Hatton Prairie Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment for 1 of 13 sampled residents (Resident #29) reviewed for advance directives. Failure to ensure the medical record accurately reflected each resident's code status limited the facility's ability to communicate to direct care staff and emergency personnel the residents' choice in the event of a medical emergency.Findings include:Review of Residents #29's medical record occurred all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition.A physician's order signed on 05/21/25 stated code level I (All available reasonable technology will be used in the event of cardiac or respiratory arrest). The resident's demographic face sheet and code status form, signed by the resident and facility representative on 08/27/25 showed Code Status: DNR [do not resuscitate]/DNI [do not intubate]. The medical record lacked the current code status for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 5 sampled residents (Resident #6) reviewed for unnecessary medications. Failure to correctly transcribe physician orders placed residents at risk for medication errors and adverse health events. Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Clarification from any other source is unacceptable and regarded as a departure from competent nursing practice.Review of the facility policy titled Physician Signature occurred on 09/24/25. This policy, dated June 2024, stated, . To establish a consistent process for obtaining physician signatures on all required clinical and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview the facility failed to follow standards of infection control for 1 of 2 sampled residents (Resident #12) observed during a dressing change. Failure to follow infection control practices during wound care has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Dressing Change (Clean) occurred on 09/24/25. This policy, dated June 2024, stated, . Perform hand hygiene . Create clean field with paper towels or towelette dressing . Open dressing pack. Put on first pair of disposable gloves. Remove soiled dressing and discard . Dispose of gloves . Put on second pair of disposable gloves . Cleanse wound . Apply dressings . Review of Resident #12's medical record occurred on all days of survey. The current care plan stated, . Resident has a pressure ulcer present upon admission . Monitor pressure ulcer daily, change dressing daily. A current physician's order stated, Change Mepilex [an absorbent foam dressing] to coccyx [tailbone] daily and PRN [as needed]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, and staff interview the facility failed to ensure residents were offered the pneumococcal immunization for 1 of 5 sampled residents (Resident #5) reviewed for immunizations. Failure to administer the pneumococcal vaccine to all eligible residents and document the administration has the potential for non-immunized residents to contract pneumonia and spread the infection to other residents, visitors, and staff.Findings include:Review of the CDC: Vaccines and Preventable Diseases webpage (https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html), dated October 26, 2024, stated, . CDC recommends pneumococcal vaccination . age [AGE] years or older who have . Not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown .Review of Resident #5's medical record occurred on all days of survey. A form titled, 2023-2024 Vaccination Season, signed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect residents' current status for 5 of 13 sampled residents (Resident #4, #13, #15, #30 and #32) and 1 supplemental resident (Resident #35). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plans and Care Plan Team occurred on 09/05/24. This policy, dated 10/28/22, stated, . The Care Plan Team will develop and implement a comprehensive care plan for each resident. The care plan includes the following: Resident's doctor's plan of medical care to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . Care plans will be individualized to meet the needs of a resident . Each resident will have care plan meetings when moving into the facility, quarterly, annually and if the resident has a significant change in health. The care plan team will review and revise a resident's care plan at each of these…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of professional reference, and staff interview, the facility failed to ensure food is stored in accordance with professional standards and in a sanitary environment in 1 of 1 kitchen (main kitchen). Failure to ensure food is safe from sources of contamination may result in a foodborne illness or adverse effects for residents, visitors, and staff. Findings include: The 2022 Food and Drug Administration (FDA) Food Code, Annex 3-100 stated, . Preventing contamination from the premises . 3-305.11 Food Storage. Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate . can be sources of microbial contamination for stored food. Chapter 6-3 Physical Facilities . 6-202.12 Heating, Ventilating, Air Conditioning System Vents. Heating, ventilating, and air conditioning systems shall be designed and installed so that . air intake and exhaust vents do not cause contamination of FOOD, FOOD-CONTACT SURFACES, EQUIPMENT, or UTENSILS. Observation of the kitchen on 09/03/24 at 11:45 a.m. showed the following: - Walk-in Freezer: Two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer or a copy of the notice to the State Long Term Care Ombudsman for 1of 1 resident (Resident #4) reviewed for hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights and does not allow the ombudsman to be aware of facility practices regarding transfer and discharge or advocate on the resident's behalf. Findings include: Review of the facility policy Transfer and Discharge of Resident occurred on 09/05/24. This policy, dated October 2022, stated, . Notify the resident and resident's representative in writing of the transfer . Give original notice to resident and resident's personal representative by first class mail or personal delivery; . send copies of transfer and discharge notices to the Office of the State Long Term Care Ombudsman . Review of Resident #4's medical record occurred…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or resident's representative a written bed hold notice for 1 of 1 resident (Resident #4) reviewed for hospital transfer. Failure to provide a written copy of the bed hold notice and include the reserve bed amount does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy Holding A Resident's Bed During Absences occurred on 09/05/24. This policy, dated November 2016, stated, . will inform a resident, legal representative and interested family members of our policy on holding a resident's bed during a resident's absence from our facility. prior to any hospitalization or therapeutic leave, including the amount of the bed-hold charge. Review of Resident #4's medical record occurred on all days of survey. A hospital transfer occurred on 06/17/24. The medical record lacked evidence the facility provided the resident and/or their representative with a written bed hold notice or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to complete a significant change is status assessment (SCSA) for 1 of 1 supplemental resident (Resident #35) who elected hospice services. Failure to complete a SCSA may affect the development of a comprehensive care plan and the care provided to the resident. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, page 2-25 stated, . An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program . The ARD [assessment reference date] must be within 14 days from the effective date of the hospice election. Review of Resident #35's medical record occurred on September 3-4, 2024. A progress note, dated 07/03/24, identified the resident elected hospice services. The facility failed to complete a SCSA when Resident #35 elected hospice services. During an interview on 09/05/24 at 8:30 a.m., an administrative nurse (#7) confirmed the facility failed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 13 sampled residents (Resident #4, #12, and #32). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2023, pages I-7 to I-8, stated, . Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Review of Resident #12's medical record occurred on all days of survey. The care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring for 1 of 1 sampled resident (Resident #28) with an elopement. Failure to identify the resident's risk for elopement and implement, monitor, and modify individualized resident-centered interventions when necessary placed the resident's health and safety at risk when they eloped from the facility. Findings include: Review of the facility policy titled MISSING RESIDENT occurred on 09/05/24. This policy, dated November 2018, stated, . [NAME] Prairie Village assesses residents prior to and upon admission for elopement risk, including all cognitively impaired residents. It also reassesses residents periodically to see if elopement risk is now present, has decreased or increased. Review of Resident #28's medical record occurred on all days of survey and included the diagnoses of dementia and restlessness and agitation. The care plan, dated 07/24/24, stated, .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 2 of 5 sampled residents (Resident #4, and #12) and 1 supplemental resident (Resident #35) observed during cares. Failure to follow infection control practices during resident cares related to hand hygiene, glove use, and enhanced barrier precautions (EBP), has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Glove Use occurred on 09/05/24. This policy, dated June 2024, stated, . Gloves shall be used for touching excretions, secretions, blood, body fluids, mucous membranes, and non-intact skin. Handwashing is necessary even if gloves are worn. Handwashing should be completed after every removal of gloves. Review of the facility policy titled Enhanced Barrier Precautions (EBP) occurred on 09/05/24. This policy, dated April 2024, stated, . staff will use EBP (gowns and gloves) for residents with any of the following: . Indwelling medical devices, . Indwelling medical device…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to provide care in accordance with professional standards for 1 of 13 sampled residents (Resident #13) who experienced an unwitnessed fall. Failure to perform neurological assessments and follow up on a blood pressure identified as out-of-range following a fall may result in delayed identification and treatment of a resident's medical condition. Findings include: Review of the facility policy titled NEUROLOGICAL ASSESSMENT occurred on 10/05/23. This undated policy stated, . All residents experiencing an unwitnessed fall will have a neurological assessment completed by a nurse. The neurological assessment will be done every 12 hours x [for] 3 days . Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 535-536, stated, . blood pressure . is an important indicator of the client's condition and is used extensively as a basis for nursing interventions. confirm accuracy of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.