Inspection Reports for
Locust Grove Village

The administrator failed to ensure disaster and emergency preparedness by not conducting quarterly reviews of the facility's emergency management plan with employees and residents as required.

The Plan of Correction details updates to the Medication Administration Record to include pulse checks, training of the Medical Record clerk, removal of outdated medications, and ongoing monitoring responsibilities assigned to the Director of Nursing and consulting pharmacists.

The survey found an isolated 'D' level deficiency that constitutes no actual harm but has potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility is found to be in substantial compliance effective 2018-09-18.

The facility failed to assess one resident's pulse prior to medication administration as ordered by the physician, and failed to discard expired medications including insulin and calcium tablets, placing residents at risk for physical decline and ineffective medication use.

The survey found the facility was not in substantial compliance and conditions constituted immediate jeopardy to resident health or safety related to F689, "J", CFR 483.25 (d)(1)(2). Enforcement remedies including denial of payment for new admissions were imposed without opportunity to correct.

Complaint investigation #130370 regarding failure to report an incident where Resident #1's wheelchair became unsecured in the facility van, resulting in a life-threatening situation and death. The incident was not reported timely to the state agency due to ongoing police investigation. The facility investigation revealed inconsistent training and failure to secure wheelchairs properly.

The facility failed to report the incident in a timely manner and failed to provide thorough, consistent training to van drivers on securing residents in wheelchairs. The resident's wheelchair became unsecured on two occasions, with the last incident resulting in death. The facility lacked documentation of driver training and did not perform routine competency checks. Immediate jeopardy was abated after retraining drivers and removing the van from service.

The administration timely reported the incident to law enforcement and the KDADS Complaint Hotline. No abuse, neglect, or mistreatment by staff was found. Retraining of van drivers was implemented, including competency audits and policy reviews, with ongoing compliance responsibilities assigned to the Director of Maintenance and Administrator.

The report confirms that the previously cited deficiency with regulation number 28-39-158(a) was corrected as of 02/24/2017. No other deficiencies or findings are noted in this revisit report.

The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-206 (a)(b) and 26-41-206 (d) have been corrected as of 02/24/2017.

The Plan of Correction addresses deficiencies related to dietary services and food preparation, including staff training and policy compliance regarding facial hair covering procedures.

The Plan of Correction addresses multiple deficiencies including failure to report incidents timely, pressure sore treatment and prevention, accident hazard management, drug regimen issues, food storage and preparation, infection control, and dietary services. The facility outlines training, policy reviews, and quality assurance measures to ensure compliance.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy. Due to repeated noncompliance, the facility was denied payment for new Medicare and Medicaid admissions effective February 19, 2017, until substantial compliance is achieved or the provider agreement is terminated.

The facility failed to provide a full-time certified dietary manager for its 13 residents and failed to maintain sanitary food preparation and serving conditions, placing residents at risk for inadequate nutrition and foodborne illness.

The facility failed to provide a full-time certified dietary manager for 40 of 41 residents receiving meals from the facility's kitchen, placing residents at risk of inadequate nutrition.

The survey found the most serious deficiencies at the facility to be at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy.

The revisit confirmed that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 10/01/2016. No other deficiencies or uncorrected issues were noted.

The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy for F323 "J", CFR 483.25(h). Deficiencies were cited that constituted a level of actual harm or above, leading to enforcement remedies including denial of payment for new admissions.

The complaint investigation #105429 and #105414 revealed that Resident #1, diagnosed with dementia and anxiety disorder, displayed exit-seeking behavior with 11 attempts to leave the facility in one day. The resident eloped without staff knowledge and was found 3 blocks away by an off-duty staff member. The Wanderguard alarm system was not functioning properly and staff failed to monitor it, leading to immediate jeopardy.

The facility failed to provide adequate supervision to prevent elopement for one cognitively impaired resident who attempted to leave the facility 11 times in one day and eventually left unnoticed, placing the resident in immediate jeopardy. The Wanderguard alarm system was found to be malfunctioning and staff failed to monitor it properly. The facility implemented corrective actions including staff training, 1:1 supervision, and policy changes to prevent recurrence.

The revisit confirmed that the identified deficiencies, specifically related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4), were corrected as of the revisit date.

Complaint investigation related to an incident on 09/08/2016 involving resident elopement risk.

The facility implemented multiple corrective actions including psychiatric evaluation and medication adjustments for the resident involved, enhanced monitoring of residents at risk for elopement, daily and weekly checks of door alarms and wanderguard systems, staff education on elopement prevention, and ongoing quality monitoring by designated staff.

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.

Complaint investigation #103426 regarding failure to report mistreatment and neglect when a CMA removed the battery from Resident #1's call light. The violation was substantiated by observations, record review, and interviews.

The facility failed to immediately report the incident involving the removal of the call light battery by a CMA, which placed the resident at risk for isolation and injury. Multiple staff members knew about the incident but did not report it promptly, and the facility reported the incident to the state agency four days after it occurred.

The incident was self-reported to the KDADS hotline on 7/21/2016 following an event on 7/19/2016. The perpetrator was suspended and terminated. The complaint was investigated with disciplinary actions taken against involved employees and retraining scheduled.

The incident involved a perpetrator who was suspended and terminated following investigation. Three employees aware of the incident were disciplined and retrained on abuse, neglect, and exploitation (ANE) reporting. The facility has implemented measures including call light system checks and staff training to prevent recurrence.

All previously cited deficiencies were corrected as of 05/11/2016, with completion dates documented for each regulation cited.

The survey found the most serious deficiency to be a "G" level deficiency, isolated, with no actual harm but with potential for more than minimal harm that is not immediate jeopardy. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended due to failure to achieve substantial compliance.

The visit was triggered by multiple complaint investigations (#98098, #98422, #98743, #97460, #98857) involving failure to notify physicians, abuse allegations, infection control issues, and medication administration problems.

The facility failed to timely notify a resident's physician regarding antibiotic treatment for a UTI, failed to report and investigate allegations of abuse by staff, failed to implement abuse prevention policies, failed to provide comprehensive care plans for residents with specific needs, failed to provide timely medication leading to hospitalization, failed to monitor fall prevention plans resulting in injury, and failed to implement infection control procedures to prevent spread of scabies among residents and staff.

This Plan of Correction is in response to a complaint investigation at Locust Grove Village dated 04/13/2016.

The Plan of Correction addresses multiple deficiencies related to notification of changes, investigation and reporting of allegations, abuse policies, comprehensive care plans, prevention of urinary tract infections, fall prevention, and infection control. The facility outlines corrective actions, staff training, policy reviews, and quality assurance measures to achieve substantial compliance by May 11, 2016.

The report confirms that all previously identified deficiencies related to regulations 483.20(d)(3), 483.10(k)(2), 483.25, and 483.25(i) have been corrected as of the revisit date.

The Plan of Correction addresses multiple deficiencies including care planning participation, provision of care for highest well-being, maintenance of nutrition status, and ensuring the drug regimen is free from unnecessary drugs. The facility outlines training, audits, and ongoing compliance measures to correct these issues by December 30, 2015.

The revisit found the most serious deficiencies to be isolated 'D' level deficiencies, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.

The report indicates that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 11/07/2015. No other deficiencies or uncorrected issues were noted.

The report shows that all previously identified deficiencies, each referenced by regulation number and prefix code, were corrected by 11/07/2015 as verified by the state surveyor.

The visit was complaint-related, triggered by complaints #93447, #93002, and #92583, involving failures in care planning, neurological assessments, pain management, and nutrition.

The facility failed to review and revise care plans for residents after significant changes in condition or falls, failed to complete physician ordered neurological assessments and timely pain management after a fall, failed to administer a registered dietician recommended nutritional supplement, and failed to provide pain medication prior to restorative services as care planned.

The revisit report confirms that the deficiencies identified in the prior survey were corrected as of the revisit date, with specific regulation citations noted for correction completion.

The Plan of Correction details multiple corrective actions including staff training, policy updates, care plan revisions, environmental maintenance, and quality assurance processes to achieve substantial compliance by November 7, 2015.

The facility has taken corrective actions including enrolling a person in the Certified Dietary Manager course and cleaning overhead lights, with ongoing compliance ensured through a preventative maintenance program and oversight by the Director of Maintenance.

The survey found the most serious deficiencies in the facility to be at an 'F' level, indicating significant noncompliance. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended.

Complaint Investigation #91394 focused on allegations of abuse, neglect, dignity concerns, falls, infection control, medication management, and resident rights.

The facility was found deficient in multiple areas including failure to thoroughly investigate and report incidents, maintain resident dignity, provide choice in care, implement activities, maintain housekeeping and maintenance, develop comprehensive care plans, provide appropriate care and services, maintain nutrition, ensure drug regimens are free from unnecessary drugs, maintain infection control, and ensure a working call system.

The facility failed to employ a full-time certified dietary manager and failed to maintain sanitary conditions in the kitchen, including inadequate cleaning of overhead lights and presence of dead bugs, resulting in failure to prepare and serve food under sanitary conditions for the 6 residents.

The revisit confirmed that corrections were completed for deficiencies related to regulations 483.10(f)(2), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), and 483.25(h) as of 09/24/2015.

This Plan of Correction is related to a complaint investigation at Locust Grove, with deficiencies cited and addressed including incident reporting and resident fall precautions.

The plan addresses concerns related to family communication, incident reporting to the state hotline, and fall precautions for residents, with commitments to ongoing quality assurance and compliance by September 24, 2015.

The survey found the most serious deficiencies to be "D" level deficiencies that constitute 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 submitted plan.

The visit was complaint-related, involving grievances about staff care and failure to report incidents. The complaints were substantiated as the facility failed to maintain grievance logs, promptly resolve grievances, report incidents, and follow care plans.

The facility failed to promptly resolve grievances for a resident and maintain a grievance log. It also failed to report a fall incident involving a resident who sustained skin tears, and did not follow care plans to prevent falls for two residents, resulting in injuries and safety risks.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.

The plan details corrective actions including staff training on resident dignity and bathing procedures, updates to care plans and documentation systems, replacement of unsafe equipment, and ongoing quality assurance audits to ensure compliance.

The survey found the most serious deficiencies to be 'E' level deficiencies, 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 July 22, 2014.

The facility failed to provide dignity and respect during dining for some residents, did not provide scheduled bathing services as per care plans for multiple residents, failed to respond to resident grievances regarding bathing, did not assist a resident during meals as required, and failed to assess and provide safe side rails for a resident.

This Plan of Correction is related to deficiencies cited during a complaint investigation at Locust Grove on November 21, 2013.

The plan outlines corrective actions including staff training on resident rights, skin assessment and care protocols, and competency in accessing electronic health records, with Quality Assurance oversight to ensure ongoing compliance.

The inspection was triggered by complaint investigations #KS00068462 and #KS00066058. The complaints involved dignity issues during incontinence care and failure to provide proper nursing assessments and incontinence care.

The facility failed to promote dignity and respect for one resident during incontinence care, failed to provide necessary nursing assessments related to skin issues for two residents, and failed to provide incontinence care as planned for one resident, resulting in a period of over 3 hours without care.

The report confirms that the previously identified deficiency with regulation number 26-40-305 (e)(1)(2) and ID prefix S1358 was corrected as of 04/04/2013.

All previously reported deficiencies identified on the CMS-2567 Statement of Deficiencies were corrected as of the revisit date 2013-04-04.

The plan outlines corrective actions including education sessions, audits, documentation improvements, and ongoing compliance monitoring by the Director of Nursing and other staff to address deficiencies such as incomplete medication diagnoses, discharge planning, infection control practices, and equipment sanitation.

The facility failed to have a backflow prevention valve on the south beauty shop sink, which is required to prevent contamination of the water supply system.