Inspection Reports for Via Christi Village Hays Ks LLC
2225 CANTERBURY DR., KS, 67601
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 22, 2020, found the facility in compliance with CMS and CDC recommended practices for COVID-19 preparation, with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including issues with bathing services, medication administration, care planning, pressure ulcer prevention, and discharge procedures. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved inadequate bathing care and incomplete discharge documentation. Enforcement actions were noted in 2016 related to medication errors and staffing, but no fines or license suspensions appeared in the available reports. The facility’s record shows improvement over time, with recent surveys indicating compliance and correction of prior deficiencies.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
27.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
357% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
88 residents
Based on a March 2020 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 22, 2020
Visit Reason
A targeted Infection Control Survey/COVID-19 Focused Survey and a complaint survey were conducted on 10/22/2020 for complaints #157064 and #157069.
Complaint Details
Complaints #157064 and #157069 were investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation. The allegations made in the complaints were not substantiated and no noncompliance was found.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 22, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by CMS on 10/22/2020. Additionally, a complaint survey was conducted on the same date for complaints #157064 and #157069.
Complaint Details
Complaints #157064 and #157069 were investigated and found to be not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation. The complaints investigated were not substantiated, and no noncompliance was found.
Report Facts
Complaint numbers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 6, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 10/06/2020 to assess compliance with COVID-19 preparation and infection control practices.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 during the targeted infection control survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 6, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 27, 2020
Visit Reason
A Focused Infection Control/COVID-19 and complaint survey were conducted on 08/27/2020 for complaints #150583, #150315, and #154955.
Complaint Details
Complaints #150583, #150315, and #154955 were investigated and found not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 27, 2020
Visit Reason
A Focused Infection Control/COVID-19 and complaint survey were conducted on 08/27/2020 for complaints #150583, #150315, and #154955.
Complaint Details
Complaints #150583, #150315, and #154955 were investigated and found not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 27, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/27/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 06/23/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 6, 2020
Visit Reason
An offsite revisit survey was conducted on 05/06/2020 for all previous deficiencies cited on 03/11/2020.
Findings
All deficiencies have been corrected as of the compliance date of 03/20/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Mar 11, 2020
Visit Reason
The inspection was conducted as a complaint investigation (#150879) regarding the facility's compliance with transfer and discharge requirements.
Complaint Details
Complaint investigation #150879 focused on transfer and discharge requirements. The facility was found noncompliant in properly handling an involuntary discharge for Resident 1.
Findings
The facility failed to provide an appropriate involuntary discharge notice to a resident, did not document a valid reason for discharge, failed to obtain a physician's discharge order, and did not secure a new facility placement for the resident.
Deficiencies (1)
Failed to provide Resident 1 with an appropriate involuntary discharge notice, document an appropriate reason for discharge, obtain a discharge order from the physician, and find a new facility to meet the resident's needs.
Report Facts
Resident census: 88
Facilities contacted for placement: 48
Facilities responded: 3
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided information about outreach to other facilities and discussions with resident's DPOA. | |
| Administrative Staff B | Reported lack of physician discharge order and ongoing search for new facility placement. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 11, 2020
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays in response to deficiencies cited in a prior survey, specifically addressing transfer and discharge requirements including involuntary discharge procedures.
Findings
The facility acknowledges deficiencies related to transfer and discharge requirements and outlines corrective actions including education of staff and ongoing compliance monitoring through the Quality Assurance Performance Improvement Committee.
Deficiencies (1)
Failure to meet transfer and discharge requirements including involuntary discharge procedures
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamika Atkins | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 2, 2019
Visit Reason
An offsite revisit survey was conducted on 12/02/2019 for all previous deficiencies cited on 10/29/2019.
Findings
All deficiencies have been corrected as of the compliance date of 11/15/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: Oct 29, 2019
Compliance date: Nov 15, 2019
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 30, 2019
Visit Reason
The visit was a resurvey conducted in response to complaint #141645 at the assisted living facility.
Complaint Details
Complaint #141645 was investigated during this resurvey; no citations were issued.
Findings
The resurvey conducted on 10/29 and 10/30/2019 resulted in no citations.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 4
Date: Oct 29, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint Investigations #146888, #146827, and #147021.
Complaint Details
The inspection was triggered by complaints identified as #146888, #146827, and #147021.
Findings
The facility failed to provide bathing services as care planned/requested for multiple residents, placing them at risk for poor hygiene. Specific residents (R1, R5, R6, and R8) did not receive showers or baths as scheduled or requested, despite documented care plans and preferences.
Deficiencies (4)
Failed to provide bathing services as care planned/requested for Resident 5, including not receiving a shower until seven days after admission.
Failed to provide bathing services as care planned/requested for Resident 6, with showers not provided as scheduled.
Failed to provide bathing services as care planned/requested for Resident 1, including not receiving showers three times a week as requested.
Failed to provide bathing services as care planned/requested for Resident 8, including infrequent showers and refusal documentation issues.
Report Facts
Census: 92
Days between showers for Resident 5: 7
Days between showers for Resident 6: 13
Days between showers for Resident 1: 3
Days between showers for Resident 8: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Stated that residents should receive showers within 24 hours of admission and that refusals should be documented. | |
| Certified Nurse Aide M | CNA | Reported on shower schedules and refusals for residents. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 29, 2019
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays in response to deficiencies cited during a prior survey inspection.
Findings
The facility identified deficiencies related to activities of daily living specific to bathing for residents, including issues with care plans and bathing preferences. The plan outlines corrective actions including weekly reviews of resident no-bath lists, regular care plan reviews, and staff education to prevent recurrence.
Deficiencies (2)
Deficiency related to activities of daily living specific to bathing for residents (F676-D).
Deficiency related to care and services for dependent residents specific to bathing (F677-D).
Report Facts
Complete Date: Nov 15, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamika Atkins | Nursing Home Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 31, 2019
Visit Reason
An offsite revisit survey was conducted on 05/31/2019 for all previous deficiencies cited on 04/10/2019.
Findings
All deficiencies have been corrected as of the compliance date of 4/20/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Apr 20, 2019
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays in response to deficiencies cited in a prior survey to comply with state and federal regulations.
Findings
The facility identified multiple deficiencies related to medication administration, care planning, drug regimen review, and labeling/storage of drugs. Corrective actions include revising care plans, monitoring medication administration, conducting regular audits, and ensuring appropriate diagnosis and documentation.
Deficiencies (6)
Medication administration not completed per resident’s plan of care for Residents #69 and #19.
Inadequate care planning and positioning for Resident #30.
Incomplete drug regimen review and lack of appropriate diagnosis for psychotropic medications for Resident #43.
Ensuring resident drug regimens are free from unnecessary drugs; review of physician lab orders for Resident #46.
Failure to complete drug regimen review and report irregularities; maintain appropriate diagnosis for psychotropic medications for Resident #43.
Inappropriate labeling and storage of drugs and biologicals; removal of E-Kit from facility.
Report Facts
Date of substantial compliance: Apr 20, 2019
Frequency of medication administration monitoring: 2
Frequency of drug regimen review: 1
Date of Director of Nursing care plan updates: Apr 16, 2019
Date E-Kit removed: Apr 8, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamika Atkins | Administrator | Submitted the Plan of Correction |
| Director of Nursing | Responsible for revising care plans and obtaining appropriate diagnoses |
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 6
Date: Apr 10, 2019
Visit Reason
The inspection was a Health Resurvey conducted to evaluate the facility's compliance with professional standards of care, medication administration, quality of care, drug regimen review, and medication storage.
Findings
The facility failed to administer medications according to accepted standards for two residents, failed to meet the highest level of care for positioning for one resident, and the consultant pharmacist failed to identify and address medication irregularities including missing lab tests and inappropriate psychotropic medication use. Additionally, the facility failed to secure an expired emergency medication kit.
Deficiencies (6)
Failed to administer medications according to accepted standards for Residents #69 and #19, including lack of physician orders for self-administration and failure to observe medication administration.
Failed to meet the highest level of care for Resident #30 by not repositioning the resident when observed in a compromised position.
Consultant pharmacist failed to identify and address failure to obtain blood laboratory tests per physician orders for Resident #46, failure to obtain appropriate diagnosis for scheduled antipsychotic medication, and lack of stop date for PRN antipsychotic medication for Resident #43.
Failed to ensure staff obtained physician ordered HgA1c blood tests every 3 months for Resident #46.
Failed to ensure appropriate diagnosis for Resident #43's use of scheduled antipsychotic medication and appropriate stop date for PRN antianxiety medication.
Failed to secure and return an expired emergency medication kit after use.
Report Facts
Residents in census: 93
Residents in sample: 19
Residents reviewed for unnecessary medications: 5
Days PRN Ativan administered after original order: 81
Expired emergency medication kit date: 201903
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Confirmed Resident #69 had no medication self-administration order and observed medication administration | |
| Licensed Nurse H | Confirmed Resident #19 had no medication self-administration order and explained medication handling | |
| Administrative Nurse D | Provided expectations on medication administration and positioning, verified missing lab tests and pharmacy consultant failures, and confirmed expired emergency kit | |
| Medication Aide M | Observed administering medications and checking blood pressure for Resident #46 | |
| Direct Care Staff N | Involved in transferring Resident #30 and observed positioning | |
| Direct Care Staff O | Involved in transferring Resident #30 and observed positioning | |
| Physical Therapy Aide GG | Stated therapy department would complete positioning evaluations upon request | |
| Nurse I | Verified expired emergency medication kit finding |
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Dec 6, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates when corrective actions were accomplished.
Findings
The report shows that multiple deficiencies previously cited were corrected by the facility, with completion dates documented as December 4, 2018.
Deficiencies (3)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-102 (d)
Deficiency related to regulation 26-41-105 (f) (11)
Inspection Report
Renewal
Census: 42
Deficiencies: 3
Date: Oct 31, 2018
Visit Reason
The inspection was a licensure resurvey conducted on 10/29/18, 10/30/18, and 10/31/18 to assess compliance with regulatory requirements for the assisted living facility.
Findings
The facility failed to provide or coordinate necessary health care services for a resident with recurring wounds on the ankles, failed to maintain evidence of criminal background checks for two certified medication aides hired in 2018, and failed to ensure complete documentation of incidents, symptoms, and actions taken related to the resident's skin condition.
Deficiencies (3)
Licensed nurse/operator C failed to provide or coordinate necessary health care services to meet the needs of a resident with recurring wounds on the ankles, resulting in redevelopment of wounds.
The facility failed to have evidence of criminal background verification for certified medication aides hired in 2018.
Licensed nurse/operator C failed to ensure documentation of all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results for a resident with recurring wounds.
Report Facts
Census: 42
Sample size: 3
Certified Medication Aides without background check: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse/operator C | Named in findings related to failure to provide necessary health care services and documentation failures | |
| Licensed nurse D | Interviewed regarding wound assessments and documentation | |
| Licensed nurse E | Documented skin check on resident | |
| Licensed nurse F | Documented wound measurements and notes |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 20, 2018
Visit Reason
A revisit survey was conducted on 6/20/18 for all previous deficiencies cited on 2/28/18.
Findings
All deficiencies have been corrected as of the compliance date of 3/20/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 20, 2018
Visit Reason
A revisit survey was conducted on 6/20/18 to verify correction of all previous deficiencies cited on 2/28/18.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 3/20/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Deficiencies (1)
Previous deficiencies cited on 2/28/18 have been corrected.
Report Facts
Deficiency correction compliance date: Mar 20, 2018
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 9, 2018
Visit Reason
A complaint survey was conducted on 5/9/18 for complaint #129258.
Complaint Details
Complaint #129258 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 9, 2018
Visit Reason
A complaint survey was conducted on 5/9/18 for complaint #129258.
Complaint Details
Complaint #129258 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 12
Date: Feb 28, 2018
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to assess compliance with resident rights, comprehensive assessments, care planning, pressure ulcer prevention and treatment, medication use, accident hazards, and infection control.
Complaint Details
The inspection included a complaint investigation #121626.
Findings
The facility was found deficient in maintaining resident dignity, completing timely comprehensive assessments and care plans, preventing pressure ulcers, ensuring appropriate wheelchair positioning, managing psychotropic medications appropriately, and implementing an antibiotic stewardship program.
Deficiencies (12)
Failure to maintain dignity for Resident #240 by leaving urinary catheter bag uncovered and visible to others.
Failure to complete a comprehensive assessment within required timeframe for Resident #191.
Failure to include basic information regarding needs of newly admitted Resident #191 in baseline care plan.
Failure to include information regarding dialysis care in comprehensive care plan for Resident #191.
Failure to review and revise care plans to prevent pressure ulcers and bruising for Residents #18, #27, #30, and #71.
Failure to provide treatment and services to ensure appropriate wheelchair positioning for Resident #4.
Failure to provide necessary treatment and services to promote healing and prevent new pressure ulcers for Residents #27, #18, #30, and #71.
Failure to ensure the environment was free of accessible hazardous chemicals for 4 cognitively impaired, independently mobile residents.
Consultant pharmacist failed to identify and address inappropriate diagnosis for use of antipsychotic medication for Resident #59.
Failure to ensure PRN psychotropic medication Ativan had discontinue date and documented rationale for continued use beyond 14 days for Resident #24.
Failure to ensure psychotropic medications were used only when necessary to treat a specific condition for Residents #55, #59, and #79.
Failure to develop and implement an antibiotic stewardship program including antibiotic use protocols and a system to monitor antibiotic use.
Report Facts
Census: 93
Deficiencies cited: 12
Medication administration: 6
Medication administration: 4
Braden Scale score: 18
Braden Scale score: 19
Braden Scale score: 13
BIMS score: 5
BIMS score: 12
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse K | Nurse | Named in pressure ulcer dressing and wound care observations. |
| Administrative Nurse C | Administrative Nurse | Verified multiple findings including catheter bag, care plan deficiencies, and medication issues. |
| Administrative Nurse G | Administrative Nurse | Verified wound assessments and care plan deficiencies. |
| Administrative Nurse D | Administrative Nurse | Verified incomplete assessments and antibiotic stewardship program absence. |
| Administrative Nurse F | Administrative Nurse | Verified care plan deficiencies related to dialysis. |
| Administrative Nurse E | Administrative Nurse | Verified lack of antibiotic stewardship program. |
| Dietary Consultant GG | Dietary Consultant | Verified lack of dietary interventions for pressure ulcers. |
| Nurse Aide S | Nurse Aide | Observed resident with pressure ulcers and foot positioning. |
| Nurse Aide P | Nurse Aide | Observed resident without foot protectors and bruising. |
| Nurse Aide U | Nurse Aide | Reported resident's right side paralysis and repositioning. |
| Nurse J | Nurse | Reported resident's thin skin and repositioning. |
| Nurse I | Nurse | Assessed resident's skin and bruises. |
| Nurse L | Nurse | Reported resident's pressure ulcers and foot protectors. |
| Nurse G | Licensed Nurse | Provided wound care and verified wound measurements. |
| Nurse H | Licensed Nurse | Reported wound dressing changes. |
| Direct Care Staff O | Direct Care Staff | Reported resident's bruising and behaviors. |
| Direct Care Staff N | Direct Care Staff | Aware of resident's pressure area and positioning. |
| Nurse Aide M | Nurse Aide | Verified unlocked washroom door and hazardous chemicals. |
| Dietary Staff BB | Dietary Staff | Verified accessible hazardous chemicals. |
| Pharmacist Consultant II | Pharmacist Consultant | Verified inappropriate use of Risperdal for Alzheimer's diagnosis. |
| Licensed Nurse S | Licensed Nurse | Administered medication to Resident #24. |
| Nurse Aide R | Nurse Aide | Reported resident's pressure ulcers and wheelchair use. |
| Therapy Staff HH | Therapy Staff | Reported no wheelchair evaluation requested for Resident #4. |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Feb 28, 2018
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays to address deficiencies cited in a prior survey report dated 02/28/2018. The plan outlines corrective actions to ensure compliance with state and federal regulations.
Findings
The plan addresses multiple deficiencies related to resident dignity, comprehensive assessments, care plan accuracy and revisions, wheelchair positioning, pressure ulcer prevention, environmental safety, appropriate diagnosis for antipsychotic medication use, and infection prevention and control including antibiotic stewardship. The facility commits to education, auditing, and ongoing monitoring to prevent recurrence.
Deficiencies (11)
Failure to promote resident dignity for residents with catheters
Incomplete comprehensive assessments within required timeframes
Failure to implement basic care plans for newly admitted residents
Inaccurate or incomplete care plans
Care plans not reviewed and revised regularly
Inadequate wheelchair positioning and related care plans
Failure to prevent and heal pressure ulcers
Environmental hazards not properly controlled
Inappropriate diagnosis for antipsychotic medication use
Inadequate diagnoses for antipsychotic and psychotropic medications
Inadequate infection prevention and control program including antibiotic stewardship
Report Facts
Deficiency completion dates: Mar 20, 2018
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 10, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies were corrected as of 08/01/2016, with each correction documented and completed according to the regulatory requirements.
Report Facts
Deficiencies corrected: 15
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Aug 1, 2016
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays to address deficiencies cited in a prior survey. It outlines corrective actions to ensure compliance with state and federal regulations.
Findings
The plan details corrective actions for multiple deficiencies related to care planning, skin assessments, hygiene, pressure ulcer prevention, range of motion, accident hazards, nutrition, medication management, staffing, food safety, and infection control. The facility commits to education, audits, and ongoing monitoring to prevent recurrence.
Deficiencies (15)
Incomplete comprehensive care plans regarding bruising and contractures
Care plans not reviewed and revised accurately
Inadequate weekly skin assessments and monitoring of bruising
Insufficient care for dressing, grooming, and personal hygiene
Failure to provide physician ordered services to prevent pressure ulcers
Lack of services to prevent further decrease of range of motion
Environment not free of accident hazards related to recliners and wheelchairs
Failure to maintain acceptable nutritional status parameters
Duplicate medication therapy and inadequate diagnoses
Significant medication errors
Insufficient nursing staff to provide necessary care
Improper food and drink temperatures served
Failure to ensure correct medication received and administered
Failure to obtain appropriate diagnoses for antipsychotic medications
Inadequate cleaning of rooms with C-diff infection
Report Facts
Substantial compliance date: Aug 1, 2016
QAPI Committee review date: Jul 22, 2016
Medication order audit review date: Mar 1, 2016
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 11, 2016
Visit Reason
The Assisted Living/Residential Healthcare resurvey of the facility was conducted to verify compliance and check for any deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 0
Date: Jul 11, 2016
Visit Reason
A Health survey was conducted on July 11, 2016, by the Kansas Department for Aging and Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Complaint Details
The enforcement action is based on deficiencies found on the current survey and a complaint survey conducted on May 21, 2016.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, with deficiencies cited that require correction. Due to prior noncompliance on a May 21, 2015 survey and a complaint survey on May 21, 2016, the facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.
Report Facts
Denial of payment effective date: Aug 2, 2016
Noncompliance recommendation deadline: Jan 11, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the enforcement action. |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 15
Date: Jul 11, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with bruising and hand contracture, failure to revise care plans for pressure ulcers, inadequate skin assessments and care to prevent bruising, failure to provide necessary ADL care, failure to provide physician ordered pressure ulcer prevention services, failure to prevent decrease in range of motion, environmental hazards leading to falls, failure to monitor nutritional supplement intake, duplicate antipsychotic medication therapy without proper diagnosis, a significant medication error involving antibiotic overdose, insufficient nursing staff, improper food temperature control, and inadequate infection control cleaning practices.
Deficiencies (15)
Failed to develop comprehensive care plans for bruising and hand contracture for residents #67, #5, and #9.
Failed to revise care plan to include physician orders for pressure ulcer prevention for Resident #67.
Failed to complete weekly skin assessments and provide necessary care to prevent further bruises for Residents #67, #5, and #9.
Failed to provide necessary ADL care including bathing and grooming for Residents #9 and #57.
Failed to provide physician ordered services to prevent pressure ulcers for Resident #67.
Failed to provide range of motion services or splint device for Resident #9 with hand contracture.
Failed to ensure environment free of accident hazards for Residents #9 (fall from recliner) and #57 (damaged wheelchair arm pads).
Failed to monitor intake of nutritional supplements ordered for Residents #67 and #84.
Failed to ensure medication regimen free from duplicate antipsychotic medications and proper diagnoses for Resident #9.
Medication error: Resident #28 received double dose of antibiotic Bactrim DS instead of single strength, resulting in acute renal failure and hospitalization.
Failed to have sufficient nursing staff to provide care to 94 residents, with multiple complaints from residents and families.
Failed to serve salads, milk, and juice at proper temperature on two units, placing residents at risk for food-borne illness.
Failed to provide pharmaceutical services to prevent medication errors, specifically the antibiotic overdose for Resident #28.
Failed to ensure drug regimen review by pharmacist identified duplicate antipsychotic therapy and improper diagnoses for Resident #9.
Failed to maintain infection control by improper cleaning of a room with C-diff infection, exposing 28 residents to infection risk.
Report Facts
census: 94
sample size: 22
Bruises documented: 17
Refrigerator temperature readings above 40F: 24
Bactrim DS tablets delivered: 60
Supplement doses ordered: 2
Supplement doses ordered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Licensed Nurse | Provided statements about skin assessments and resident care |
| Nurse C | Licensed Nurse | Provided statements about bruise monitoring and care |
| Administrative Nurse F | Administrative Nurse | Verified care plan and skin assessment requirements |
| Nurse G | Nurse | Provided statements about bruise measurement and resident care |
| Nurse Aide N | Nurse Aide | Provided statements about bruise care |
| Nurse Aide I | Nurse Aide | Provided statements about resident bruising |
| Nurse H | Administrative Nurse | Verified care plan and bruise care for residents |
| Nurse K | Licensed Nurse | Provided statements about resident range of motion and care |
| CNA S | Certified Nurse Aide | Provided statements about resident hand swelling and care |
| CNA T | Certified Nurse Aide | Provided statements about resident splint and restorative program |
| Nurse Aide D | Nurse Aide | Provided statements about resident ADL care |
| Nurse Aide M | Nurse Aide | Provided statements about resident wheelchair condition and ADL care |
| Administrative Staff L | Administrative Staff | Verified medication error and corrective actions |
| Physician O | Physician | Verified medication error impact |
| Certified Dietary Manager Q | Dietary Manager | Provided statements about refrigerator temperature and food safety |
| Dietary Staff P | Dietary Staff | Observed serving food at improper temperature |
| Dietary Staff R | Dietary Staff | Observed serving food at improper temperature |
| Housekeeping Staff A | Housekeeping Staff | Observed cleaning practices in C-diff isolation room |
| Housekeeping Staff B | Housekeeping Staff | Verified cleaning practices in C-diff isolation room |
| Licensed Nurse E | Licensed Nurse | Provided statements about medication monitoring and resident care |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 11, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Via Christi Hays AL dated 07/11/2016.
Findings
No deficiencies were cited in the referenced inspection report.
Deficiencies (1)
No deficiencies were cited
Inspection Report
Life Safety
Deficiencies: 1
Date: May 5, 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 a 'D' level, indicating no harm with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
Deficiencies found at 'D' level severity related to Life Safety Code compliance
Report Facts
Effective date for denial of payments: Aug 5, 2016
Provider agreement termination date: Nov 5, 2016
IDR request timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 2, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that the deficiency identified under regulation 483.25(c) with ID prefix F0314 was corrected as of 10/02/2015.
Deficiencies (1)
Deficiency under regulation 483.25(c) previously cited as F0314
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 9, 2015
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays in response to deficiencies cited in a complaint-related survey conducted at the facility.
Complaint Details
The plan of correction is in response to a complaint investigation survey conducted at Via Christi Village Hays.
Findings
The facility was cited for deficiencies related to prevention and treatment of pressure sores. The plan outlines corrective actions including review and revision of care plans, staff education, audits, and ongoing monitoring to ensure compliance and prevent recurrence.
Deficiencies (1)
Deficiency related to prevention and treatment of pressure sores in residents.
Report Facts
Complete Date for Plan of Correction: Oct 2, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Schwien | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 8, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency related to pressure ulcers, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective October 2, 2015.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the information in the letter |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 1
Date: Sep 8, 2015
Visit Reason
The inspection was conducted as a result of Complaint Investigation #90203 to assess the facility's compliance with treatment and services to prevent and heal pressure sores.
Complaint Details
Complaint Investigation #90203. The facility failed to complete skin assessments under Resident #2's knee immobilizer to check for changes in skin integrity to prevent skin breakdown.
Findings
The facility failed to provide adequate care and treatment to prevent the development of pressure ulcers and to promote healing for one resident reviewed. Specifically, the facility did not complete skin assessments under a knee immobilizer to check for skin integrity changes, resulting in a pressure ulcer.
Deficiencies (1)
Failure to provide care and treatment to prevent pressure ulcers and promote healing for one resident.
Report Facts
Census: 95
Pressure ulcer measurements: 1.8
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Nurse | Provided statements about skin checks and communication with department heads and physician. |
| Administrative Nurse A | Administrative Nurse | Verified lack of documentation for scheduled skin checks under immobilizer. |
| Nurse Aide D | Nurse Aide | Described use of full body lift for transfers and frequency of bed baths and skin assessments. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 29, 2015
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiency identified under regulation 483.12(a)(2) with ID prefix F0201 was corrected as of 07/29/2015.
Deficiencies (1)
Deficiency under regulation 483.12(a)(2) previously cited and corrected.
Report Facts
Deficiencies corrected: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 28, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a "D" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Deficiencies (1)
Most serious deficiency found was a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and plan of correction correspondence. |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Jul 28, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#89472) regarding the facility's failure to obtain proper documentation for an involuntary discharge of a resident.
Complaint Details
Complaint investigation #89472 focused on the facility's failure to obtain proper documentation for the involuntary discharge of Resident #1, including substantiation that the resident was a danger to self or others. The resident was discharged after smoking while on oxygen, causing burns, but no physician documentation supported the discharge decision.
Findings
The facility failed to obtain required physician documentation supporting the involuntary discharge of Resident #1, who was discharged due to endangering other residents by smoking while on oxygen, resulting in burns. The medical record lacked physician statements confirming the resident was a danger to self or others.
Deficiencies (1)
Failure to obtain documentation by a physician clearly stating the reasons for the resident's involuntary discharge due to endangering other residents.
Report Facts
Census: 91
BIMS score: 15
BIMS score: 5
Oxygen therapy: 3
Discharge notice period: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff B | Verified lack of physician documentation supporting resident's danger to self or others. | |
| Social Service Staff A | Verified issuance of involuntary discharge letter and efforts to locate placement for resident. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 27, 2015
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays in response to deficiencies cited in a complaint survey related to required physician documentation for resident discharges.
Complaint Details
This Plan of Correction addresses deficiencies cited in a complaint survey related to discharge documentation compliance.
Findings
The facility lacked required physician documentation for an involuntary discharge of Resident #1, which was subsequently obtained and added to the record. The plan outlines corrective actions to ensure compliance with discharge documentation requirements.
Deficiencies (1)
Failure to obtain required physician documentation regarding Resident #1's involuntary discharge.
Report Facts
Date corrective action completed: Jul 28, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Schwien | Administrator | Administrator submitting the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Person who added and modified the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 25, 2015
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 revisit report shows that all previously cited deficiencies were corrected as of 06/12/2015, with no uncorrected deficiencies remaining as of the revisit date.
Report Facts
Deficiencies corrected: 17
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 25, 2015
Visit Reason
The Assisted Living/Residential Healthcare Resurvey of the facility was conducted to verify compliance and check for any deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 20
Date: Jun 12, 2015
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays to address deficiencies cited in a prior survey and to demonstrate compliance with state and federal regulations.
Findings
The plan outlines corrective actions for multiple deficiencies including notification of family and physicians, fall investigations, resident dignity, comprehensive assessments, care plan accuracy, pain management, pressure sore prevention, catheter care, accident prevention, nutrition status, medication management, staffing adequacy, food safety, and quality assurance processes. The facility commits to education, audits, and ongoing monitoring to ensure substantial compliance by June 12, 2015.
Deficiencies (20)
Failure to notify family and physicians regarding pressure ulcers, weight loss, and refusal of medications
Inadequate investigation and reporting of falls and injuries of unknown origin
Failure to maintain resident dignity and respect
Incomplete annual comprehensive assessments
Inaccurate or incomplete care plans
Failure to implement temporary care plans upon admission
Inadequate pain management and fluid restriction monitoring
Failure to prevent and treat pressure sores
Inappropriate catheter care and irrigation training
Unsafe environment and inadequate fall precautions
Poor nutritional status monitoring and documentation
Improper treatment and care for special services such as tube feedings
Use of unnecessary drugs and inadequate medication monitoring
Medication errors and inadequate medication administration education
Insufficient nursing staff and staffing models
Improper food handling and hairnet use
Failure to ensure monthly drug regimen reviews by pharmacist
Failure to properly label and dispose of expired medications
Inefficient use of resources to maintain resident well-being
Lack of effective Quality Assurance Performance Improvement (QAPI) Committee
Report Facts
Deficiency completion date: Jun 12, 2015
Date of care plan reviews and assessments: May 27, 2015
Date of medication aide counseling: May 6, 2015
Date of medication removal: May 5, 2015
Date of staffing schedule review: May 26, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Schwien | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 21, 2015
Visit Reason
A Health survey was conducted on May 21, 2015, 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 facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from February 16, 2015 through May 15, 2015 related to pressure ulcers (F314 CFR 01-483.25(c)). Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were recommended.
Deficiencies (1)
Noncompliance with F314 CFR 01-483.25(c) related to pressure ulcers
Report Facts
Denial of payment effective date: Jun 13, 2015
Termination date recommendation: Nov 21, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Schwien | Administrator | Facility administrator named in the report |
| Irina Strakhova | Enforcement Coordinator | Signed the letter containing enforcement actions |
Inspection Report
Census: 90
Deficiencies: 17
Date: May 21, 2015
Visit Reason
The survey included a Health Resurvey, Extended Health Resurvey, and Complaint Investigations to assess compliance with regulatory requirements.
Findings
The facility had multiple deficiencies including failure to notify family and physicians of changes, inadequate care plans, failure to prevent pressure ulcers and falls, medication errors, insufficient nursing staff, and poor infection control practices.
Deficiencies (17)
Failure to notify family and physicians of resident condition changes including pressure ulcers and weight loss.
Failure to thoroughly investigate and report falls and injuries of unknown origin.
Failure to promote dignity and respect for residents during care and meals.
Failure to conduct comprehensive annual assessments within required timeframes.
Failure to review and revise care plans after hospitalizations, medication changes, and new conditions.
Failure to implement admission care plans including interventions to prevent skin breakdown.
Failure to follow physician orders and provide appropriate care for residents with pressure ulcers, resulting in osteomyelitis and surgical intervention.
Failure to provide appropriate catheter care and monitoring for residents with indwelling urinary catheters.
Failure to maintain a safe environment free of accident hazards, resulting in falls and injuries.
Failure to provide adequate nutritional assistance and interventions to prevent significant weight loss.
Failure to follow physician orders for tube feeding including flushing volumes.
Failure to ensure drug regimens are free from unnecessary drugs and to monitor effectiveness of PRN medications.
Medication error: failure to separate administration of Pulmocort and Brovana nebulizer treatments by at least one hour.
Failure to provide sufficient nursing staff and related services to maintain residents' highest practicable well-being.
Failure to store, prepare, and serve food under sanitary conditions including failure to contain hair under hairnets.
Failure to remove expired medications from medication storage areas.
Failure of quality assessment and assurance program to identify and correct multiple quality deficiencies.
Report Facts
resident_census: 90
pressure_ulcer_size: 4.8
pressure_ulcer_size: 5.5
pressure_ulcer_size: 0.1
weight_loss_percentage: 11.5
weight: 200
weight: 177
medication_dose: 3000
medication_administration_count: 18
medication_administration_count: 10
medication_administration_count: 12
medication_administration_count: 7
medication_administration_count: 13
medication_administration_count: 12
medication_administration_count: 18
medication_administration_count: 12
medication_administration_count: 7
medication_administration_count: 2
medication_administration_count: 3
medication_administration_count: 4
medication_administration_count: 3
medication_administration_count: 1
medication_administration_count: 1
medication_administration_count: 2
medication_administration_count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Licensed Nurse | Verified resident had MRSA in heel wound and no nursing interventions in place to prevent breakdown |
| Nurse B | Nurse | Observed assisting resident with eating and stated resident required cueing and prompting |
| Nurse D | Nurse | Verified staff used sit to stand lift incorrectly for resident requiring full body lift |
| Nurse G | Nurse | Observed and verified inappropriate catheter irrigation technique |
| Nurse H | Licensed Nurse | Verified resident had MRSA and no interventions to prevent heel breakdown |
| Nurse N | Nurse | Verified staff failed to investigate or report fall incident |
| Nurse Consultant Staff DDD | Nurse Consultant | Verified staff did not initiate admission temporary care plan |
| Nurse Aide FF | Nurse Aide | Verified resident had not been repositioned for 4 hours |
| Nurse Aide KK | Nurse Aide | Verified staff used sit to stand lift instead of full body lift |
| Nurse Aide U | Nurse Aide | Verified staff did not monitor fluid restriction for resident on dialysis |
| Nurse Aide Z | Nurse Aide | Verified staff did not reposition resident correctly for pressure ulcer prevention |
| Nurse Aide QQ | Nurse Aide | Verified resident required two staff for transfer and did not move legs |
| Nurse Aide LL | Nurse Aide | Verified resident requested pain medication frequently |
| Medication Aide MM | Medication Aide | Administered Pulmocort and Brovana nebulizer treatments together |
| Medication Aide U | Medication Aide | Verified no follow up on effectiveness of PRN pain medications |
| Administrative Nurse A | Administrative Nurse | Verified multiple failures including lack of follow up on PRN medications, failure to investigate falls, and failure to monitor fluid restriction |
| Physician HH | Physician Nurse | Verified staff should have had interventions to prevent skin breakdown |
| Physician UU | Physician Assistant | Verified osteomyelitis caused by pressure ulcer and skin breakdown was avoidable |
| Physician CCC | Physician | Verified facility should have been notified of resident's weight loss |
| Dietary Staff M | Dietary Staff | Verified no documentation of pressure ulcers in wound report |
| Dietary Consultant Staff I | Dietary Consultant | Not aware resident had pressure ulcer |
| Administrative Staff TT | Administrative Staff | Stated QAA committee looked at wounds, falls, and weight loss issues with no further information |
| Nurse L | Nurse | Verified expired medication in medication room |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 9, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.10(b)(11) and 483.25 have been corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.25
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 9, 2014
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village, Hays in response to deficiencies cited in a complaint-related survey.
Complaint Details
This Plan of Correction is related to deficiencies cited in a complaint survey for Via Christi Village, Hays.
Findings
The facility identified deficiencies related to skin care and physician notification for residents with wounds or skin deterioration. The plan outlines corrective actions including resident discharge, physician notification protocols, staff education, and auditing procedures to ensure compliance.
Deficiencies (2)
Failure to properly notify physicians and manage skin deterioration for residents with wounds.
Inadequate skin assessments and timely notification to physicians of changes in care and service needs.
Report Facts
Substantial Compliance Date: Jun 9, 2014
Education Date: May 20, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Evans | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Date: May 12, 2014
Visit Reason
The inspection was an abbreviated survey conducted for investigation of complaint #KS00074203 regarding failure to notify of changes in resident conditions and failure to provide necessary care and services related to skin wounds and open wounds.
Complaint Details
The complaint investigation focused on failure to notify changes in resident conditions and failure to provide appropriate care for skin wounds and open wounds in residents #1, #2, and #3. The complaint was substantiated with findings of delayed or absent notifications to physicians and legal representatives and inadequate wound assessments and care.
Findings
The facility failed to immediately inform physicians and/or legal representatives of significant changes in residents' conditions related to skin wounds for 2 of 5 sampled residents and failed to provide necessary care and services to 2 of 3 residents with non-pressure related skin issues, including timely communication with physicians and proper wound assessments.
Deficiencies (2)
Failure to immediately inform the physician and/or resident's legal representative of significant changes in condition related to skin wounds for residents #1 and #2.
Failure to provide necessary care and services to attain or maintain the highest practicable physical well-being for residents #2 and #3, including assessment of open wounds and timely communication with physicians.
Report Facts
Census: 84
Residents sampled: 5
Residents with skin conditions/open wounds: 3
Days without wound assessment: 14
Days delay in physician response: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Interviewed and confirmed lack of notification and wound assessments for residents #1, #2, and #3 | |
| Administrative Nurse B | Confirmed clinical record details regarding notification failures and wound assessments for resident #2 |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Apr 25, 2014
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village, Hays to address deficiencies cited in a prior survey and to comply with state and federal regulations.
Findings
The facility identified multiple deficiencies related to grievance resolution, admission assessments, comprehensive assessments, care plans, pressure ulcer prevention, infection control, medication management, staffing, food safety, and environmental safety. The plan outlines corrective actions including staff education, care plan reviews, routine audits, and monitoring responsibilities with completion dates set for April 25, 2014.
Deficiencies (12)
Failure to promptly resolve grievances involving resident #80
Admission assessments not conducted within 14 calendar days for resident #48
Inaccurate completion of comprehensive assessments
Incomplete initial/admission plan of care for newly admitted residents
Failure to provide necessary treatment and services to residents at risk for pressure ulcers
Failure to provide necessary treatment and services to prevent urinary tract infections
Failure to maintain a safe resident environment to prevent accidents
Failure to monitor targeted behaviors for residents on psychotropic medication
Insufficient nursing staff to maintain residents' well-being
Failure to store and serve food under sanitary conditions and properly obtain temperatures for cold foods
Failure to monitor refrigerator temperature, store medications safely, and remove expired drugs
Failure to track infection locations and ascertain antibiotic effectiveness; inadequate infection control during wound care
Report Facts
Completion date: Apr 25, 2014
In-service make-up deadline: May 15, 2014
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 25, 2014
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 have been corrected.
Findings
The revisit report shows that all previously cited deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 13
Inspection Report
Census: 84
Deficiencies: 11
Date: Mar 26, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements including resident rights, comprehensive assessments, care planning, infection control, medication management, and staffing adequacy.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, incomplete and inaccurate resident assessments, inadequate care planning, failure to provide necessary treatments for pressure ulcers and urinary tract infections, insufficient nursing staff to meet resident needs, improper food handling and storage, expired medications in stock, and inadequate infection control practices.
Deficiencies (11)
Failure to ensure prompt efforts to resolve resident grievances.
Failure to conduct comprehensive admission assessments within 14 days and ensure accuracy of assessments.
Failure to provide services meeting professional standards including lack of initial care plan and fall prevention interventions for a resident with fractured hip.
Failure to provide necessary treatment and services to prevent and heal pressure ulcers including timely repositioning.
Failure to provide appropriate catheter care and individualized toileting plan to prevent urinary tract infections and restore bladder function.
Failure to provide adequate supervision and assistive devices to prevent falls and failure to investigate causal factors related to falls.
Failure to monitor target behaviors for residents receiving antipsychotic medications.
Failure to provide sufficient nursing staff to meet resident care needs and ensure highest practicable well-being.
Failure to store and serve food under sanitary conditions including failure to wear hair coverings during food service and failure to properly monitor cold food temperatures.
Failure to store medications at safe temperatures, failure to monitor refrigerator temperatures daily, and failure to remove expired medications from stock.
Failure to maintain an effective infection control program including failure to track infection origins and antibiotic effectiveness, and failure to follow infection control practices during wound care.
Report Facts
Census: 84
Deficiencies cited: 11
Fall risk assessment scores: 25
Medication room refrigerator temperature: 34
Expired medication count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse J | Nurse | Observed poor infection control practices during wound care for resident #48 |
| Nurse I | Licensed Nurse | Reported lack of initial care plan and fall prevention interventions for resident #115 |
| Nurse D | Administrative Nurse | Verified lack of infection tracking and antibiotic effectiveness monitoring |
| Staff G | Direct Care Staff | Reported no knowledge of fall prevention interventions for resident #115 |
| Staff K | Direct Care Staff | Reported resident refusals and lack of repositioning for resident #22 |
| Staff Z | Direct Care Staff | Reported resident #13 behaviors and documentation practices |
| Staff HH | Dietary Staff | Reported failure to wear hair covering during food service |
| Staff II | Dietary Staff | Reported improper cold food temperature monitoring |
| Staff AA | Direct Care Staff | Reported insufficient staffing and incomplete cares due to staffing |
| Staff KK | Direct Care Staff | Reported staffing shortages and resident complaints about wait times |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 19, 2014
Visit Reason
The inspection 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: 2
Date: Mar 1, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously reported under regulations 483.10(b)(11) and 483.25(c) were corrected as of 03/01/2014.
Deficiencies (2)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.25(c)
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jan 31, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a complaint investigation.
Complaint Details
This Plan of Correction is related to deficiencies cited in a complaint investigation (Event ID OPJ711).
Findings
The plan addresses deficiencies related to communication with physicians regarding elevated temperatures and updating care plans and interventions for residents at risk of pressure ulcers. The facility outlines corrective actions including staff education, audits, and ongoing monitoring to prevent recurrence.
Deficiencies (3)
Preparation and execution of the plan of correction does not constitute admission or agreement by this provider of the truth of the facts set forth in the Statement of Deficiencies.
Communication parameters for when to contact physicians for elevated temperature were not followed.
Care plans and interventions for residents at risk of pressure ulcers were not adequately reviewed or updated.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Date: Jan 30, 2014
Visit Reason
The inspection was conducted as a result of complaint investigations #KS00072097 and #KS00071892.
Complaint Details
The citations represent findings from complaint investigations #KS00072097 and #KS00071892.
Findings
The facility failed to immediately notify the physician of a significant change in a resident's physical condition (elevated temperature) and failed to ensure residents with pressure ulcers received necessary treatment and services including consistent wound assessments and use of prescribed devices such as air boots.
Deficiencies (2)
Failed to immediately notify the physician of a significant change in a resident's physical condition (elevated temperature) for 1 of 3 sampled residents (#11).
Failed to ensure 2 of 3 residents reviewed for pressure ulcers received necessary treatment and services (consistent skin/wound assessments and use of 'air boots' as care planned) to promote healing and prevent new sores from developing (#11 and #13).
Report Facts
Resident temperatures: 103
Census: 88
Pressure ulcer measurements: 4.7
Pressure ulcer measurements: 5.3
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 1.7
Pressure ulcer measurements: 0.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Administrative Nurse | Verified licensed staff should notify physician immediately of fever and confirmed air boots should be on resident #11 at all times |
| Nurse C | Administrative Nurse | Assisted with wound care and confirmed weekly skin assessments should be documented |
| Nurse L | Licensed Nurse | Stated staff documented dressing changes but did not document wound condition with each dressing change |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Oct 24, 2013
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 confirms that the deficiencies previously cited under regulations 483.25(a)(3), 483.25(h), and 483.30(a) were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.30(a)
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Sep 24, 2013
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays in response to deficiencies cited in a complaint survey conducted at the facility.
Complaint Details
This Plan of Correction is in response to a complaint survey identified by Event ID 29NF11 and linked to Deficiency Report (2567).
Findings
The plan addresses deficiencies related to resident bathing schedules and documentation, environmental safety including door alarms, and sufficient nursing staff to provide care. The facility outlines corrective actions including staff education, audits, and quality assurance reviews to ensure compliance.
Deficiencies (3)
Failure to provide residents who are unable to carry out activities of daily living with necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision and assistive devices to prevent accidents.
Failure to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Report Facts
Deficiencies cited: 3
Plan of Correction completion date: All corrective actions targeted for completion by 10/24/2013
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 3
Date: Sep 24, 2013
Visit Reason
The inspection was an abbreviated survey conducted for investigation of complaint #KS68655 regarding failure to provide necessary bathing and hygiene services to residents.
Complaint Details
The visit was triggered by complaint #KS68655 concerning inadequate bathing and hygiene care for residents.
Findings
The facility failed to provide adequate bathing and hygiene care to 4 sampled residents as per their care plans and preferences. Staff shortages and inadequate supervision contributed to failure in meeting residents' needs, including delayed response to call lights and door alarms. Additionally, staff failed to respond to a door alarm leading to a stairwell for over 23 minutes, posing a safety hazard.
Deficiencies (3)
Failure to provide necessary bathing and hygiene care to 4 sampled residents as per care plans and preferences.
Failure to ensure the environment remained free of potential hazards when staff failed to respond to a door alarm on a stairwell door for more than 23 minutes.
Failure to have sufficient nursing staff to meet residents' needs related to bathing, supervision, grooming, toileting, and response to alarms.
Report Facts
Residents sampled: 4
Facility census: 90
Bathing failures for Resident #4: 25
Bathing failures for Resident #4: 22
Bathing failures for Resident #4: 16
Bathing failures for Resident #4: 14
Baths provided to Resident #1: 1
Baths provided to Resident #2: 4
Baths provided to Resident #2: 5
Baths provided to Resident #2: 7
Baths provided to Resident #2: 2
Baths provided to Resident #3: 0
Baths provided to Resident #3: 1
Baths provided to Resident #3: 3
Baths provided to Resident #3: 0
Door alarm duration: 23
Number of nursing units: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Reported awareness of bathing documentation issues and staffing shortages |
| Licensed Nurse B | Licensed Nurse | Reported residents sometimes do not receive scheduled baths due to staffing shortages |
| Direct Care Staff D | Direct Care Staff | Reported facility does not use bath aides and confirmed bathing deficiencies due to staffing |
| Direct Care Staff E | Direct Care Staff | Reported day shift occasionally lacks time to complete baths and passes them to evening shift |
| Administrative Nurse C | Administrative Nurse | Reported door alarm activation and staff responsibility to respond |
| Administrative Staff G | Administrative Staff | Reported staff expected to respond to resident pages within 5 minutes |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 19, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report shows that deficiencies identified under regulations 483.25, 483.25(m)(2), and 483.75(j)(1) were corrected as of 07/18/2013.
Report Facts
Deficiency correction dates: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jun 21, 2013
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays in response to deficiencies cited in a complaint survey conducted at the facility.
Complaint Details
This Plan of Correction is related to a complaint investigation survey conducted at Via Christi Village Hays.
Findings
The facility identified deficiencies related to monitoring vital signs and weights per physician orders, medication administration errors, and timely provision of laboratory services. The plan outlines corrective actions including re-education of clinical staff, clarification of physician orders, and ongoing compliance monitoring.
Deficiencies (3)
Failure to monitor vital signs and weights per physician orders
Significant medication errors
Failure to provide or obtain laboratory services in a timely manner
Report Facts
Date of plan completion: Jul 18, 2013
Resident discharge date: May 28, 2013
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Date: Jun 21, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#KS00066524) to evaluate allegations related to the facility's provision of care and services to residents.
Complaint Details
The complaint investigation (#KS00066524) found deficiencies related to failure to provide care and services as ordered, medication errors, and delayed laboratory services.
Findings
The facility failed to provide necessary care and services to maintain residents' highest practicable well-being, including failure to monitor vital signs and weights as ordered for residents #1 and #2. Additionally, the facility failed to ensure residents were free from significant medication errors and timely laboratory services, resulting in hospitalization of resident #1.
Deficiencies (3)
Failure to provide necessary care and services including monitoring vital signs and weights daily as ordered for residents #1 and #2.
Failure to ensure residents are free of significant medication errors; resident #1 did not receive medications as ordered resulting in hospitalization.
Failure to provide or obtain laboratory services in a timely manner for resident #1, resulting in delayed treatment and hospitalization.
Report Facts
Census: 88
Residents sampled: 3
Weight recordings for resident #2: 2
Weight recordings for resident #2: 2
Weight recordings for resident #2: 2
Vital signs recorded for resident #2: 5
Vital signs recorded for resident #2: 8
Vital signs recorded for resident #2: 2
Weight not recorded for resident #1: 1
Metolazone doses administered: 4
Lab test delay: 5
Critical low sodium level: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Confirmed lack of monitoring vital signs and weights, medication errors, and lab test delays. |
| Direct Care Staff C | Reported nurse aides obtain weights and vital signs and write them down. | |
| Direct Care Staff D | Reported nurses recently started giving aides lists of residents needing weights and vital signs. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 20, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report shows that deficiencies identified under regulations 483.25(h) and 483.30(a) were corrected as of 04/20/2013.
Deficiencies (2)
Deficiency under regulation 483.25(h)
Deficiency under regulation 483.30(a)
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 20, 2013
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays in response to deficiencies cited in an abbreviated survey inspection.
Findings
The facility identified deficiencies related to accident hazards and supervision during mechanical lifts, as well as insufficient nursing staff to meet resident needs. The plan includes re-education of clinical staff and review of work schedules to ensure compliance and resident safety.
Deficiencies (2)
Failure to provide an environment free of accident hazards and adequate supervision during mechanical lifts.
Insufficient nursing staff to meet the needs of residents requiring assistance with care.
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Date: Mar 21, 2013
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #KS00064457 and #KS00064469 regarding resident safety and staffing issues.
Complaint Details
The visit was triggered by complaint investigations #KS00064457 and #KS00064469. The complaints involved inadequate supervision and assistance during mechanical lift transfers and insufficient staffing leading to delays in resident care.
Findings
The facility failed to ensure that residents' environments remained free of accident hazards due to staff not following the policy for using sit-to-stand lifts, affecting residents #6 and #7. Additionally, the facility failed to provide sufficient nursing staff to safely perform mechanical lift transfers, impacting 2 sampled residents and 15 non-sampled residents.
Deficiencies (2)
Failure to ensure resident environment remained free of accident hazards due to improper use of sit-to-stand lift for residents #6 and #7.
Failure to provide sufficient nursing staff to safely perform mechanical lift transfers for residents, including #6 and #7.
Report Facts
Census: 93
Residents sampled for accident hazards: 5
Residents requiring mechanical lift: 17
Residents affected by staffing deficiency: 17
Resident #6 Fall Risk Assessment Score: 35
Resident #7 Fall Risk Assessment Score: 9
High risk fall score threshold: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff E | Reported that approximately 20% of the time staff transferred residents with sit-to-stand lift alone due to lack of help | |
| Direct Care Staff H | Reported using sit-to-stand lift alone for residents, including resident #6, and described staffing challenges | |
| Consultant J | Reported physical therapy recommendations for two staff to transfer residents using mechanical lifts and provided in-service training | |
| Administrative Nursing Staff B | Reported 17 residents used mechanical lifts | |
| Administrative Staff A | Reported facility expectation of two staff for sit-to-stand lifts including for resident #6 and #7 | |
| Licensed Nursing Staff C | Reported difficulty monitoring staff due to assignment to two neighborhoods | |
| Licensed Staff I | Reported staffing patterns and challenges with two-person assists | |
| Licensed Nursing Staff D | Reported being stretched thin and inability to monitor staff and resident needs adequately |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 7, 2013
Visit Reason
The document is a licensure resurvey conducted to assess compliance for renewal of the facility's license.
Findings
The licensure resurvey resulted in a finding of no deficiency citations for the facility.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 7, 2013
Visit Reason
This revisit report documents the follow-up inspection to verify that previously reported deficiencies have been corrected and the dates such corrective actions were accomplished.
Findings
The report confirms that deficiencies identified in the prior survey were corrected by the dates indicated, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (2)
Deficiency with regulation number 28-39-161 corrected
Deficiency with regulation number 26-40-302 (5)(a)(b)(i)(ii)(c)(d)(e) corrected
Inspection Report
Follow-Up
Deficiencies: 24
Date: Feb 7, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report shows that all previously cited deficiencies were corrected as of 01/04/2013, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (24)
Deficiency identified under regulation 483.10(b)(5)-(10), 483.10(b)(1)
Deficiency identified under regulation 483.10(g)(1)
Deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency identified under regulation 483.15(a)
Deficiency identified under regulation 483.15(b)
Deficiency identified under regulation 483.15(f)(1)
Deficiency identified under regulation 483.20(b)(1)
Deficiency identified under regulation 483.20(b)(2)(ii)
Deficiency identified under regulation 483.20(d), 483.20(k)(1)
Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2)
Deficiency identified under regulation 483.20(k)(3)(i)
Deficiency identified under regulation 483.25
Deficiency identified under regulation 483.25(a)(2)
Deficiency identified under regulation 483.25(c)
Deficiency identified under regulation 483.25(d)
Deficiency identified under regulation 483.25(h)
Deficiency identified under regulation 483.25(i)
Deficiency identified under regulation 483.25(l)
Deficiency identified under regulation 483.30(a)
Deficiency identified under regulation 483.35(i)
Deficiency identified under regulation 483.60(a),(b)
Deficiency identified under regulation 483.60(c)
Deficiency identified under regulation 483.65
Deficiency identified under regulation 483.75(o)(1)
Report Facts
Correction completion date: Jan 4, 2013
Follow-up survey date: Feb 7, 2013
Previous survey date: Dec 13, 2012
Inspection Report
Plan of Correction
Deficiencies: 26
Date: Jan 4, 2013
Visit Reason
This document is a Plan of Correction submitted by Via Christi Village Hays in response to deficiencies cited during a prior survey. It outlines corrective actions to address various regulatory compliance issues identified in the facility.
Findings
The plan details multiple areas requiring improvement including resident care plans, investigation of un-witnessed injuries, provision of dignified services, individualized care and activity programming, infection control, medication management, staffing adequacy, food safety, and environmental safety. The facility commits to staff re-education, care plan revisions, and quality assurance monitoring to ensure compliance.
Deficiencies (26)
Failure to provide contact information for State advocacy groups
Failure to maintain survey results accessible to residents
Failure to thoroughly investigate un-witnessed injuries and report to state agency
Failure to provide services in a dignified manner
Failure to honor resident choices and preferences
Failure to provide activity programming meeting resident preferences
Failure to complete comprehensive resident assessments using RAI
Failure to complete comprehensive assessment within 14 days of significant change
Failure to create and provide individualized and comprehensive care plans
Failure to review and revise care plans based on individual resident needs
Failure to develop individualized temporary care plans upon admission
Failure to provide individualized interventions and ongoing reassessment for behavioral interventions
Failure to provide appropriate treatment and services to improve or maintain ADLs
Failure to provide necessary treatment and services to promote healing and prevent pressure sores
Failure to provide appropriate bladder and catheter care
Failure to provide an environment free of accident hazards and adequate supervision
Failure to consistently provide fortified foods as planned
Failure to monitor drug regimens to be free of unnecessary drugs
Failure to provide sufficient nursing staff
Failure to store, prepare, and serve food in a sanitary manner
Failure to provide appropriate services to assure accurate insulin administration
Failure to act upon reports of drug regimen irregularity
Failure to maintain an infection control program
Failure to maintain a quality assessment and assurance committee
Failure to monitor wash water temperatures to conform with chemical supplier instructions
Failure to maintain an air gap on ice maker drain lines
Report Facts
Deficiencies cited: 25
Re-education dates: 12
Inspection dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Renee Davison | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Dec 13, 2012
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation into complaint #62306.
Complaint Details
The visit was complaint-related, investigating complaint #62306. The complaint was substantiated as deficiencies were found in infection control and dietary service areas.
Findings
The facility failed to ensure daily monitoring of wash water temperatures for low temperature washing of linens and failed to maintain an air gap on six ice machine drains across six neighborhoods.
Deficiencies (2)
Failure to ensure staff monitored wash water temperatures daily to conform with chemical suppliers' instructions for low temperature washing of linens.
Failure to maintain an air gap on six ice machine drains in the facility's neighborhoods.
Report Facts
Facility census: 92
Number of ice machines without air gap: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff BB | Administrative staff | Interviewed regarding wash water temperature monitoring. |
| Staff O | Administrative maintenance staff | Confirmed no daily monitoring of wash water temperatures and lack of awareness of state requirements. |
| Staff N | Maintenance staff | Interviewed regarding ice machine drain connections. |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Oct 7, 2011
Visit Reason
This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies have been corrected as of the revisit date, with corrections completed on 10/07/2011 for multiple regulatory items.
Deficiencies (6)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 6
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Oct 7, 2011
Visit Reason
This report is a revisit conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the deficiency identified under regulation 26-40-304(d) with ID prefix Z1330 was corrected as of 10/07/2011.
Deficiencies (1)
Deficiency under regulation 26-40-304(d) previously reported
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 1
Date: Sep 7, 2011
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements related to facility safety and monitoring systems.
Findings
The facility failed to ensure that three exit doors to the building exterior had an adequate monitoring system, with keypad codes posted and alarm delays that could allow residents to exit without triggering alarms.
Deficiencies (1)
Failed to ensure 3 exit doors to the building exterior had an adequate monitoring system.
Report Facts
Residents present: 58
Residents independently mobile with cognitive impairment: 20
Residents at risk for elopement: 4
Exit doors with keypad locks: 3
Alarm delay seconds: 15
Alarm delay seconds after reset: 3
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