Inspection Report Summary
The most recent inspection on July 5, 2018, found no deficiencies after a revisit confirmed previous issues had been corrected. Earlier inspections identified recurring deficiencies primarily related to medication management, nursing assessments, care planning, infection control, and safety practices. Several complaint investigations substantiated concerns about delayed or inadequate resident care, including wound treatment, fall management, and monitoring of medications with black box warnings. Enforcement actions included fines and restrictions tied to deficiencies rated at levels indicating actual harm without immediate jeopardy, with some enforcement remedies such as denial of payment for new admissions noted in prior years. The facility’s inspection history shows a pattern of addressing cited deficiencies through plans of correction, with recent reports indicating improvement and compliance with regulatory requirements.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
13.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
127% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
29 residents
Based on a May 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 5, 2018
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID 7ZFW13 and State ID N057004.
Findings
No specific deficiencies or findings are detailed in this document; it serves as a placeholder or status page for the Plan of Correction with no records found.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jul 5, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report shows that the previously cited deficiencies identified by regulation numbers 26-41-204(i) and 26-41-205(d)(1-2) were corrected as of 07/05/2018. No uncorrected deficiencies were noted.
Deficiencies (2)
Deficiency related to regulation 26-41-204(i)
Deficiency related to regulation 26-41-205(d)(1-2)
Inspection Report
Follow-Up
Census: 29
Deficiencies: 3
Date: May 24, 2018
Visit Reason
This was a revisit inspection for correction order 18-60 conducted on 5/23/18 and 5/24/18 at an assisted living facility.
Findings
The facility failed to ensure that health care services were provided by qualified staff, specifically a licensed nurse, and failed to ensure proper assessments and administration of medications were conducted according to medical orders and professional standards. Deficiencies included medication management errors, lack of licensed nurse assessments for self-administration of medications, and incomplete medication administration records.
Deficiencies (3)
Operator/CMA B failed to ensure a health care service was provided to resident #1031 by qualified staff (a licensed nurse) when requesting and receiving medication orders.
Operator/CMA B failed to ensure a licensed nurse performed an assessment of resident #1031's ability to safely and accurately self-administer medication before the resident began self-administration.
Operator/CMA B failed to ensure medications and biologicals were administered in accordance with medical care provider's written orders and professional standards for residents #1031, #1032, #1033, #1034, #1035, and #1036.
Report Facts
Census: 29
Residents sampled: 3
Residents receiving medication management: 6
Medication administration initials: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator/CMA B | Certified Medication Aide | Named in multiple findings related to medication administration and failure to ensure licensed nurse involvement |
Inspection Report
Follow-Up
Deficiencies: 4
Date: May 24, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies were corrected as of 05/23/2018, with corrections documented for multiple regulation citations.
Deficiencies (4)
Deficiency related to regulation 26-41-205 (d) (3)
Deficiency related to regulation 26-41-105 (f) (1 - 10)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 5
Date: Apr 18, 2018
Visit Reason
The inspection was a resurvey of the assisted living facility conducted on 4/16/18, 4/17/18, and 4/18/18 to evaluate compliance with medication administration, resident records, emergency preparedness, infection control, and other regulatory requirements.
Findings
The facility failed to ensure medications were administered according to medical provider's written orders, failed to document medication administration properly, lacked admission agreements in resident records, did not conduct quarterly emergency management plan reviews with staff and residents, and failed to comply with tuberculosis screening guidelines for residents and employees.
Deficiencies (5)
Facility administration of medications not in accordance with medical care provider's written orders for all residents receiving medication management.
Medication administration records (MAR) did not document administration of each individual medication immediately before or after administration.
Resident records lacked admission agreements and any amendments for sampled residents.
Failed to ensure quarterly review of the facility's emergency management plan with employees and residents.
Failed to ensure compliance with tuberculosis guidelines including lack of annual TB symptom screening for residents and incomplete TB testing for employees.
Report Facts
Census: 27
Residents sampled: 3
Non-sampled residents receiving medication management: 3
Medication administration times per day: 2
Medication administration times per day: 4
Medication administration times per day: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| operator/CMA B | Certified Medication Aide | Named in multiple findings related to medication administration, documentation, and compliance failures |
| human resources director C | Human Resources Director | Mentioned in relation to employee TB testing documentation and policy issues |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 18, 2017
Visit Reason
An offsite visit was completed on 12/18/17 to verify correction of previous deficiencies cited on 09/29/17.
Findings
The deficiencies previously cited have been corrected and no new non-compliance was found. The facility is in compliance with all regulations surveyed effective 10/27/17.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 29, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective 2017-10-27.
Deficiencies (1)
Most serious deficiencies found were a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 7
Date: Sep 29, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving multiple complaint numbers.
Complaint Details
The visit was triggered by multiple complaints as part of a Health Resurvey and Complaint Investigation.
Findings
The facility was found deficient in multiple areas including failure to complete comprehensive assessments, failure to revise care plans to reflect resident needs and preferences, failure to monitor residents for adverse drug effects including lack of black box warnings in care plans, failure to maintain sanitary food preparation and storage conditions, failure to monitor blood pressure as ordered, failure to conduct neuro checks after falls, failure to track and trend antibiotic use, and failure to maintain essential equipment in safe operating condition.
Deficiencies (7)
Failure to complete a comprehensive Minimum Data Set (MDS) assessment for one resident (#62).
Failure to ensure resident participation and revise care plans to reflect resident preferences and needs for multiple residents (#37, #29, #21, #16, #32).
Failure to provide appropriate treatment and services including failure to initiate neurological checks for resident #6 after repeated falls.
Failure to maintain nutritional status for resident #32 with weight loss and lack of follow-up on dietitian recommendations.
Failure to ensure drug regimens are free from unnecessary drugs including lack of black box warnings in care plans and inadequate blood pressure monitoring for resident #61 and others.
Failure to implement and maintain an infection control program including inadequate tracking and trending of antibiotic use and follow-up.
Failure to maintain essential equipment in safe and sanitary operating condition, specifically a rusted commercial mixer in the dietary department.
Report Facts
Residents reviewed: 13
Antibiotic administrations: 72
Cultures: 14
Weight loss: 11.8
Blood pressure readings: 19
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 11, 2017
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 report indicates that the previously cited deficiency with ID Prefix F0309 related to regulations 483.24 and 483.25(k)(l) was corrected and completed as of 12/21/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency with ID Prefix F0309 related to regulations 483.24 and 483.25(k)(l)
Report Facts
Deficiency correction completion date: Dec 21, 2016
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 8, 2016
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 most serious deficiency to be F309, rated 'G' at a level of actual harm that is not immediate jeopardy, requiring corrections. Based on this deficiency, the facility will not be given an opportunity to correct before enforcement remedies are imposed.
Deficiencies (1)
Deficiency F309 rated 'G' at a level of actual harm that is not immediate jeopardy
Report Facts
Denial of payment effective date: Jan 3, 2017
Timeframe for substantial compliance: 6
Termination recommendation date: Jun 8, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as contact for questions and informal dispute resolution |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Date: Dec 8, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#108352) regarding the facility's failure to provide necessary care and services to a resident, including inadequate assessments and delayed treatment following a fall.
Complaint Details
Complaint investigation #108352 focused on Resident #1's care related to a skin tear and subsequent fall. The complaint alleged failure to remove or examine initial dressing for 7 days, medication error with allergic ointment, and delayed x-ray after fall. The investigation substantiated these concerns.
Findings
The facility failed to provide appropriate care for Resident #1, including failure to document dressing changes for a skin tear, failure to recognize and respond to the resident's allergy to Neosporin TAO, failure to obtain timely physician orders for wound care, and delayed response to the resident's wrist injury after a fall, resulting in a fractured wrist diagnosed after a significant delay.
Deficiencies (4)
Failure to provide necessary care and services for Resident #1, including inadequate assessment and delayed dressing changes for a skin tear.
Failure to recognize and respond to resident's allergy to Neosporin TAO, resulting in an allergic skin reaction.
Failure to obtain physician orders for dressing changes and wound treatment in a timely manner.
Failure to promptly obtain an x-ray and medical evaluation after resident's fall and complaints of wrist pain, resulting in delayed diagnosis of wrist fractures.
Report Facts
Census: 44
Sample size: 4
Days without documented dressing change: 12
Hours delay for x-ray order: 34
Pain medication dosage: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Nurse | Provided statements regarding resident's fall, pain complaints, and wound care practices |
| Administrative Nurse A | Administrative Nurse | Verified dressing change practices and physician order documentation |
| Physician D | Physician | Assessed resident in emergency room and commented on delayed care |
| Nurse Aide B | Nurse Aide | Reported resident's fall and injury circumstances |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
This document is a Plan of Correction submitted by Parkside Homes in response to deficiencies cited during a complaint investigation survey conducted on 12/08/2016.
Complaint Details
This Plan of Correction is in response to a complaint investigation survey conducted on 12/08/2016 at Parkside Homes.
Findings
The facility acknowledged deficiencies related to nursing documentation practices, review of resident medical history especially allergies, and physician notification protocols regarding skin tears, injuries, and pain. The Plan of Correction outlines in-service training for nursing staff and ongoing audits to ensure compliance and prevent recurrence.
Deficiencies (1)
Deficient nursing documentation practices, inadequate review of resident medical history especially allergies, and failure in physician notification protocol regarding skin tears, injuries, and pain.
Report Facts
Audit frequency: 2
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valerie McGhee | CEO/Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Feb 26, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date, with completion documented for each item.
Deficiencies (7)
Deficiency with regulation 483.20(d), 483.20(k)(1)
Deficiency with regulation 483.20(d)(3), 483.10(k)(2)
Deficiency with regulation 483.25(c)
Deficiency with regulation 483.25(h)
Deficiency with regulation 483.25(l)
Deficiency with regulation 483.60(c)
Deficiency with regulation 483.65
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 2, 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 to be at 'E' level, indicating no harm with potential for more than minimal harm and no immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
Deficiencies found at 'E' level severity during the Life Safety Code survey
Report Facts
Effective date for denial of payments: Apr 27, 2016
Provider agreement termination date: Jul 27, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 27, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective February 26, 2016.
Deficiencies (1)
Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 7
Date: Jan 27, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #95945, #96157 to assess compliance with care plan development, pressure ulcer prevention and treatment, accident prevention, medication monitoring, and infection control.
Complaint Details
The visit was triggered by complaint investigations #95945 and #96157.
Findings
The facility failed to develop comprehensive care plans for some residents, failed to implement timely interventions to prevent and treat pressure ulcers, failed to provide adequate supervision to prevent accidents, failed to monitor adverse effects of medications including those with Black Box Warnings, and failed to maintain proper infection control practices including hand hygiene and oxygen equipment handling.
Deficiencies (7)
Failed to develop a comprehensive care plan for 1 of 14 sampled residents to direct all aspects of care.
Failed to review/revise care plan with appropriate interventions to prevent pressure ulcers for 1 of 3 sampled residents.
Failed to implement timely interventions to reduce pressure on vulnerable areas for 1 of 3 sampled residents who developed a pressure ulcer.
Failed to provide adequate supervision to prevent accidents for 2 of 5 residents reviewed and failed to provide an environment free from accident hazards for 1 cognitively impaired resident.
Failed to have a system in place to monitor adverse effects of medications including Black Box Warnings for 5 sampled residents.
Failed to notify the director of nursing of the lack of a system to monitor adverse effects of medications including Black Box Warnings for 5 sampled residents.
Failed to provide a sanitary environment to help prevent infection by improper hand hygiene after personal care for 2 residents, during wound dressing change for 1 resident, and improper handling and storage of oxygen equipment for 4 residents.
Report Facts
Residents sampled: 14
Residents reviewed for pressure ulcers: 3
Residents reviewed for accidents: 5
Residents reviewed for unnecessary drugs: 5
Medications with Black Box Warnings: 6
Medications with Black Box Warnings: 5
Medications with Black Box Warnings: 6
Medications with Black Box Warnings: 5
Medications with Black Box Warnings: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse M | Observed performing wound dressing change with improper glove use. | |
| Nurse Aide I | Observed providing personal hygiene care with improper glove use. | |
| Nurse Aide J | Observed providing personal hygiene care with improper glove use and offering drink with unwashed hands. | |
| Nurse Aide B | Observed assisting Resident #27 and noted spouse's unsafe transfer attempts. | |
| Nurse Aide L | Observed assisting Resident #27 with personal hygiene care with improper glove use. | |
| Administrative Nurse A | Verified failures in care plan development, medication monitoring, infection control, and supervision. | |
| Consultant Pharmacist N | Verified failure to note or report lack of medication side effect monitoring system. | |
| Nurse C | Verified residents with new medications are assessed for side effects but side effects were not documented on MAR. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jan 27, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated January 27, 2016.
Findings
The Plan of Correction outlines multiple corrective actions including policy reviews and revisions, staff education, audits of care plans and medication records, and monitoring through Quality Assurance Performance Improvement (QAPI) meetings to address deficiencies related to care planning, skin and wound care, medication monitoring, fall management, infection control, and safety policies.
Deficiencies (5)
Care plans not developed or revised timely with appropriate interventions.
Inadequate skin protection and wound care policies and procedures.
Falls management and accident/incident reporting policies needing revision.
Medication monitoring policies, including adverse drug reactions and black box warnings, not fully implemented or accurate.
Oxygen cannula and tubing storage policy not developed or implemented.
Report Facts
Plan of Correction completion date: Feb 26, 2016
Mandatory in-service training date: Feb 19, 2016
Care Plan meeting date: Feb 9, 2016
Telephone meeting date: Jan 18, 2016
Follow-up telephone call date: Feb 4, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erichuebert | Administrator | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Dec 30, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.25, 483.25(d), and 483.25(h) were corrected by 12/18/2015.
Deficiencies (4)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Dec 3, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Parkside Homes.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Parkside Homes.
Findings
The plan addresses multiple deficiencies related to physician notification protocols, care plan accuracy, fall risk assessments, infection control, and documentation practices. The facility outlines corrective actions including audits, staff education, policy reviews, and ongoing monitoring to ensure compliance and improve resident care.
Deficiencies (4)
Physician Notification Protocol, Notification of a Significant Change in Condition, Nurse Notification of Physician, and Vital Signs Protocol deficiencies
Care plan accuracy and individualized interventions for residents with dementia deficiencies
Physician Notification Protocol, Infection Control Policy, and addressing urinary tract infections deficiencies
Fall Policy and Fall Investigation Form deficiencies including fall assessments and care plan audits
Report Facts
Complete Date: Dec 18, 2015
Submission Date: Dec 3, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Wagner | Executive Director | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 19, 2015
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 most serious deficiency in the facility to be a 'G' level. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended.
Deficiencies (1)
Most serious deficiency found to be a 'G' level
Report Facts
Denial of Payment for New Admissions Effective Date: Feb 19, 2016
Noncompliance Termination Recommendation Date: May 19, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions and informal dispute resolution |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Nov 19, 2015
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint numbers (#92925, #93061, 93014, 92179).
Complaint Details
The inspection was triggered by complaints #92925, #93061, 93014, and 92179.
Findings
The facility failed to provide comprehensive care plans for residents with significant changes, failed to provide individualized dementia care interventions, failed to prevent urinary tract infections and timely treat UTIs, and failed to provide an environment free of accident hazards resulting in multiple falls and injuries.
Deficiencies (4)
Failed to provide a comprehensive care plan for a resident with significant physical decline, cognition changes, and an open wound.
Failed to provide individualized interventions for dementia care for a resident with behaviors.
Failed to provide appropriate care and services to prevent urinary tract infections and timely treatment for residents with UTIs.
Failed to ensure the resident environment was free of accident hazards and provide adequate supervision to prevent falls, resulting in multiple falls and injuries including a fractured hip.
Report Facts
Residents sampled: 6
UTI positive urinalysis count: 6
Falls: 3
Falls: 2
Falls: 5
BIMS score: 15
BIMS score: 5
BIMS score: 2
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified resident's increased behaviors and medication concerns; observed resident care and excessive secretions. | |
| Nurse F | Verified resident's behavioral changes and decline; verified communication with physicians by fax. | |
| Nurse Aide C | Verified resident's decline, vomiting, and temperature issues; described resident's restlessness and care needs. | |
| Medication Aide D | Verified dressing changes and resident's decline; verified toileting attempts and assistance. | |
| Administrative Nurse E | Verified resident's decline and lack of psychiatric history; verified lack of 1:1 supervision and fall prevention interventions. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 23, 2015
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
The report confirms that the deficiency identified by regulation 26-43-205 (h) with ID prefix S2235 was corrected as of 03/23/2015.
Deficiencies (1)
Deficiency related to regulation 26-43-205 (h) previously cited
Report Facts
Deficiencies corrected: 1
Inspection Report
Follow-Up
Deficiencies: 2
Date: Mar 20, 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 report confirms that the deficiencies previously cited under regulation numbers 483.25 and 483.25(l) were corrected as of the revisit date.
Deficiencies (2)
Deficiency identified under regulation 483.25
Deficiency identified under regulation 483.25(l)
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 9, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to ensure compliance with regulations.
Findings
The facility identified staffing shortages and outlined plans to recruit qualified staff, including posting job openings, encouraging current staff to obtain certifications, and utilizing staff from a nearby nursing home to cover care and medication needs until positions are filled.
Deficiencies (1)
Staffing shortages requiring hiring of CNA's, CMA's, and licensed nurses to meet background check requirements.
Report Facts
Date of Quality Assurance committee review: Mar 9, 2015
Date of job posting: Feb 26, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Wagner | Executive Director | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 27, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The facility identified deficiencies related to resident bowel management and physician notification protocols, and outlined corrective actions including staff education, monitoring, and quality assurance review.
Deficiencies (2)
Assessment completed on affected resident with medium hard stool; follow-up and education provided to nursing staff regarding bowel management protocols.
Resident physician notified with orders for notification via phone; education provided to nursing staff on following physician orders and documentation.
Report Facts
Dates of monitoring: 30
Dates of staff inservice: Mar 19, 2015
Date of Quality Assurance committee review: Mar 9, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Wagner | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Feb 25, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation based on complaints #83156 and #83866.
Complaint Details
The visit was complaint-related, involving complaints #83156 and #83866. The findings were substantiated as the facility failed to meet care and medication regimen requirements for residents.
Findings
The facility failed to adequately assess Resident #31 for pain and bowel elimination, resulting in no bowel movement interventions despite complaints of pain and no bowel movements for over 3 days. Additionally, the facility failed to follow physician orders for Resident #14 by not reporting blood sugar results outside of prescribed parameters to the physician.
Deficiencies (2)
Failure to adequately assess Resident #31 for pain and bowel elimination, with no interventions provided despite no bowel movements for over 3 days and complaints of buttock and back pain.
Failure to follow physician orders for Resident #14 by not reporting blood sugar results outside of parameters to the physician.
Report Facts
Census: 51
Sample size: 11
Residents reviewed for unnecessary medications: 5
Blood sugar results outside parameters: 6
Days without bowel movement: 8
Inspection Report
Enforcement
Deficiencies: 1
Date: Feb 25, 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 the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
Deficiencies cited at 'D' level, isolated, 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 letter and enforcement coordinator for the Kansas Department for Aging & Disability Services |
Inspection Report
Renewal
Census: 34
Deficiencies: 2
Date: Feb 25, 2015
Visit Reason
The inspection was conducted as an Assisted Living/Residential Healthcare Licensure resurvey to assess compliance with licensure requirements.
Findings
The facility failed to ensure that only licensed nurses or medication aides had access to stored medications and failed to provide continuous nursing staff attendance for the 34 residents during night shifts. Non-licensed and uncertified staff, including CNAs, had access to medication storage and were responsible for medication delivery during some night shifts.
Deficiencies (2)
Failure to ensure licensed nurses or medication aides were the only staff to have access to stored medications.
Failure to provide continuous, qualified nursing staff attendance at all times for the 34 residents, specifically from 5:00 PM to 5:00 AM.
Report Facts
Census: 34
Staffing gaps: 18
Unlicensed staff shifts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide A | Medication Aide | Stated that non-licensed/non-certified staff and CNAs carried keys to medication storage and delivered medications during night shifts. |
| Administrative Staff B | Administrative Staff | Verified staffing included unlicensed staff some nights and CNAs other nights. |
| CNA C | Certified Nurse Aide | Observed using keys to unlock medication room and cabinet. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 8, 2014
Visit Reason
A Life Safety Code survey was conducted 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 potential for more than minimal harm that is not immediate jeopardy.
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
Denial of payments effective date: Nov 8, 2014
Provider agreement termination date: Feb 8, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Wagner | Administrator | Named as facility administrator. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Joe Ewert | Commissioner | Copied on the enforcement letter. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 31, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report documents that corrective actions for previously cited deficiencies under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.25(c), and 483.25(h) were completed by 12/06/2013.
Report Facts
Correction completion date: Dec 6, 2013
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 29, 2013
Visit Reason
This document is a Plan of Correction prepared by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to achieve substantial compliance with regulations.
Findings
The Plan of Correction addresses deficiencies related to reporting of untwitnessed falls with injury, prevention and treatment of pressure sores, and maintaining a safe environment with proper use and assessment of lift recliner chairs. The facility implemented policy revisions, staff education, and ongoing monitoring to ensure compliance.
Deficiencies (3)
Failure to report untwitnessed falls with injury as required
Failure to prevent pressure sores or provide necessary treatment
Failure to maintain a safe environment and adequate supervision related to use of lift recliner chairs
Report Facts
Dates of corrective actions completion: Corrective actions completed between 2013-11-29 and 2013-12-06
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Wagner | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 3
Date: Nov 26, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #70456, #70463, focusing on allegations of abuse, neglect, and failure to report falls and injuries.
Complaint Details
The visit was complaint-related, investigating allegations of abuse, neglect, and failure to report incidents. The facility was found to have failed in reporting falls and providing adequate supervision and safety measures.
Findings
The facility failed to report unwitnessed falls with injury for cognitively impaired residents, failed to prevent development of a stage 3 pressure ulcer for one resident, and failed to provide adequate supervision and a safe environment to prevent accidents for two residents, including failure to manage an electric recliner hazard.
Deficiencies (3)
Failure to notify appropriate state agency of unwitnessed falls with injury for cognitively impaired residents (#15, #39).
Failure to provide care and services to prevent development of pressure ulcers for Resident #26, resulting in a stage 3 pressure ulcer requiring wound clinic care.
Failure to ensure a safe environment and adequate supervision to prevent accidents and injuries related to falls and electric recliner hazards for Residents #15 and #39.
Report Facts
Resident census: 58
Sample size: 14
Falls reviewed: 3
Pressure ulcer cases reviewed: 1
Pressure ulcer size: 6
Pressure ulcer size: 4.5
Pressure ulcer size: 12.5
Pressure ulcer wound measurement: 5.3
Pressure ulcer wound measurement: 6
Pressure ulcer wound measurement: 2.5
Pressure ulcer wound measurement: 2
Pressure ulcer wound depth: 0.3
Medication dosage: 250
Medication dosage: 500
Medication dosage: 500
Medication dosage: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Nurse | Discussed resident's fall and electric recliner controls. |
| Administrative Staff A | Administrator | Provided information about resident education and recliner removal. |
| Nurse Aide D | Nurse Aide | Reported resident's behavior with recliner control. |
| Nurse B | Nurse | Reported attempts to secure recliner remote. |
| Physician Q | Physician | Commented on resident's cognition and recliner control use. |
| Nurse F | Nurse | Provided wound care and described resident's pressure ulcer. |
| Nurse Aide G | Nurse Aide | Reported resident's pain and repositioning efforts. |
| Maintenance Staff E | Maintenance Staff | Reported no documentation of mattress change. |
| Physical Therapy Staff H | Physical Therapist | Described resident's mobility and activity. |
| Medical Practitioner J | Medical Practitioner | Commented on resident's mobility and activity level. |
| Nurse A | Nurse | Reported resident's unwitnessed falls and incomplete investigations. |
| Nurse Aide N | Nurse Aide | Observed transferring resident from recliner. |
| Nurse Aide O | Nurse Aide | Observed transferring resident from recliner. |
| Nurse Aide L | Nurse Aide | Assisted resident with morning activities. |
| Nurse Aide P | Nurse Aide | Assisted resident with morning activities. |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 26, 2013
Visit Reason
The visit was a licensure resurvey of the facility to assess compliance with regulatory requirements.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 7
Date: Oct 5, 2012
Visit Reason
This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.
Deficiencies (7)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.20(g)-(j)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.25(n)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.60(b), (d), (e)
Report Facts
Deficiencies corrected: 7
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 7
Date: Sep 6, 2012
Visit Reason
The inspection was an annual health resurvey of Parkside Homes to assess compliance with federal regulations regarding resident rights, assessment accuracy, accident hazards, medication management, immunizations, and drug regimen review.
Findings
The facility failed to provide residents with choices regarding bathing preferences, failed to accurately complete resident assessments, did not maintain a safe environment free of accident hazards, failed to monitor and document adverse consequences of medications with Black Box Warnings for multiple residents, failed to provide education on influenza and pneumococcal immunizations, and had outdated stock medications in the medication room.
Deficiencies (7)
Failed to provide residents #34, #35, and #75 with choice of tub, shower, or bed bath.
Failed to accurately assess residents #15 and #35 in their Minimum Data Set (MDS) assessments.
Failed to provide an environment free from accident hazards; unlocked physical therapy storage door with hot Hydroculator accessible.
Failed to identify and monitor residents with Black Box Warning medications on care plans for 8 of 10 sampled residents.
Failed to provide education regarding benefits and risks of influenza vaccination to residents or their representatives for 5 residents.
Consultant pharmacist failed to notify facility nursing staff of irregularities in medication regimen and failed to ensure monitoring of Black Box Warnings for multiple residents.
Failed to ensure stock medications were not outdated; expired pneumovax and influenza vaccines found in medication room.
Report Facts
Census: 61
Sample size: 27
Residents reviewed for unnecessary drugs: 10
Expired pneumovax vaccine vials: 1
Expired influenza vaccine vials: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified lack of individualized care plans for monitoring adverse medication consequences | |
| Nurse B | Verified staff had not addressed Black Box Warnings or adverse consequences for medications on care plans or MAR | |
| Nurse C | Verified Black Box Warnings were not on resident care plans | |
| Administrative Nurse A | Verified resident care plans did not include Black Box Warning information | |
| Administrative Staff J | Verified facility identified resident choices as a concern including bathing preferences | |
| Nurse Assistant H | Revealed tub bath was not available and broken | |
| Maintenance Staff I | Verified whirlpool tub was in working order and available | |
| Nurse Assistant G | Revealed lack of training on whirlpool tub use |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: N057004 POC L22211
Visit Reason
This document is a Plan of Correction submitted by Parkside Homes in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction outlines specific corrective actions to address deficiencies related to resident bathing preferences, urinary tract infection documentation, medication storage security, black box warning medication management, immunization policies, medication review processes, and outdated medication disposal.
Deficiencies (7)
Resident bathing preferences not fully honored.
Documentation of urinary tract infections not meeting MDS 3.0 criteria.
Storage room door lock not secure.
Lack of black box warning care plans for residents on flagged medications.
Immunization policy and education needing update and implementation.
Medication record review and Black Box Warning education incomplete.
Outdated medications not consistently disposed or audited.
Report Facts
Dates for corrective actions: Sep 26, 2012
Dates for corrective actions: Oct 5, 2012
Date for corrective action: Oct 1, 2012
Date for policy revision: Sep 11, 2012
Date for education: Sep 13, 2012
Date for medication disposal: Aug 28, 2012
Inspection Report
Plan of Correction
Deficiencies: 9
Date: N057004 POC T2OJ11
Visit Reason
This document is a Plan of Correction submitted by Parkside Homes in response to deficiencies cited in a prior survey conducted on 09/29/2017.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including comprehensive resident assessments, care plan revisions, neuro checks after falls, nutrition monitoring, medication regimen oversight, food service sanitation, infection control, and equipment safety.
Deficiencies (9)
Deficient practice in comprehensive assessment of resident needs using the RAI system.
Failure to ensure residents' right to participate in person-centered care plan development and implementation.
Lack of neuro checks for residents after unwitnessed falls.
Failure to maintain nutrition status and ensure dietitian orders are authorized by physician timely.
Residents' drug regimen not free from unnecessary drugs; failure to note Black Box Warnings (BBW) on care plans.
Failure to prepare and serve food under sanitary conditions.
Failure to have residents' drug regimen reviewed monthly by licensed pharmacist and irregularities reported timely.
Failure to maintain infection prevention and control program to prevent spread of infection.
Failure to maintain essential equipment in safe operating condition; commercial mixer taken out of service.
Report Facts
Deficiencies cited: 9
Dates of corrective actions: Oct 16, 2017
Dates of corrective actions: Oct 27, 2017
Date of original survey: Sep 29, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valerie McGhee | CEO/Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
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