Inspection Reports for Protection Valley Manor
600 S BROADWAY, PO BOX 448, KS, 67127
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 1, 2025, identified deficiencies related to elopement prevention, specifically failure to ensure operational door locks, alarms, and adequate supervision for a high-risk resident who left the facility unsupervised. Earlier inspections showed a pattern of issues primarily involving care plan revisions, food safety and sanitation, infection control, and supervision concerns, with several deficiencies corrected in follow-up surveys. Complaint investigations were mostly unsubstantiated, and no fines, immediate jeopardy findings, or license actions were listed in the available reports for recent years, though earlier surveys in 2016 and 2017 did note immediate jeopardy related to quality of care and infection control that were subsequently addressed. The facility has implemented corrective actions such as staff education, policy updates, and technology improvements like a WanderGuard system to address these issues. The overall trend indicates ongoing attention to compliance with some recurring themes but also shows efforts toward improvement over time.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
41 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 41
Deficiencies: 1
Date: Jul 1, 2025
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS to investigate an immediate jeopardy incident involving Resident 1 eloping from the facility through an unsecured front door.
Findings
The facility failed to ensure operational door locks, alarms, and adequate supervision for Resident 1, who was at high risk for elopement, resulting in the resident leaving the facility unsupervised. Corrective actions were completed prior to the survey, and the deficiency was cited as past noncompliance at a scope and severity of 'J'.
Deficiencies (1)
Failure to ensure operational door locks, alarms, and supervision to prevent Resident 1 from eloping through an unlocked door.
Report Facts
Census: 41
Elopement Risk Assessment Score: 22
BIMS Score: 6
Visual Checks Frequency: 30
Date of Incident: Jun 4, 2025
Date of Corrective Completion: Jun 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Documented placement and monitoring of WanderGuard, involved in investigation and corrective actions |
| Administrative Staff A | Administrative Staff | Informed of Immediate Jeopardy and involved in corrective actions and policy changes |
| Licensed Nurse H | Licensed Nurse | Documented observations and assessments related to Resident 1's elopement |
| Certified Nurse Aide M | Certified Nurse Aide | Witnessed door unlocked and assisted in securing door and locating Resident 1 |
| Dietary BB | Dietary Staff | Identified Resident 1 outside the facility and returned her safely |
| Certified Medication Aide S | Certified Medication Aide | Confirmed lack of prior knowledge of WanderGuard procedures before elopement |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 1, 2025
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS on 07/01/25 to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with regulations. Corrective actions included implementation of a WanderGuard system with visual checks, a new override code procedure, staff education on elopement prevention, a Quality Assurance meeting, and policy updates. All corrections were completed prior to the onsite survey, and the deficient practice was cited as past noncompliance at a scope and severity of 'J'.
Deficiencies (1)
Deficient practice related to elopement prevention and WanderGuard system implementation.
Report Facts
Deficiency severity level: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Twyss Tamarawyss | Submitted the Plan of Correction | |
| Administrative Nurse D | Staff member knowing the new override code | |
| Administrative Staff A | Staff member knowing the new override code | |
| Maintenance W | Staff member knowing the new override code |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
An offsite revisit survey was conducted on 04/14/25 for all previous deficiencies cited on 03/05/25.
Findings
All deficiencies have been corrected as of the compliance date of 04/04/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 4, 2025
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection at Protection Valley Manor.
Findings
The plan addresses deficiencies related to food storage practices and hand hygiene/Enhanced Barrier Precautions (EBP). Corrective actions include policy revisions, staff training, competency checks, signage updates, and ongoing monitoring for compliance.
Deficiencies (2)
Food stored incorrectly without dates within industry standards.
Staff not trained properly on hand hygiene and appropriate signage for Enhanced Barrier Precautions (EBP).
Report Facts
Completion Date: Apr 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Sandra Cline | Administrator | Submitted the Plan of Correction |
| Jessica Patterson | Added the Plan of Correction | |
| Lori Mouak | Modified the Plan of Correction |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 2
Date: Mar 5, 2025
Visit Reason
The inspection was a Health Recertification Survey to assess compliance with food safety and infection control regulations.
Findings
The facility failed to store, prepare, and serve food in a sanitary manner, risking food-borne illness. Additionally, the facility did not properly implement infection prevention and control protocols, including failure to identify residents on Enhanced Barrier Precautions (EBP) and inadequate hand hygiene by staff.
Deficiencies (2)
Failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness.
Failed to ensure Enhanced Barrier Precautions residents were identified for staff and visitors and failed to ensure staff used appropriate hand hygiene between glove changes.
Report Facts
Census: 40
Sample size: 12
Expiration date: May 31, 2024
Date on thawing hamburger: Feb 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager DD | Interviewed regarding food storage and labeling practices | |
| Certified Nurse Aide (CNA) M | Observed failing to perform hand hygiene between glove changes | |
| Certified Nurse Aide (CNA) O | Observed failing to perform hand hygiene between glove changes | |
| Certified Nurse Aide (CNA) P | Confirmed presence of EBP resident list in breakroom | |
| Licensed Nurse (LN) I | Confirmed EBP signage and supplies requirements | |
| Administrative Nurse D | Confirmed some EBP residents lacked door signs |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 6, 2023
Visit Reason
An offsite revisit survey was conducted on 05/06/2023 for all previous deficiencies cited on 03/16/2023 to verify correction of cited deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 04/14/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 16, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report dated 3-16-2023 for Protection Valley Manor.
Findings
The plan addresses deficiencies related to care plan revisions following resident falls and dietary staff practices concerning food storage and sanitation to prevent food borne illnesses.
Deficiencies (2)
Care plans were not properly updated following resident falls.
Dietary staff did not follow proper food storage and sanitation guidelines, risking food borne illness.
Report Facts
Completion Date: Apr 14, 2023
Inspection Date: Mar 16, 2023
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 2
Date: Mar 16, 2023
Visit Reason
The inspection was a Health Resurvey conducted to review compliance with care plan timing and revision requirements and food safety standards.
Findings
The facility failed to review and revise care plans for three residents related to fall prevention interventions after multiple falls. Additionally, the facility failed to maintain sanitary food preparation, storage, and serving conditions, risking foodborne illness.
Deficiencies (2)
Failed to review and revise care plans for residents after falls to include updated fall prevention interventions.
Failed to provide sanitary food preparation, storage, and serving conditions, including issues with ice machine drain, uncovered dishes stored near floor, improperly stored dry cereals, and expired food items.
Report Facts
Facility census: 42
Residents in sample: 12
Stacks of dishes: 12
Bowls of dry breakfast cereals: 14
Expiration date of open tapioca: Jan 6, 2021
Expiration date of open cereal box 1: Feb 9, 2023
Expiration date of open cereal box 2: Feb 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) E | Reported knowledge of resident falls without injuries | |
| Licensed Nurse (LN) D | Stated care plans should be updated after incidents | |
| Administrative Nurse B | Confirmed care plans should be revised after every fall and interdisciplinary team meets weekly | |
| Certified Nurse Aide (CNA) F | Reported resident falls without injuries and acclimation period | |
| Licensed Nurse (LN) C | Reported nurse on duty implements immediate interventions after falls | |
| Dietary Staff BB | Provided information on food storage and expiration policies during kitchen tour |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 25, 2021
Visit Reason
An offsite revisit survey was conducted on 10/25/21 for all previous deficiencies cited on 08/30/21.
Findings
All deficiencies have been corrected as of the compliance date of 10/08/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Aug 30, 2021
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report dated 08-30-2021.
Findings
The plan addresses multiple deficiencies including bed hold notification, timely submission of death in facility MDS, care plan revisions, accurate skin assessments, and safe storage of chemicals. Corrective actions and monitoring responsibilities are outlined for each deficiency.
Deficiencies (5)
Bed hold notification not properly provided to residents or their representatives.
Failure to timely submit 'Death in the Facility MDS' following resident deaths.
Care plans not updated promptly to reflect changes in resident conditions.
Skin assessments not completed accurately or documented properly.
Unsafe storage of chemicals; chemicals not stored in locked cabinet inaccessible to residents.
Report Facts
Completion Date: Oct 8, 2021
Inspection Date: Aug 30, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Cline | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Lanae Workman | Added the Plan of Correction on 12/18/2019. | |
| Jessica Patterson | Modified the Plan of Correction on 11/05/2021. |
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 5
Date: Aug 30, 2021
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide bed-hold policy upon hospital transfer, untimely completion of required resident assessments, failure to update care plans timely after falls and changes in resident condition, failure to provide care and treatment according to professional standards including wound care and skin assessments, and failure to maintain a safe environment by securing hazardous chemicals.
Deficiencies (5)
Failed to provide Resident 6 or her representative with a bed-hold policy upon transfer to a hospital.
Failed to complete the required 'Death in The Facility MDS' in a timely manner for Resident 30.
Failed to update three residents' care plans timely regarding fall interventions for Residents 4 and 8, and nutritional status for Resident 15.
Failed to provide treatment and care in accordance with professional standards by not completing dressing changes as ordered for Resident 4 and not accurately completing skin assessments for Resident 8.
Failed to provide residents with a safe environment by failing to secure dangerous chemicals in a locked place, accessible to cognitively impaired, independently mobile residents.
Report Facts
Facility census: 39
Residents sampled: 13
Resident weight loss: 6.48
Resident BIMS scores: 14
Resident BIMS scores: 13
Resident BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Acknowledged failure to provide bed-hold policy and expected care plans and orders to be updated timely and accurately | |
| Licensed Nurse C | Reported failure to provide bed-hold policy, failure to update care plans after falls, and confirmed wound care orders were entered as PRN instead of scheduled | |
| Certified Medication Aide F | Reported observations related to resident falls and wound care | |
| Social Service staff D | Reported lack of knowledge about bed-hold policy requirements upon hospitalization transfers | |
| Administrative Nurse B | Reported failure to complete 'Death in the Facility MDS' assessment and acknowledged failure to update care plan for Resident 15 | |
| Certified Nursing Assistant F | Reported resident meal consumption patterns | |
| Certified Nursing Assistant G | Reported resident meal consumption patterns |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a Targeted Infection Control Survey/COVID-19 Focused Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
A revisit survey was conducted on 07/23/2020 for all previous deficiencies cited on 06/16/2020.
Findings
All deficiencies have been corrected as of the compliance date of 06/17/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 17, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified related to COVID-19 exposure prevention practices at the facility.
Findings
The facility had deficient practices related to COVID-19 exposure prevention, including inadequate screening and masking policies. The plan outlines corrective actions such as staff wearing masks in resident areas, screening all entrants, securing facility entryways, and staff education on infection control.
Deficiencies (1)
Deficient practice related to COVID-19 exposure prevention including screening and masking policies.
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 2
Date: Jun 16, 2020
Visit Reason
A Targeted Infection Control/COVID-19 Survey was conducted due to concerns about the facility's failure to promptly review staff and visitor screenings for COVID-19 symptoms and failure of staff to wear protective masks, constituting immediate jeopardy.
Findings
The facility failed to promptly review COVID-19 screenings for staff and visitors before entry and failed to ensure staff wore protective face masks while in the facility, placing all 42 residents in immediate jeopardy. The facility presented an acceptable plan of removal which was validated by the survey team the following day.
Deficiencies (2)
Failure to promptly review screenings of staff and visitors for COVID-19 symptoms before gaining full entrance into the facility and access to residents.
Failure to ensure staff wore protective face coverings inside the facility and around residents.
Report Facts
Resident census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Named in relation to failure to wear protective masks and screening process | |
| Administrative Nurse B | Named in relation to failure to wear protective masks and screening process | |
| Certified Medication Aide M | CMA | Named in relation to failure to wear protective masks and screening process |
| Certified Medication Aide N | CMA | Named in relation to failure to wear protective masks and screening process |
| Certified Nurse Aide O | CNA | Named in relation to failure to wear protective masks |
| Physician JJ | Physician | Reported agreement with facility suggestion not to wear masks |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 31, 2020
Visit Reason
An offsite revisit survey was conducted on 01/31/2020 for all previous deficiencies cited on 12/05/19.
Findings
All deficiencies have been corrected as of the compliance date of 01/15/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Dec 5, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated 2019-12-05. It outlines corrective actions the facility will take to address identified deficiencies.
Findings
The Plan of Correction addresses multiple deficiencies including mail delivery, monitoring of resident behaviors, updating activity calendars, securing service hallway doors, staff training, posting staffing hours, behavior monitoring related to antipsychotic medications, proper insulin dating, and cleaning of blood glucose monitors. The facility commits to monitoring and sustaining compliance with these corrective actions.
Deficiencies (9)
Mail delivery to residents was deficient.
Targeted behaviors of residents were not adequately monitored.
Activity calendar did not include weekend activities.
Service hallway door was not secured with a locking mechanism.
Staff training on resident care needs was inadequate.
Staffing hours were not posted in an accessible location.
Behavior monitoring to prevent unnecessary antipsychotic medication was deficient.
Insulin was not correctly dated and medications were pre-set.
Blood glucose monitors were not cleaned appropriately and medications were not handled safely.
Report Facts
Completion Date: Jan 15, 2020
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 9
Date: Dec 5, 2019
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements and to investigate specific complaints and concerns related to resident rights, care planning, activities, safety, staffing, medication management, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide timely mail delivery, incomplete care plan revisions for targeted behaviors, inadequate activity programming on weekends, unsafe environment hazards, incomplete nurse aide in-service training, improper posting of nurse staffing information, failure to monitor unnecessary psychotropic medications, improper medication labeling and storage, and lapses in infection prevention and control practices.
Deficiencies (9)
Failure to provide mail to residents on the day of delivery, including Saturdays.
Failure to revise care plans to include specific targeted behaviors related to use of antipsychotic medications for a resident.
Failure to provide an ongoing activity program for residents, including weekends.
Failure to ensure a safe environment free from accident hazards due to unlocked service hall door and unsecured maintenance cart with hazardous items.
Failure to complete required 12 hours of nurse aide in-service training per year for multiple CNAs.
Failure to post nurse staffing information in a prominent, accessible, and legible location.
Failure to ensure one resident did not receive unnecessary psychotropic medications due to lack of behavior monitoring.
Failure to date opened insulin pens and pre-pop medications prior to administration.
Failure to properly clean glucometer between resident uses and failure to follow proper hand hygiene prior to medication administration.
Report Facts
Deficiency count: 9
Resident census: 41
CNA in-service training hours: 11
CNA in-service training hours: 2
CNA in-service training hours: 3
CNA in-service training hours: 8
CNA in-service training hours: 5
Residents with pre-popped medications: 34
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Named in findings related to mail delivery, care plan revisions, behavior monitoring, nurse aide training, medication administration, and infection control |
| Certified Nurse Aide I | Certified Nurse Aide | Named in findings related to mail delivery and resident behavior |
| Licensed Nurse K | Licensed Nurse | Named in findings related to resident behavior and infection control |
| Certified Medication Aide H | Certified Medication Aide | Named in findings related to medication handling and hand hygiene |
| Maintenance Staff E | Maintenance Staff | Named in findings related to unsecured maintenance cart and hazardous items |
| Administrative Staff L | Administrative Staff | Named in findings related to mail delivery and service hall door alarm |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 24, 2019
Visit Reason
An offsite revisit survey was conducted on 01/24/2019 for all previous deficiencies cited on 11/06/2018.
Findings
All deficiencies have been corrected as of the compliance date of 12/01/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 6, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in the Protection Valley Manor inspection conducted on November 6, 2018.
Findings
The plan addresses deficiencies related to fall investigations, root cause analysis, care plan updates, and registered nurse supervision. The facility commits to weekly fall reviews by an interdisciplinary team, education for nursing staff, and ensuring eight hours of registered nurse supervision daily.
Deficiencies (3)
Fall investigations completed with causal factors determined and care plans updated accordingly.
Fall investigation packets completed to identify causal factors for residents with limited mobility.
Provision of eight hours daily registered nurse supervision to all residents.
Report Facts
Completion date: Dec 1, 2018
Registered nurse supervision hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Baker | Office Manager | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 6, 2018
Visit Reason
A Health 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 widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-12-01.
Deficiencies (1)
Most serious deficiency found was a widespread 'F' level deficiency constituting no actual harm but potential for more than minimal harm.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Contact person for questions concerning the information in the letter. |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 3
Date: Nov 6, 2018
Visit Reason
The inspection was conducted as a health resurvey to assess compliance with comprehensive assessments, timing, accident hazards, supervision, and staffing requirements.
Findings
The facility failed to ensure a resident remained in a safe environment by not adequately planning interventions or revising care plans to prevent falls. Additionally, the facility failed to determine causal factors for falls and did not provide 8 hours of registered nurse coverage on 15 days during the review period.
Deficiencies (3)
Failure to plan interventions and revise care plan to prevent further falls for one resident.
Failure to ensure resident environment free of accident hazards and provide adequate supervision to prevent falls.
Failure to provide 8 hours of registered nurse coverage 15 days from 6/27/18 to 10/29/18.
Report Facts
Facility census: 42
Days without 8 hours RN coverage: 15
Falls reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Administrative Nurse | Reported awareness of need for causal factors and acknowledged nurses were not completing causal analysis for falls |
| Administrative nurse B | Administrative Nurse | Reported nurse on duty responsible for updating care plan with new interventions to prevent further falls |
| Licensed nurse C | Licensed Nurse | Reported responsibility for fall investigation and care plan updates |
| Direct care staff D | Direct Care Staff | Reported resident would transfer self without calling for help and had falls |
Inspection Report
Follow-Up
Deficiencies: 15
Date: Jun 15, 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 had been corrected and to confirm the date such corrective actions were accomplished.
Findings
All previously cited deficiencies listed with their regulation numbers and identification prefixes were marked as corrected and completed as of 05/09/2017.
Deficiencies (15)
Deficiency with regulation 483.10(c)(7)
Deficiency with regulation 483.20(b)(1)
Deficiency with regulations 483.20(d)(3), 483.10(k)
Deficiency with regulation 483.25(c)
Deficiency with regulation 483.25(e)(2)
Deficiency with regulation 483.25(h)
Deficiency with regulation 483.35(i)
Deficiency with regulation 483.40(a)
Deficiency with regulation 483.40(c)(1)-(2)
Deficiency with regulations 483.60(a),(b)
Deficiency with regulation 483.60(c)
Deficiency with regulation 483.65
Deficiency with regulations 483.75(e)(5)-(7)
Deficiency with regulation 483.75(f)
Deficiency with regulation 483.75(k)(1)(i-ii)
Report Facts
Deficiencies corrected: 15
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 18, 2017
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 facility was found not in substantial compliance with participation requirements, constituting immediate jeopardy to resident health or safety from January 19, 2017 through April 8, 2017. Deficiencies cited included substandard quality of care related to F323"J" CFR 01-483.25(h).
Deficiencies (1)
Noncompliance with F323 CFR 01-483.25(h) at "J" constituting immediate jeopardy and substandard quality of care
Report Facts
Civil Money Penalty: 7000
Denial of Payment Effective Date: May 9, 2017
Termination Effective Date: Oct 18, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions concerning the instructions in the letter |
Inspection Report
Census: 42
Deficiencies: 15
Date: Apr 18, 2017
Visit Reason
The inspection was conducted as a Health Resurvey, Extended Health Survey and Complaint Investigation.
Findings
The facility had multiple deficiencies including failure to hold a sufficient surety bond for resident funds, incomplete comprehensive assessments and care area assessments (CAAs) for multiple residents, failure to revise care plans to reflect moderate risk for elopement, failure to prevent pressure ulcers, failure to provide restorative services for range of motion, inadequate supervision for residents at risk of elopement, failure to assess bed rails for entrapment hazards, failure to complete root cause analysis and implement fall interventions, failure to ensure food safety in nutrition refrigerators, failure to have signed physician admission orders, failure to ensure timely physician visits, failure to hold insulin per physician orders, failure to review medication administration during pharmacy reviews, failure to maintain sanitary environment and hand hygiene by housekeeping, failure to verify nurse aide registry status prior to employment, failure to provide nurse aide competency checks, and failure to have a contract for diagnostic services.
Deficiencies (15)
Failure to hold a surety bond or other assurance sufficient to ensure security of all resident funds managed by the facility.
Failure to complete comprehensive assessments and care area assessments (CAAs) for multiple residents.
Failure to revise care plans to reflect moderate risk for elopement and implement interventions.
Failure to prevent development of pressure ulcers and implement effective interventions.
Failure to provide restorative services to maintain range of motion and prevent further decrease.
Failure to provide adequate supervision and implement interventions for residents at risk for elopement; failure to investigate falls and implement interventions; failure to assess bed rails for entrapment hazards.
Failure to ensure foods were stored safely in nutrition refrigerator by failing to monitor temperatures and remove expired items.
Failure to have signed physician admission orders and approved medication orders for residents.
Failure to ensure residents were seen by a physician within required timeframes post admission and every 60 days thereafter.
Failure to obtain physician orders or notify physician when insulin was held based on blood sugar levels.
Failure to ensure pharmacist reviewed medication administration for irregularities including held medications and lack of physician notification.
Failure to maintain sanitary environment and hand hygiene by housekeeping staff between resident rooms.
Failure to verify nurse aide registry status prior to allowing nurse aides to provide care.
Failure to provide nurse aide competency checks to ensure skills and techniques necessary to care for residents.
Failure to have a contract with an outside source to provide diagnostic services.
Report Facts
census: 42
resident_sample: 12
deficiency_count: 14
bed_rail_gap: 7
bed_rail_gap: 7.5
expired_buttermilk: 3
days_missing_physician_visit: 113
days_between_physician_visits: 62
days_between_physician_visits: 44
days_between_physician_visits: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Staff | Verified surety bond amount, reported resident elopement events, described facility policies and supervision practices |
| Staff B | Administrative Nursing Staff | Reported incomplete CAAs, lack of restorative staff, fall investigations, and physician visit practices |
| Staff C | Administrative Nursing Staff | Reported incomplete CAAs, elopement risk assessment issues, fall investigations, and supervision practices |
| Staff T | Social Services Staff | Interacted with resident #24 prior to elopement, provided emotional support |
| Staff G | Administrative Dietary Staff | Reported nutrition refrigerator temperature monitoring and removal of expired items |
| Staff R | Housekeeping Staff | Observed cleaning practices and hand hygiene failures |
| Staff M | Licensed Nurse | Reported skin assessments and fall investigations |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Nov 7, 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 related to various regulatory requirements were corrected as of 10/21/2016, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (4)
Deficiency related to regulation 483.13(c)(1)(i)-(iii), (c)(2)-(4)
Deficiency related to regulations 483.20(d)(3), 483.10(k)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.70(f)
Report Facts
Deficiencies corrected: 4
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 26, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy.
Deficiencies (1)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: Jan 26, 2017
Termination effective date: Apr 26, 2017
Plan of correction submission timeframe: 10
Informal Dispute Resolution submission timeframe: 10
Fair hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned as contact for questions. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution requests. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Oct 10, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, addressing issues such as investigation procedures, resident care plans, supervision to prevent burns, and call light system functionality.
Findings
The facility failed to conduct thorough investigations, revise care plans for safety concerns related to hot liquids, provide adequate supervision to prevent accidental burns, and maintain a functioning call light system accessible to residents, resulting in multiple deficiencies.
Deficiencies (6)
The facility failed to have evidence of a thorough investigation.
Facility failed to revise resident’s care plan for safety concerns in regard to hot liquid and treatment of burns received from a hot liquid spill.
The facility failed to assess residents at risk and failed to provide adequate supervision to prevent accidental burns from hot liquids delivered by a commercial coffee and hot water dispensing machine.
The facility failed to provide a functioning call light for 6 of 44 residents which put the residents at risk for not receiving care and assistance when needed.
The facility failed to develop and implement a preventative maintenance program of testing the call light system at least weekly to verify the function of the system.
The facility failed to ensure the emergency call or pull cord function and/or was accessible to residents and staff caring for residents at each resident’s toilet and shower.
Report Facts
Residents without functioning call light: 6
Total residents referenced: 44
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 7, 2016
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be F323, "K", CFR 483.25(h), which was immediate jeopardy from September 18, 2016 to September 28, 2016. The facility was found to have substandard quality of care and immediate jeopardy was abated.
Deficiencies (1)
Deficiency F323, "K", CFR 483.25(h) related to substandard quality of care and immediate jeopardy.
Report Facts
Civil Money Penalty: 5000
Denial of payment effective date: 2016
Termination effective date: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named in relation to complaint coordination and contact for questions. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Sep 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation and partial extended survey to evaluate the facility's compliance with nursing facility support system requirements, specifically regarding the call light system functionality and emergency call buttons.
Complaint Details
The visit was triggered by a complaint investigation and partial extended survey #105847. The complaint involved non-functioning call lights and emergency call buttons, which were confirmed by observations, interviews, and record reviews.
Findings
The facility failed to develop and implement a preventative maintenance program to test the call light system weekly, resulting in multiple call lights and emergency call buttons not functioning or registering alerts at the nurses' station or on pagers. This deficient practice had the potential to affect all 44 residents in the facility.
Deficiencies (2)
Failure to develop and implement a preventative maintenance program to test the call light system weekly, resulting in call lights not displaying on pagers or nurses' station.
Failure to ensure emergency call buttons or pull cords functioned and were accessible at each resident-use toilet and shower, with multiple call buttons not registering alerts.
Report Facts
Facility census: 44
Number of common bathing/toilet rooms: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| maintenance staff P | Interviewed regarding call light system functionality and maintenance. | |
| administrative staff A | Interviewed regarding knowledge of call light system testing and functionality. |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Nov 1, 2015
Visit Reason
This document is a Plan of Correction submitted by Protection Valley Manor addressing multiple deficiencies identified in a prior inspection, outlining corrective actions to comply with Federal Medicare and Medicaid requirements.
Findings
The plan addresses deficiencies related to resident rights, care planning participation, accident prevention, medication management, infection control, and quality assurance. The facility commits to policy revisions, staff education, monitoring, and documentation to prevent recurrence of deficiencies.
Deficiencies (10)
Residents not informed orally and in writing of their rights and rules governing conduct.
Residents' right to choose activities, schedules, and health care not fully ensured.
Residents' right to participate in planning care not ensured.
Residents not free of accidents due to inadequate supervision and assistance devices.
Residents' drug regimens not free from unnecessary drugs.
Food not served prepared sanitarily.
Residents' drug regimens not reviewed monthly by licensed pharmacist with irregularities reported.
Medication storage policies inadequate for insulin vials and pens.
Infection Control Program not established.
Quality Assessment and Assurance Committee not established or meeting quarterly.
Report Facts
Plan of correction completion date: Nov 1, 2015
Frequency of QA meetings: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Swede Swagerty | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction document |
Inspection Report
Follow-Up
Deficiencies: 10
Date: Nov 1, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers have been corrected as of the revisit date.
Deficiencies (10)
Deficiency with ID Prefix F0156 related to Reg. # 483.10(b)(5) - (10), 483.10(b)(1)
Deficiency with ID Prefix F0242 related to Reg. # 483.15(b)
Deficiency with ID Prefix F0280 related to Reg. # 483.20(d)(3), 483.10(k)(2)
Deficiency with ID Prefix F0323 related to Reg. # 483.25(h)
Deficiency with ID Prefix F0329 related to Reg. # 483.25(l)
Deficiency with ID Prefix F0371 related to Reg. # 483.35(i)
Deficiency with ID Prefix F0428 related to Reg. # 483.60(c)
Deficiency with ID Prefix F0431 related to Reg. # 483.60(b), (d), (e)
Deficiency with ID Prefix F0441 related to Reg. # 483.65
Deficiency with ID Prefix F0520 related to Reg. # 483.75(o)(1)
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 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 the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, 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
Complaint Investigation
Census: 50
Deficiencies: 9
Date: Oct 2, 2015
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation #91431 to assess compliance with resident rights, self-determination, care planning, accident prevention, drug regimen, infection control, and quality assurance requirements.
Complaint Details
The visit was triggered by complaint investigation #91431 related to resident rights, care planning, accident prevention, drug regimen, infection control, and quality assurance.
Findings
The facility failed to periodically inform residents of their rights, failed to assess and follow resident preferences, did not review and revise care plans after falls, failed to thoroughly investigate falls and implement interventions, failed to ensure residents were free from unnecessary drugs including monitoring for black box warnings and behaviors, failed to label and date insulin products, failed to ensure proper hand hygiene during feeding, failed to track infection organisms for trending, and failed to ensure physician attendance at quality assurance meetings.
Deficiencies (9)
Facility failed to inform residents of their rights periodically including their right to contact the state complaint hotline.
Facility failed to ensure staff identified and followed resident #1's preferences for waking time.
Facility failed to review and revise care plan related to accidents for resident #32 after multiple falls.
Facility failed to thoroughly investigate falls and implement planned fall interventions for resident #32.
Facility failed to ensure residents were free of unnecessary drugs including monitoring for psychoactive medications and black box warnings for residents #45, #51, #32, and #52.
Facility failed to label and date insulin pen and insulin vial properly.
Facility failed to ensure proper hand hygiene when assisting residents to eat and failed to track and trend infection organisms.
Facility failed to ensure pharmacist notified physician and director of nursing of irregularities related to black box warnings and behavior monitoring.
Facility failed to ensure physician attended quality assurance meetings at least quarterly.
Report Facts
Residents present: 50
Resident sample size: 13
Deficiency count: 9
PRN Lorazepam doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant pharmacist Q | Consultant Pharmacist | Reported on medication regimen reviews and black box warning documentation |
| Administrative nurse B | Administrative Nurse | Reported expectations for behavior monitoring and QA meeting attendance |
| Licensed nursing staff C | Licensed Nurse | Interviewed about resident behaviors and medication monitoring |
| Direct care staff G | Direct Care Staff | Interviewed about resident #32 behaviors and medication use |
| Direct care staff K | Direct Care Staff | Interviewed about resident #32 behaviors and medication use |
| Administrative staff D | Administrative Staff | Reported on QA meeting attendance |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 25, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy.
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: Sep 25, 2015
Termination effective date: Dec 25, 2015
Plan of correction submission timeframe: 10
IDR submission timeframe: 10
Fair hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 9, 2014
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 previously cited deficiency with ID Prefix S1174 and Regulation 26-40-303 (2)(a)(i)(ii)(iii) was corrected as of 07/09/2014.
Deficiencies (1)
Deficiency with ID Prefix S1174 related to Regulation 26-40-303 (2)(a)(i)(ii)(iii)
Inspection Report
Follow-Up
Deficiencies: 7
Date: Jul 9, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected by the facility.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Deficiencies (7)
Deficiency with regulation 483.15(h)(2)
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(h)
Deficiency with regulation 483.25(l)
Deficiency with regulation 483.25(n)
Deficiency with regulation 483.35(i)
Report Facts
Deficiencies corrected: 7
Inspection Report
Census: 40
Deficiencies: 7
Date: Jun 10, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements including housekeeping, care planning, medication management, immunizations, and food safety.
Findings
The facility failed to maintain a sanitary environment in resident bathrooms, develop comprehensive care plans for dental and fall-related care, ensure safe medication use with proper behavior monitoring and black box warnings, maintain immunization documentation, and enforce sanitary food preparation practices including hair restraints and food temperature monitoring.
Deficiencies (7)
Failure to ensure a sanitary environment in resident bathrooms with soiled toilets and unmarked towel bars.
Failure to develop a comprehensive care plan for dental services for one resident.
Failure to revise care plans following resident falls and ensure implementation of fall prevention interventions.
Failure to ensure a safe environment free of accident hazards including unsecured chemicals and cigarette butts in resident areas.
Failure to ensure residents were free from unnecessary drugs due to lack of behavior monitoring and black box warning monitoring for psychoactive medications.
Failure to maintain documentation of influenza and pneumococcal immunizations or refusals in medical records.
Failure to ensure sanitary food procurement, storage, preparation, and service including failure to restrain hair fully and failure to take temperatures of pureed foods prior to serving.
Report Facts
Census: 40
Deficiency count: 7
Temperature: 176
Temperature: 186
Temperature: 192
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff T | Housekeeping Staff | Confirmed soiled toilet riser and unmarked towel bars |
| Staff R | Maintenance Staff | Confirmed unmarked towel bars and chemicals improperly stored |
| Resident #55 | Reported confusion about towel bar assignments | |
| Staff I | Dietary Staff | Assisted resident with food and reported food temperature procedures |
| Staff J | Dietary Staff | Observed plating food with hair not fully restrained and failed to take food temperature initially |
| Staff K | Dietary Staff | Observed serving food with hair not fully restrained |
| Staff L | Direct Care Staff | Reported resident behaviors and fall risks |
| Staff M | Direct Care Staff | Reported resident complaints and behaviors |
| Staff E | Licensed Nurse | Reported uncertainty about behavior monitoring and black box warnings |
| Staff H | Licensed Nurse | Reported resident behaviors and fall risk interventions |
| Staff B | Administrative Nurse | Reported lack of fall investigation records and black box warning monitoring |
| Staff P | Administrative Nursing Staff | Reported care plan update procedures |
| Pharmacist Q | Pharmacy Consultant | Reported medication reviews and black box warning documentation |
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Mar 19, 2013
Visit Reason
This document is a Plan of Correction submitted by Protection Valley Manor to address deficiencies identified in a prior CMS-2567 statement of deficiencies report.
Findings
The plan outlines corrective actions to address multiple deficiencies including abuse prevention, reasonable accommodation of resident needs, activity programming, comprehensive assessments, care plans, wound care, accident prevention, and quality assurance processes.
Deficiencies (9)
Lack of policy for reporting suspected abuse, neglect, and exploitation
Failure to fulfill reasonable accommodations of needs and preferences
Inadequate activities meeting resident needs and interests
Incomplete comprehensive assessments for residents
Incomplete comprehensive care plans for residents
Failure to provide care/services for highest well-being
Inadequate prevention and healing of pressure sores
Failure to ensure residents are free of accidents and receive adequate supervision and assistance devices
Lack of quality assessment and assurance committee activities
Report Facts
Plan of correction implementation date: Mar 19, 2013
QA meetings frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Swede Swagerty | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 19, 2013
Visit Reason
This is a post-certification revisit to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.13(c), 483.15(e)(1), 483.15(f)(1), 483.20(b)(1), 483.20(d), 483.20(k)(1), 483.25, 483.25(c), 483.25(h), and 483.75(o)(1) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 10
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 9
Date: Feb 19, 2013
Visit Reason
The inspection was conducted as a health survey and complaint survey into complaint #62578, focusing on allegations of abuse, neglect, and mistreatment, as well as other regulatory compliance issues.
Complaint Details
The inspection was triggered by complaint #62578 regarding allegations of abuse and neglect. The complaint was substantiated as the facility failed to develop and implement appropriate policies and procedures to handle abuse allegations and protect residents during investigations.
Findings
The facility was found deficient in multiple areas including failure to develop and implement abuse/neglect policies, failure to accommodate resident needs such as call light access, inadequate activity programs especially for cognitively impaired residents, incomplete comprehensive assessments and care area assessments, failure to develop comprehensive care plans addressing activities and pain, inadequate pain management, failure to properly assess and measure pressure ulcers, and inadequate supervision and accident prevention measures. The facility's Quality Assurance program failed to adequately address these deficiencies.
Deficiencies (9)
Failed to develop and implement written policies and procedures prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property.
Failed to accommodate the needs of a resident by not ensuring call light was within reach while the resident was sick.
Failed to provide evening and weekend activities and an activity program for cognitively impaired residents.
Failed to complete comprehensive assessments and care area assessments as required.
Failed to develop comprehensive care plans related to activities and pain for sampled residents.
Failed to ensure one resident received pain medication on a scheduled basis and failed to manage pain effectively.
Failed to measure and assess a pressure ulcer to ensure healing.
Failed to provide adequate protection from hazards and failed to provide adequate supervision and assistance devices to prevent accidents.
Failed to maintain an effective Quality Assessment and Assurance program to identify and correct quality deficiencies related to pressure ulcers, activities, pain, assessments, and care plans.
Report Facts
Deficiencies cited: 9
Resident census: 43
Pain medication doses: 40
Fall risk score: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Named in findings related to failure to report abuse, failure to accommodate resident needs, incomplete assessments, and pain management. |
| Licensed Nursing staff G | Licensed Nurse | Named in findings related to abuse investigation, pain management, and pressure ulcer assessment. |
| Licensed Nurse E | Licensed Nurse | Named in findings related to lack of scheduled activities and documentation. |
| Activity staff B | Activity Staff | Named in findings related to failure to provide adequate activities and one-on-one visits. |
| Direct Care staff O | Direct Care Staff | Named in findings related to resident care and call light accessibility. |
| Direct Care staff M | Direct Care Staff | Named in findings related to resident pain and mobility assistance. |
| Licensed Nurse F | Licensed Nurse | Named in findings related to care plan knowledge and resident supervision. |
| Staff S | Administrative Staff | Named in findings related to Quality Assurance program deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 17
Date: N017002 POC OY9M11
Visit Reason
This document is a Plan of Correction submitted by Protection Valley Manor in response to deficiencies identified in a prior inspection.
Findings
The plan outlines corrective actions taken or to be taken for multiple deficiencies including financial surety bonds, care area assessments, resident care plans, pressure ulcer prevention, restorative services, bed rail safety, elopement risk, fall investigations, food safety, physician orders, staff competency, and diagnostic service contracts.
Deficiencies (17)
Residents' funds not insured by adequate surety bond.
Care Area Assessments (CAA) not consistently completed and addressed in care plans.
Assessments and care plans not updated to reflect risk of elopement.
Residents at risk for pressure ulcers not properly assessed or provided with pressure relieving devices.
Restorative services not provided three times a week as required.
Bed rails with gaps over 4 ¾ inch not mechanically altered to meet safety code.
Residents at risk for elopement not secured with appropriate door codes and sign-out procedures.
Fall investigations not conducted for residents with falls.
Food items not checked for expiration and snack refrigerator not monitored for correct temperatures.
Residents' physician orders not signed or properly maintained in charts.
Residents not seen by physician on required 30/60/90 day visits and every 60 days thereafter.
Physician orders and treatment administration records lack specific parameters for diabetic residents.
Pharmacist not reviewing residents' charts or notifying physicians of held medications.
Resident rooms not cleaned with appropriate disinfecting wet times.
Certified Nursing Assistants (CNAs) lack Registry Verifications in personnel files.
CNA competency testing not conducted to ensure staff competence.
Facility lacks contract with area hospital for diagnostic services.
Report Facts
Surety Bond amount: 40000
Corrective action completion dates: Apr 21, 2017
Corrective action completion dates: May 9, 2017
Inspection Report
Plan of Correction
Deficiencies: 8
Date: N017002 POC TUCK11
Visit Reason
This document is a Plan of Correction submitted by Protection Valley Manor addressing multiple deficiencies identified in a prior inspection related to housekeeping, care planning, resident participation, fall prevention, medication management, immunizations, food safety, and facility safety.
Findings
The plan outlines corrective actions including policy development, staff education, resident involvement, audits, and follow-up measures to ensure compliance with federal Medicare and Medicaid requirements and to prevent recurrence of the cited deficiencies.
Deficiencies (8)
Deficient towel bar and towel bar labeling practice affecting sanitary, orderly, and comfortable interior.
Lack of comprehensive care plans for all residents.
Residents' right to participate in care planning and revise care plans not ensured.
Residents not free of accidents and lacking adequate supervision and assistance devices to prevent accidents.
Residents' drug regimens not free from unnecessary drugs.
Influenza and pneumococcal immunizations not adequately offered or documented.
Food not being served prepared and sanitary; deficient hair net policy and food temperature monitoring.
Nursing facility lacks an electrical monitoring system on each door that exits the facility.
Report Facts
Plan of correction completion dates: Jul 4, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance |
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