Inspection Reports for Medicalodges Arkansas City
203 E. OSAGE AVENUE, KS, 67005-1255
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Aug 13, 2025
Visit Reason
The inspection was conducted as a non-compliance revisit and complaint investigation related to allegations of verbal abuse by staff towards a resident.
Findings
The facility failed to ensure Resident 1 was free from staff verbal abuse when a Certified Nurse Aide (CNA M) taunted the resident by making fun of her eyebrows and wrinkles. Additionally, the facility failed to report the incident immediately to the Administrator as required. Corrective actions were completed prior to the survey, including termination of CNA M and staff re-education.
Complaint Details
The complaint investigation revealed that on 07/31/25, CNA M verbally abused Resident 1 by mocking her eyebrows and wrinkles. The incident was not reported immediately to the Administrator, violating reporting requirements. The facility took corrective actions including suspension and termination of CNA M, notification of law enforcement, family notification, and staff training.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure Resident 1 remained free from staff-to-resident verbal abuse by CNA M who taunted the resident about her eyebrows and wrinkles. | Level D |
| Failure to report an incident of verbal abuse immediately to the Administrator as required. | Level D |
Report Facts
Census: 40
Case number: Local law enforcement case number A25-10288 related to the abuse incident.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in verbal abuse finding for taunting Resident 1. |
| Administrative Staff A | Administrator who suspended CNA M and conducted investigation. | |
| CNA O | Certified Nurse Aide | Witness who reported CNA M's verbal abuse and attempted to intervene. |
| CNA P | Certified Nurse Aide | Witness who described the incident and confirmed attendance at abuse training. |
| CNA N | Certified Nurse Aide | Witness who observed CNA M's behavior and notified Administrative Staff A. |
| Administrative Staff D | Staff member who could not recall being notified of the incident. |
Inspection Report
Plan of Correction
Deficiencies: 7
Jun 30, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 06/30/2025.
Findings
The plan outlines corrective actions for multiple deficiencies including environmental issues, abuse and neglect prevention, accuracy of assessments, care plan development and revision, accident hazard prevention, and management of urinary incontinence. The facility commits to education, audits, monitoring, and achieving substantial compliance by 07/29/2025.
Severity Breakdown
D: 5
E: 1
G: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Safe/Clean/Comfortable/Homelike Environment | E |
| Free from Abuse and Neglect | G |
| Accuracy of Assessments | D |
| Develop/Implement Comprehensive Care Plan | D |
| Care Plan Timing and Revision | D |
| Free of Accident Hazards/Supervision/Devices | D |
| Bowel/Bladder Incontinence, Catheter, UTI | D |
Report Facts
Deficiency completion dates: Jul 29, 2025
Inspection report date: Jun 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myoshia Knox | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 12
Jun 26, 2025
Visit Reason
The inspection was conducted as a Health Recertification Survey and complaint survey regarding allegations in KS00196133.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; failure to prevent resident-to-resident sexual abuse; inaccurate resident assessments; incomplete care plans; failure to prevent falls and accidents; inadequate urinary tract infection prevention and care; failure to maintain nutritional status; lack of annual nurse aide performance reviews; ineffective behavioral health interventions; unsanitary food preparation and storage conditions; inadequate infection prevention and control practices; and unsafe and unsanitary environmental conditions.
Complaint Details
The complaint investigation was triggered by allegations in KS00196133, including resident-to-resident sexual abuse involving Resident 1 exposing himself to Resident 9, resulting in psychosocial harm and fear. The facility failed to provide adequate supervision and interventions following the incident.
Severity Breakdown
E: 2
G: 1
D: 6
F: 2
C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to maintain a safe, clean, and homelike environment in resident halls and supply storage rooms. | E |
| Failure to ensure residents remained free from resident-to-resident sexual abuse. | G |
| Failure to complete accurate Minimum Data Set (MDS) assessments regarding antidepressant medication. | D |
| Failure to develop and implement comprehensive care plans including Black Box Warnings and interventions for weight loss. | D |
| Failure to implement appropriate interventions following falls and failure to utilize foot pedals for wheelchair residents. | D |
| Failure to provide adequate care and services to prevent urinary tract infections (UTI) and monitor signs and symptoms. | D |
| Failure to maintain acceptable nutritional status and implement dietary interventions for weight loss. | D |
| Failure to complete annual nurse aide performance reviews at least once every 12 months. | E |
| Failure to implement effective behavioral health interventions for resident with inappropriate behaviors. | D |
| Failure to prepare and serve food under sanitary conditions, including dirty equipment, unsanitizable cutting boards, uncovered food, and food debris. | F |
| Failure to establish and maintain an effective infection prevention and control program, including inadequate laundry handling and storage practices. | F |
| Failure to provide a safe, functional, sanitary, and comfortable environment including peeling paint, broken light fixtures, and flaking paint in laundry areas. | C |
Report Facts
Deficiencies cited: 12
Resident census: 40
Staff education attendance: 20
Weight loss percentage: 10
BIMS scores: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Notified about resident-to-resident sexual abuse incident and involved in intervention decisions. | |
| Administrative Staff B | Received report of sexual abuse from Resident 9 and notified appropriate staff. | |
| Licensed Nurse G | Involved in reporting and managing sexual abuse incident and resident care. | |
| Consultant Staff II | Psychiatric Nurse Practitioner | Provided psychiatric care and medication management for Resident 1. |
| Certified Nurse Aide M | CNA | Lacked annual performance review. |
| Certified Nurse Aide R | CNA | Reported on fall interventions and resident mobility. |
| Certified Nurse Aide S | CNA | Assisted Resident 3 with meals and reported on dietary issues. |
| Certified Medication Aide T | CMA | Reported on resident behaviors and dietary intake. |
| Dietary Staff CC | Reported on dietary orders and fortified foods. | |
| Housekeeping U | Reported on laundry and housekeeping deficiencies. | |
| Maintenance V | Reported on housekeeping and laundry area conditions. |
Inspection Report
Re-Inspection
Deficiencies: 0
May 19, 2025
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 04/10/25.
Findings
All deficiencies cited in the prior inspection have been corrected as of 04/11/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 3
Apr 10, 2025
Visit Reason
The inspection was conducted as a partial extended survey and complaint investigation related to allegations of resident-to-resident sexual and physical abuse involving Resident 1 and other cognitively impaired residents.
Findings
The facility failed to ensure cognitively impaired residents remained free from sexual and physical resident-to-resident abuse by Resident 1, who repeatedly engaged in inappropriate sexual behaviors including grabbing breasts and stroking legs of female residents. The facility also failed to implement adequate interventions and failed to notify law enforcement or conduct thorough investigations for multiple incidents, placing residents in immediate jeopardy.
Complaint Details
The complaint investigation revealed multiple incidents of sexual abuse by Resident 1 against cognitively impaired female residents R2 and R3, including grabbing breasts and inappropriate touching. The facility failed to implement adequate interventions, failed to notify law enforcement for any incidents between 01/25/25 and 04/09/25, and failed to conduct thorough investigations.
Severity Breakdown
G: 1
K: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents remained free from sexual and physical resident-to-resident abuse. | G |
| Failure to report allegations of resident-to-resident abuse to the Licensed Nursing Home Administrator, State Agency, and Law Enforcement as appropriate. | K |
| Failure to immediately implement protective measures to prevent further potential abuse and failure to conduct thorough investigations of alleged abuse incidents. | K |
Report Facts
Census: 41
Residents reviewed for abuse: 13
Female residents with moderate to severe cognitive impairment: 11
Severity level: G
Severity level: K
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN I | Licensed Nurse | Documented incidents of abuse and received disciplinary action for failure to report incident on 03/10/25 |
| LN F | Licensed Nurse | Documented incidents of abuse and received disciplinary action for failure to report incident on 03/30/25 until 04/02/25 |
| Administrative Staff A | Facility staff who provided interviews regarding abuse incidents and reporting failures | |
| Administrative Nurse C | Facility nurse who provided interviews regarding abuse incidents and reporting failures | |
| Social Services Designee M | Documented observations and referral for Resident 1 transfer | |
| CNA H | Certified Nurse Aide | Reported observations of Resident 1's behavior and staff interventions |
| CNA J | Certified Nurse Aide | Reported staff interventions to protect residents from Resident 1 |
| Administrative Staff L | Received Immediate Jeopardy notification |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 10, 2025
Visit Reason
This document is a Plan of Correction submitted by Medicalodge of Ark City in response to deficiencies cited during a prior inspection related to abuse, neglect, and exploitation concerns.
Findings
The plan outlines corrective actions including one-on-one resident monitoring, staff education on abuse and neglect reporting, resident and staff interviews, law enforcement notification, and disciplinary actions against staff members for failure to report incidents.
Deficiencies (1)
| Description |
|---|
| Failure to provide adequate supervision and reporting of abuse, neglect, and exploitation. |
Report Facts
Dates of staff education completion: Apr 10, 2025
Dates of resident assessments: Mar 12, 2025
Dates of resident assessments: Jan 25, 2025
Dates of disciplinary actions: Mar 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Hess | Staff Member | Received disciplinary action for failure to report abuse resulting in self-termination |
| Linda Boswell | Staff Member | Received verbal disciplinary action for failure to report abuse resulting in self-termination |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 5, 2023
Visit Reason
An offsite revisit was conducted on 12/05/2023 to verify correction of all previous deficiencies cited on 10/10/2023.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 11/09/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies compliance date: Nov 9, 2023
Inspection Report
Plan of Correction
Deficiencies: 11
Oct 10, 2023
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 10/10/2023, outlining corrective actions to achieve substantial compliance with federal Medicare/Medicaid requirements.
Findings
The plan details multiple corrective actions including staff education, monitoring processes, and care plan updates to address deficiencies related to discharge processes, assessments, medication storage, dietary sanitation, and infection control, with a target compliance date of 11/09/2023.
Deficiencies (11)
| Description |
|---|
| Discharge and transfer process including providing Transfer/Discharge letter and Ombudsman notification |
| Providing a copy of the facility bed hold policy to resident or responsible party on discharge/transfer |
| Completion of BIMS assessments for residents |
| Updating care plans timely to reflect treatments such as daily wraps to legs |
| Completion of scheduled treatment orders and care plan updates |
| Completion of MRR and pharmacy recommendations timely |
| Completion of DISCUS assessments for residents on psychotropic medications |
| Medication storage including ensuring medication carts are locked when not in direct sight of licensed staff |
| Dietary staff education on food sanitation, hand washing, glove use, cleaning techniques, and proper food storage |
| Staff education on reporting RN hours appropriately and timely |
| In-service on infection control techniques and weekly audits of infection control practices |
Report Facts
Deficiency completion target date: Nov 9, 2023
Discharge dates for resident #26: 2
Dates of staff education: Nov 1, 2023
Dates of assessments completed: Oct 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myoshiaknox | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 12
Oct 10, 2023
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements including notice requirements before transfer/discharge, bed hold policy, accuracy of assessments, comprehensive care plans, quality of care, nurse aide training, drug regimen review, psychotropic medication use, medication storage, food safety, payroll based journal submission, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to notify the State Ombudsman of resident transfers, failure to provide bed hold policy notice, inaccurate cognitive assessments, incomplete care plans, failure to apply physician-ordered leg wraps, inadequate nurse aide training hours, failure to follow up on pharmacist medication recommendations, improper monitoring of psychotropic medication side effects, unsecured medication carts, unsanitary food preparation and storage, inaccurate payroll staffing data submission, and improper glove use and hand hygiene during resident care.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=F: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to notify the Office of the State Long-Term Care Ombudsman of resident transfer reasons. | SS=D |
| Failed to provide written notice of bed hold policy to resident and/or representative at time of hospital transfer. | SS=D |
| Failed to accurately assess and document cognitive status via BIMS score on MDS for multiple residents. | SS=E |
| Failed to develop a comprehensive care plan for resident related to physician-ordered bilateral leg wraps. | SS=D |
| Failed to provide treatment and care in accordance with professional standards by not applying physician-ordered leg wraps for edema. | SS=D |
| Failed to ensure certified nurse aide received required 12 hours of annual training. | SS=D |
| Failed to have attending physician document review and response to pharmacist medication regimen irregularities for multiple residents. | SS=E |
| Failed to appropriately monitor side effects of psychotropic medications including lack of required AIMS or DISCUS assessments. | SS=D |
| Failed to secure medication carts by leaving them unlocked when unattended and not in direct line of sight. | SS=F |
| Failed to provide sanitary food preparation and storage including unclean cutting boards, uncovered plates with debris, expired foods, unsealed containers, lack of hair restraints, and uncovered outside trash dumpster. | SS=F |
| Failed to electronically submit complete and accurate direct care staffing information to CMS, inaccurately reporting licensed nurse coverage on 27 dates. | SS=F |
| Failed to ensure clean, sanitary techniques related to proper glove usage and hand hygiene during incontinent care for a resident. | SS=D |
Report Facts
Residents sampled: 12
Residents census: 29
Deficiency dates with no licensed nurse coverage: 27
CNA training hours: 8.5
Bologna expiration date: Jul 31, 2023
Expired diced bell peppers date: Sep 24, 2023
Expired coleslaw dressing date: Sep 2, 2023
Expired pickle relish date: Sep 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Reported lack of policies, confirmed deficiencies, and provided explanations during interviews |
| Certified Nurse Aide M | CNA | Observed and interviewed regarding resident care and medication wrap application |
| Certified Nurse Aide N | CNA | Observed providing incontinent care with improper glove use |
| Licensed Nurse G | Licensed Nurse | Observed leaving medication cart unlocked and interviewed about medication cart security |
| Consultant Pharmacist GG | Consultant Pharmacist | Reported concerns about facility not following up on medication recommendations |
| Administrative Staff A | Administrative Staff | Interviewed regarding missing medication review documents and PBJ reporting |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 20, 2023
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 08/16/2023.
Findings
All deficiencies cited in the prior inspection have been corrected as of 09/06/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 20, 2023
Visit Reason
A revisit survey was conducted from 09/18/23 to 09/20/23 to verify correction of all previous deficiencies cited on 06/27/23.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 07/26/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Dates of survey: Revisit survey conducted from 09/18/23 to 09/20/23; previous deficiencies cited on 06/27/23; compliance date 07/26/23
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Aug 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of abuse, neglect, and mistreatment at Medicalodges Arkansas City.
Findings
The facility failed to report multiple allegations of abuse to the State Survey Agency, failed to investigate abuse allegations thoroughly, and failed to suspend a staff member pending investigation. Several residents reported or were involved in incidents of verbal and physical mistreatment by staff, and the facility did not take appropriate corrective actions.
Complaint Details
The complaint investigation involved allegations of staff being rough with residents, verbal abuse, and improper care. Specific incidents included a Certified Medication Aide (CMA) being rough with Resident 2, verbal abuse towards Resident 8 by a staff member, and a male agency nurse allegedly applying powder too hard to Resident 9's skin. The facility failed to report these allegations to the state and did not conduct thorough investigations or suspend implicated staff.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report allegations of abuse to the State Survey Agency in a timely manner. | SS=D |
| Failure to investigate allegations of abuse thoroughly and prevent further potential abuse. | SS=D |
Report Facts
Census: 35
Dates of allegations: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrator/Director of Nursing | Responsible for investigation and reporting of abuse allegations; failed to report and investigate multiple abuse allegations. |
| Certified Medication Aide R | Certified Medication Aide | Named in anonymous complaint for being 'rough' with residents; facility failed to suspend pending investigation. |
| Certified Medication Aide S | Certified Medication Aide | Reported witnessing verbal and physical mistreatment of residents; reported concerns to administration. |
| Certified Nurse Aide M | Certified Nurse Aide | Accused of placing a blanket over Resident 2 and holding him down; involved in verbal abuse incident. |
| Licensed Nurse G | Agency Nurse | Alleged to have applied powder too hard to Resident 9's skin; facility did not investigate or report. |
| Social Service Staff X | Social Service Staff | Received complaints from residents and family members regarding staff mistreatment. |
| Consultant Staff GG | Consultant Staff | Provided information about complaint investigations and facility responses. |
| Certified Nurse Aide P | Certified Nurse Aide | Witnessed and reported concerns about care of Resident 2. |
| Certified Nurse Aide N | Certified Nurse Aide | Reported witnessing rude behavior by CMA S toward Resident 8. |
Inspection Report
Plan of Correction
Deficiencies: 2
Aug 16, 2023
Visit Reason
The document is a Plan of Correction submitted in response to a complaint survey conducted on 08/16/2023 regarding abuse allegations at the facility.
Findings
Investigations were completed on 08/16/2023 for abuse allegations identified during the complaint survey. The facility provided education to all staff and leadership on timely reporting and investigation of alleged violations. Monitoring and audits will continue until compliance is attained.
Complaint Details
The visit was complaint-related due to abuse allegations identified during the complaint survey on 08/16/2023. Investigations were completed and education was provided to staff and leadership. The facility aims to be in substantial compliance by 09/16/2023.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| F609 Reporting of alleged violations | D |
| F610 Investigate/Prevent/Correct Alleged Violation | D |
Report Facts
Date of complaint survey: Aug 16, 2023
Plan of correction completion date: Sep 6, 2023
Target substantial compliance date: Sep 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myoshia Knox | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 5
Jun 27, 2023
Visit Reason
Complaint investigation #180708 and #181002 and a Targeted Infection Control Survey/COVID-19 Focused Survey conducted by the Kansas Department for Aging and Disability Services on 06/13/23 through 06/15/23.
Findings
The facility failed to prevent neglect by not ensuring licensed nursing staff assessed and treated a wound on Resident R1's right lateral foot timely and properly, leading to deterioration, osteomyelitis diagnosis, hospitalization, and possible amputation. The facility also failed to revise care plans for Resident R3's skin conditions and failed to provide proper treatment and monitoring for pressure ulcers for Residents R1 and R2. Infection control deficiencies were noted including improper hand hygiene and handling of linens.
Complaint Details
Complaint investigation #180708 and #181002 triggered the visit. Immediate jeopardy was identified related to neglect of Resident R1's wound care, which was removed on 06/14/23.
Severity Breakdown
Level G: 2
Level D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure licensed nursing staff assessed a wound on Resident R1's right lateral foot weekly from 12/21/22 to 02/16/23, failed to initiate treatment for a wound identified on 12/26/22 until 01/27/23, failed to complete treatments as ordered, failed to notify the primary care physician when the wound deteriorated, and failed to notify the physician timely with critical radiology results, leading to osteomyelitis and hospitalization. | Level G |
| Failure to review and revise the care plan for Resident R3 for presence of pressure ulcers and interventions after admission with excoriation to coccyx and buttocks which later developed into three pressure areas. | Level D |
| Failure to monitor Resident R2's skin thoroughly and perform treatments as ordered, including failure to ensure physician ordered dressings were in place to pressure areas on coccyx and right buttocks. | Level G |
| Failure to ensure Resident R1 was seen by his primary care physician during admission from 12/16/22 to 06/04/23. | Level D |
| Failure to maintain an effective infection control program including failure to keep linens off the floor, failure to change gloves when moving from dirty to clean surfaces, and failure to perform hand hygiene after glove removal, risking spread of infection for Residents R2 and R3. | Level D |
Report Facts
Census: 34
Days without wound treatment: 31
WBC count: 24000
Wound measurements: 8
Wound measurements: 2.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in multiple findings related to wound care failures, failure to notify physician, and infection control |
| Consultant Wound Care Staff HH | Consultant Wound Care Staff | Performed wound assessments and treatments for Resident R1, involved in deficient wound care practices |
| Licensed Nurse J | Licensed Nurse | Provided wound care and described wound care practices for Resident R1 |
| Licensed Nurse G | Licensed Nurse | Provided wound care and described wound care practices for Resident R1 |
| Consultant Nurse II | Consultant Nurse | Commented on facility policy for physician visits |
| Consultant Physician Extender Staff JJ | Consultant Physician Extender | Provided physician visit notes for Resident R2 |
| Certified Nurse Aide M | Certified Nurse Aide | Observed providing care to Resident R2 with infection control deficiencies |
| Certified Nurse Aide N | Certified Nurse Aide | Observed providing care to Resident R2 with infection control deficiencies |
| Administrative Staff A | Administrative Staff | Provided information on physician visit responsibilities and infection control |
| Licensed Nurse I | Licensed Nurse | Described training and observations related to skin assessments |
Inspection Report
Plan of Correction
Deficiencies: 4
Jun 27, 2023
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection on 6/27/2023.
Findings
The plan addresses deficiencies related to skin integrity assessments, physician notifications, treatment implementation, care plan updates, infection control education, and timely physician visits. The facility outlines corrective actions including staff education, audits, monitoring, and ongoing quality assurance to achieve substantial compliance by 07/26/2023.
Deficiencies (4)
| Description |
|---|
| Residents with skin integrity impairment were assessed with documentation, physician notified, treatments completed, and supplies made available. |
| Care Plan was revised to reflect skin conditions and treatments. |
| Education on infection control techniques including hand washing and handling of linens. |
| Timely physician visits for residents within required timeframes. |
Report Facts
Date of prior inspection: Jun 27, 2023
Compliance target date: Jul 26, 2023
Education completion dates: Jun 14, 2023
Skin assessment dates: Jul 20, 2023
Physician visit date: Jul 9, 2023
Infection control education date: Jul 12, 2023
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 6, 2022
Visit Reason
An offsite revisit survey was conducted on 01/06/2022 for all previous deficiencies cited on 11/19/2021.
Findings
All deficiencies have been corrected as of the compliance date of 12/22/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 4
Nov 19, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection on 11/19/2021.
Findings
The plan outlines corrective actions including staff in-service training on medication administration and food sanitation, cleaning and maintenance schedules for kitchen and dietary areas, freezer repair, and concrete repair for the gazebo patio. Monitoring and audits will be conducted regularly to ensure compliance.
Severity Breakdown
D: 1
F: 2
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Medication administration issues requiring in-service training and audits | D |
| Kitchen sanitation and food storage deficiencies requiring cleaning and staff training | F |
| Freezer malfunction requiring repair and defrosting | F |
| Concrete repair needed for gazebo patio | E |
Report Facts
Staff medication administration audit frequency: 2
Dates for corrective actions completion: Dec 22, 2021
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 4
Nov 19, 2021
Visit Reason
The inspection was conducted as a Health Facility Resurvey and investigation of complaint #156237.
Findings
The facility was found to have a medication error rate of 7.41%, failing to ensure one resident remained free of medication errors. Additionally, sanitary deficiencies were noted in food procurement, storage, preparation, and serving, unsafe kitchen equipment conditions, and unsafe environmental conditions in the outdoor covered gazebo area.
Complaint Details
The visit was triggered by complaint #156237 and included a resurvey of the facility.
Severity Breakdown
SS=D: 1
SS=F: 2
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure medication error rates were below 5%, with two medication errors observed for one resident during 26 opportunities. | SS=D |
| Failed to provide sanitary food preparation, storage, and serving to prevent the spread of food borne infections, including multiple cleanliness issues in the kitchen. | SS=F |
| Failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically a reach-in freezer with ice buildup and lack of repair. | SS=F |
| Failed to provide a safe, functional, sanitary, and comfortable environment in the covered gazebo area due to cracked cement flooring creating trip hazards. | SS=E |
Report Facts
Medication error rate: 7.41
Resident census: 27
Medication opportunities: 26
Medication errors observed: 2
Crack lengths: 4
Crack length: 7
Raised gap: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) R | Administered incorrect doses of inhaled medications to Resident 9. | |
| Licensed Nurse (LN) G | Notified physician of medication error and expected staff to read MAR and medication labels. | |
| Administrative Nurse D | Expected staff to follow physician orders and read MAR and medication labels before medication administration. | |
| Dietary Staff BB | Participated in kitchen environmental tour and confirmed cleaning schedule but noted short staffing. | |
| Administrative Staff A | Expected dietary staff to follow cleaning schedule and noted residents used gazebo less in colder months. | |
| Maintenance Staff U | Reported residents used gazebo area with staff accompaniment and described cracks in gazebo flooring. |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 29, 2021
Visit Reason
An off-site revisit was conducted on 06/29/21 to verify correction of all previous deficiencies cited on 04/07/21.
Findings
All deficiencies have been corrected as of the compliance date of 04/09/21 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 9, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited related to medication misappropriation and exploitation.
Findings
The facility identified a deficiency involving misappropriation/exploitation related to Xanax medication, which was discontinued and scheduled for destruction. Staff education and daily audits were implemented to ensure compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Free from Misappropriation/Exploitation related to Xanax medication | D |
Report Facts
Complete Date for Plan of Correction: Apr 9, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lori Hughes | Administrator | Submitted the Plan of Correction |
| Teresa Edwards | Added the Plan of Correction | |
| Janice VanGotten | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Apr 7, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#161463) regarding the misappropriation of medications at the facility.
Findings
The facility failed to prevent the misappropriation of a controlled substance medication (Xanax) for one resident. Surveillance footage and staff interviews indicated that a licensed nurse removed medication cards and possibly misappropriated the medication. The facility suspended the nurse and notified law enforcement.
Complaint Details
Complaint investigation #161463 regarding misappropriation of medications. The complaint was substantiated as evidenced by missing medication cards and video footage implicating a licensed nurse. The facility suspended the nurse and notified law enforcement.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent misappropriation of medications for one resident, specifically a missing discontinued medication card with Xanax. | SS=D |
Report Facts
Census: 33
Medication tablets missing: 30
Date of medication removal: Mar 27, 2021
Date of notification to law enforcement: Mar 31, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse D | Licensed Nurse | Named in medication misappropriation finding and suspension following video review |
| Administrative Nurse B | Administrative Nurse | Had the only key to the locked medication cabinet and involved in investigation |
| Licensed Nurse C | Licensed Nurse | Reported inability to find medication card and participated in investigation |
| Licensed Nurse F | Licensed Nurse | Witnessed Licensed Nurse D entering medication room but did not see medication card placement |
| Administrative staff A | Administrative Staff | Involved in counting controlled substances and suspension decision |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 5, 2020
Visit Reason
A revisit survey was conducted on 10/05/2020 to verify correction of all previous deficiencies cited on 07/29/2020.
Findings
All deficiencies cited previously have been corrected as of the compliance date of 08/28/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Abbreviated Survey
Census: 40
Deficiencies: 4
Jul 29, 2020
Visit Reason
The inspection was a Targeted Infection Control Survey/COVID-19 Focused Survey conducted by the Kansas Department for Aging and Disability Services on behalf of CMS from 07/27 to 07/29/2020.
Findings
The facility failed to provide adequate restorative services to maintain residents' range of motion, failed to implement appropriate fall interventions for a resident with Alzheimer's disease, failed to perform proper perineal hygiene to prevent urinary tract infections, and failed to ensure proper infection prevention and control practices including proper mask usage and sanitization of oxygen tubing.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide restorative services for three residents to maintain or prevent decline in range of motion ability. | SS=D |
| Failed to implement an appropriate fall intervention for one resident following a fall to prevent further falls. | SS=D |
| Failed to properly perform perineal hygiene for one resident to prevent potential urinary tract infections. | SS=D |
| Failed to require staff to properly wear facial masks and failed to sanitize/replace oxygen tubing that contacted the floor, risking respiratory infections. | SS=F |
Report Facts
Residents sampled: 11
Days restorative exercises performed: 7
Days restorative exercises performed: 4
Days restorative exercises performed: 4
Fall assessments: 3
BIMS score: 7
BIMS score: 0
BIMS score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided statements regarding restorative aide scheduling, fall interventions, peri-care, and mask wearing. |
| Certified Nurse Aide Q | Certified Nurse Aide | Stated restorative exercises were performed by restorative aide and admitted failure to perform peri-care. |
| Certified Nurse Aide MM | Certified Nurse Aide | Stated restorative exercises were done only when restorative aide was scheduled. |
| Certified Nurse Aide N | Certified Nurse Aide | Observed not wearing face mask properly and improperly handled oxygen tubing. |
| Certified Nurse Aide O | Certified Nurse Aide | Observed not wearing face mask properly when opening locked door. |
Inspection Report
Plan of Correction
Deficiencies: 4
Jul 29, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a COVID-related inspection conducted on 07/29/2020.
Findings
The plan addresses multiple deficiencies including restorative care assessments, fall care plan interventions, perineal hygiene for incontinent residents, and infection control practices related to mask wearing and oxygen tubing handling. The facility outlines corrective actions, staff education, monitoring, and auditing processes to achieve and maintain compliance.
Severity Breakdown
D: 3
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Restorative assessment and care plan updates for residents #1, #2, and #3, with education for restorative aides and nurses. | D |
| Review and revision of fall care plan interventions for resident #5 and other affected residents, with staff re-education on fall interventions. | D |
| Ensuring proper perineal hygiene for incontinent residents with staff training and audits. | D |
| Implementation of CMS infection control techniques including mask wearing and oxygen tubing replacement, with staff re-education and audits. | F |
Report Facts
Deficiency completion date: Aug 28, 2020
Audit frequency: 5
Audit duration: 4
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 22, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a COVID-19 survey conducted on 06/22/2020.
Findings
The facility was found to be deficiency free in the COVID-19 survey conducted on 06/22/2020.
Deficiencies (1)
| Description |
|---|
| Deficiency Free Covid-19 Survey |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 22, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Kansas Department for Aging and Disability Services.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 26, 2020
Visit Reason
An offsite revisit was conducted on 03/26/2020 to verify correction of all previous deficiencies cited on 01/28/2020.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 02/14/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies compliance date: Feb 14, 2020
Inspection Report
Plan of Correction
Deficiencies: 7
Jan 28, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on January 28, 2020.
Findings
The plan outlines corrective actions taken or planned for multiple deficiencies including call light monitoring, discharge summaries, nursing practice standards, restorative assessments, fall interventions, medication management, and policy reviews. The facility commits to ongoing education, audits, and monitoring to achieve substantial compliance by mid-February 2020.
Deficiencies (7)
| Description |
|---|
| Failure in call light monitoring and check-in/check-out system for pagers. |
| Incomplete discharge summaries for discharged residents. |
| Nurse failed to follow standard of practice leading to suspension and termination. |
| Lack of restorative assessment and care plan updates for residents. |
| Inadequate fall intervention care plans and staff education. |
| Medication management issues including lack of justification for continued use and necessary labs/diagnostics. |
| Need for education and monitoring of administrative staff on quality systems and policy review. |
Report Facts
Resident discharge dates: Resident 36 discharged on 2019-11-09 and Resident 38 discharged on 2019-11-27
Plan of correction completion dates: Feb 14, 2020
Education dates: Multiple education sessions held between 2020-01-22 and 2020-02-13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Hughes | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 9
Jan 28, 2020
Visit Reason
A health survey and extended survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS from 01/21/2020 through 01/28/2020 due to complaints and concerns regarding call light system failures, discharge summaries, quality of care, restorative services, fall prevention, medication management, and facility administration.
Findings
The facility failed to ensure an adequate call light pager system, placing residents in immediate jeopardy. Deficiencies were found in discharge summaries, quality of care assessments after falls, restorative services for range of motion, fall prevention measures, medication management including failure to obtain ordered labs and inappropriate use of psychotropic medications, and facility administration including lack of governing body oversight and failure to ensure staff had pagers to respond to call lights.
Complaint Details
The visit was complaint-related due to concerns about call light system failures, medication management, fall prevention, and quality of care. Immediate jeopardy was identified related to the call light pager system.
Severity Breakdown
F: 3
G: 1
D: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure an adequate call light pager system, placing 36 residents in immediate jeopardy without ability to contact staff when needed. | F |
| Failure to complete thorough discharge summaries for residents discharged to hospital or home. | D |
| Failure to adequately assess a resident following a fall resulting in a fractured collarbone. | D |
| Failure to provide adequate restorative services and positioning devices to prevent contractures for a resident with quadriplegia. | D |
| Failure to provide adequate fall prevention measures for a resident with repeated falls and a head laceration requiring sutures. | G |
| Failure to obtain laboratory tests as ordered by physician for a resident, resulting in delayed CBC and CMP tests. | D |
| Failure to ensure psychotropic medications were not administered beyond 14 days without physician documentation of rationale and duration. | D |
| Failure to administer the facility in a manner that effectively and efficiently maintains the highest well-being of residents, including failure to ensure staff carried call light pagers. | F |
| Failure of the governing body to review and approve policies and procedures for all disciplines to ensure appropriate care and services. | F |
Report Facts
Residents: 36
Call lights initiated: 1113
Call lights not responded within 10 minutes: 440
Call lights not responded at all: 137
Fall Risk Assessment Score: 12
PRN psychotropic medication duration: 14
Delayed lab test completion: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NN | Certified Nurse Aide | Reported not having a pager for weeks, related to call light pager deficiency |
| OO | Certified Nurse Aide | Reported not having a pager for about a week |
| VV | Certified Nurse Aide | Reported not having a pager for quite a while |
| PP | Certified Nurse Aide | Reported not having a pager since beginning job |
| Certified Nurse Aide | Reported working without a pager at times | |
| RR | Certified Nurse Aide | Reported staff had pagers on day of interview but had gone long without pagers |
| G | Licensed Nurse | Unaware CNAs did not have pagers |
| E | Licensed Nurse | Unaware staff only had one pager |
| D | Administrative Nurse | Unaware staff did not have pagers until discovery during survey |
| A | Administrative Staff | Reported last known availability of pagers and new pagers received 01/23/2020 |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Dec 26, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#148528) regarding failure to follow physician's orders for tube feedings for a resident.
Findings
The facility failed to ensure a resident requiring tube feedings received them as ordered, missing at least 15 of 36 feedings from 12/06/19 to 12/12/19, resulting in a 5.2 pound weight loss over five days. The nurse responsible was suspended and terminated. The facility implemented corrective actions including video review, formula counts, resident weighing, and staff training.
Complaint Details
Complaint investigation #148528 found substantiated neglect related to failure to provide ordered tube feedings to Resident 1, resulting in weight loss and staff disciplinary actions.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to administer tube feedings six times per day as ordered, missing at least 15 of 36 feedings from 12/06/19 through 12/12/19. | SS=G |
Report Facts
Census: 34
Missed tube feedings: 15
Weight loss (pounds): 5.2
Weight loss (percentage): 2.83
Ordered tube feedings: 36
Tube feeding volume: 237
Tube feeding frequency: 6
Tube feeding formula containers counted: 35
Tube feeding formula containers extra: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) E | Reported absence of tube feeding items in resident's trash and weighed resident on 12/12/19 | |
| Administrative Nurse B | Received report from CNA E, compared resident weights, and evaluated nurse shifts via video surveillance | |
| Licensed Nurse (LN) C | Documented administration of tube feedings but failed to provide at least three feedings; suspended and terminated | |
| Administrative Staff A | Participated in formula counts, video review, and QAA meetings | |
| Director of Nursing | Completed nursing staff training related to tube feedings and implemented monitoring procedures |
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 26, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior inspection on December 26, 2019.
Findings
Deficiencies were cited at the facility on December 26, 2019, identified by tags F0000 and F600-G, which are addressed in this Plan of Correction.
Deficiencies (2)
| Description |
|---|
| Deficiencies cited at PNC |
| Deficiencies cited at PNC |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 27, 2019
Visit Reason
An offsite revisit was conducted on 10/27/19 to verify correction of all previous deficiencies cited on 08/27/19.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/30/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies compliance date: Aug 30, 2019
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 27, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited related to fall interventions and care plans.
Findings
The facility identified deficiencies in care plan fall interventions for residents and outlined corrective actions including review and revision of care plans, daily review of risk events, staff education, and ongoing monitoring to achieve substantial compliance by 2019-09-18.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents R1, R3 & R4 care plan fall interventions were not appropriately reflecting interventions related to falls on specified dates. | D |
Report Facts
Deficiency completion date: Sep 18, 2019
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Aug 27, 2019
Visit Reason
The inspection was conducted as a complaint investigation for complaint numbers #KS00143242 and #KS00144560 regarding falls and accident hazards at the facility.
Findings
The facility failed to develop and implement appropriate immediate interventions following falls to prevent further falls for three of the four residents reviewed. Interventions such as timely room changes, use of non-skid footwear, and other fall prevention measures were either delayed or not implemented, especially for residents with cognitive impairments.
Complaint Details
The findings represent the results of complaint investigation #KS00143242 and #KS00144560. The facility failed to implement timely and appropriate fall prevention interventions after residents experienced falls.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to develop appropriate immediate interventions following falls to prevent further falls for three of four residents reviewed. | SS=D |
Report Facts
Census: 41
Falls: 2
Falls: 1
Falls: 2
Fall Risk Assessment Dates: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | Certified Nurse Aide | Interviewed regarding fall interventions and resident supervision |
| Certified Nurse Aide N | Certified Nurse Aide | Interviewed regarding fall interventions and resident supervision |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding fall interventions and facility procedures |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding fall interventions, root cause analysis, and facility policies |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 2, 2019
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-06-20.
Findings
All deficiencies cited in the prior inspection were corrected as of the compliance date 2019-07-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 11, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 6/20/2019.
Findings
The facility addressed a deficiency related to the safety of residents by relocating door codes to locations not easily visible to dementia residents and providing staff education on door code postings and elopement risks.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Door codes were displayed in locations easily visible to dementia residents, posing a safety risk. | D |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Jun 20, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers 142221 and 138746 regarding resident safety and elopement risks.
Findings
The facility failed to ensure resident safety by not displaying the door code in a secure location, allowing a resident with moderate cognitive impairment and elopement risk to exit the facility without staff knowledge. Multiple witness statements and video footage confirmed the resident eloped by reading and entering the door code.
Complaint Details
The visit was triggered by complaints #142221 and #138746. The resident was confirmed to have eloped multiple times, and the facility failed to prevent this by not securing the door code. The resident was assessed as an elopement risk with moderate cognitive impairment. The complaint was substantiated by observations, interviews, and video evidence.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to display the door code in a place not easily noticed, allowing a resident at risk for elopement to exit the facility without staff knowledge. | SS=D |
Report Facts
Resident census: 41
Elopement risk residents: 3
BIMS score: 9
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 5, 2019
Visit Reason
An offsite revisit survey was conducted on 03/05/2019 for all previous deficiencies cited on 01/15/2019.
Findings
All deficiencies have been corrected as of the compliance date of 02/14/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 6
Jan 25, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies, outlining corrective actions and timelines to achieve substantial compliance with federal Medicare/Medicaid requirements.
Findings
The plan addresses multiple deficiencies including grievance process improvements, individualized activity programs, installation of safety monitors, dietary department sanitation, and staff education, with all corrective actions targeted for completion by February 14, 2019.
Severity Breakdown
E: 3
D: 1
F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Resident Counsel to review grievance process and ensure prompt investigation and resolution. | E |
| Written responses to residents regarding grievance investigations over the last 12 months. | E |
| Ensure all residents receive individualized activity programs to maintain physical, mental, and psychosocial well-being. | D |
| Installation of a monitor at the nurses station to display visuals of halls to prevent accident hazards. | E |
| Maintain a clean and sanitary dietary department to prevent food-borne illnesses. | F |
| Dietary Supervisor to become certified on or before 7/19/19. | F |
Report Facts
Completion date: Feb 14, 2019
Certification date: Jul 19, 2019
Education dates: Jan 23, 2019
Education dates: Jan 21, 2019
Education dates: Jan 31, 2019
Cleaning dates: Jan 14, 2019
Cleaning dates: Jan 16, 2019
Dishwasher temperature initiation: Jan 25, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Hughes | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 2
Jan 15, 2019
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. A Life Safety Code survey found deficiencies at a level of no harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and substantial compliance was found effective 2019-02-14.
Severity Breakdown
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
| Life Safety Code survey deficiencies at a level of no harm with potential for more than minimal harm that is not immediate jeopardy. | — |
Report Facts
Denial of Payment for New Admissions (DPNA) effective date: Apr 15, 2019
Substantial compliance effective date: Feb 14, 2019
Termination recommendation date: Jul 15, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Contact person for the survey and enforcement actions. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution related to fire safety deficiencies. |
Inspection Report
Follow-Up
Census: 39
Deficiencies: 1
Jan 15, 2019
Visit Reason
The inspection was a health resurvey to assess compliance with dietary services regulations, specifically focusing on staffing and supervisory responsibilities in the dietary department.
Findings
The facility failed to retain the services of a full-time certified dietary manager to oversee the dietary department. Dietary Staff K was acting as dietary manager since July 2018 but was not certified and was attending dietary manager classes at the time of the inspection.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to retain the services of a full-time certified dietary manager to oversee the dietary department. | SS=F |
Report Facts
Census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff K | Dietary Manager (not certified) | Acting dietary manager since July 2018 but not certified, attending dietary manager classes |
| Administrative Staff A | Reported that Dietary Staff K was not certified but taking classes |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 2, 2019
Visit Reason
A desk review was conducted for a previously cited deficiency from November 20, 2018, to verify correction.
Findings
The deficiency cited on November 20, 2018, was corrected as of the compliance date of December 5, 2018.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 20, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
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 which was accepted, and the facility was found to be in substantial compliance effective December 5, 2018.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and coordinator related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Nov 20, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#135533) related to allegations of neglect at the facility.
Findings
The facility failed to report an allegation of neglect when a dependent resident fell forward from a wheelchair onto the facility van floor, sustaining redness to the left temple and right knee. The incident was witnessed by staff but was not reported to the state hotline as required.
Complaint Details
Complaint investigation #135533. The allegation involved neglect when a resident fell from a wheelchair in the facility van and the incident was not reported to the state hotline as required.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an allegation of neglect involving a resident who fell from a wheelchair in the facility van. | SS=D |
Report Facts
Resident census: 45
Fall risk assessment score: 12
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 14, 2018
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified related to a resident fall with injury reported to KDADS.
Findings
The facility reported a resident fall with injury that occurred on 11/14/18 and outlined corrective actions including staff in-service training, daily progress note reviews, and audits to ensure proper event recording and reporting to KDADS.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident #1 Fall with injury which occurred on 11/14/18 was reported to KDADS on 11/29/18. A mandatory in-service regarding ANE including reporting expectations will be provided on 12/5/18 for all staff. Progress notes will be reviewed daily through Clinical Excellence Meeting. Audit of 'risk module' will occur to ensure all events are recorded appropriately per policy. DON and/or Administrator and/or designee will monitor all risk events are recorded properly and reported to KDADS. | D |
Report Facts
Date of fall: Nov 14, 2018
Date fall reported to KDADS: Nov 29, 2018
In-service training date: Dec 5, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Hughes | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 26, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Findings
The facility addressed deficiencies related to dietary management, kitchen sanitation, cleaning schedules, and food storage. Actions include hiring a dietary manager, staff education, deep cleaning, replacement of worn kitchen items, and implementation of a weekly audit system to ensure ongoing compliance.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as Medicalodges Arkansas City Complaint 06262018.
Deficiencies (1)
| Description |
|---|
| Deficiencies related to dietary management and kitchen sanitation including cleaning schedules, proper food storage, and sanitation techniques. |
Report Facts
Complete Date: Jul 26, 2018
Staff Education Dates: Jul 19, 2019
Staff Education Dates: Jul 25, 2019
Registered Dietitian Visit: Jul 20, 2019
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 26, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'F' 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 which was accepted, and the facility was found to be in substantial compliance effective July 26, 2018.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'F' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 26, 2018
Visit Reason
A desk review was conducted for the deficiencies cited on June 26, 2018.
Findings
The deficiencies cited on June 26, 2018, were corrected as of the compliance date of July 26, 2018.
Report Facts
Compliance date: Jul 26, 2018
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Jun 26, 2018
Visit Reason
The inspection was conducted as a complaint investigation #KS00130424 regarding the facility's dietary services and kitchen sanitation.
Findings
The facility failed to employ a full-time qualified dietary manager and maintain a clean and sanitary kitchen environment. Numerous sanitation issues were observed including heavily soiled dishwashing areas, dirty kitchen equipment, outdated and uncovered food items, and unclean floors and vents, posing a risk for food-borne illnesses.
Complaint Details
The visit was triggered by complaint investigation #KS00130424. The findings substantiated the complaint regarding dietary staffing and sanitation issues.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to employ a full-time qualified dietary manager to oversee and manage the dietary department. | SS=F |
| Failure to maintain a clean and sanitary kitchen and storage areas, risking food-borne illnesses. | SS=F |
Report Facts
Census: 40
Outdated food items: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Staff / Dietary Manager (resigned July 2018) | Interviewed regarding kitchen sanitation, cleaning schedules, and dietary manager position |
| Staff B | Dietary Staff | Interviewed regarding cleaning duties and kitchen floor maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 9, 2018
Visit Reason
A complaint survey was conducted on 2/9/18 for complaint # KS00125536.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint # KS00125536 was investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 9, 2018
Visit Reason
A revisit survey was conducted on 2/9/18 to verify correction of all previous deficiencies cited on 12/20/17.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 1/4/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Deficiencies cited: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 9, 2018
Visit Reason
A complaint survey was conducted on 2/9/18 for complaint # KS00125536.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint # KS00125536 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 9, 2018
Visit Reason
A revisit survey was conducted on 2/9/18 to verify correction of all previous deficiencies cited on 12/20/17.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 1/4/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 14
Jan 4, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a complaint investigation.
Findings
The plan outlines corrective actions taken to address multiple deficiencies including resident accommodations for safe smoking, environmental repairs, care plan updates, wound care monitoring, restorative assessments, fall interventions, toileting and hydration programs, staffing levels, infection control, medication monitoring, laundry and housekeeping improvements, and maintenance of non-accessible areas.
Deficiencies (14)
| Description |
|---|
| Resident #6 provided education on accommodations for safe smoking and designated smoking area established. |
| All resident rooms and public areas to receive necessary repairs and cleaning including scratches, gouges, maintenance of bathroom and shower rooms, window cleaning, and wheelchair repairs. |
| Care plans for residents #6, #16, #31, and #29 reviewed and updated to meet needs. |
| Resident #6 care plan updated for wound care monitoring with weekly skin assessments. |
| Resident #31 restorative assessment completed and care plan updated; restorative services education provided. |
| Resident #16 and #31 care plans reviewed and revised for fall interventions. |
| Resident #29 to have 3-day toileting diary completed and care plan updated accordingly. |
| Resident #29 order for thickened liquids reviewed and hydration policy education provided. |
| Staff levels to reflect care necessary for resident well-being with monitoring. |
| Staff education on BIPA posting and RN coverage with monitoring. |
| Resident #13 medication review completed; care plans updated for Black Box Warnings; staff education on medication monitoring. |
| Laundry equipment cleaning and maintenance improved; infection control audits implemented. |
| Shared bathroom call light repaired; call light audits scheduled. |
| Rooms behind locked doors to receive cleaning, maintenance, and repairs with audits. |
Report Facts
Date of Plan of Correction completion: 2018
Frequency of water temperature audits: 3
Frequency of call light audits: 3
Date of staff education: Dec 27, 2017
Date of medication review for Resident #13: Nov 7, 2017
Date of wire laundry carts replacement: Dec 19, 2017
Date of call light repair: Dec 6, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Griffin | Administrator | Administrator named as responsible for monitoring compliance and submitting the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 7
Dec 20, 2017
Visit Reason
The inspection was conducted as a Health Facility Resurvey and Complaint #120317 investigation to assess compliance with nursing staff sufficiency and infection control standards.
Findings
The facility failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed responses to call lights and inadequate care. Additionally, the facility failed to implement and maintain an effective infection prevention and control program, including inadequate hand hygiene, improper cleaning practices, and lack of policies for room cleaning and laundry maintenance.
Complaint Details
The visit was triggered by Complaint #120317. The complaint investigation found substantiated issues related to insufficient nursing staff and infection control deficiencies.
Severity Breakdown
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Insufficient nursing staff to ensure nursing and related services to attain or maintain the highest physical, mental, and psychosocial well-being of residents. | SS=F |
| Failure to implement effective interventions to prevent development of pressure ulcers for a resident. | — |
| Failure to provide restorative services to maintain range of motion for a resident's lower extremity. | — |
| Failure to ensure adequate supervision and assistive devices to prevent repeated accidents for residents and failure to ensure safe hot water temperatures. | — |
| Failure to provide timely toileting to maintain normal bladder function for an incontinent resident. | — |
| Failure to encourage hydration between meals to prevent dehydration for a dependent resident. | — |
| Failure to establish and maintain an infection prevention and control program to prevent spread of infection, including inadequate hand-washing, improper cleaning of equipment, and lack of policies for cleaning resident rooms and laundry areas. | SS=F |
Report Facts
Resident census: 39
Residents sampled: 3
Upper Respiratory Infections (URIs) in February 2017: 5
Infections in March 2017: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Housekeeping staff | Observed improperly handling cleaning cloths and gloves during bathroom cleaning. |
| Staff AA | Laundry staff | Responsible for cleaning dryer vents but admitted vents were not clean at time of observation. |
| Environmental supervisor H | Provided statements regarding improper cleaning practices and equipment maintenance needs. | |
| Administrative nursing staff B | Acknowledged incomplete infection control tracking sheets. | |
| Administrative staff A | Advised staffing requirements for night shifts based on census and resident care needs. | |
| Direct care staff DD | Reported inadequate staffing on night shifts affecting timely completion of nursing care tasks. | |
| Direct care staff I | Reported inadequate staffing on night shifts affecting timely completion of nursing care tasks. |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 14, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 07/14/2016. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID Prefix F0323 related to regulation 483.25(h) |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jul 13, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level, indicating no actual harm but 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.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be 'D' level, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Jul 13, 2016
Visit Reason
The inspection was conducted as a result of the investigation of complaint #101954 regarding the facility's failure to provide adequate supervision and assistive devices to prevent a resident from exiting the facility without staff knowledge.
Findings
The facility failed to provide adequate supervision and assistive devices for one resident at high risk for elopement, who exited the facility unnoticed through a door with an alarm set to chime rather than continuous alarm. The resident was found outside and returned safely without injury. The facility subsequently changed the door alarm to a continuous alarm and provided staff in-service education on elopement procedures.
Complaint Details
Investigation of complaint #101954 found the facility failed to prevent a high elopement risk resident from exiting the facility unnoticed. The resident exited through a door with an alarm set to chime, staff did not immediately detect the exit, and the resident was found outside and returned safely. The complaint was substantiated by these findings.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide assistive devices and/or adequate supervision for one resident to prevent exiting the facility without staff knowledge. | SS=D |
Report Facts
Census: 48
Resident sample size: 3
Resident involved: 1
Date of elopement event: Jun 14, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Heard door closing, checked exits, located resident trying to re-enter facility after elopement | |
| Direct Care Staff D | Saw resident standing outside exit door and assisted resident back inside | |
| Maintenance Man D | Checked door alarm and changed alarm setting from chime to continuous |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 28, 2016
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Arkansas City in response to deficiencies cited in a revised complaint survey conducted on 2016-07-13.
Findings
The facility addressed issues related to door alarm settings and staff education on elopement policy. The door alarm was reset to a loud continuous sound, staff were educated on policies, and audits were conducted to ensure proper functioning and compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Door alarm sound setting was changed to the loudest, disruptive continuous sound level to alert staff of door opening; staff education on elopement policy was completed; audits conducted to ensure door alarms function properly. | D |
Report Facts
Date of staff education: Jun 14, 2016
Date of door alarm validation: Jun 28, 2016
Date of audit: Jun 14, 2016
Date of Plan of Correction completion: Jul 28, 2016
Inspection Report
Follow-Up
Deficiencies: 3
Apr 7, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all previously cited deficiencies identified by regulation numbers 483.10(b)(11), 483.25(l), and 483.65 were corrected as of 04/07/2016.
Deficiencies (3)
| Description |
|---|
| Deficiency with regulation 483.10(b)(11) |
| Deficiency with regulation 483.25(l) |
| Deficiency with regulation 483.65 |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Apr 7, 2016
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Arkansas City in response to deficiencies cited in a prior survey (Deficiency Report 2567). It outlines corrective actions to address issues identified during the inspection.
Findings
The Plan of Correction details corrective actions including nurse education on physician notification for blood sugar levels, audits to identify affected residents, and staff education on cleaning protocols. The facility aims to achieve substantial compliance through these measures.
Severity Breakdown
D: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure proper physician notification on resident blood sugar levels. | D |
| Failure to ensure routine lab work is ordered for diabetic residents and consistent blood glucose parameters. | D |
| Failure to follow proper cleaning processes in resident rooms and change gloves before handling resident items or linens. | F |
Report Facts
Date of nurse education: Apr 7, 2016
Date of staff education: Mar 31, 2016
Audit date: Apr 1, 2016
Observation dates: Apr 1, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MARCRILEY | Administrator | Submitted the Plan of Correction to KDADS |
| IRINASTRAKHOVA | Added and modified the Plan of Correction | |
| Environmental Services Director | Responsible for monitoring cleaning process and staff education | |
| DON/ADON | Responsible for nurse education, audits, and monitoring effectiveness of corrective actions | |
| Health Information Coordinator | Conducted audits related to blood sugar parameters and lab work |
Inspection Report
Re-Inspection
Deficiencies: 1
Mar 30, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but 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 effective April 7, 2016.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to the acceptance of the plan of correction and compliance status. |
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 3
Mar 30, 2016
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements, including monitoring of resident health status and medication management.
Findings
The facility failed to notify the physician when a resident's blood glucose levels were outside prescribed parameters and failed to obtain ordered lab work for monitoring. Additionally, the facility did not follow proper infection control procedures during housekeeping, risking spread of infection.
Severity Breakdown
Level D: 1
Level F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify physician of blood glucose levels outside parameters for resident #53. | Level D |
| Failure to ensure drug regimen was free from unnecessary drugs due to inadequate monitoring and lab work for resident #53. | Level F |
| Failure to maintain infection control by improper housekeeping practices risking spread of infection. | Level F |
Report Facts
Resident census: 45
Residents reviewed for unnecessary medications: 5
Blood sugar out of parameters: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative nursing staff | Advised on blood sugar notification procedures and lack of documentation |
| Staff D | Licensed nursing staff | Advised on blood sugar parameters and notification requirements |
| Staff C | Administrative staff | Advised facility lacked policy on physician notification and lab testing |
| Staff H | Housekeeping staff | Observed performing improper infection control cleaning procedures |
Inspection Report
Life Safety
Deficiencies: 1
Dec 16, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an "F" level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at "F" level severity related to Life Safety Code compliance. | F |
Report Facts
Effective date for denial of payments: Mar 16, 2016
Provider agreement termination date: Jun 16, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 8
Dec 23, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by their regulation numbers and prefix codes were corrected by the revisit date of 12/23/2014.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.13(c) |
| Deficiency related to regulation 483.15(f)(1) |
| Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 7
Dec 23, 2014
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Arkansas City in response to deficiencies cited in a prior inspection (Event ID 3D6Z11). It outlines corrective actions to address issues related to staff background checks, resident activities, care plans, fall interventions, nail care, blood pressure monitoring, kitchen sanitation, and infection control.
Findings
The Plan of Correction details multiple corrective actions including staff in-service trainings, audits of personnel files and resident care plans, implementation of new tracking forms, and ongoing monitoring by the Quality Assurance Performance Improvement (QAPI) committee to ensure substantial compliance with federal and state requirements.
Severity Breakdown
E: 1
D: 4
F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to complete reference and background checks for staff | E |
| Inadequate resident participation in activities | D |
| Incomplete or outdated care plans and fall interventions | D |
| Inadequate nail care for residents | D |
| Failure to verify blood pressure parameters and adherence to physician orders | D |
| Unsanitary kitchen conditions including dirty cookie sheets and maintenance issues | F |
| Improper barrier technique and sanitization of supplies for resident treatments | F |
Report Facts
Date of staff in-service for background checks: Dec 17, 2014
Date of audit of personnel files: Dec 17, 2014
Date of nursing education in-service on fall care plans: Dec 23, 2014
Date of audit of falls: Dec 19, 2014
Date of dietary staff in-service: Dec 22, 2014
Date of kitchen maintenance: Dec 23, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MARCRILEY | Administrator | Administrator responsible for plan of correction and submitted the document |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 15, 2014
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but 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 is found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marc Riley | Administrator | Named as facility administrator in the report. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Janice VanGotten | Regional Manager | Copied on the letter as Regional Manager, Office of the Long Term Care Ombudsman. |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 8
Dec 15, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #77790, 80749 and 82072.
Findings
The facility was found deficient in multiple areas including failure to complete employee background screenings, failure to provide ongoing activity programs for residents, failure to review and revise care plans after falls, failure to provide adequate grooming services, failure to prevent repeated falls with adequate supervision and assistive devices, failure to monitor medications properly, failure to maintain a clean and sanitary kitchen, and failure to maintain an effective infection control program.
Complaint Details
The inspection was triggered by complaint investigations #77790, 80749 and 82072.
Severity Breakdown
SS=E: 1
SS=D: 5
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to complete screenings for 4 of 5 newly hired employees, including reference checks and criminal background checks. | SS=E |
| Failure to provide an ongoing program of activities for 2 of 3 residents reviewed for activities. | SS=D |
| Failure to review and revise care plans following falls for 3 of 4 residents reviewed for accidents. | SS=D |
| Failure to provide necessary services to maintain good grooming for 1 of 3 residents reviewed for activities of daily living. | SS=D |
| Failure to ensure resident environment remains free of accident hazards and provide adequate supervision and assistive devices to prevent repeated accidents for 3 of 4 residents reviewed for accidents. | SS=D |
| Failure to ensure drug regimen is free from unnecessary drugs by failing to adequately monitor blood pressure and follow physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications. | SS=F |
| Failure to maintain a clean and sanitary kitchen for food storage, preparation, and service. | SS=F |
| Failure to maintain an infection control program to help prevent the spread of infection in the laundry, during dressing change, and during inhalation treatment. | SS=F |
Report Facts
Census: 53
Deficiency count: 9
Fall risk scores: 20
Fall risk scores: 17
Blood pressure readings: 130
Blood pressure readings: 80
Fall count: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff T | Laundry Staff | Failed to complete background checks and left wet laundry in washer overnight |
| Staff DD | Dietary Staff | Failed to complete background checks |
| Staff W | Direct Care Staff | Failed to obtain reference checks |
| Staff EE | Licensed Nursing Staff | Failed to obtain reference checks |
| Staff R | Administrative Staff | Confirmed missing background checks and reference checks |
| Staff B | Administrative Nursing Staff | Failed to obtain reference checks and reported usual hiring practices |
| Staff Q | Activity Staff | Reported limited activity engagement and attendance records |
| Staff C | Administrative Staff | Reported activity assessment and documentation practices |
| Staff O | Direct Care Staff | Interviewed resident about activity participation |
| Staff K | Licensed Staff | Reported nursing responsibilities for care plan updates after falls |
| Staff P | Direct Care Staff | Reported lack of asking resident about activity participation |
| Staff BB | Direct Care Staff | Reported lack of asking resident about activity participation |
| Staff X | Direct Care Staff | Reported resident required assistance with transfers and fall risk |
| Staff Y | Direct Care Staff | Witnessed resident fall and documented incident |
| Staff G | Licensed Nursing Staff | Reported failure to update care plan after falls |
| Staff L | Direct Care Staff | Reported resident dependent on staff for personal cares |
| Staff M | Direct Care Staff | Reported resident dependent on staff for personal cares |
| Staff D | Dietary Staff | Reported kitchen sanitation issues and cleaning schedule |
| Staff S | Direct Care Staff | Failed to sanitize medication box after inhalation treatment |
| Staff F | Laundry Staff | Reported leaving wet linens in washer overnight for years |
| Staff K | Licensed Staff | Verified failure to monitor blood pressure as ordered |
| Staff B | Licensed Administrative Staff | Reported possible misunderstanding of blood pressure parameters |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 11, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.15(h)(2), 483.25(l), 483.25(m)(2), 483.60(c), and 483.60(b), (d), (e) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 11, 2013
Visit Reason
This revisit report documents the follow-up inspection to verify that previously reported deficiencies have been corrected at the facility.
Findings
The report confirms that the deficiencies previously cited under regulation numbers 28-39-162(a) and 26-40-303 have been corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 7
Sep 23, 2013
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Arkansas City addressing deficiencies identified in a prior survey (2567). It outlines corrective actions to maintain substantial compliance with Federal Medicare and State Medicaid requirements.
Findings
The Plan of Correction details multiple corrective actions including environmental repairs, staff education on medication and resident monitoring protocols, installation of visual signals in utility rooms, and ensuring proper medication management and documentation. The facility commits to ongoing monitoring through Quality Assurance Performance Improvement (QAPI) meetings.
Severity Breakdown
E: 3
D: 4
C: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Hallway wall carpeting on multiple halls required professional cleaning, disinfection, and flame retardant treatment; wallpaper and painting repairs needed. | E |
| Staff education needed on monitoring behaviors, pain, PRN medication follow-up, and vital signs; antihypertensive protocol required modification. | D |
| Nurse education required to ensure correct insulin dosing and blood sugar monitoring with physician notification. | D |
| Staff education and consultant pharmacist involvement to ensure proper monitoring of blood sugar, behaviors, pain, and medication follow-up. | D |
| Nurse education on removal of expired medications and proper reconciliation documentation; medication cart and room inspections required. | E |
| Installation of visual signals in all residence soiled and clean utility rooms to notify staff of activated resident call lights. | E |
| Hand-washing sink in therapy room reconnected to sump pump and tested for proper working order. | C |
Report Facts
Dates for corrective actions: Sep 23, 2013
Dates for corrective actions: Sep 27, 2013
Dates for corrective actions: Oct 10, 2013
Dates for corrective actions: Oct 11, 2013
Dates for corrective actions: Nov 15, 2013
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 5
Sep 11, 2013
Visit Reason
Health resurvey conducted to assess compliance with previously cited deficiencies and evaluate medication management and housekeeping services.
Findings
The facility failed to maintain sanitary housekeeping and maintenance, failed to ensure residents were free from unnecessary medications and significant medication errors, failed to adequately monitor resident behaviors and medication effects, and failed to maintain proper medication records and storage including outdated medications.
Severity Breakdown
Level D: 3
Level E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide effective housekeeping and maintenance services to maintain a sanitary and comfortable environment, including stained carpets, peeling paint, cracks in walls, and peeling wallpaper. | Level D |
| Failed to ensure residents' drug regimens were free from unnecessary drugs, including inadequate behavior monitoring, pain and bowel movement monitoring, and follow-up of lab reports related to Coumadin administration. | Level D |
| Failed to ensure residents were free of significant medication errors, including administering incorrect insulin doses and failure to notify physician of missed doses. | Level D |
| Failed to ensure drug regimen review by pharmacist identified irregularities such as inadequate monitoring of blood sugars, behaviors, and lab follow-up for anticoagulant therapy. | Level E |
| Failed to maintain a system for reconciliation of discontinued medications held for destruction or return and failed to discard expired medications, including outdated insulin and untracked medication bubble packs. | — |
Report Facts
Resident census: 53
Residents reviewed for unnecessary medications: 5
Residents reviewed for medication errors: 18
Missed insulin dose: 1
Incorrect insulin dose days: 15
Blank behavior monitoring shifts: 4
Blank behavior monitoring shifts: 6
Blank behavior monitoring shifts: 7
Lab PT results: 27.1
Lab PT results: 24.5
Lab PT results: 14.4
Lab PT results: 18.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff H | Licensed Nurse | Verified insulin dose error and failure to notify physician |
| licensed administrative staff B | Administrative Nursing Staff | Verified medication errors and lack of lab follow-up |
| consultant staff Q | Consultant Pharmacist | Reported failure to monitor blood sugars and behaviors |
| licensed nursing staff K | Licensed Nurse | Reported on resident behaviors and documentation practices |
| licensed nursing staff E | Licensed Nurse | Acknowledged lack of lab follow-up for Coumadin therapy |
Inspection Report
Follow-Up
Deficiencies: 11
Jun 22, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as of the revisit date.
Findings
All previously cited deficiencies listed on the CMS-2567 were corrected by the revisit date of 06/22/2012, as documented by the correction completion dates.
Deficiencies (11)
| Description |
|---|
| Deficiency related to regulation 483.20(b)(2)(ii) |
| Deficiency related to regulations 483.20(d), 483.20(k)(1) |
| Deficiency related to regulations 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(e)(2) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
Report Facts
Deficiencies corrected: 11
Inspection Report
Plan of Correction
Deficiencies: 12
Jun 22, 2012
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Arkansas City in response to deficiencies cited in a prior survey (Deficiency Report 2567). It outlines corrective actions to address identified issues and maintain substantial compliance with Federal Medicare and State Medicaid Requirements.
Findings
The plan addresses multiple deficiencies including the completion of significant change assessments, development and revision of individualized care plans for restorative needs, toileting, skin and nutritional care, medication management including black box warnings, sanitation and treatment of skin issues, and staff education. The facility commits to ongoing monitoring and education to ensure substantial compliance.
Severity Breakdown
D: 11
F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to complete significant change assessments (MDS) when appropriate. | D |
| Lack of individualized care plans for residents' restorative needs, including contractures. | D |
| Careplans not properly addressing toileting, skin, and nutritional needs. | D |
| Dependent resident with incontinence and excoriated skin area not properly treated. | D |
| Nursing staff not properly educated on prevention and identification of skin issues due to incontinence. | D |
| Nursing staff not educated on revised restorative dining program to maintain resident's ability to eat independently. | D |
| Improper handling of catheter bags by nursing staff. | D |
| Failure to maintain restorative program to prevent decline in resident's contracture. | D |
| Failure to assess and address residents' nutritional status and weight loss. | D |
| Failure to complete labs and include black box warnings on medication careplans. | D |
| Sanitation issues with dirty and disrepair items in dietary area. | F |
| Failure to include black box warnings on residents' medication careplans and monitoring. | D |
Report Facts
Date of Plan of Correction completion: Jun 22, 2012
Number of deficiencies cited: 12
Date of staff in-service: Jun 5, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Stephenson | Submitted the Plan of Correction to KDADS | |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 55
Deficiencies: 7
May 23, 2012
Visit Reason
The inspection was a re-survey to evaluate compliance with previously cited deficiencies related to comprehensive assessments, care planning, treatment, and medication monitoring.
Findings
The facility failed to conduct timely comprehensive assessments after significant changes, develop individualized care plans including restorative programs, provide appropriate nutritional interventions, maintain sanitary food preparation conditions, monitor medication regimens for adverse effects, and ensure proper treatment of skin conditions and catheter care.
Severity Breakdown
SS=D: 6
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to identify and perform a comprehensive assessment after significant change for resident #15. | SS=D |
| Failed to develop individualized care plans for residents #35, #72, and #65 including restorative programs and nutritional/toileting needs. | SS=D |
| Failed to provide treatment for an open skin area for resident #65. | SS=D |
| Failed to provide services to maintain or improve ADL abilities for resident #72. | SS=D |
| Failed to prevent urinary tract infections and provide appropriate catheter care for resident #53. | SS=D |
| Failed to monitor and provide appropriate treatment for residents on medications with black box warnings (#65, #72, #53). | SS=D |
| Failed to maintain sanitary conditions in the kitchen including uncovered plates, peeling laminate, dirty utensils, and rusted surfaces. | SS=F |
Report Facts
Resident census: 55
Residents reviewed: 13
Deficiencies cited: 7
Resident weight: 119
Resident weight: 124
Resident weight: 120
Resident weight: 126
Resident weight: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Direct Care Staff | Mentioned in relation to restorative program and hand roll placement for resident #35 |
| Staff P | Direct Care Staff | Mentioned in relation to restorative program and hand roll placement for resident #35 |
| Staff L | Licensed Staff | Mentioned in relation to restorative program for resident #35 |
| Staff W | Therapy Staff | Mentioned in relation to restorative program and discharge instructions for resident #35 and #72 |
| Staff R | Direct Care Staff | Mentioned in relation to feeding and encouragement for resident #72 |
| Staff S | Direct Care Staff | Mentioned in relation to feeding and toileting for residents #72 and #65 |
| Staff D | Dietary Staff | Mentioned in relation to nutritional care and fortified foods for resident #65 |
| Staff C | Administrative Nursing Staff | Mentioned in relation to skin care and open area monitoring for resident #65 |
| Staff H | Administrative Nursing Staff | Mentioned in relation to multiple findings including care plan and medication monitoring |
| Staff B | Administrative Nursing Staff | Mentioned in relation to skin care and medication monitoring |
| Staff E | Administrative Nursing Staff | Mentioned in relation to feeding and medication monitoring |
| Staff M | Licensed Nursing Staff | Mentioned in relation to catheter care and medication monitoring |
| Staff U | Direct Care Staff | Mentioned in relation to catheter care for resident #53 |
| Staff T | Direct Care Staff | Mentioned in relation to catheter care for resident #53 |
| Staff V | Direct Care Staff | Mentioned in relation to catheter care and toileting for resident #53 |
| Staff N | Direct Care Staff | Mentioned in relation to catheter care for resident #53 |
| Consultant I | Consultant Pharmacist | Mentioned in relation to medication monitoring and black box warnings |
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