Inspection Reports for
Medicalodges Arkansas City
203 E. OSAGE AVENUE, ARKANSAS CITY, KS, 67005-1255
Back to Facility ProfileDeficiencies (last 14 years)
Deficiencies (over 14 years)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
217% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
89% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Aug 13, 2025
Visit Reason
The inspection was conducted as a non-compliance revisit and complaint investigation following previous deficiencies cited on 2025-06-30. The investigation focused on allegations of verbal abuse by staff toward a resident.
Complaint Details
The complaint investigation was substantiated. The facility failed to prevent verbal abuse by a CNA toward Resident 1 and failed to report the incident immediately to the Administrator. The CNA was terminated, and corrective actions were implemented.
Findings
The facility failed to ensure Resident 1 was free from staff-to-resident verbal abuse when a Certified Nurse Aide taunted the resident about her eyebrows and wrinkles. The facility also failed to report the incident of verbal abuse immediately to the Administrator as required. Corrective actions were completed prior to the survey, including staff re-education and termination of the involved CNA.
Deficiencies (2)
CFR 483.12(a)(1): The facility failed to prevent verbal abuse when a CNA mocked Resident 1's eyebrows and wrinkles, placing the resident at risk for psychosocial harm.
CFR 483.12(b)(5)(i)(A)(B)(c)(1)(4): The facility failed to report an incident of verbal abuse immediately to the Administrator as required, placing the resident at risk for ongoing abuse.
Report Facts
Resident census: 40
Case number: Law enforcement case number A25-10288 related to the abuse allegation
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in verbal abuse finding and subsequent termination |
| Administrative Staff A | Administrator who suspended CNA M and conducted investigation | |
| CNA O | Certified Nurse Aide | Witness to verbal abuse incident |
| CNA P | Certified Nurse Aide | Witness to verbal abuse incident |
| CNA N | Certified Nurse Aide | Witness who reported the incident to administration |
| Administrative Staff D | Staff member unaware of verbal abuse incident |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Jun 30, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection conducted on 2025-06-30.
Findings
The plan addresses multiple deficiencies including environmental safety, abuse and neglect prevention, accuracy of assessments, comprehensive care planning, care plan timing and revision, accident hazard prevention, and management of bowel/bladder incontinence and UTIs. The facility outlines corrective actions, staff education, audits, and monitoring to achieve substantial compliance by 2025-07-29.
Deficiencies (7)
F584 - Safe/Clean/Comfortable/Homelike Environment: Boxes on the floor in Hall A storage room will be removed and stored properly. Shower rooms will have repairs and cleaning completed by specified dates.
F600 - Free from Abuse and Neglect: Resident 1 placed on 1:1 observation with psych services; care plans reviewed and revised. Staff received abuse and neglect training and education on behavioral interventions.
F641 - Accuracy of Assessments: Resident 1's MDS will be corrected and submitted. Weekly audits of newly coded MDS for medication accuracy will be conducted.
F656 - Develop/Implement Comprehensive Care Plan: Black Box Warning care plan implemented for Resident 23; audit of all residents' BBW care plans completed.
F657 - Care Plan Timing and Revision: Resident 3's care plan will be revised to reflect current physician orders and dietary needs. Dietary care plans will be audited and staff educated.
F689 - Free of Accident Hazards/Supervision/Devices: Residents 24 and 30 will have foot pedals on wheelchairs during transport; care plans updated. Staff educated on fall interventions.
F690 - Bowel/Bladder Incontinence, Catheter, UTI: Resident 2's care plan will be revised to meet urinary incontinence needs. Licensed nurses educated on timely assessments and physician notification for UTI signs.
Inspection Report
Routine
Census: 40
Deficiencies: 13
Date: Jun 26, 2025
Visit Reason
Routine inspection of Medicalodges Arkansas City nursing home to assess compliance with regulatory standards across multiple areas including resident care, environment, and infection control.
Findings
The facility had multiple deficiencies including failure to maintain a clean environment, prevent resident-to-resident sexual abuse, complete accurate assessments and care plans, ensure resident safety, provide adequate nutrition, maintain infection control, and ensure safe facility conditions.
Deficiencies (13)
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment in two of three resident halls, including shower rooms and supply storage, exposing residents to unsanitary conditions.
F 0600: The facility failed to prevent resident-to-resident sexual abuse when Resident 1 exposed himself to Resident 9, resulting in psychosocial harm to Resident 9.
F 0641: The facility failed to complete an accurate Minimum Data Set (MDS) for Resident 1 regarding antidepressant medication, placing the resident at risk for impaired care.
F 0656: The facility failed to complete a comprehensive care plan for Resident 23 regarding Black Box Warnings for medications, risking inadequate care.
F 0657: The facility failed to revise Resident 3's care plan with interventions to prevent further weight loss, risking continued weight loss.
F 0689: The facility failed to ensure safe wheelchair use and appropriate fall interventions for Residents 9, 24, and 30, placing them at risk for injury.
F 0690: The facility failed to provide adequate care to prevent urinary tract infections for Resident 2, including monitoring, timely toileting, and reporting symptoms.
F 0692: The facility failed to provide adequate nutrition and implement recommended interventions for Resident 3, resulting in continued weight loss.
F 0730: The facility failed to complete an annual performance review for Certified Nurse Aide M, risking decreased quality of care.
F 0740: The facility failed to implement effective behavioral interventions for Resident 37, who exhibited inappropriate touching and disruptive behaviors.
F 0812: The facility failed to maintain sanitary food preparation and storage conditions in the kitchen and kitchenette, risking foodborne illness.
F 0880: The facility failed to implement adequate infection control practices related to laundry services, including uncovered soiled and clean laundry and improper storage of cleaning equipment.
F 0921: The facility failed to maintain a safe environment, including peeling paint and broken light fixture covers in laundry areas, risking contamination and safety hazards.
Report Facts
Residents affected: 40
Sample size: 14
Weight loss percentage: 10
Days shake refused: 14
Staff educated on abuse prevention: 20
Staff employed: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Lacked annual performance review placing residents at risk for decreased quality of care |
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding care plans, behavioral interventions, and infection control |
| Administrative Staff A | Administrative Staff | Reported on abuse incident notification and environmental concerns |
| CNA Q | Certified Nurse Aide | Observed resident behavior and staff interactions with Resident 37 |
| Consultant GG | Consultant | Provided expert opinion on UTI prevention and monitoring |
| Consultant HH | Consultant | Reported on behavioral monitoring for Resident 37 |
| Dietary Staff CC | Dietary Staff | Reported on resident diet and fortified food provision |
| Housekeeping U | Housekeeping Staff | Reported on laundry storage and infection control practices |
| Maintenance V | Maintenance Staff | Reported on laundry room conditions and environmental safety |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 12
Date: Jun 26, 2025
Visit Reason
The inspection was conducted as a Health Recertification Survey and complaint survey regarding allegations in KS00196133.
Complaint Details
The complaint investigation was triggered by allegations in KS00196133 related to abuse, neglect, and environmental concerns.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, preventing resident-to-resident sexual abuse, completing accurate assessments and care plans, preventing falls and injuries, managing urinary tract infections, maintaining nutritional status, providing adequate nurse aide performance reviews, implementing behavioral health services, ensuring sanitary food preparation, and infection control practices.
Deficiencies (12)
F0584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a clean, comfortable, and homelike environment in two of the three resident halls including shower rooms and supply storage, with issues such as dust, rust, and discolored toilet seats.
F0600 Freedom from Abuse and Neglect. The facility failed to ensure residents remained free from resident-to-resident sexual abuse when Resident 1 exposed himself to Resident 9, resulting in psychosocial harm to Resident 9.
F0641 Accuracy of Assessments. The facility failed to complete an accurate Minimum Data Set for Resident 1 regarding antidepressant medication, placing the resident at risk for impaired care.
F0656 Develop/Implement Comprehensive Care Plan. The facility failed to complete a comprehensive care plan for Resident 23 regarding Black Box Warnings for medications, and failed to revise Resident 3's care plan to prevent further weight loss.
F0689 Free of Accident Hazards/Supervision/Devices. The facility failed to implement appropriate interventions following falls for Resident 9 and failed to utilize foot pedals for Residents 30 and 24, placing residents at risk for injuries and further accidents.
F0690 Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide adequate care and services to prevent urinary tract infection for Resident 2, including monitoring, identifying, and reporting signs and symptoms of ongoing UTI.
F0692 Nutrition/Hydration Status Maintenance. The facility failed to provide care and services to maintain acceptable nutritional status for Resident 3 by not implementing interventions and recommendations including providing fortified foods.
F0730 Nurse Aide Perform Review-12 hr/yr In-Service. The facility failed to complete an annual performance review for Certified Nurse Aide M, placing residents at risk for decreased quality of care.
F0740 Behavioral Health Services. The facility failed to implement effective behavioral interventions for Resident 37's behaviors, placing the resident at risk for mental anguish, social isolation, and impaired quality of life.
F0812 Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to prepare and serve food under sanitary conditions, including dirty kitchen equipment, food debris, uncovered food, and unsanitizable cutting boards, placing residents at risk for foodborne illness.
F0880 Infection Prevention & Control. The facility failed to implement adequate infection control practices related to laundry services, including uncovered clean and soiled laundry, dirty mop buckets stored near washers, and personal items stored on clean laundry counters.
F0921 Safe/Functional/Sanitary/Comfortable Environment. The facility failed to ensure a safe environment including peeling paint in the laundry dryer room and broken fluorescent light fixture covers hanging above clean laundry areas.
Report Facts
Deficiencies cited: 12
Resident census: 40
Staff educated on abuse, neglect, and exploitation prevention: 20
Weight loss: 10
BIMS scores: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Named in multiple interviews related to abuse investigation and care plan discussions. | |
| Administrative Nurse D | Named in interviews related to abuse investigation, care plan updates, and infection control. | |
| Certified Medication Aide T | Named in relation to resident care and observations. | |
| Consultant Staff II | Psychiatric Nurse Practitioner | Named in relation to medication management for Resident 1. |
| Consultant Staff JJ | Named in relation to staff education. | |
| Consultant HH | Named in relation to behavioral health services for Resident 37. | |
| CNA M | Certified Nurse Aide | Named in relation to missing annual performance review. |
| CNA Q | Certified Nurse Aide | Named in relation to behavioral observations of Resident 37. |
Inspection Report
Routine
Census: 40
Deficiencies: 13
Date: Jun 26, 2025
Visit Reason
Routine inspection of Medicalodges Arkansas City nursing home to assess compliance with regulatory standards including resident care, safety, infection control, and facility environment.
Findings
The facility had multiple deficiencies including failure to maintain a clean environment, prevent resident-to-resident sexual abuse, complete accurate assessments and care plans, ensure resident safety, provide adequate infection control, maintain nutritional status, and ensure proper staff performance evaluations. Environmental and infection control issues were noted in kitchen and laundry areas.
Deficiencies (13)
F 0584: Facility failed to maintain a clean, comfortable, and homelike environment in two of three resident halls including shower rooms and supply storage, with dust, rust, and discolored fixtures.
F 0600: Facility failed to prevent resident-to-resident sexual abuse when Resident 1 exposed himself to Resident 9, resulting in psychosocial harm and risk of ongoing abuse.
F 0641: Facility failed to complete an accurate Minimum Data Set for Resident 1 regarding antidepressant medication, placing resident at risk for impaired care.
F 0656: Facility failed to complete a comprehensive care plan for Resident 23 regarding Black Box Warnings for medications, risking inadequate care due to uncommunicated needs.
F 0657: Facility failed to revise Resident 3's care plan with interventions to prevent further weight loss, risking continued weight loss due to uncommunicated care needs.
F 0689: Facility failed to ensure safe wheelchair use and appropriate fall interventions for Residents 9, 24, and 30, placing residents at risk for injury and further accidents.
F 0690: Facility failed to provide adequate care to prevent urinary tract infections for Resident 2, including monitoring, toileting, and reporting symptoms, placing resident at risk for ongoing UTI and complications.
F 0692: Facility failed to provide adequate nutrition and implement recommended interventions for Resident 3, resulting in continued weight loss and risk to health.
F 0730: Facility failed to complete an annual performance review for Certified Nurse Aide M, risking decreased quality of care.
F 0740: Facility failed to implement effective behavioral interventions for Resident 37, who exhibited inappropriate touching and disruptive behaviors, placing resident at risk for mental anguish and impaired quality of life.
F 0812: Facility failed to prepare and serve food under sanitary conditions in the kitchen and kitchenette, including dirty equipment, sticky surfaces, uncovered food, and dust-covered containers, risking foodborne illness.
F 0880: Facility failed to implement adequate infection control practices related to laundry services, including uncovered soiled laundry, dirty mop buckets near washers, and personal items stored with clean laundry, placing residents at risk for infections.
F 0921: Facility failed to maintain a safe environment, including peeling paint near dryers and broken fluorescent light covers above clean laundry areas, risking contamination and safety hazards.
Report Facts
Resident census: 40
Sample size: 14
Weight loss percentage: 10
Days shake refused: 14
Staff educated on abuse prevention: 20
Staff employed: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Reported lack of annual evaluation for CNA M and involvement in abuse incident | |
| Administrative Staff B | Notified of sexual abuse incident involving Resident 1 and Resident 9 | |
| Administrative Nurse D | Administrative Nurse | Provided multiple interviews regarding abuse incident, care plans, and facility policies |
| Certified Nurse Aide M | Certified Nurse Aide | Lacked annual performance review |
| Certified Nurse Aide Q | Certified Nurse Aide | Observed Resident 37's inappropriate behavior and did not redirect |
| Certified Medication Aide T | Certified Medication Aide | Reported Resident 3's refusal of nutritional shakes and assisted Resident 30 |
| Consultant Staff II | Psychiatric Nurse Practitioner | Follow-up on Resident 1's behavior and medication |
| Dietary Staff CC | Reported Resident 3 was not on fortified diet | |
| Housekeeping U | Reported laundry policy absence and cleaning concerns | |
| Maintenance V | Reported paint flaking and refrigerator use in laundry area |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 19, 2025
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-04-10.
Findings
All deficiencies have been corrected as of the compliance date of 2025-04-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Enforcement
Census: 41
Deficiencies: 3
Date: Apr 10, 2025
Visit Reason
The inspection was conducted due to allegations and incidents of resident-to-resident abuse involving sexual behaviors by Resident 1 towards cognitively impaired female residents, including failure to prevent abuse, failure to report to authorities, and failure to implement protective interventions.
Findings
The facility failed to ensure residents remained free from sexual and physical resident-to-resident abuse by Resident 1, who repeatedly touched female residents without consent. The facility also failed to notify law enforcement and conduct thorough investigations for multiple incidents. Immediate jeopardy was identified due to these failures, and corrective actions were implemented.
Deficiencies (3)
F 0600: The facility failed to protect residents from all types of abuse including sexual abuse by Resident 1, who repeatedly touched female residents without consent and the facility did not implement adequate interventions to prevent further abuse.
F 0609: The facility failed to timely report suspected abuse and notify proper authorities including law enforcement for multiple incidents of resident-to-resident sexual abuse involving Resident 1.
F 0610: The facility failed to respond appropriately to alleged violations by not immediately implementing protective measures or conducting thorough investigations after multiple incidents of resident-to-resident sexual abuse by Resident 1.
Report Facts
Resident census: 41
Female residents with moderate to severe cognitive impairment: 11
Residents reviewed for abuse: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN I | Licensed Nurse | Documented incidents of abuse and received disciplinary action for failure to report |
| LN F | Licensed Nurse | Documented incidents of abuse and received disciplinary action for failure to report |
| Administrative Staff A | Provided multiple interviews regarding abuse incidents and facility procedures | |
| Administrative Nurse B | Notified of abuse incidents and involved in documentation | |
| Administrative Nurse C | Provided interview on facility expectations and abuse prevention | |
| Social Services Designee M | Documented observations and referrals related to Resident 1 | |
| CNA H | Certified Nurse Aide | Interviewed about observations and staff responsibilities |
| CNA J | Certified Nurse Aide | Interviewed about staff response to abuse incidents |
| LN K | Licensed Nurse | Interviewed about staff response and reporting procedures |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 3
Date: 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.
Complaint Details
The complaint investigation was triggered by multiple incidents of resident-to-resident sexual abuse by Resident 1 (R1) against cognitively impaired female residents, including grabbing breasts and inappropriate touching. The facility failed to implement adequate interventions, failed to notify law enforcement, and failed to conduct thorough investigations.
Findings
The facility failed to ensure cognitively impaired residents remained free from sexual and physical resident-to-resident abuse by Resident 1 (R1), who repeatedly engaged in inappropriate sexual behaviors including touching female residents without consent. The facility also failed to notify law enforcement and conduct thorough investigations for multiple incidents. Immediate jeopardy was identified due to the risk to vulnerable residents.
Deficiencies (3)
F 600: The facility failed to ensure residents were free from verbal, mental, sexual, or physical abuse, as R1 repeatedly touched female residents without consent and the facility did not implement adequate interventions or protections.
F 609: The facility failed to report allegations of resident-to-resident abuse to the Licensed Nursing Home Administrator, State Agency, and Law Enforcement as appropriate, despite multiple incidents involving R1.
F 610: The facility failed to immediately implement protective measures to prevent further potential abuse and failed to conduct thorough investigations after allegations of resident-to-resident abuse involving R1.
Report Facts
Census: 41
Residents reviewed for abuse: 13
Female residents with moderate to severe cognitive impairment: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN I | Licensed Nurse | Named in failure to report incidents on 03/10/25 |
| LN F | Licensed Nurse | Named in failure to report incidents on 03/30/25 until 04/02/25 |
| Administrative Staff A | Interviewed regarding failure to notify law enforcement and investigation procedures | |
| Administrative Nurse C | Interviewed regarding facility expectations and failure to notify law enforcement | |
| CNA H | Certified Nurse Aide | Interviewed regarding observations of R1's behavior |
| CNA J | Certified Nurse Aide | Interviewed regarding protective actions taken for female residents |
| LN K | Licensed Nurse | Interviewed regarding reporting and safety procedures |
| Social Services Designee M | Documented observations and referral for R1 |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 10, 2025
Visit Reason
This document is a Plan of Correction submitted by Medicalodge of Ark City in response to deficiencies cited in a prior inspection related to abuse, neglect, and exploitation concerns.
Findings
The facility implemented immediate corrective actions including one-on-one supervision for a resident, staff education on abuse and neglect, notification of law enforcement and families, and ongoing monitoring through resident and staff interviews and QAPI meetings.
Deficiencies (3)
F600-J: Resident #1 was placed one on one until appropriate alternative placement is secured. Staff received immediate education on abuse, neglect, and exploitation including reporting and intervention.
F609-K: Immediate education was provided to all staff on abuse, neglect, and exploitation. Law enforcement was notified and families of affected residents were informed. Staff disciplinary actions were taken for failure to report.
F610-K: Resident #1 was placed one on one until alternate placement is secured. Facility conducted resident and staff interviews to solicit complaints and concerns, and held QAPI meetings for ongoing monitoring.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Hess | Received disciplinary action for failure to report resulting in self termination. | |
| Linda Boswell | Received verbal disciplinary action for failure to report resulting in self termination. |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Sep 25, 2024
Visit Reason
The inspection was conducted following a complaint regarding failure to use a gait belt while assisting a resident, which resulted in an injury.
Complaint Details
The investigation was triggered by a complaint about staff not using a gait belt while assisting Resident 1, which led to a fall and injury. The complaint was substantiated as the facility confirmed the failure to use the gait belt.
Findings
The facility failed to ensure staff used a gait belt when assisting Resident 1 in the shower room, resulting in a fall and a left ankle fracture. The facility provided education and training to staff and took disciplinary action prior to the survey.
Deficiencies (1)
F 0689: The facility failed to ensure staff utilized a gait belt when assisting Resident 1, who required assistance lowering to the floor, causing a fracture to his left ankle when his leg was underneath him.
Report Facts
Residents present: 38
Dates of training: Facility trained all nursing staff on 07/28/24 and 07/29/24 for gait belt and mechanical lift training
Disciplinary action date: Disciplinary action to CNA M on 07/31/24 for lack of gait belt use
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in the finding for failure to use gait belt when assisting Resident 1 |
| LN G | Licensed Nurse | Assessed Resident 1 after fall and provided education to CNA M |
| Administrative Nurse D | Stated gait belts are required when providing more than supervision for transfers | |
| Administrative Staff A | Stated facility did not have a gait belt policy but it was standard practice | |
| CNA N | Certified Nurse Aide | Stated staff were to use gait belts on everyone and Resident 1 should have had one |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 5, 2023
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2023-10-10.
Findings
All deficiencies have been corrected as of the compliance date of 2023-11-09, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Oct 10, 2023
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Arkansas City in response to deficiencies cited during a prior inspection on 10/10/2023.
Findings
The plan outlines corrective actions including staff education, monitoring, and process improvements to address issues such as discharge procedures, BIMS assessments, care plan updates, medication storage, infection control, and dietary sanitation. The facility aims to achieve substantial compliance by 11/9/2023.
Deficiencies (12)
F623-D: Resident #26 discharged and returned without proper discharge and transfer process documentation. Administrative personnel received in-service training on 10/24/2023.
F625-D: Resident #26 discharged and returned without providing a copy of the facility bed hold policy. Staff received in-service training on 10/24/2023.
F641-E: BIMS assessments were incomplete for several residents; education and monitoring were implemented to ensure timely completion.
F656-D: Care plan for Resident #11 was not updated timely to reflect daily leg wraps; nursing staff educated on care plan updates.
F684-D: Care plan for Resident #11 updated to reflect resident needs as of 10/24/2023.
F730-D: Staff not meeting annual education requirements will complete training by 11/1/2023; audits will monitor compliance.
F756-E: Medication review records for residents R4, R9, R11, and R21 were incomplete; administrative nurses educated on timely completion.
F758-D: DISCUS assessments for psychotropic medications were incomplete; staff educated and monitoring established.
F761-F: Licensed nursing staff received in-service on medication storage and locking medication carts; random audits to be conducted.
F812-F: Dietary staff educated on food sanitation, hand washing, and cleaning procedures; weekly audits implemented.
F851-F: Staff educated on reporting RN hours and ensuring 8 hours of RN coverage; monitoring and recruitment ongoing.
F880-D: Nursing staff received in-service on infection control techniques; weekly audits to monitor compliance.
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 12
Date: Oct 10, 2023
Visit Reason
Annual health resurvey inspection of Medicalodges Arkansas City to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including failure to notify the Ombudsman of resident transfers, failure to provide bed hold policy notices, inaccurate resident assessments, incomplete care plans, failure to apply physician-ordered treatments, inadequate nurse aide training, failure to follow up on pharmacist medication reviews, improper psychotropic medication monitoring, unsecured medication carts, unsanitary food preparation and storage, inaccurate payroll staffing submissions, and improper infection control practices.
Deficiencies (12)
F623: The facility failed to notify the Office of the State Long-Term Care Ombudsman of Resident 26's hospitalization transfer as required by regulation.
F625: The facility failed to provide Resident 26 and/or their representative with written notice of the bed hold policy duration and cost at the time of hospital transfer.
F641: The facility failed to accurately assess and document cognitive status via BIMS score on the Minimum Data Set for five sampled residents, potentially leading to inaccurate care needs.
F656: The facility failed to develop a comprehensive care plan for Resident 11 related to physician-ordered bilateral leg wraps for edema.
F684: The facility failed to provide care according to professional standards by not applying bilateral leg wraps as ordered for Resident 11, risking worsening edema.
F730: The facility failed to ensure Certified Nurse Aide O received the required 12 hours of annual training, providing only 8.5 hours.
F756: The facility failed to ensure attending physicians documented review and response to consultant pharmacist medication irregularities for five residents, including Residents 4, 9, 11, and 21.
F758: The facility failed to appropriately monitor side effects of psychotropic medications for Resident 21, including lack of required AIMS or DISCUS assessments and incomplete care plan instructions.
F761: The facility failed to secure medication carts, leaving them unlocked and unattended, risking unauthorized access to medications.
F812: The facility failed to maintain sanitary food preparation and storage practices, including use of damaged cutting boards, unclean plates, expired foods, uncovered foods, lack of hair restraints, and uncovered outside trash.
F851: The facility failed to accurately submit complete and accurate licensed nurse staffing data to CMS for 27 dates between 07/01/22 and 03/31/23.
F880: The facility failed to ensure proper glove use and hand hygiene during incontinent care for Resident 21, risking infection transmission.
Report Facts
Resident census: 29
Deficiency cited: 12
Training hours: 8.5
Dates with missing licensed nurse coverage: 27
Expired food items: 5
Inspection Report
Routine
Census: 29
Deficiencies: 12
Date: Oct 10, 2023
Visit Reason
Routine inspection of Medicalodges Arkansas City nursing home to assess compliance with regulatory requirements including resident care, medication management, staffing, infection control, and food safety.
Findings
The facility had multiple deficiencies including failure to notify the Ombudsman of resident transfers, incomplete cognitive assessments, inadequate care planning and treatment for edema, insufficient CNA training hours, failure to follow up on pharmacist medication recommendations, unsecured medication carts, unsanitary food storage and preparation, inaccurate staffing data submission, and improper infection control practices.
Deficiencies (12)
F 0623: The facility failed to notify the State Long-Term Care Ombudsman of the reason for Resident 26's hospitalization transfer as required.
F 0625: The facility failed to provide Resident 26 or their representative with written notice of the bed hold policy specifying duration and cost at the time of hospital transfer.
F 0641: The facility failed to accurately assess and determine cognitive status via BIMS score on the MDS for five residents, risking inaccurate care needs.
F 0656: The facility failed to develop a comprehensive care plan for Resident 11 regarding physician-ordered bilateral leg wraps for edema.
F 0684: The facility failed to provide treatment according to physician orders by not applying bilateral leg wraps for Resident 11 as ordered.
F 0730: The facility failed to ensure CNA O received the required 12 hours of annual training including resident care.
F 0756: The facility failed to follow up on consultant pharmacist recommendations for five residents, including Resident 4, 9, 11, and 21, risking unnecessary medications and adverse effects.
F 0758: The facility failed to monitor side effects of psychotropic medications for Resident 21, including lack of required AIMS or DISCUS assessments.
F 0761: The facility failed to secure medication carts which were left unlocked and unattended, risking medication safety.
F 0812: The facility failed to provide sanitary food preparation and storage, including unclean cutting boards, expired foods, uncovered foods, and lack of hair restraints for kitchen staff.
F 0851: The facility failed to accurately submit licensed nurse staffing data to CMS for 27 dates between 07/01/22 and 03/31/23.
F 0880: The facility failed to ensure proper glove use and hand hygiene during incontinent care for Resident 21, risking infection transmission.
Report Facts
Residents sampled: 12
Residents census: 29
Dates with missing licensed nurse coverage: 27
CNA O training hours: 8.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Reported lack of policies for Ombudsman notification, MDS data entry, medication carts, leg wrap application, hand hygiene, and staffing data submission; confirmed CNA training and medication cart issues. |
| Administrative Nurse F | Administrative Nurse | Confirmed incomplete/incorrect MDS assessment data and lack of follow-up on pharmacist recommendations. |
| Administrative Staff A | Administrative Staff | Reported missing pharmacist medication review reports and lack of follow-up. |
| CNA N | Certified Nurse Aide | Observed using improper glove use and hand hygiene during incontinent care. |
| CNA O | Certified Nurse Aide | Failed to receive required annual training hours. |
| Licensed Nurse G | Licensed Nurse | Observed leaving medication cart unlocked. |
| Consultant Pharmacist GG | Consultant Pharmacist | Reported facility not following up on pharmacist recommendations. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
A revisit survey was conducted on 09/20/2023 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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 06/27/23.
Findings
All 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.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Aug 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of abuse, neglect, and mistreatment reported through multiple complaint investigations (#KS00182064, #KS00182065, and #KS00182069).
Complaint Details
The complaint investigation involved allegations of staff being rough with residents, verbal abuse, and improper care. Specific complaints included a Certified Medication Aide (CMA) being rough, failure to report abuse allegations to the state, and failure to investigate or act on resident complaints. The allegations were substantiated as the facility failed to report and investigate properly.
Findings
The facility failed to report allegations of abuse to the State Survey Agency, failed to investigate allegations of abuse thoroughly, and failed to suspend staff pending investigation. Multiple residents reported or were involved in abuse or neglect incidents that were not properly addressed or reported by the facility.
Deficiencies (2)
F 609: The facility failed to report allegations of abuse to the State Survey Agency within required timeframes, including allegations involving staff being rough with residents and verbal abuse.
F 610: The facility failed to thoroughly investigate allegations of abuse, failed to suspend staff pending investigation, and failed to protect residents from potential further abuse.
Report Facts
Resident census: 35
Dates of allegations: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in failure to report and investigate abuse allegations and failure to suspend staff. |
| Consultant Staff GG | Provided statements regarding complaint investigations and facility responses. | |
| Certified Medication Aide R | Certified Medication Aide | Named in complaint of being rough with residents; facility failed to suspend pending investigation. |
| Certified Medication Aide S | Certified Medication Aide | Named in verbal abuse allegations and rude behavior toward resident R8. |
| Certified Nurse Aide M | Certified Nurse Aide | Named in allegation of inappropriate handling of resident R2. |
| Licensed Nurse G | Licensed Nurse | Agency nurse alleged to have applied powder too hard to resident R9. |
| Certified Nurse Aide P | Certified Nurse Aide | Witnessed and reported on care of resident R2. |
| Certified Nurse Aide N | Certified Nurse Aide | Reported rude behavior of CMA S toward resident R8. |
| Social Service Staff X | Social Service Staff | Received complaints from residents and family members regarding staff behavior. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 16, 2023
Visit Reason
This plan of correction addresses abuse allegations identified during a complaint survey conducted on 08/16/2023.
Complaint Details
The visit was complaint-related due to abuse allegations identified during the complaint survey on 08/16/2023.
Findings
Investigations for abuse allegations were completed on 08/16/2023. Education was provided to all staff, the Director of Nursing, and the Administrator on timely reporting and investigation completion. Monitoring and audits will continue until compliance is achieved by 09/16/2023.
Deficiencies (2)
F609 Reporting of alleged violations: Investigations completed on 08/16/23 for abuse allegations identified during complaint survey. Education completed with all staff and leadership on timely reporting. Monitoring and audits will ensure proper recording and reporting to KDADS until compliance is attained.
F610 Investigate/Prevent/Correct Alleged Violation: Investigations completed on 08/16/23 for abuse allegations identified during complaint survey. Education completed with all staff and leadership on investigation completion and timely reporting. Monitoring and audits will ensure proper recording and reporting to KDADS until compliance is attained.
Report Facts
Date of complaint survey: Aug 16, 2023
Plan of correction completion target date: Sep 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Myoshia Knox | Administrator | Administrator submitting the plan of correction |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of staff to resident abuse, including failure to report and investigate abuse allegations and verbal abuse incidents.
Complaint Details
The complaint investigation involved allegations of staff being rough with residents, verbal abuse by staff to resident R8, and improper care by an agency nurse to resident R9. The facility failed to report these allegations to the state agency and failed to conduct proper investigations or suspend implicated staff.
Findings
The facility failed to timely report allegations of abuse to the State Survey Agency, failed to suspend staff pending investigation, and failed to thoroughly investigate multiple abuse allegations involving residents R2, R8, and R9. Several staff members were reported to have been rough or verbally abusive, and the facility did not adequately protect residents or follow policy.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse and neglect allegations to the proper authorities, including failure to report an allegation involving staff being rough and failure to report abuse allegations involving residents R2 and R9.
F 0610: The facility failed to respond appropriately to all alleged violations by not suspending staff pending investigation, not conducting thorough investigations, and failing to investigate abuse allegations involving residents R8 and R9.
Report Facts
Residents present: 35
Date of survey completion: Aug 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in multiple findings related to failure to report, investigate, and respond to abuse allegations |
| Consultant Staff GG | Consultant Staff | Provided statements regarding complaint investigations and facility responses |
| Certified Medication Aide R | Certified Medication Aide | Named in complaint of being rough and failure to suspend pending investigation |
| Certified Medication Aide S | Certified Medication Aide | Named in allegations of verbal abuse and rude behavior toward resident R8 |
| Licensed Nurse G | Licensed Nurse | Named in allegation of rough treatment applying powder to resident R9 |
| Certified Nurse Aide P | Certified Nurse Aide | Witnessed and reported on care incidents involving resident R2 |
| Certified Nurse Aide M | Certified Nurse Aide | Named in allegations of rough handling of resident R2 |
| Social Service Staff X | Social Service Staff | Reported concerns from residents and family members regarding staff behavior |
| CNA N | Certified Nurse Aide | Reported witnessing rude behavior by CMA S toward resident R8 |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 5
Date: Jun 27, 2023
Visit Reason
The inspection was conducted due to complaints regarding skin and wound management, care plan revisions, pressure ulcer care, physician visits, and infection control practices at the facility.
Complaint Details
The investigation was complaint-driven, focusing on allegations of neglect, inadequate wound care, failure to revise care plans, lack of physician visits, and infection control deficiencies. The complaint was substantiated with findings of immediate jeopardy related to wound care and neglect.
Findings
The facility failed to ensure proper wound assessment and treatment for Resident 1, leading to wound deterioration, osteomyelitis, hospitalization, and pending amputation. The care plan for Resident 3 was not revised to reflect skin conditions. Resident 2 developed unstageable pressure ulcers with inadequate assessment and treatment. The facility also failed to ensure Resident 1 was seen by a physician during admission and did not maintain effective infection control practices.
Deficiencies (5)
F 0600: The facility failed to prevent neglect by not ensuring weekly wound assessments, timely treatment initiation, completion of treatments, and timely physician notification for Resident 1's foot wound, resulting in deterioration and possible amputation.
F 0657: The facility failed to review and revise the care plan for Resident 3 to include excoriation and pressure areas, and failed to notify physician and responsible party of skin conditions.
F 0684: The facility failed to provide appropriate wound care and monitoring for Resident 1 and Resident 2, including failure to perform weekly skin assessments, incomplete wound documentation, failure to notify physician of wound deterioration, and failure to provide physician-ordered treatments.
F 0712: The facility failed to ensure Resident 1 was seen by his primary care physician during admission and stay at the facility.
F 0880: The facility failed to maintain an effective infection control program by not ensuring proper hand hygiene, glove use, and handling of linens and wound care supplies, increasing risk of infection spread.
Report Facts
Resident census: 34
Days without wound treatment: 31
Braden Pressure Ulcer Risk score: 10
Braden Pressure Ulcer Risk score: 13
Braden Pressure Ulcer Risk score: 15
Wound measurements: 8
Wound measurements: 3.5
Wound measurements: 0.5
White blood cell count: 24000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in wound care deficiencies and infection control findings |
| Consultant Wound Care Staff HH | Consultant Wound Care Staff | Performed wound assessments and treatments for Resident 1 |
| Licensed Nurse J | Licensed Nurse | Provided wound care and skin assessments for Resident 1 |
| Certified Nurse Aide M | Certified Nurse Aide | Observed in infection control and wound care practices |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: 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 facility identified issues related to skin integrity assessments, physician notifications, treatment completion, care plan updates, infection control, and timely physician visits. Staff education and ongoing monitoring plans were implemented to address these deficiencies.
Deficiencies (6)
F600-J Residents with skin integrity impairment were assessed with documentation, the resident's physician was notified of changes, treatments were implemented and completed, and treatment supplies were made available on 6/14/23. Staff received education on skin assessments, physician notification, treatment orders, and supply management.
F657-D The care plan was revised to reflect skin conditions and treatments on 7/19/23. Education was provided to the interdisciplinary team on updating care plans with newly identified skin conditions.
F684-J Residents with skin integrity impairment were assessed with documentation, physician notification, treatment completion, and supply availability on 6/14/23. Licensed staff and supply clerks were educated on related procedures.
F686-G Resident R2 had skin assessments completed on 7/20/23. Staff were educated on skin assessments, physician notification, treatment orders, and timely reporting of skin conditions. Monitoring and audits were planned.
F712-D Resident R1 was seen by his physician on 7/9/23. Education was completed on the need for timely physician visits post-admission. Monitoring of physician visit timeliness was established.
F880-D Education was completed with all staff on infection control techniques including hand washing and handling of linens on 7/12/23. Weekly audits of infection control practices were planned.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 6
Date: Jun 27, 2023
Visit Reason
Complaint investigation and Targeted Infection Control Survey/COVID-19 Focused Survey conducted by the Kansas Department for Aging and Disability Services on behalf of CMS.
Complaint Details
Complaint investigation #180708 and #181002 included findings of neglect related to wound care and infection control.
Findings
The facility failed to prevent neglect by not ensuring weekly wound assessments, timely treatment initiation, completion of treatments, and timely physician notification for wound deterioration and critical radiology results. This led to a resident's wound deteriorating to osteomyelitis requiring hospitalization and possible amputation. The facility also failed to revise care plans for pressure ulcers and failed to ensure physician visits and infection control practices met standards.
Deficiencies (6)
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 and failed to initiate treatment for the wound identified on 12/26/22 until 01/27/23.
Failure to complete treatments as ordered and notify the primary care physician when the wound deteriorated and with critical radiology results in a timely manner.
Failure to review and revise the care plan for Resident R3 for presence of pressure ulcers and interventions after admission with excoriation and development of pressure areas.
Failure to monitor Resident R2's skin thoroughly and perform treatments as ordered for unstageable pressure ulcer to toes and failure to ensure physician ordered dressings were in place for pressure areas.
Failure to ensure Resident R1 was seen by his primary care physician during admission from 12/16/22 to 06/04/23.
Failure to maintain an effective infection control program including failure to keep linens off the floor, change gloves when moving from dirty to clean surfaces, and perform hand hygiene after glove removal.
Report Facts
Census: 34
Days without wound treatment: 31
Wound measurements: 8
WBC count: 24000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Named in multiple findings related to wound care management, physician notification, and infection control. | |
| Consultant Wound Care Staff HH | Wound care provider involved in wound assessments and treatment orders for Resident R1. | |
| LN G | Licensed Nurse | Provided dressing changes and reported concerns about wound care for Resident R1. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 5
Date: Jun 27, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding skin and wound management, pressure ulcer care, physician visits, and infection control practices at the facility.
Complaint Details
The investigation was complaint-driven focusing on wound care deficiencies, failure to revise care plans, inadequate physician visits, and infection control breaches.
Findings
The facility failed to ensure timely and adequate wound assessments and treatments for Resident 1, resulting in wound deterioration and osteomyelitis requiring hospitalization and possible amputation. The care plan for Resident 3 was not revised to reflect skin conditions. Resident 2 developed unstageable pressure ulcers with inadequate assessment and treatment. The facility also failed to ensure Resident 1 was seen by a physician during admission and failed to maintain effective infection control practices.
Deficiencies (5)
F 0684: Resident 1's wound was not assessed weekly from 12/21/22 to 02/16/23, treatment was delayed for 31 days, treatments were not completed as ordered, and critical x-ray results were not timely communicated. This led to wound deterioration, osteomyelitis, hospitalization, and possible amputation.
F 0657: Resident 3's care plan was not reviewed or revised to include excoriation and pressure areas on the coccyx and buttocks, despite documented skin conditions and treatment orders.
F 0686: Resident 2 developed unstageable pressure ulcers on the right third and fourth toes and had inadequate skin assessments and treatment. Physician ordered treatments were not fully implemented.
F 0712: Resident 1 was not seen by his primary care physician during his admission to the facility, violating required physician visit intervals.
F 0880: Infection control practices were deficient, including failure to perform hand hygiene after glove removal, failure to change gloves between clean and dirty tasks, and placing wound care supplies and linens on unclean surfaces, increasing infection risk.
Report Facts
Resident census: 34
Days without wound treatment: 31
Braden Pressure Ulcer Risk Score: 10
Braden Pressure Ulcer Risk Score: 13
Braden Pressure Ulcer Risk Score: 15
Wound measurements: 8
Wound measurements: 3.5
Wound measurements: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in wound care deficiencies and infection control failures |
| Consultant Wound Care Staff HH | Consultant Wound Care Staff | Performed wound assessments and treatments for Resident 1 |
| Licensed Nurse J | Licensed Nurse | Provided wound care and described wound assessment practices |
| Certified Nurse Aide M | Certified Nurse Aide | Observed in infection control and wound care practices |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 6, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of 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.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 4
Date: Nov 19, 2021
Visit Reason
This inspection was a Health Facility Resurvey and investigation of complaint #156237.
Complaint Details
The visit was triggered by complaint #156237. The medication error deficiency was substantiated with a 7.41% error rate found.
Findings
The facility failed to ensure medication error rates were below 5%, sanitary food preparation and storage, safe operating condition of kitchen equipment, and a safe environment in the covered gazebo area for residents.
Deficiencies (4)
F 759 Medication error rates exceeded 5% with one resident receiving incorrect doses of two inhaled medications, resulting in a 7.41% error rate.
F 812 The facility failed to provide sanitary food preparation, storage, and serving, with multiple areas of contamination and expired food items observed in the kitchen.
F 908 The facility failed to maintain kitchen equipment in safe operating condition, specifically a reach-in freezer with large ice buildup and no repair completed.
F 921 The facility failed to ensure the covered gazebo area had intact cement flooring, with large cracks and raised gaps creating potential trip hazards for residents.
Report Facts
Resident census: 27
Medication error rate: 7.41
Medication error 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 medication doses 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 | |
| Dietary Staff BB | Confirmed kitchen sanitation issues and freezer problems | |
| Administrative Staff A | Expected dietary staff to follow cleaning schedule and commented on gazebo usage | |
| Maintenance Staff U | Reported residents used gazebo area and described flooring cracks |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: 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 for medication administration, kitchen sanitation and maintenance, freezer repair, and outdoor maintenance including concrete repair to the gazebo patio. The facility commits to ongoing audits and staff in-service training to ensure compliance.
Deficiencies (4)
F759-D: In-service training was provided to licensed nursing staff regarding medication administration. Random audits of medication administration and storage will be conducted weekly to ensure compliance.
F812-F: Kitchen sanitation deficiencies were addressed including cleaning of windows, steam table, carts, ceiling, stove, microwave, vent, cupboards, and proper food storage. A weekly audit system was implemented for ongoing compliance.
F908-F: The kitchen freezer was inspected and repaired following a malfunction. The freezer was defrosted and maintenance audits will continue to ensure functionality.
F921-E: Concrete repair to the gazebo patio was scheduled with the patio remaining out of use until completion. Maintenance staff received training on hazard reporting and will perform weekly compliance audits.
Report Facts
Medication administration audit frequency: 2
Plan completion dates: Dec 22, 2021
Inspection Report
Routine
Census: 27
Deficiencies: 4
Date: Nov 19, 2021
Visit Reason
Routine inspection to assess compliance with medication administration, food safety, equipment maintenance, and environmental safety standards at the nursing home.
Findings
The facility had a medication error rate of 7.41% due to incorrect dosing of inhaled medications for one resident. The kitchen environment was unsanitary with multiple issues including dirty equipment, expired food, and inadequate cleaning. The reach-in freezer was not maintained and unsafe due to ice buildup. The covered gazebo area had cracked cement flooring creating a trip hazard.
Deficiencies (4)
F 0759: The facility failed to ensure one resident received the correct dose of two inhaled medications, resulting in a medication error rate of 7.41%.
F 0812: The facility failed to provide sanitary food preparation, storage, and serving conditions, including dirty kitchen equipment and expired food items.
F 0908: The facility failed to ensure all kitchen equipment was in safe operating condition, specifically a reach-in freezer with ice buildup needing compressor repair.
F 0921: The facility failed to maintain the covered gazebo area, resulting in cracked cement flooring with raised gaps creating a trip hazard for residents.
Report Facts
Medication error rate: 7.41
Census: 27
Medication administration opportunities: 26
Crack lengths: 4
Crack length: 7
Raised gap: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
An off-site revisit was conducted 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.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 9, 2021
Visit Reason
This document is a plan of correction submitted by the facility in response to deficiencies cited in a prior inspection related to medication misappropriation/exploitation.
Findings
The facility reported discontinuing Xanax and scheduling it for destruction. Nurses received education on diversion, medication storage, and destruction. Daily narcotic audits are conducted with ongoing monitoring by the quality assurance committee until compliance is maintained.
Deficiencies (1)
F602 Free from Misappropriation/Exploitation: Xanax was discontinued and scheduled for destruction. Nurses were educated on diversion and medication handling, and daily narcotic audits are performed.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Apr 7, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#161463) regarding the misappropriation of medications at the facility.
Complaint Details
Complaint investigation #161463. The complaint was substantiated based on observation, interview, record review, and video footage showing medication misappropriation.
Findings
The facility failed to prevent the misappropriation of a discontinued controlled substance medication (Xanax) for one resident. Surveillance footage and staff interviews indicated that a licensed nurse removed the medication card and the medication was not found in the secured storage area.
Deficiencies (1)
CFR 483.12: The facility failed to prevent the misappropriation of medications for one resident. The discontinued Xanax medication card was missing from the locked narcotic cabinet and medication room.
Report Facts
Resident census: 33
Medication tablets missing: 30
Date of medication removal: Mar 27, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse D | Licensed Nurse | Named in medication misappropriation finding and video surveillance |
| Licensed Nurse C | Licensed Nurse | Reported inability to find the medication card on 03/31/21 |
| Administrative Nurse B | Administrative Nurse | Had the only key to the locked medication cabinet and participated in investigation |
| Administrative staff A | Administrative staff | Participated in medication count and suspension of Licensed Nurse D |
| Licensed Nurse F | Licensed Nurse | Witnessed Licensed Nurse D entering medication room but did not see medication card placement |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 7, 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 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.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: 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 facility submitted corrective actions addressing restorative care assessments, fall care plan interventions, perineal hygiene for incontinent residents, and infection control practices including mask wearing and oxygen tubing handling.
Deficiencies (4)
F688-D Resident #1, #2, and #3 will have their restorative assessment reviewed and care plan updated. Education and monitoring of restorative services will be conducted to prevent decline or maintain function.
F689-D Resident #5 care plan fall interventions will be reviewed and revised to reflect appropriate fall-related interventions. Staff will be re-educated and falls reviewed regularly to ensure proper care plans.
F690-D The facility will ensure residents with incontinence receive proper perineal hygiene. Staff will be trained and audits conducted to maintain compliance.
F880-F The facility implemented CMS infection control techniques to prevent disease spread. Staff will be re-educated on mask wearing and oxygen tubing replacement with audits to ensure compliance.
Inspection Report
Abbreviated Survey
Census: 40
Deficiencies: 4
Date: Jul 29, 2020
Visit Reason
The survey 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 07/27/2020 to 07/29/2020.
Findings
The facility failed to provide adequate restorative services to maintain or prevent decline in range of motion for three residents, failed to implement appropriate fall interventions for a resident with Alzheimer's disease, failed to perform proper perineal hygiene for a resident with urinary incontinence, and failed to ensure staff properly wore facial masks and sanitized oxygen tubing to prevent infections.
Deficiencies (4)
F 688: The facility failed to provide restorative services to three residents to maintain or prevent decline in range of motion ability as documented by insufficient restorative exercise frequency and staff interviews.
F 689: The facility failed to implement an appropriate fall intervention for a resident with Alzheimer's disease following a fall, relying on an ineffective education intervention given the resident's cognitive impairment.
F 690: The facility failed to perform peri-care on a male resident after removing a wet brief and before applying a clean brief, risking urinary tract infections.
F 880: The facility failed to ensure staff properly wore facial masks covering both mouth and nose and failed to sanitize or replace oxygen tubing that contacted the floor before reapplying it to a resident, risking infection transmission.
Report Facts
Resident census: 40
Residents sampled: 11
Restorative exercise days for Resident 1: 7
Restorative exercise days for Resident 2: 4
Restorative exercise days for Resident 3: 4
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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 CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 22, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a COVID-19 survey conducted on June 22, 2020.
Findings
The facility was found to be deficiency free during the COVID-19 survey conducted on June 22, 2020.
Deficiencies (1)
F0000 Deficiency Free Covid-19 Survey conducted on 06/22/2020.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 26, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 01/28/2020.
Findings
All deficiencies cited in the prior inspection have been corrected as of 02/14/2020 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Jan 28, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection on 01/28/2020.
Findings
The plan outlines corrective actions for multiple deficiencies including call light monitoring, discharge summary completion, nursing practice standards, restorative assessments, fall interventions, medication management, and policy reviews. The facility commits to education, audits, and ongoing monitoring to achieve substantial compliance by mid-February 2020.
Deficiencies (9)
F600-L: Staff were not properly monitoring call light systems. Corrective actions include staff education, pager system improvements, and weekly maintenance testing.
F661-D: Discharge summaries were incomplete for discharged residents. Education and risk management reviews were implemented to ensure compliance.
F684-D: A nurse failed to follow standard nursing practice and was terminated. In-service training and weekly care audits were initiated to ensure proper care.
F688-D: Restorative assessments and care plans were incomplete. Education and monitoring were established to update care plans and ensure timely restorative services.
F689-G: Fall intervention care plans were inadequate. Staff education and audits were planned to improve fall risk assessments and interventions.
F757-D: Medication orders lacked necessary labs and diagnostics. In-service training and audits were scheduled to ensure proper medication justification.
F758-D: Psychotropic medication use lacked 14-day stop dates and justification. Education and audits were planned to address this issue.
F835-F: Administrative staff received education on quality systems to maintain resident well-being. Compliance monitoring through meetings and audits was established.
F837-F: Annual policy review was completed with the medical director. Administrator and DON were educated on maintaining compliance with policy reviews.
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 9
Date: 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 to assess compliance with federal regulations.
Findings
The facility was found not to be in substantial compliance with multiple deficiencies including failure to maintain a functioning call light pager system, incomplete discharge summaries, inadequate fall prevention and assessment, failure to provide adequate restorative services, unnecessary medication use, and lack of governing body oversight of policies.
Deficiencies (9)
§483.12(a)(1) The facility failed to ensure an adequate call light pager system on three resident hallways, placing 36 residents in immediate jeopardy without ability to contact staff when needed.
§483.21(c)(2) The facility failed to complete thorough discharge summaries for two residents discharged to hospital and home, lacking summaries of stay and follow-up plans.
§483.25 Quality of Care The facility failed to adequately assess one resident following a fall, delaying injury assessment for over 14 hours resulting in a fractured collarbone.
§483.25(c) Mobility The facility failed to provide adequate restorative range of motion services and positioning devices to prevent contractures for one resident.
§483.25(d) Accidents The facility failed to provide adequate fall prevention measures for one resident with repeated falls and a head laceration requiring sutures.
§483.45(d) Unnecessary Drugs The facility failed to obtain physician-ordered laboratory tests timely for one resident, risking adverse effects from unnecessary medications.
§483.45(e) Psychotropic Drugs The facility failed to ensure one resident did not receive as needed antianxiety medication beyond 14 days without physician documentation of rationale and duration.
§483.70 Administration The facility failed to administer in a manner to effectively and efficiently maintain the highest well-being of residents by failing to ensure staff carried call light pagers to respond to residents' needs.
§483.70(d) Governing body The facility's governing body failed to review and approve policies for all disciplines to ensure appropriate care and services for residents.
Report Facts
Residents: 36
Call lights initiated: 1113
Call lights not responded within 10 minutes: 440
Call lights not responded at all: 137
Residents reviewed for unnecessary medications: 6
Residents reviewed for restorative services: 2
Residents reviewed for accidents: 4
Residents reviewed for discharge: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Discovered lack of pagers, involved in call light pager system issue |
| Certified Nurse Aide NN | Certified Nurse Aide | Reported not having a pager for weeks |
| Certified Nurse Aide OO | Certified Nurse Aide | Reported not having a pager for about a week |
| Certified Nurse Aide VV | Certified Nurse Aide | Reported not having a pager for quite a while |
| Certified Nurse Aide PP | Certified Nurse Aide | Reported not having a pager since starting job |
| Certified Nurse Aide QQ | Certified Nurse Aide | Reported working without a pager at times |
| Certified Nurse Aide RR | Certified Nurse Aide | Reported staff had pagers on day of interview but had gone long without them |
| Licensed Nurse G | Licensed Nurse | Unaware CNAs lacked pagers, involved in medication and call light system |
| Licensed Nurse E | Licensed Nurse | Unaware staff only had one pager |
| Consultant Staff II | Consultant Staff | Provided expert opinion on discharge summary requirements |
| Consultant Pharmacist Staff GG | Consultant Pharmacist | Confirmed issue with psychotropic medication orders exceeding 14 days |
| Consultant therapy staff JJ | Consultant Therapist | Discussed restorative services and hospice involvement |
| Administrative Staff A | Administrative Staff | Provided information on pager availability and governing body meeting |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
The Plan of Correction addresses deficiencies identified at the previous inspection, specifically those tagged F0000 and F600-G.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Dec 26, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#148528) regarding allegations of neglect related to failure to administer ordered tube feedings to a resident.
Complaint Details
Complaint investigation #148528 substantiated neglect related to failure to administer ordered tube feedings to Resident 1.
Findings
The facility failed to ensure a resident (R1) received ordered tube feedings six times per day, missing at least 15 of 36 feedings from 12/06/19 through 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.
Deficiencies (1)
F600: The facility failed to ensure a resident remained free from neglect when staff did not follow physician orders to administer tube feedings six times daily, missing at least 15 of 36 feedings over a week, causing a 2.83% weight loss in five days.
Report Facts
Resident census: 34
Missed tube feedings: 15
Weight loss: 5.2
Ordered tube feedings: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN C | Licensed Nurse | Named in finding for failing to administer ordered tube feedings, suspended and terminated |
| Administrative Nurse B | Administrative Nurse | Conducted evaluation and audit of tube feeding administration and formula counts |
| Administrative Staff A | Administrative Staff | Participated in evaluation, audits, and corrective action planning |
| Director of Nursing | Director of Nursing | Completed nursing staff training related to tube feedings and conducted random compliance checks |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 27, 2019
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 08/27/19.
Findings
All deficiencies 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.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Aug 27, 2019
Visit Reason
The inspection was conducted as a complaint investigation for allegations related to falls and accident hazards at Medicalodges Arkansas City.
Complaint Details
The findings represent the results of complaint investigation #KS00143242 and #KS00144560.
Findings
The facility failed to develop and implement appropriate immediate interventions following falls for three of four residents reviewed, resulting in repeated falls without timely or effective preventive measures.
Deficiencies (1)
F 689: The facility failed to develop appropriate immediate interventions following falls to prevent further falls for three of four residents reviewed, including delays and inadequate responses to falls.
Report Facts
Resident census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | Certified Nurse Aide | Interviewed regarding fall interventions and resident care. |
| Certified Nurse Aide N | Certified Nurse Aide | Interviewed regarding fall interventions and resident care. |
| 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
Plan of Correction
Deficiencies: 1
Date: Aug 27, 2019
Visit Reason
This document is a plan of correction submitted by the facility in response to deficiencies related to fall interventions identified during a prior inspection on 8-27-19.
Findings
The facility identified issues with care plan fall interventions for residents and committed to reviewing and revising interventions for all fall risk events since January 1, 2019. The plan includes staff education and ongoing monitoring to ensure compliance.
Deficiencies (1)
F689-D: Residents R1, R3, and R4 care plan fall interventions will be reviewed and revised to reflect appropriate interventions related to falls. All risk events since January 1, 2019 will be reviewed and new events monitored daily to ensure appropriate interventions are documented and implemented.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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 have been corrected as of the compliance date 2019-07-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 11, 2019
Visit Reason
This document is a plan of correction submitted by the facility in response to cited deficiencies related to resident safety and compliance with federal Medicare/Medicaid requirements.
Findings
The facility was found to have an issue with door codes being displayed in locations easily visible to dementia residents, posing a risk of elopement. The plan of correction addresses relocating door codes and staff education to ensure resident safety.
Deficiencies (1)
F689-D The facility displayed door codes in locations easily visible to dementia residents, risking elopement. The codes have been moved to less visible locations and staff educated on monitoring residents at risk.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Jun 20, 2019
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint investigation numbers 142221 and 138746.
Complaint Details
The investigation was based on complaints #142221 and #138746. The resident eloped by reading and entering the door code displayed openly, exiting the facility without triggering alarms or staff awareness. Multiple witness statements and interviews confirmed the incident and the resident's moderate cognitive impairment and elopement risk status.
Findings
The facility failed to ensure resident safety by not displaying the door code in a place not easily noticed, allowing a resident at risk for elopement with moderate cognitive impairment to exit the facility without staff knowledge.
Deficiencies (1)
F 689: The facility failed to display the door code in a place not easily noticed, allowing a resident at risk for elopement and with moderate cognitive impairment to identify the code and exit the facility without staff knowledge.
Report Facts
Resident census: 41
Elopement risk residents: 3
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-01-15.
Findings
All deficiencies have been corrected as of the compliance date of 2019-02-14, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Feb 14, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies, outlining corrective actions 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, and ensuring a clean and sanitary dietary department to prevent food-borne illnesses.
Deficiencies (7)
F0000 This plan of correction constitutes a written allegation of substantial compliance with federal Medicare/Medicaid requirements and ongoing monitoring for compliance.
F565-E Resident Counsel to be held to review grievance process and ensure prompt investigation and resolution of resident concerns.
F585-E Written responses will be provided to residents regarding grievance investigations recorded over the last 12 months.
F679-D The facility will ensure all residents receive individualized activity programs to maintain physical, mental, and psychosocial well-being.
F689-E A monitor will be installed at the nurses station to display visuals of halls to ensure residents remain free from accident hazards.
F812-F The facility will ensure a clean and sanitary dietary department to prevent food-borne illnesses, including cleaning, repairs, and staff education.
S0600-F The current Dietary Supervisor will become certified on or before 7/19/19.
Report Facts
Completion date: Feb 14, 2019
Certification deadline: Jul 19, 2019
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 1
Date: Jan 15, 2019
Visit Reason
The visit was a health resurvey to assess compliance following previous findings.
Findings
The facility failed to retain a full-time certified dietary manager to oversee the dietary department. Dietary staff reported that the current dietary manager was not certified but was attending classes to obtain certification.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to employ a full-time certified dietary manager to oversee the dietary department for residents. The current dietary manager was not certified but was attending dietary manager classes.
Report Facts
Resident census: 39
Inspection Report
Enforcement
Deficiencies: 2
Date: Jan 15, 2019
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The survey found the most serious deficiencies at a 'F' level, 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.
Deficiencies (2)
The facility was cited with a 'F' level deficiency that is widespread and constitutes no actual harm but has potential for more than minimal harm that is not immediate jeopardy.
The Life Safety Code survey found deficiencies at a level of no harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of Payment Effective Date: Apr 15, 2019
Termination Recommendation Date: Jul 15, 2019
Months to Achieve Compliance: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Signed the enforcement letter and contact for the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution related to fire safety deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 2, 2019
Visit Reason
A desk review was conducted to verify correction of a previously cited deficiency from November 20, 2018.
Findings
The deficiency cited on November 20, 2018 was corrected as of the compliance date of December 5, 2018.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Date: Nov 20, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#135533) regarding the facility's failure to report an allegation of neglect involving a resident who fell from a wheelchair in the facility van.
Complaint Details
The complaint investigation #135533 was substantiated as the facility failed to report an allegation of neglect involving a resident fall in the facility van.
Findings
The facility failed to report an allegation of neglect for one resident who fell forward from a wheelchair onto the 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.
Deficiencies (1)
CFR 483.12(c)(1)(4) - The facility failed to report an allegation of neglect to the staff agency when a resident fell from a wheelchair in the facility van after staff released the seat belt.
Report Facts
Resident census: 45
Fall risk assessment score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Staff B | Witnessed the resident fall from the wheelchair in the facility van. | |
| Licensed Nursing Staff A | Assessed the resident after the fall and implemented neurological checks. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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.
Deficiencies (1)
A 'D' level deficiency was cited indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 14, 2018
Visit Reason
This 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 monitoring of risk event reporting to ensure compliance.
Deficiencies (1)
F609-D: Resident #1 fall with injury on 11/14/18 was reported late to KDADS. The facility will provide mandatory in-service training on abuse, neglect, and exploitation reporting and monitor risk event documentation and reporting until compliance is maintained.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 27, 2018
Visit Reason
A desk review was conducted to verify correction of 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.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: 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, and food storage by hiring a dietary manager, conducting staff education, deep cleaning the kitchen, replacing worn items, and implementing a weekly audit system to ensure ongoing compliance.
Deficiencies (2)
F801-F: The facility hired a dietary manager enrolled in a dietary manager's course and scheduled consultations with a qualified dietitian. The kitchen was deep cleaned, older utensils replaced, and dietary staff received education on cleaning schedules, sanitation, and food storage.
F812-F: All kitchen areas were deep cleaned including grease and grime removal. Dietary staff education was completed, worn kitchen items replaced, and a weekly audit system was implemented to monitor cleaning schedules and sanitation compliance.
Report Facts
Complete Date: Jul 26, 2018
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Jun 26, 2018
Visit Reason
The inspection was conducted as a complaint investigation #KS00130424 regarding the facility's dietary services and kitchen sanitation.
Complaint Details
Complaint investigation #KS00130424. The complaint was substantiated based on findings of inadequate dietary management and unsanitary kitchen conditions.
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 soiled floors, dirty equipment, outdated and uncovered food items, and lack of cleaning schedules.
Deficiencies (2)
F 801: The facility failed to provide a full-time qualified dietary manager to oversee and manage the dietary department. The kitchen exhibited multiple sanitation issues including heavily soiled floors, buildup of debris on equipment, and unclean food storage areas.
F 812: The facility failed to maintain a clean and sanitary kitchen and storage areas, risking food-borne illnesses. Observations included dirty dishwashing areas, soiled preparation tables, outdated and uncovered food items, greasy vents, and lack of cleaning assignments.
Report Facts
Resident census: 40
Outdated food items: 4
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 a most serious deficiency at level "F" indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective July 26, 2018.
Deficiencies (1)
A level "F" deficiency was cited indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signer of the report letter. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 9, 2018
Visit Reason
A complaint survey was conducted on 2018-02-09 for complaint # KS00125536.
Complaint Details
Complaint # KS00125536 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 9, 2018
Visit Reason
A complaint survey was conducted on 2018-02-09 for complaint #KS00125536.
Complaint Details
Complaint #KS00125536 was investigated and found not substantiated.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 9, 2018
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2017-12-20.
Findings
All previously cited deficiencies have been corrected as of the compliance date 2018-01-04, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 9, 2018
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2017-12-20.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2018-01-04, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Jan 4, 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 plan outlines corrective actions addressing multiple deficiencies including resident care plans, environmental maintenance, infection control, staff education, and safety measures. The facility commits to ongoing monitoring and compliance through audits and quality assurance processes.
Deficiencies (14)
F558-D Resident #6 provided education on accommodations for safe smoking and designated smoking area established with lighting and receptacle relocated. Staff educated on smoking policy accommodations.
F584-E All resident rooms and public areas will receive necessary repairs including paint, maintenance of doors, drawers, bathrooms, and cleaning. Housekeeping and maintenance staff will be in-serviced and conduct weekly rounds for compliance.
F657-E Care plans for residents #6, #16, #31, and #29 reviewed and updated to meet needs. Staff educated on care plan updates and audits will monitor compliance.
F686-G Resident #6 care plan updated for wound care. DON educated on wound monitoring and weekly skin assessments implemented with monitoring for compliance.
F688-D Resident #31 restorative assessment completed and care plan updated. Staff educated on restorative services and program monitored for timely initiation.
F689-E Care plans for residents #16 and #31 reviewed and revised for fall interventions. Staff educated on fall prevention and intervention documentation with audits for compliance.
F690-D Resident #29 will have a 3-day toileting diary completed and care plans updated for incontinence management. Staff educated and audits conducted for compliance.
F692-D Resident #29 thickened liquids order reviewed with physician. Staff educated on hydration policy and audits conducted to ensure hydration needs met.
F725-F Staffing levels will reflect care necessary for resident well-being with monitoring during daily meetings and ongoing compliance review.
F732-C Staff educated on BIPA posting including RN coverage. Monitoring of posting conducted during daily clinical excellence.
F757-D Resident #13 medication GDR completed and care plan updated for Black Box Warnings. Staff educated on medication monitoring and audits conducted for compliance.
F880-F Laundry staff educated on cleaning procedures. Repairs made to laundry equipment and weekly maintenance scheduled. Housekeeping staff trained on infection control cleaning techniques with audits for compliance.
F919-E Shared bathroom call light repaired. Maintenance will conduct call light audits three times weekly with results reviewed for compliance.
F921-E Rooms behind locked doors will receive necessary cleaning and maintenance including floors, cabinets, light bulbs, and shelving. Staff educated and weekly audits conducted for compliance.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 3
Date: Dec 20, 2017
Visit Reason
This inspection was a Health Facility Resurvey and Complaint #120317 investigation to assess compliance with nursing staff sufficiency and infection control requirements.
Complaint Details
This visit was triggered by Complaint #120317 and included a resurvey to verify compliance.
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, cleaning practices, and equipment maintenance in the laundry area.
Deficiencies (3)
F725: The facility failed to provide sufficient nursing staff to ensure nursing and related services to attain or maintain the highest physical, mental, and psychosocial well-being of residents. Residents reported delays in assistance and call light responses, and staff interviews confirmed inadequate staffing levels.
F725: The facility failed to implement effective interventions to prevent pressure ulcers, provide restorative services, ensure supervision to prevent accidents, maintain safe hot water temperatures, provide timely toileting, and encourage hydration for selected residents.
F880: The facility failed to establish and maintain an infection prevention and control program to prevent infection spread, including inadequate hand hygiene during room cleaning and insufficient cleaning and maintenance of laundry equipment.
Report Facts
Resident census: 39
Upper Respiratory Infections (URIs) in February 2017: 5
Infections in March 2017: 5
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 14, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously reported deficiencies have been corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Jul 13, 2016
Visit Reason
The inspection was conducted as a result of investigation of complaint #101954 regarding resident safety and supervision.
Complaint Details
The deficiency citation resulted from investigation of complaint #101954. The complaint was substantiated as the facility failed to prevent elopement of a high-risk resident.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent a cognitively impaired resident from exiting the facility without staff knowledge. The resident exited through a door with an alarm set to chime instead of continuous alarm, allowing the resident to leave unnoticed for several minutes.
Deficiencies (1)
483.25(h) The facility failed to provide assistive devices and adequate supervision to prevent a resident from exiting the facility without staff knowledge, resulting in an elopement risk.
Report Facts
Resident census: 48
Number of sampled residents: 3
Date of elopement incident: Jun 14, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse C | Acknowledged hearing door closure but failed to verify alarm sound and initially failed to check outside | |
| Direct care staff D | Observed resident outside exit door and assisted resident back inside | |
| Maintenance man D | Checked and adjusted door alarm system after incident |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 13, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be at a 'D' level, indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The most serious deficiency was classified as 'D' level, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 28, 2016
Visit Reason
This Plan of Correction document addresses issues identified in a prior complaint survey related to door alarm functioning and elopement policy compliance at Medicalodges Arkansas City.
Findings
The facility implemented corrective actions including adjusting door alarm sound settings to the loudest continuous level, conducting staff education on elopement policy, and performing audits to ensure proper door alarm functioning. The plan aims to maintain substantial compliance as verified by the surveyor on 2016-06-28.
Deficiencies (1)
F323-D: Door alarm sound was changed to the loudest continuous level to alert staff of door openings. Staff received education on elopement policy and audits confirmed proper door alarm functioning.
Report Facts
Date of staff education: Jun 14, 2016
Date of surveyor validation: Jun 28, 2016
Inspection Report
Plan of Correction
Deficiencies: 3
Date: 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 (Event ID ZR6B11). It outlines corrective actions to address issues related to nurse notification, lab work for diabetic residents, and environmental cleaning.
Findings
The plan addresses deficiencies involving improper physician notification of blood sugar levels, inconsistent lab work orders for diabetic residents, and inadequate cleaning procedures. Corrective actions include staff education, audits, and ongoing monitoring through Quality Assurance & Performance Improvement (QAPI) meetings.
Deficiencies (3)
Tag F157-D: Nurse education was conducted to ensure proper physician notification on resident blood sugar levels. Audits confirmed no additional affected residents.
Tag F329-D: Nurse education ensured routine lab work orders for diabetic residents and consistent blood glucose parameters. Audits found no further issues.
Tag F441-F: Staff education was conducted to ensure proper cleaning of resident rooms and glove changes before handling resident items. Observations confirmed compliance.
Report Facts
Complete Date: Apr 7, 2016
Complete Date: Apr 6, 2016
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 7, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
All previously reported deficiencies identified on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 3
Date: Mar 30, 2016
Visit Reason
This was a health resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility failed to notify the physician of blood glucose levels outside prescribed parameters for one resident, failed to monitor and obtain lab work as ordered for that resident, and failed to maintain sanitary housekeeping practices to prevent infection spread.
Deficiencies (3)
F 157: The facility failed to notify the physician when a resident's blood glucose levels were outside physician-ordered parameters on numerous occasions.
F 329: The facility failed to monitor blood sugars adequately and obtain ordered lab work for a resident with diabetes, resulting in unnecessary medication use.
F 441: The facility failed to provide housekeeping services in a sanitary manner, risking the spread of infection among residents.
Report Facts
Resident census: 45
Residents reviewed for unnecessary medications: 5
Blood sugar out of parameters: 83
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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 Medicare and/or Medicaid programs.
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.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the plan of correction acceptance letter. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 16, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Report Facts
Effective date for denial of payments: Mar 16, 2016
Provider agreement termination date: Jun 16, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 23, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: 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 report (Event ID 3D6Z11). It outlines corrective actions to address identified compliance issues.
Findings
The Plan of Correction details multiple corrective actions including staff in-service trainings, audits, process changes, and monitoring plans to ensure compliance with federal and state requirements across areas such as background checks, resident activities, care plans, fall interventions, nail care, medication administration, kitchen sanitation, and infection control.
Deficiencies (9)
F0000: Medicalodges Arkansas City will modify its Quality Assurance Performance Improvement efforts to maintain substantial compliance with federal and state requirements.
F226: Administrator in-serviced hiring Directors and Business Office Manager on completion of reference and background checks; audits showed no missing background checks.
F248: Administrator in-serviced Activities Director and direct care staff to ensure resident participation in activities; developed an Activities Tracker for resident preferences.
F280: All identified care plans were reviewed and updated; nursing in-service ensured temporary care plans for falls with appropriate interventions and communication.
F312: Resident nails were cleaned and trimmed; nursing in-service educated staff on nail care during scheduled baths and ongoing audits were planned.
F323: Care plans reviewed and updated; nursing education ensured fall care plans and alerts; audits to verify interventions and staff compliance.
F329: Staff education ensured proper verification of blood pressure parameters and adherence to physician orders; audits found no additional affected residents.
F371: Dietary Manager in-serviced kitchen staff on sanitation and maintenance; mixer stand professionally sandblasted and painted; cleaning schedule updated.
F441: Nurse in-service ensured proper barrier technique and sanitization of supplies; Environmental Services Director educated laundry staff to prevent leaving washed clothing overnight.
Report Facts
Date of completion: Dec 23, 2014
Audit period: Nov 1, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 15, 2014
Visit Reason
The visit was a Health survey 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 was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The survey identified 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 8
Date: Dec 15, 2014
Visit Reason
Health Resurvey and Complaint Investigations #77790, 80749 and 82072 were conducted to assess compliance with regulatory requirements.
Complaint Details
The inspection was triggered by complaint investigations #77790, 80749, and 82072.
Findings
The facility was found deficient in multiple areas including failure to complete employee background screenings, inadequate activity programs for residents, failure to revise care plans after falls, inadequate grooming services, failure to prevent repeated falls, improper medication monitoring, unsanitary kitchen conditions, and ineffective infection control practices.
Deficiencies (8)
F226: The facility failed to complete screenings for 4 of 5 newly hired employees, missing reference checks and criminal background checks, risking potential resident abuse.
F248: The facility failed to provide an ongoing program of activities for 2 of 3 residents reviewed, with residents not participating in planned activities and lacking documented preferences.
F280: The facility failed to review and revise care plans following falls for 3 of 4 residents reviewed, lacking updated interventions to prevent further falls.
F312: The facility failed to provide necessary grooming services, with one resident's fingernails remaining long and dirty despite scheduled care.
F323: The facility failed to provide adequate supervision and assistive devices to prevent repeated falls for 3 of 4 residents, and failed to implement new interventions after multiple falls.
F329: The facility failed to adequately monitor blood pressure and follow physician-ordered parameters for one resident, administering medications despite low readings.
F371: The facility failed to maintain a clean and sanitary kitchen, with soiled equipment, dirty pans, and lack of cleaning policies.
F441: The facility failed to maintain an infection control program, with improper handling of medications, wet linens left overnight, and unsanitary dressing change practices.
Report Facts
Resident census: 53
Deficiency count: 8
Fall risk scores: 20
Blood pressure readings: 140
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 11, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by the revisit date of 10/11/2013.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Oct 11, 2013
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at Medicalodges Arkansas City.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 28-39-162(a) and 26-40-303 were corrected as of the revisit date.
Deficiencies (2)
Regulation 28-39-162(a) deficiency was corrected by the revisit date.
Regulation 26-40-303 deficiency was corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Sep 23, 2013
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Arkansas City to address deficiencies identified in a prior survey and to outline corrective actions to achieve 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.
Deficiencies (7)
F253-E: The hallway wall carpeting on Halls A, B, C, and D required professional cleaning, disinfection, and flame retardant treatment, with repairs to wallpaper and painting needed in common areas and resident rooms.
F329-D: Staff education was needed to ensure proper monitoring of resident behaviors, pain, medications, vital signs, and physician notifications, with audits planned to ensure compliance.
F333-D: Nurse education was required to ensure correct insulin dosing, blood sugar monitoring, and physician notification, with audits to identify affected residents.
F428-D: Staff education and consultant pharmacist involvement were planned to ensure proper monitoring of blood sugar, behaviors, pain, medications, and vital signs, with audits and ongoing monitoring.
F431-E: Nurse education was planned on removal and documentation of expired medications, with inspections and audits to ensure medication accountability.
S1000-E: Visual signals were added to all residence soiled and clean utility rooms to notify staff of activated resident call lights, with routine testing and monitoring established.
S1126-C: The hand-washing sink in the therapy room was reconnected to a sump pump and tested to be in proper working order, with routine inspections planned.
Report Facts
Complete Date: Sep 23, 2013
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 5
Date: Sep 11, 2013
Visit Reason
The inspection was a health resurvey to evaluate compliance with previously cited deficiencies and overall facility conditions.
Findings
The facility failed to maintain a sanitary environment, failed to ensure residents were free from unnecessary medications and significant medication errors, and failed to adequately monitor resident behaviors and medication effectiveness. Additionally, the facility lacked proper medication reconciliation and storage procedures.
Deficiencies (5)
F253: The facility failed to provide effective housekeeping and maintenance services, resulting in stained carpets, peeling paint and wallpaper, wall cracks, and other unsanitary conditions in multiple resident rooms and hallways.
F329: The facility failed to ensure 3 of 5 residents were free from unnecessary medications, including inadequate monitoring of behavior, pain, bowel movements, and lab follow-up for Coumadin therapy, and failed to notify physicians of abnormal blood sugar readings.
F333: The facility failed to ensure one resident was free from significant medication errors by administering incorrect doses of insulin and failing to notify the physician of a missed dose.
F428: The facility's consultant pharmacist failed to identify irregularities in medication monitoring, including lack of behavior monitoring, inadequate follow-up on pain and constipation medications, and failure to monitor blood pressure and pulse for residents on antihypertensives.
F431: The facility 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 unaccounted medication bubble packs.
Report Facts
Resident census: 53
Residents reviewed for unnecessary medications: 5
Residents reviewed for medication errors: 18
Days insulin dose incorrect: 15
Days blood pressure readings missing: 50
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Jun 22, 2012
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Arkansas City in response to deficiencies identified in a prior inspection report (2567). It outlines corrective actions to address various care and compliance issues.
Findings
The plan details corrective measures including completion of significant change assessments, individualized care plans for restorative needs, careplan revisions, treatment for skin issues, staff education, and monitoring processes to ensure substantial compliance with federal and state requirements.
Deficiencies (11)
F274-D: A significant change assessment (MDS) was completed for the identified resident and the facility reviewed all residents to determine if such assessments were appropriate. The MDS Coordinator was re-educated on completing these assessments.
F279-D: The facility developed individualized care plans for residents with restorative needs, including contractures, and educated nursing staff on these plans. Weekly reviews ensure appropriate restorative programs are in place.
F280-D: Careplans for two residents were revised to address toileting, skin, and nutritional needs. The facility reviews and revises other residents' careplans as needed and educates staff accordingly.
F309-D: The facility obtained treatment for a dependent resident with incontinence and an excoriated area. Staff were educated on prevention and identification of skin issues related to incontinence.
F311-D: Nursing staff were educated on a resident's revised restorative dining program. The facility reviews and revises restorative programs for other residents as needed.
F315-D: A mandatory in-service educated nursing staff on proper catheter bag handling. No other residents currently have catheters, and new hires receive this education upon hire.
F318-D: The facility reinitiated a restorative program to prevent further decline in a resident's contracture and reviews all residents for unaddressed restorative needs, providing staff education.
F325-D: The facility assessed a resident's nutritional status and implemented approaches to prevent weight loss. Dietary and nursing staff review all residents' weights and nutritional needs regularly.
F329-D: Labs were completed and communicated to physicians for identified residents. The facility audits resident orders to ensure labs and black box warnings on medications are properly documented and monitored.
F371-F: Items found dirty were cleaned and those in disrepair repaired or replaced. Dietary Manager performs sanitation rounds and ensures cleaning schedules are followed and reviewed monthly.
F428-D: Black box warnings were included in residents' careplans. The MDS Coordinator reviews medications daily to identify warnings and educates staff and pharmacy consultants on this process.
Report Facts
Deficiencies cited: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Stephenson | Submitted the Plan of Correction to KDADS |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 22, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2012-05-23.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report lists multiple regulation citations with correction completion dates on 2012-06-22.
Report Facts
Deficiencies corrected: 12
Inspection Report
Re-Inspection
Census: 55
Deficiencies: 11
Date: May 23, 2012
Visit Reason
This is a re-survey inspection to verify correction of previous deficiencies at Medicalodges Arkansas City.
Findings
The facility was found deficient in multiple areas including failure to identify significant changes in resident status, failure to develop and revise comprehensive care plans, failure to provide restorative programs, failure to maintain nutritional status, failure to monitor medications with black box warnings, and unsanitary food preparation conditions.
Deficiencies (11)
F 274: The facility failed to identify a significant decline in status for resident #15, including declines in transfers, toileting, cognitive status, and mood.
F 279: The facility failed to provide individualized care plans for residents #35, #72, and #65, including failure to develop a restorative program and failure to revise care plans after therapy discharge.
F 280: The facility failed to ensure residents #72 and #65 received care plan review and revision to provide consistent quality care, including nutritional and toileting needs.
F 309: The facility failed to provide treatment for an open skin area for resident #65, resulting in untreated excoriation related to incontinence for 3 days.
F 311: The facility failed to provide services to maintain resident #72's ability to eat independently after therapy discharge.
F 315: The facility failed to prevent urinary tract infections for resident #53 by improper Foley catheter care, including holding the drainage bag above bladder level.
F 318: The facility failed to provide a restorative program to prevent further decline in left hand contracture for resident #35.
F 325: The facility failed to identify and address weight loss for resident #15, including failure to provide fortified foods and supplements as ordered.
F 329: The facility failed to monitor residents #65, #72, and #53 for adverse consequences of medications with black box warnings and failed to include black box warnings in care plans.
F 371: The facility failed to maintain sanitary conditions in the kitchen, including uncovered plates, peeling laminate, dirty utensils, dust on dishwasher hood, and greasy stove.
F 428: The facility pharmacist failed to identify drug irregularities related to monitoring for adverse consequences of medications with black box warnings for residents #72 and #53.
Report Facts
Resident census: 55
Residents reviewed: 13
Weight measurements: 119
Weight measurements: 124
Weight measurements: 120
Weight measurements: 126
Weight measurements: 135
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018003 POC IZ4911
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
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