Should the facility be unable or unwilling to make necessary corrections, the federal and state agencies will place the nursing center on a watch list and designate the Home as a Special Focus Facility (SFF). This undesirable designation helps to alert the administration and nursing staff that serious concerns of ongoing violations will no longer be tolerated. With this designation, the nursing home will have to undergo many more investigations and surveyors compared to facilities in good standing. If the Home continues to pass surveys and inspections over the months and years after receiving the designation, CMS can remove the nursing home’s designation from the list.
Recently, Orange Gardens (Woodlawn) Care and Rehabilitation Center was designated a Special Focus Facility (SFF). The facility must now take appropriate measures to develop, implement and enforce new policies and procedures to overcome the underlying problems causing serious concerns at the facility. Some of those concerns are listed below.
Woodlawn Care and Rehab, LLC, d.b.a. Orchard Gardens provides nursing cares and services to the residents of Wichita and Sedgwick County, Kansas. The facility is located at:
1600 S. Woodlawn Blvd.
Wichita, KS 67218
(316) 691-9999
In addition to providing long-term care and short-term rehabilitation, the facility also provides bariatric care, wound care, respite and hospice care, cardiac rehabilitation, post-surgical rehab, transitional care, IV therapy, diabetes care, cancer care, pain management, nutritional management, and restorative nursing.
Once the Centers for Medicare and Medicaid Services and Kansas state investigators have concluded on-site inspections and surveys, the administration is made aware of any identifiable violation of nursing home regulations. In addition to needing to perform immediate corrections, the facility might also face stringent penalties and monetary fines for any violation that causes harm, or could cause harm, to a resident, visitor or staff member.
Woodlawn Care and Rehabilitation (Orchard Gardens) was issued a $15,286 fine on January 9, 2017, and a $37,863 fine on June 14, 2016, totaling more than $50,000 in monetary penalties.
Both the CMS and the state of Kansas routinely update information posted on the federal Medicare.gov website on every nursing home facility in the United States. The data on the site provides valuable information and uses a star rating system to compare different facilities in local communities. Currently, Orchard Gardens (Woodlawn) Care and Rehabilitation Center maintains an overall one out of five stars compared to other facilities nationwide. This ranking includes one out of five stars for health inspections, one out of five stars for staffing, and one out of five stars for quality measures.
Current safety concerns involving nursing home residents at Orchard Gardens are listed below. They include:
Failure to Protect Every Resident from Abuse, Physical Punishment, and Being Separated from Others
In a summary statement of deficiencies dated June 29, 2017, the state investigators noted the facility’s failure “to ensure [that a resident] remained free from sexual abuse when [another resident placed their private parts in the abused resident’s] face.” The assaulting resident “tried to get [the abused resident] to perform a sexual act. This deficient practice placed [the abused resident] in Immediate Jeopardy.”
The abused resident was interviewed in the early afternoon of June 20, 2017, after reporting that the alleged sexual perpetrator resident “was mean to him/her. The resident stated that [the alleged sexual perpetrator kissed them] on the lips and tried to get [them] to perform a sexual act.” The resident stated that they “were afraid of [the alleged sexual perpetrator] and the staff moved [the perpetrator] to a different room.”
An administrative staff member “stated since there was no actual contact” the case was never reported. This individual stated that “they were aware that [the victim] was afraid of [the alleged sexual perpetrator].” A different administrative staff member “confirmed the facility did not protect all the other residents in the facility by just moving [the alleged sexual perpetrator] to a different room where [they] would have access to residents on that hall.”
The state investigator reviewed the facility’s undated policy titled “Abuse, Neglect, and Exploitation (ANE)” that revealed “staff would report all allegations of ANE immediately to the Administrator. The Administrator would ensure all alleged violations needed to be investigation reported immediately to the State Agency Complaint Hotline. If any suspect the resident to resident abuse, staff would provide continuous, uninterrupted 1:1 supervision of the resident and to the physician, family and facility management staff assess the resident and provided treatment to stop any further incidents.”
Failure to Hire Individuals without a Legal History of Abusing, Neglecting, or Mistreating Residents
Failure to Report and Investigate Any Action Reports of Abuse, Neglect, or Mistreatment of Residents
In a summary statement of deficiencies dated June 29, 2017, the state investigator noted that the facility had failed to “provide adequate supervision to a mobile resident who was found sexually abusing [another resident].” At the time of the investigation, there were 68 residents at the facility. The state investigator also noted the facility’s failure “to immediately report an allegation of “resident to resident” abuse which involved [the abusive perpetrator] to the State Agency.
It was also noted that the facility “failed to thoroughly investigate the incident, and failed to submit the results of the investigation to the State Agency within five working days [as required by law].” The failure “to implement appropriate actions to protect all residents after the allegation of resident to resident sexual abuse placed all the residents in Immediate Jeopardy.”
In a separate summary statement of deficiencies dated June 14, 2016, state investigator noted the facility’s failure “ensure that all alleged violations involving mistreatment, the neglect or abuse and, including injuries of unknown source …were reported immediately to the Administrator of the facility, and other officials in accordance with State law. This deficient practice affected [two residents] in regards to a resident to resident altercation and an allegation of stolen resident property.”
The state investigator reviewed “a list of resident-to-resident altercations provided by the facility from January 1, 2016, through May 31, 2016, that “revealed known investigation reporting of the altercation which involved a resident and his/her roommate on March 20, 2016, or April 6, 2016.” The state investigator noted that the facility failed to file their August 2013 policy titled Abuse, Prevention, and Prohibition that reads in part:
“The facility prohibits mistreatment, neglect or abuse of the residents by anyone. The facility employee or agent who became aware of abuse shall immediately report the matter to the facility Administrator and/or the Director of Nursing. Any allegation of abuse or neglect should report or cause a report to be made to the mandated State Agency per reporting criteria.”
The investigator stated that the facility “failed to report allegations of mistreatment/abuse to the State agency when [one resident] pulled [another resident from their bed] and the second incident when [the same abuse of resident] stood over [the same victim] threatening them.”
Failure to Develop, Implement and Enforce Policy to Prevent Mistreatment, Neglect or Abuse
It was also noted in the June 29, 2017, summary statement of deficiencies that the facility had failed “to protect all residents from …abuse and failed to report the allegation of resident-to-resident sexual abuse of [the victim and sexual perpetrator] to the State Agency. An administrative nursing staff member at the facility “confirmed [that] the facility did not protect all the other residents in the facility by just moving [the alleged sexual perpetrator) to a different room.” This is because the perpetrator would have access to all the other residents in the facility. It was noted that the facility “failed to implement their Written Policy regarding protecting, reporting, and investigating an allegation of sexual abuse.”
In a separate summary statement of deficiencies dated June 14, 2016, the state investigator noted the facility had failed to “develop written policies and procedures to prohibit mistreatment, neglect or abuse of residents and the misappropriation of resident property in regards to identification and reporting. This deficient practice had the potential to affect all 78 residents.”
The investigator noted that the facility had failed to follow their own August 2013 policy titled Abuse, prevention, and Prohibition that revealed that “the facility prohibited mistreatment, neglect or abuse of the resident by anyone. The facility also prohibited misappropriation of resident property.”
Failure to Provide Every Resident a Safe Environment with Sufficient Supervision to Prevent Avoidable Accidents
In a summary statement of deficiencies dated June 29, 2017, the surveyor noted the facility’s failure “to determine causal factors, and develop and implement interventions to [protect a resident].” It was noted that the resident “received an antipsychotic, antidepressant and a hypnotic medication daily for seven days.” A review of the resident’s February 8, 2017, ADL Functional Care Area Assessment revealed that “the resident needed the limited assistance of one staff [member] for most activities of daily living but needed extensive assistance with locomotion and personal hygiene. The resident walked with the limited assistance of one staff [members].”
A review of the resident’s February 2017 Care Plan revealed that “staff identified the resident at risk for elopement” and had significant interventions that included “check wander guard placement and function every shift.” However, a review of the June 26, 2017, Notarized Witness Statement revealed that a licensed nurse “was in the dining room area and heard an alarm.” That staff member “walked around to see what the alarm was and as [they] got closer to Hall 2 exit door, [they] realized the alarm was the Hall 2 door.”
Looking outside, the licensed medical professional noticed “all the residents sitting in [their] wheelchair just outside the door.” The resident was found to be “alert but confused and [their] vital signs were within normal limits.”
In a separate summary statement of deficiencies dated June 14, 2016, the state investigator noted the facility’s failure “to provide adequate monitoring of water temperatures to maintain safe water temperatures in resident areas.” During an observation, it was noted that the facility “allowed the water to reach 141°F in a common resident shower as well as resident rooms…” This failure had the potential to affect all 29 residents in the unit by potentially causing third-degree burns (a severe burn characterized by the destruction of the skin through the depth of the dermis and possibly into the underlying tissues).”
Failure to Provide Sufficient Care to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal
In a summary statement of deficiencies dated June 14, 2016, the state investigator noted the facility’s failure “to implement effective interventions to prevent the development of an avoidable Stage III pressure ulcer that developed 15 days after admission.” A Stage III pressure sore involves full thickness tissue loss; fat located beneath the skin may be visible, but bone, tendon or muscle are not exposed. It was also noted that the facility “further failed to thoroughly assess the wound at the time of discovery [using] measurements.”
The state investigator interviewed the staff members providing the resident care that revealed that the “resident required total assistance for all cares and had a pressure ulcer. However, the staff member “did not remember if the resident required turning or repositioning.
Every nursing facility in the US is required by law to provide the highest standard of care that protects and maintains the resident’s health, dignity, and well-being. Any level of substandard care could be deemed abuse, negligence, and mistreatment. If you, or your loved one, were injured while residing in a nursing facility, it is best to use the skills of a personal injury attorney who specializes in abuse and neglect cases to handle your compensation claims. With legal representation, you can file a claim for compensation before the statute of limitations expires to ensure your family receives the financial recovery they deserved for your damages.
These abuse and neglect cases are typically handled through contingency fee arrangements. This agreement means no upfront payment is necessary because all legal services are paid only after the monetary recovery case is resolved successfully through a negotiated out of court settlement or a jury trial award.
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Sources:
For more information the laws applicable to Kansas nursing homes, please visit the page here.
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Attorney Ruben Krisztal
Licensed in Kansas
Wichita Nursing Home Injury Lawyer Nursing Home Law Center LLC Home