequate housekeeping and maintenance, incomplete comprehensive assessments, inaccurate assessments, incomplete care plans, failure to monitor skin conditions, inadequate fall prevention and supervision, insufficient dietary staffing, poor food quality, unsanitary food handling, and failure to monitor drug regimen irregularities.
Deficiencies (14)
Failure to maintain call light within resident reach in shared bathroom for residents #9 and #47.
Failure to maintain resident nightstands in good condition and maintain clean surfaces in 1 of 3 halls.
Failure to conduct comprehensive assessment within 14 calendar days of admission for resident #49.
Failure to ensure MDS assessment accurately reflected resident #42's nutritional status.
Failure to develop comprehensive care plans with measurable objectives for residents #20, #8, and #28 related to pressure ulcers, urinary catheter care, and skin issues.
Failure to revise nursing care plan for resident #29 after multiple falls.
Failure to monitor resident #49's bruises on arms bilaterally with weekly skin assessments.
Failure to provide necessary treatment and services to promote healing and prevent infection of pressure ulcers for resident #20.
Failure to ensure resident environment free of accident hazards and provide adequate supervision to prevent falls for resident #29; also failure to secure hazardous chemicals accessible to cognitively impaired residents.
Failure to ensure resident drug regimen free from unnecessary drugs; lack of care plan information and monitoring for medications with black box warnings for resident #23.
Failure to employ sufficient dietary support personnel to serve meals timely and adequately.
Failure to provide food that is palatable, attractive, and properly prepared for resident #14 and others.
Failure to serve food in a sanitary manner; dietary staff failed to wear hair nets properly and failed to wash hands or change gloves appropriately.
Failure to ensure consultant pharmacist identified drug irregularities related to black box warnings and reported to nursing and physician for resident #23.
Report Facts
Census: 43
Deficiency count: 13
Residents sampled: 14
Residents reviewed for skin issues: 3
Residents reviewed for accidents: 3
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Administrative Nurse | Named in multiple findings related to care plan failures, fall prevention, and medication monitoring |
| Direct care staff G | Direct Care Staff | Named in medication monitoring and dietary staffing findings |
| Dietary staff Q | Dietary Staff | Named in dietary staffing and food quality findings |
| Licensed nurse E | Licensed Nurse | Named in skin assessment and fall prevention findings |
| Consultant Z | Consultant Pharmacist | Named in medication review and black box warning findings |
| Maintenance staff P | Maintenance Staff | Named in findings related to unsecured chemicals and environment safety |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 28, 2013
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 an 'F' level deficiency, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
Most serious deficiencies found to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payment: Jan 28, 2014
Effective date for termination: Apr 28, 2014
Days to request fair hearing: 60
Days to submit IDR request: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Brown | Administrator | Named as facility administrator. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution and appeals. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Joe Ewert | Commissioner of Survey, Certification and Credentialing Commission | Copied on the letter. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 7, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.35(d)(1)-(2), 483.35(i), 483.35(i)(3), and 483.65 were corrected as of 05/07/2013.
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Apr 18, 2013
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 addresses deficiencies related to food preparation and nutrition, food procurement and sanitation, garbage disposal, and infection control. The facility outlines corrective actions including staff retraining, policy revisions, ongoing monitoring, and infection control program implementation.
Deficiencies (4)
Facility will ensure food is prepared by methods that conserve nutritive value, flavor, and appearance; food is palatable, attractive, and at proper temperature.
Facility will procure food from approved sources and maintain sanitary conditions in storage, preparation, distribution, and serving.
Facility will dispose of garbage and refuse properly with increased dumpster pickups and monitoring.
Facility will maintain an Infection Control Program to prevent disease and infection transmission with tracking, investigations, trending, prevention, and staff education.
Report Facts
Plan of Correction completion date: May 8, 2013
Plan of Correction completion date: Apr 18, 2013
Plan of Correction completion date: Apr 19, 2013
Plan of Correction completion date: May 7, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Brown | Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 5
Date: Apr 10, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation (#KS00064959) to evaluate compliance with food preparation, sanitary conditions, garbage disposal, infection control, and related regulatory requirements.
Complaint Details
The visit was triggered by a complaint investigation (#KS00064959) concerning food preparation, sanitary conditions, garbage disposal, and infection control practices. The complaint was substantiated with multiple deficiencies found.
Findings
The facility failed to provide full portions of pureed meat to residents, failed to serve and store food under sanitary conditions, improperly disposed of garbage, and did not follow infection control protocols including improper cleaning and transport of linens. These deficiencies affected multiple residents and posed risks for infection and nutritional inadequacies.
Deficiencies (5)
Failed to ensure 7 residents with puree consistency meat orders received full meat portions and nutrients at lunch.
Failed to store and serve food under sanitary conditions, including contaminated handling of bowls and plates.
Failed to store food under sanitary conditions, including unsealed opened food items.
Failed to dispose of garbage and refuse properly; dumpster lids left open and overflowing.
Failed to implement infection control program properly, including improper cleaning procedures and transport of clean linens, and failure to monitor infection trends.
Report Facts
Census: 42
Residents on puree meat diet: 7
Dumpster lids open: 1
Disinfectant wet time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Staff | Observed failing to serve full portions of pureed meat and handling food under unsanitary conditions |
| Staff B | Dietary Staff | Reported prior issues with leftover pureed meat and failure to report to dietitian |
| Consultant J | Consultant Dietitian | Verified staff failed to serve full portions of pureed meat |
| Housekeeping Staff F | Housekeeping Staff | Observed cleaning resident rooms improperly and transporting clean laundry uncovered |
| Housekeeping Staff G | Housekeeping Staff | Reported use of disinfectants and confirmed inadequate laundry cart covers |
| Direct Care Staff I | Direct Care Staff | Observed cleaning shower chair without proper disinfectant wet time |
| Licensed Nurse H | Licensed Nurse | Reported infection tracking but no trending analysis performed |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: H060101 POC C1MF11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Meade District Hospital LTCU.
Complaint Details
This Plan of Correction is related to a complaint investigation at Meade District Hosp LTCU dated 01/12/2017.
Findings
The plan addresses deficiencies related to quality of life and safety, including ensuring complete nursing assessments following resident elopements and maintaining a safe environment free from accident hazards with adequate supervision and device use.
Deficiencies (2)
483.24 Quality of Life; incomplete nursing assessment following an elopement
483.25 Free of Accidents, Hazards, Supervision, Devices; failure to ensure resident environment free from accident hazards and adequate supervision
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Blehm | RN Risk management director | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
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