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The Plan of Correction details corrective actions related to medication administration and removal of outdated medications, including updates to the Medication Administration Record and ongoing monitoring responsibilities assigned to the Director of Nursing.

The survey found a single isolated 'D' level deficiency that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was 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 and failed to discard expired medications including insulin and calcium tablets, placing residents at risk.

Complaint investigation #130370 regarding failure to timely report an incident where Resident #1's wheelchair became unsecured in the facility van, resulting in death. The incident was not reported to the state agency due to ongoing police investigation. The complaint was substantiated with findings of immediate jeopardy.

The facility failed to report the incident to the state agency in a timely manner and lacked a thorough system for training van drivers on securing wheelchairs. Resident #1's wheelchair became unsecured twice during transport, leading to a fatal incident. Multiple staff interviews revealed inconsistent training and lack of documentation. The facility abated the immediate jeopardy by retraining drivers, auditing competencies, and suspending van use until further assessment.

The facility was found 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.

The administration timely reported the incident to law enforcement and the KDADS Complaint Hotline. No abuse, neglect, or mistreatment by staff was found. Van driver retraining and competency audits were implemented to ensure compliance with vehicle usage policies.

Complaint #127631 was investigated and found to be unsubstantiated with no noncompliance identified.

The allegations made in the complaints were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.

The report documents that previously cited deficiencies have been corrected as of the dates indicated. No uncorrected deficiencies are noted in this revisit report.

The report confirms that the deficiencies identified in the prior survey have been corrected as of the revisit date.

The Plan of Correction addresses multiple deficiencies including incident reporting, pressure sore treatment, accident hazards, drug regimen management, food storage, and infection control. The facility outlines corrective actions, staff training, policy reviews, and quality assurance measures to achieve substantial compliance by February 24, 2017.

The facility has corrective actions planned including completion of a Certified Dietary Manager course and mandatory inservice training for dietary staff on facial hair covering procedures. Personal counseling was provided to involved employees and ongoing compliance will be monitored by the Dietary supervisor.

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 not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions.

The facility failed to employ a full-time certified dietary manager for the 13 residents and failed to store, prepare, distribute, and serve food under sanitary 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 kitchen, placing residents at risk of inadequate nutrition.

The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The complaint investigation #105429 and #105414 substantiated that the facility failed to prevent elopement of Resident #1 who left the facility without staff knowledge due to inadequate supervision and a non-functioning Wanderguard alarm.

The facility failed to provide adequate supervision to prevent an elopement of a cognitively impaired resident who displayed exit-seeking behavior and left the facility unnoticed. The Wanderguard alarm system was not functioning properly, and staff did not adequately monitor or document its use, placing the resident in immediate jeopardy.

The facility was found not in substantial compliance with participation requirements, constituting immediate jeopardy for F323 "J", CFR 483.25(h). Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.

This Plan of Correction is in response to a complaint investigation identified as Locust Grove complaint 09122016.

The plan addresses corrective actions including resident safety measures, psychiatric evaluation, medication adjustments, updated care plans, staff education on elopement prevention, and ongoing quality monitoring of door alarms and wanderguard systems.

The report confirms that the previously identified deficiencies, including those under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4), have been corrected as of the revisit date.

Complaint investigation #103426 involved failure to immediately report mistreatment and neglect when a certified medication aide removed the battery from Resident #1's call light. The incident was reported to the state agency 4 days after occurrence, although staff became aware earlier. The allegation was substantiated by observations, interviews, and record review.

The facility failed to immediately report an alleged violation involving mistreatment and neglect when a certified medication aide took the battery out of a resident's call light, delaying notification to the charge nurse, administrator, and state agency. This placed the resident at risk for isolation and injury due to inability to use the call light.

The survey found a 'D' level deficiency indicating 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 plan.

The incident was self-reported by Locust Grove Village to the KDADS hotline on 7/21/2016 following an event on 7/19/2016. The perpetrator was suspended and terminated. Three employees were disciplined and retrained. No other residents were affected.

The incident involved a perpetrator who was suspended and terminated following an event on 7/19/2016. Three employees were disciplined and retrained on reporting abuse, neglect, and exploitation (ANE). The facility has procedures for call light system checks and incident reporting.

This Plan of Correction is in response to a complaint investigation conducted on April 13, 2016, related to Locust Grove Village.

The Plan of Correction addresses multiple deficiencies including failure to notify physicians of changes, investigation and reporting of allegations, development and implementation of abuse policies, comprehensive care plans, prevention of urinary tract infections, accident hazard prevention, and infection control related to scabies. The facility outlines corrective actions, staff training, and quality assurance measures to achieve substantial compliance by May 11, 2016.

The survey found a 'G' level deficiency that was 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 imposed due to failure to achieve substantial compliance.

The investigation was triggered by multiple complaints alleging failure to provide appropriate care, abuse by staff, and infection control issues. Allegations included abuse by Medication Aide H, failure to notify physicians timely, and inadequate infection control for scabies outbreaks.

The facility failed to timely notify a resident's physician of untreated UTI and refusal of antibiotics, failed to report and investigate abuse allegations involving staff and residents, failed to implement abuse policies, failed to provide comprehensive care plans for residents with specific needs including scabies and medication refusal, failed to provide timely physician ordered 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.

The report shows that all previously cited deficiencies identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25, 483.25(i), and 483.25(l) were corrected as of 2015-12-30.

The plan addresses deficiencies related to care planning, provision of care for highest well-being, nutrition status maintenance, and drug regimen management. The facility outlines corrective actions including staff training, audits, and protocol reviews to achieve substantial compliance by December 30, 2015.

The visit was complaint-related, involving investigations #93447, #93002, and #92583, with substantiated findings of care plan deficiencies, failure to complete neurological assessments, nutritional supplement administration failures, and medication administration issues.

The facility failed to review and revise care plans for residents after significant changes in status or falls, did not complete physician-ordered neurological assessments after a fall, failed to administer recommended nutritional supplements, and did not provide pain medication prior to restorative services as care planned.

The revisit found isolated 'D' level deficiencies constituting no actual harm but with potential for more than minimal harm. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.

The report documents that previously cited deficiencies, specifically regulation 28-39-158(a) with ID prefix S0600, were corrected as of 11/07/2015.

The revisit confirmed that all previously identified deficiencies were corrected by the facility as of 11/07/2015.

The report confirms that the deficiencies identified by regulation numbers 28-39-158(a) and 26-43-206(d) were corrected as of the revisit date.

The Plan of Correction addresses dietary services and food preparation deficiencies, including enrollment of a staff member in a Certified Dietary Manager course and cleaning of overhead lights with updated preventative maintenance scheduling.

The Plan of Correction details multiple areas of compliance including incident reporting, resident dignity and care, bathing preferences, activity preferences, maintenance, comfort care plans, medication management, infection control, and quality assurance processes. The facility commits to substantial compliance by November 7, 2015.

Complaint investigation #91394 focused on allegations of inadequate investigation and reporting of resident injury, failure to maintain dignity, inadequate care and supervision, infection control issues, medication management, and call system failures.

The facility was found deficient in multiple areas including failure to thoroughly investigate and report incidents, maintain resident dignity, provide choice in care, ensure adequate activities, maintain sanitary conditions, develop comprehensive care plans, provide appropriate care and services, maintain infection control, ensure proper medication management, and maintain a functional call system.

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

The report confirms that all previously reported deficiencies identified on the CMS-2567 have been corrected as of the revisit date.

The plan addresses concerns related to family communication, incident reporting to the state hotline, and fall precautions for residents. The facility outlines corrective actions and quality assurance measures to ensure ongoing compliance.

The survey found the most serious deficiencies to be 'D' level, indicating no actual harm but 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 plan.

The complaint investigations #90928 and #90935 involved grievances not being resolved promptly, failure to report incidents, and failure to follow care plans and policies related to resident safety and abuse prevention.

The facility failed to promptly resolve resident grievances, maintain a grievance log, report a resident fall resulting in injuries, and follow care plans and facility policies related to fall prevention and safe resident transfers. Two residents sustained injuries due to staff not following protocols.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, and not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

All deficiencies previously reported on the CMS-2567 were corrected as of the revisit date. The report lists multiple regulation numbers with correction completion dates.

The plan outlines corrective actions for multiple deficiencies related to resident dignity, bathing procedures, resident council follow-up, dining assistance, and bed safety. Quality assurance audits and staff training are planned to ensure ongoing compliance.

The survey found the most serious deficiencies to be 'E' level deficiencies, indicating no actual harm but potential for more than minimal harm without 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.

The facility failed to provide dignity and respect during dining for some residents, did not provide scheduled bathing services as planned for multiple residents, failed to respond to resident grievances about bathing, did not assist a resident with dining as care planned, and failed to ensure safe side rails for one resident.

The plan outlines corrective actions for deficiencies related to resident rights, skin assessments and care, and competency in accessing the Plan of Care in the electronic health record. The facility commits to staff training, competency assessments, and quality assurance oversight to ensure compliance.

The revisit report confirms that the deficiencies identified under regulations 483.15(a), 483.25, and 483.25(d) were corrected as of the revisit date.

The visit was triggered by complaint investigations #KS00068462 and #KS00066058.

The facility failed to promote dignity and respect for one resident during incontinence care, failed to provide necessary nursing assessments and care for skin issues for two residents, and failed to provide incontinence care as planned for one resident, resulting in a delay of over 3 hours between care.

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

The plan details corrective actions for multiple deficiencies including MDS assessments, discharge planning, pain management, medication diagnosis documentation, infection control, dietary staff training, and maintenance issues. The facility commits to ongoing education, audits, and compliance monitoring.

The facility failed to have a backflow prevention valve on the south beauty shop sink, which is required for plumbing systems in nursing facilities.