Inspection Report Summary
The most recent inspection on March 13, 2017, found that all previously cited deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related mainly to medication management, immunization education, food safety, and quality assurance meeting attendance. Complaint investigations substantiated issues with medication errors, unsanitary food handling, and failure to ensure physician participation in quality meetings, while prior complaints involved supervision lapses leading to resident elopement and fall prevention shortcomings. Enforcement actions were not listed in the available reports, and fines or license suspensions were not noted. The facility appears to have made improvements over time, as several follow-up inspections confirmed correction of prior deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
62 residents
Based on a February 2017 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 4
Mar 13, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.45(f)(1), 483.80(d)(1)(2), 483.60(i)(1)-(3), and 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i) were corrected as of the revisit date.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.45(f)(1) |
| Deficiency related to regulation 483.80(d)(1)(2) |
| Deficiency related to regulation 483.60(i)(1)-(3) |
| Deficiency related to regulation 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i) |
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 13, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective March 13, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Named as contact and signatory related to findings and compliance decision. |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 4
Feb 13, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation covering complaint numbers #99543, #107596, and #101185.
Findings
The facility was found to have medication errors exceeding the allowed rate, failure to provide current immunization education, unsanitary food preparation and storage practices, and failure to ensure physician attendance at Quality Assessment and Assurance meetings.
Complaint Details
The visit was complaint-related, investigating medication errors, immunization education, food safety, and quality assurance committee attendance issues.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Medication error rate of 8% due to failure to administer Glipizide as ordered and incorrect dosage of albuterol nebulizer treatment. | SS=D |
| Failure to provide residents or their representatives with current education regarding Pneumococcal Polysaccharide vaccine benefits and side effects. | SS=E |
| Failure to prepare, store, distribute, and serve food under sanitary conditions, including improper glove use and storage of expired sandwiches. | SS=F |
| Failure to ensure the designated physician attended Quality Assessment and Assurance meetings for 2 quarters in 2016. | SS=F |
Report Facts
Medication error rate: 8
Census: 62
Residents observed for medication administration: 13
Residents reviewed for immunizations: 5
Sandwich expiration days: 3
QAA meetings missed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Direct Care Staff | Unable to locate Glipizide medication and stated it was reordered late. |
| Staff D | Administrative Nursing Staff | Expected staff to reorder medications timely and was unaware of Glipizide unavailability. |
| Staff H | Licensed Nursing Staff | Acknowledged discrepancy in albuterol dosage and planned to contact pharmacy. |
| Staff I | Licensed Nursing Staff | Responsible for entering medication orders and audits. |
| Staff B | Administrative Staff | Confirmed outdated vaccine information was provided to residents. |
| Staff FF | Dietary Staff | Handled food and non-food items without changing gloves. |
| Staff GG | Dietary Staff | Confirmed plates were stored uncovered in upright position. |
| Staff DD | Dietary Staff | Expected plates to be covered and stated facility lacked a kitchen policy. |
| Staff EE | Dietary Staff | Stated sandwiches were outdated and should have been removed. |
| Staff A | Administrative Staff | Stated physician attended QAA meetings quarterly but missed one due to vacation. |
Inspection Report
Plan of Correction
Deficiencies: 4
Feb 13, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey of the facility.
Findings
The plan addresses multiple deficiencies including medication ordering and receiving, updating Vaccine Information Statements (VIS), disposal of expired food, and coordination of Quality Assurance activities with the medical director.
Severity Breakdown
D: 1
E: 1
F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Medication was reordered late; staff to be re-educated on ordering and receiving medications with audits planned. | D |
| Outdated VIS forms replaced with current versions; audits of admission packets for correct VIS to be conducted. | E |
| Expired food disposed of properly; staff training on food handling and expiration dates planned with ongoing audits. | F |
| Quality Assurance meetings coordinated with medical director; updates to be provided if medical director unavailable. | F |
Report Facts
Date medication reordered: Jan 31, 2017
Inservice training date: Feb 21, 2017
Quality Assurance meeting date: Feb 15, 2017
Plan of Correction completion date: Mar 13, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peter Kautz | Administrator | Administrator submitting the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Life Safety
Deficiencies: 1
Jul 11, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an 'F' level, indicating no harm 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy | F |
Report Facts
Effective date for denial of payments: Oct 11, 2016
Provider agreement termination date: Jan 11, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned as responsible for enforcement |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 20, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected.
Findings
The report confirms that the deficiency identified under regulation 28-39-162(a) was corrected as of 08/20/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-162(a) previously cited |
Report Facts
Deficiency correction date: Aug 20, 2015
Inspection Report
Follow-Up
Deficiencies: 1
Aug 20, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.25 with ID prefix F0309 was corrected as of 08/20/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25 with ID prefix F0309 |
Report Facts
Deficiency correction date: Aug 20, 2015
Inspection Report
Enforcement
Deficiencies: 1
Jul 23, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an 'E' level deficiency, pattern, 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, resulting in a finding of substantial compliance effective August 20, 2015.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were an 'E' level deficiency, pattern. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter. |
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 1
Jul 23, 2015
Visit Reason
The inspection was a Health Resurvey to assess compliance with care and service requirements, specifically focusing on neurological check assessments following resident falls.
Findings
The facility failed to complete thorough neurological check assessments for two residents (#72 and #78) who had falls or fall risks. Documentation gaps and incomplete neuro checks were noted despite policies requiring full assessments after falls or suspected head injuries.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to complete neurological check assessments for two residents with fall history and cognitive impairments. | SS=D |
Report Facts
Census: 61
Sample size: 12
Neurological checks missed: 2
Neurological checks completed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff H | Stated resident fell and neuro checks were initiated but documentation was incomplete | |
| administrative nursing staff D | Confirmed neuro checks should have been completed and documented fully | |
| direct care staff P | Reported resident fell out of bed and neuro checks were initiated |
Inspection Report
Plan of Correction
Deficiencies: 2
Jul 21, 2015
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Eudora in response to deficiencies cited during a survey ending on July 21, 2015.
Findings
The plan addresses neurological assessments after falls for residents #72 and #78 and others at risk, as well as issues with non-functional call light indicator bulbs in utility rooms, including replacement and repair actions taken.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete neurological assessments for all un-witnessed falls. | D |
| Non-functional call light indicator bulbs in clean and soiled utility rooms. | E |
Report Facts
Deficiencies cited: 2
Dates for corrective actions: Aug 11, 2015
Dates for corrective actions: Aug 20, 2015
Review meeting date: Aug 19, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Boulton | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Oct 9, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of 10/09/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(h) previously cited and corrected. |
Report Facts
Deficiencies corrected: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 9, 2014
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an 'E' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was an 'E' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the author of the letter and contact for questions regarding the survey. |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Sep 9, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#78202) regarding the facility's failure to provide adequate supervision to prevent a cognitively impaired resident from leaving the facility unsupervised.
Findings
The facility failed to ensure adequate supervision and proper functioning of door alarms to prevent resident #1, who had severe cognitive impairment and was at high risk for elopement, from leaving the facility unsupervised. Documentation showed multiple missed door alarm checks and a door alarm being turned off, allowing the resident to exit the facility.
Complaint Details
Complaint investigation #78202 focused on supervision failures leading to resident #1 leaving the facility unsupervised. The resident was cognitively impaired with a BIMS score of 3, had delusions, and was at high risk for elopement. The facility's door alarm system was not consistently checked or properly activated, contributing to the incident.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide supervision for resident #1 to prevent leaving the facility unsupervised. | SS=E |
Report Facts
Resident census: 61
Cognitively impaired residents: 12
Resident BIMS score: 3
Resident fall risk score: 17
Resident elopement risk score: 16
Missed door alarm checks: 26
Missed door alarm checks: 14
Missed door alarm checks: 28
Missed door alarm checks: 18
Missed door alarm checks: 27
Missed door alarm checks: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported on 9/5/14 about the resident exiting from the northeast side door without a Wanderguard alarm and about the assignment of departments for door alarm checks. | |
| Consultant staff Y | Brought resident back inside after being found outside and assisted with door alarm checks. | |
| Licensed nursing staff H | Reported resident was assessed as an elopement risk. | |
| Direct care staff N | Reported resident routinely walked to doors and looked out windows. | |
| Maintenance/housekeeping staff X | Reported staff were trained and oriented for checking alarmed doors. | |
| Licensed nursing staff I | Reported observations related to resident elopement and door alarm status. | |
| Housekeeping staff Z | Reported door checks on 8/9/14. | |
| Direct care staff O | Reported door alarm checks around 3 P.M. on 9/5/14. | |
| Direct care staff P | Assisted with door alarm checks and reported door alarm was off after resident returned. | |
| Direct care staff R | Reported door checks performed by housekeeping, CNAs, and CMAs at scheduled times. |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 5, 2014
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Eudora in response to deficiencies cited during a complaint survey ending on September 5th, 2014.
Findings
The plan addresses the deficiency related to the exit door alarm system for resident #1, outlining ongoing checks, staff education, risk evaluations for other residents, and weekly compliance reporting to the Risk and Quality Assurance committees.
Complaint Details
The plan of correction is in response to deficiencies cited during a complaint survey ending on September 5th, 2014. The facility neither confirms nor accepts the survey findings as legitimate but is implementing corrective actions.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Exit door alarm system not consistently checked or operational for resident #1 | E |
Report Facts
Date of complaint survey end: Sep 5, 2014
Date HCFA form 2567 received: Sep 9, 2014
Date of QA meeting for follow-up: Sep 17, 2014
Plan of correction completion date: Oct 9, 2014
Staff education completion date: Sep 23, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Boulton | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 3
Jun 25, 2014
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey, verifying that corrective actions were completed by the facility.
Findings
The report confirms that previously identified deficiencies, referenced by regulation numbers 28-39-158(a), 26-40-302(c)(i)(ii)(iii)(iv)(v)(d)(i)(ii), and 26-40-305(3), were corrected as of 05/27/2014.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 28-39-158(a) |
| Deficiency related to regulation 26-40-302(c)(i)(ii)(iii)(iv)(v)(d)(i)(ii) |
| Deficiency related to regulation 26-40-305(3) |
Report Facts
Correction completion date: May 27, 2014
Follow-up survey completion date: Apr 30, 2014
Inspection Report
Follow-Up
Deficiencies: 11
Jun 25, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the prior survey were corrected.
Findings
The report documents that all previously cited deficiencies were corrected as of 05/27/2014, with no uncorrected deficiencies remaining at the time of the revisit.
Deficiencies (11)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.13(c) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 11
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 11
Apr 30, 2014
Visit Reason
The inspection was a health resurvey to evaluate compliance with regulatory requirements including investigation and reporting of abuse, staff registry checks, care planning, prevention of skin issues, neurological checks after falls, pressure ulcer prevention and treatment, urinary incontinence management, medication regimen review, pharmaceutical services, and infection control.
Findings
The facility failed to report an allegation of abuse, timely check nurse aide registry, revise care plans, prevent skin issues, initiate neurological checks after falls, prevent and treat pressure ulcers, assess and manage urinary incontinence, provide proper diet orders, monitor psychotropic medication side effects, accurately transcribe medication orders, and maintain an effective infection control program.
Severity Breakdown
SS=D: 8
SS=G: 1
SS=F: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to report an allegation of abuse to the state survey agency for one resident. | SS=D |
| Failed to timely check the Kansas Nurse Aide Registry prior to allowing staff to perform direct care. | SS=D |
| Failed to revise care plans to reflect dietary changes and other care needs for residents. | SS=D |
| Failed to prevent skin issues and initiate neurological checks after unwitnessed falls for residents. | SS=D |
| Failed to provide services and treatment to prevent development of pressure ulcers and failed to reposition residents as planned. | SS=G |
| Failed to assess and provide toileting to meet the needs of incontinent residents and failed to change briefs timely. | SS=D |
| Failed to provide proper diet order and failed to provide nutritional diet as ordered for a resident with recent weight loss. | SS=D |
| Failed to monitor side effects of psychotropic medication for a resident receiving such drugs. | SS=D |
| Failed to accurately transcribe medication orders and failed to obtain all components of medication orders. | SS=D |
| Pharmacy consultant failed to recognize and recommend monitoring for side effects of psychotropic medication. | SS=F |
| Failed to maintain an effective infection control program including allowing a cat to sit in a water fountain and lack of infection data analysis. | SS=F |
Report Facts
Resident census: 59
Deficiency count: 11
Resident sample size: 13
Weight loss: 15
Pressure ulcer size: 2
Pressure ulcer size: 1
Inspection Report
Plan of Correction
Deficiencies: 14
Apr 28, 2014
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Eudora in response to deficiencies cited during a survey ending on April 28, 2014, aiming to address and correct the cited issues in compliance with CMS regulations.
Findings
The plan outlines corrective actions for multiple deficiencies including abuse reporting, CNA certification verification, nutritional care planning, neurological assessments after falls, pressure sore prevention, incontinence care, medication order accuracy, drug regimen reviews, infection control, and safety improvements. The facility commits to ongoing monitoring, staff education, and regular Quality Assurance Performance Improvement committee reviews.
Severity Breakdown
D: 9
G: 1
E: 1
F: 1
C: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate and report timely all allegations of abuse, including a bruise of unknown origin for resident #40. | D |
| Failure to verify CNA certification through the Nurse Aide Registry prior to hire. | D |
| Failure to update care plans for residents identified as nutritionally at risk. | D |
| Failure to assess residents' needs and identify interventions to maintain or obtain the highest practicable well-being. | D |
| Failure to provide care and services to prevent or heal pressure sores. | G |
| Failure to assess and develop appropriate care plan interventions to prevent urinary tract infections in residents with bladder incontinence. | E |
| Failure to provide nutritional diets as ordered. | D |
| Failure to assess residents receiving anti-psychotic or other medications for Extra Pyramidal Side Effects every 3 to 6 months. | D |
| Medication orders lacking all information required for safe medication administration. | D |
| Failure to review facility residents' drug regimen monthly by a licensed pharmacist and report irregularities. | D |
| Failure to establish and maintain an infection control program to prevent disease and infection transmission. | F |
| Failure of Dietary Director to have dietary manager certification yet, with a plan to complete certification by October 1, 2014. | C |
| Safety hazard with hydrocolator outlet not being a GFCI outlet, replaced on 4/22/2014. | D |
| Laundry sorting barrels without lids replaced with barrels containing lids on 5/7/2014 to comply with infection control policies. | D |
Report Facts
Deficiencies cited: 13
Dates of compliance completion: May 27, 2014
Certification exam expected completion: Oct 1, 2014
Date of survey ending: Apr 28, 2014
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 23, 2013
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.
Findings
The report confirms that the previously identified deficiency related to regulation 28-39-158(a) was corrected as of 02/23/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 28-39-158(a) |
Report Facts
Correction completion date: Feb 23, 2013
Follow-up survey completion date: Jan 24, 2013
Inspection Report
Follow-Up
Deficiencies: 4
Feb 23, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that all previously cited deficiencies identified by their regulation numbers (483.20(d), 483.20(k)(1), 483.25(h), 483.25(l), and 483.60(c)) were corrected as of the revisit date.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 1
Jan 24, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to have a Certified Dietary Manager (CDM) onsite for 4 of 4 days during the survey period. Dietary staff lacked certification and was scheduled to take the CDM exam in October 2013.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have a Certified Dietary Manager (CDM) onsite for 4 of 4 days of the survey. | SS=C |
Report Facts
Census: 60
Days without CDM onsite: 4
Inspection Report
Plan of Correction
Deficiencies: 6
Jan 22, 2013
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Eudora in response to deficiencies cited during a survey ending on January 22, 2013.
Findings
The plan addresses multiple deficiencies including the development of comprehensive care plans, fall assessments, environmental safety regarding assist bars, medication monitoring for psychotropic drugs and black box warnings, and the dietary director's certification status.
Severity Breakdown
C: 1
D: 1
E: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Lack of comprehensive care plans for residents, especially those receiving hospice care. | D |
| Incomplete fall assessments and need for nurse education on fall protocols. | E |
| Environmental hazards due to assist bars not meeting safety guidelines. | E |
| Resident behavior sheets not specifying psychotropic medications and targeted behaviors. | E |
| Pharmacy review deficiencies related to monitoring residents at risk for black box warnings. | E |
| Dietary Director not yet certified as a dietary manager. | C |
Report Facts
Deficiencies cited: 6
Dates for substantial compliance: Feb 23, 2013
Certification exam date: 201310
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Boulton | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 20, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies as noted on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that the previously cited deficiency with ID prefix F0323 related to regulation 483.25(h) was corrected as of 07/20/2012.
Deficiencies (1)
| Description |
|---|
| Deficiency identified by ID prefix F0323 related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Jun 20, 2012
Visit Reason
The inspection was conducted as a result of complaint investigation #57449 regarding the facility's failure to provide adequate supervision and assistive devices to prevent falls for sampled residents.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent falls for three sampled residents, resulting in multiple falls and injuries. Specific failures included lack of non-skid strips, call lights not within reach, failure to maintain fall risk indicators, and malfunctioning or absent bed/chair alarms.
Complaint Details
The citation resulted from complaint investigation #57449. The facility failed to ensure non-skid strips were in place, call lights were within reach, fall risk indicators were properly used, and bed/chair alarms functioned and were used as ordered for residents at high risk of falls.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide supervision and/or assistive devices to prevent falls for 3 sampled residents. | SS=D |
Report Facts
Resident census: 67
Sample size: 3
Fall risk assessment scores: 17
Fall risk assessment scores: 13
Fall risk assessment scores: 32
Fall risk assessment scores: 28
Fall risk assessment scores: 24
Fall risk assessment scores: 17
Fall risk assessment scores: 19
Falls: 2
Falls: 2
Falls: 1
Bruise size: 5
Bruise size: 2
Bruise size: 1.4
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 19, 2012
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Eudora in response to deficiencies cited during a complaint investigation survey conducted on June 19, 2012.
Findings
The plan addresses multiple deficiencies related to fall prevention, communication interventions, and care plan updates. Specific corrective actions include applying skid strips, updating the Frequent Flier list, affixing visual aids to resident room pictures, enhancing communication through new care coordinator positions, and staff education on fall prevention.
Complaint Details
This plan of correction is linked to a complaint investigation survey conducted on 6/19/2012, with a written HCFA form 2567 received on 6/20/2012.
Deficiencies (1)
| Description |
|---|
| Failure to implement adequate fall prevention interventions including communication and care plan updates. |
Report Facts
Deficiency cited date: Jun 19, 2012
Plan of Correction completion date: Jul 20, 2012
Plan of Correction submission date: Jun 28, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Fox | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Mary Jane Kennedy | Modified the Plan of Correction | |
| Irina Strakhova | Added the Plan of Correction |
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