Koester Pavilion
Inspection History Overview
Detailed Inspection Reports
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Fines and Penalties by Year
2021 3 penalties totaling $40,976
Fine
Fine
Payment Denial
2019 1 penalties totaling $23,240
Fine
Health Violations by Year
2024 13 violations
Ensure that residents are fully informed and understand their health status, care and treatments.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Assess the resident when there is a significant change in condition
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each residentβs drug regimen must be free from unnecessary drugs.
Ensure that residents are free from significant medication errors.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Provide and implement an infection prevention and control program.
2022 1 violations
Ensure staff are vaccinated for COVID-19
2021 15 violations
Reasonably accommodate the needs and preferences of each resident.
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Provide and implement an infection prevention and control program.
Ensure that residents are free from significant medication errors.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2019 9 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
2018 10 violations
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Notify the resident or the residentβs representative in writing how long the nursing home will hold the residentβs bed in cases of transfer to a hospital or therapeutic leave.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2017 4 violations
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
Ensure residents maintain acceptable nutritional status.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.