Inspection Reports for Medicalodges Fort Scott
915 SOUTH HORTON, P. O. BOX 510, KS, 66701
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 22, 2017, found no deficiencies, confirming that previously cited issues were corrected. Earlier inspections showed a pattern of deficiencies related mainly to housekeeping and maintenance, infection control, resident supervision, and food service sanitation. Complaint investigations substantiated concerns about inadequate supervision of residents at risk for elopement and failures in maintaining resident dignity and safe environments. Enforcement actions included accepted plans of correction but no fines, immediate jeopardy findings, or license suspensions were listed in the available reports. The facility’s record shows improvement over time, with repeated deficiencies addressed and resolved by subsequent revisits.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
18.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
208% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
49 residents
Based on a January 2017 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 7
Feb 22, 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 had been corrected.
Findings
All previously cited deficiencies identified by regulation numbers and prefix codes were marked as corrected and completed as of the revisit date.
Deficiencies (7)
| Description |
|---|
| Deficiency with regulation 483.10(a)(1) |
| Deficiency with regulation 483.10(i)(2) |
| Deficiency with regulation 483.24, 483.25(k)(l) |
| Deficiency with regulation 483.60(i)(1)-(3) |
| Deficiency with regulation 483.80(a)(1)(2)(4)(e)(f) |
| Deficiency with regulation 483.90(f)(2) |
| Deficiency with regulation 483.90(h)(5) |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 7
Jan 23, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for complaint numbers 105479 and 107426.
Findings
The facility was found deficient in multiple areas including failure to promote dignity by not providing a catheter drainage bag cover for a resident, inadequate housekeeping and maintenance services resulting in unsanitary conditions, failure to adequately monitor a dialysis resident, unsanitary food storage and preparation conditions, incomplete infection control program with poor infection trending and antibiotic stewardship, non-functioning resident call lights, and unsafe, unsanitary, and uncomfortable environmental conditions in various facility areas.
Complaint Details
The visit was complaint-related, triggered by complaints #105479 and #107426. The investigation found multiple deficiencies as detailed in the findings.
Severity Breakdown
SS=D: 2
SS=E: 3
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to promote dignity by not providing a catheter drainage bag cover for 1 of 4 sampled residents (#15). | SS=D |
| Failure to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident rooms, dining rooms, and beauty shop. | SS=E |
| Failure to adequately monitor 1 resident (#51) receiving dialysis, including lack of assessment of dialysis access site for bleeding or infection. | SS=D |
| Failure to store and prepare food under sanitary conditions including unsanitary refrigerator shelving, dirty stove, and unclean pans. | SS=F |
| Failure to maintain an infection control program to prevent, recognize, and control infections, including failure to trend infections and antibiotic use. | SS=F |
| Failure to ensure 7 resident call lights on 3 halls were in working order. | SS=E |
| Failure to provide a safe, functional, sanitary, and comfortable environment in public bathroom, nurses' station floors, and kitchen floor with issues such as corrosion, grime, worn flooring, and broken concrete. | SS=E |
Report Facts
Residents reviewed for dignity: 4
Residents reviewed for dialysis: 1
Number of call lights not working: 7
Number of pans with brown substance: 7
Number of residents in census: 49
Number of urinary tract infections reported in March 2016: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed administrative staff | Stated catheter drainage bag should have a cover and confirmed infection control logs were incomplete. |
| Staff F | Licensed nursing staff | Stated CNA's should put a cover over the drainage bag and described dialysis patient monitoring procedures. |
| Staff C | Maintenance staff | Revealed call lights were checked weekly and confirmed call lights were now functioning. |
| Staff K | Dietary staff | Verified unsanitary conditions in dietary department including pans and stove. |
Inspection Report
Plan of Correction
Deficiencies: 7
Jan 23, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to achieve substantial compliance with Federal Medicaid/Medicare requirements.
Findings
The plan addresses multiple deficiencies including resident dignity with catheter bags, housekeeping and maintenance issues, dialysis care, food service safety, infection control, call light system repairs, and environmental safety. The facility outlines specific corrective actions with completion dates and monitoring plans to ensure compliance.
Severity Breakdown
D: 2
E: 3
F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure dignity bag placement over urostomy or catheter bags for residents. | D |
| Housekeeping and maintenance services inadequate to maintain a sanitary, orderly, and comfortable interior. | E |
| Failure to ensure residents requiring dialysis receive appropriate services consistent with professional standards. | D |
| Failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. | F |
| Failure to maintain an infection control program to prevent and control infections within the facility. | F |
| Failure to adequately equip the facility to allow residents to call for staff assistance through a communication system. | E |
| Failure to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. | E |
Report Facts
Completion date: Feb 7, 2017
Completion date: Feb 22, 2017
Completion date: Feb 7, 2017
Completion date: Feb 10, 2017
Completion date: Feb 1, 2017
Completion date: Feb 7, 2017
Completion date: Feb 18, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lynette Emmerson | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Jan 23, 2017
Visit Reason
The visit was conducted to determine if the facility was 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 February 22, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Life Safety
Deficiencies: 1
Jun 15, 2016
Visit Reason
A Life Safety Code survey was conducted on June 15, 2016, 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. The facility was required to submit an acceptable plan of correction within ten calendar days.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited 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: Sep 15, 2016
Provider agreement termination date: Dec 15, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
May 25, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the previously cited deficiencies, including the one identified by regulation 483.25(h), were corrected as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.25(h) previously cited was corrected. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Apr 26, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#98660) regarding the facility's failure to provide adequate supervision to prevent a resident at risk of elopement from leaving the facility without staff knowledge.
Findings
The facility failed to provide adequate supervision for resident #01, who had severe cognitive impairment and was at risk for elopement. The resident exited the building without staff knowledge by following a non-facility worker through a coded exit door, and was found two blocks away without injury. The door alarm did not sound due to the manner of exit. The resident was placed on 15-minute checks upon return and the family was assisted with finding other placement.
Complaint Details
Complaint investigation #98660 regarding inadequate supervision leading to elopement of resident #01 was substantiated as the resident exited the facility without staff knowledge.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent a known elopement risk resident from exiting the building without staff knowledge. | SS=D |
Report Facts
Census: 47
Elopement risks: 7
Sampled residents: 3
Resident #01 admission date: Jan 25, 2016
Admission MDS assessment date: Feb 1, 2016
Elopement incident date: Mar 23, 2016
Door alarm sounding time: 7
Check interval: 15
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 26, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation related to resident elopement risks and supervision.
Findings
The facility was found deficient in ensuring adequate supervision of residents at risk for elopement, timely assessment and care planning, and proper response to door alarms. Corrective actions include staff education, increased monitoring, and alarm adjustments.
Complaint Details
This plan of correction is related to a complaint investigation identified as 'ml ft scott complaint 04262016'.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Inadequate supervision of residents at risk for elopement and failure to properly respond to door alarms. | D |
Report Facts
Complete Date for Plan of Correction: May 25, 2016
Resident Check Interval: 15
Resident Transfer Date: Apr 14, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lynette Emmerson | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 26, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective May 25, 2016.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 2
Dec 9, 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 deficiencies identified under regulation numbers 483.10(b)(4) and 483.75(l)(1) were corrected as of 12/09/2015.
Deficiencies (2)
| Description |
|---|
| Deficiency under regulation 483.10(b)(4) |
| Deficiency under regulation 483.75(l)(1) |
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 4, 2015
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Fort Scott in response to deficiencies identified during a complaint investigation and annual survey.
Findings
The plan addresses deficiencies related to maintaining a system for identification of code status for all residents and ensuring complete and accurate clinical records. The facility implemented staff training, audits, and ongoing monitoring to ensure compliance.
Complaint Details
This Plan of Correction is related to deficiencies cited during a complaint investigation as referenced by the linked Complaint ID and Deficiency Report.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain a system of identification of code status for all residents. | D |
| Failure to maintain complete and accurate clinical records including code status information. | D |
Report Facts
Complete Date: Dec 4, 2015
Complete Date: Dec 9, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lynette Emmerson | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 23, 2015
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 deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Nov 23, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#93883) regarding the facility's failure to maintain a system of identification of full code status for residents.
Findings
The facility failed to maintain an accurate system to identify residents' code status, resulting in a nurse not knowing whether to initiate CPR on a full code resident who was found without pulse or respirations. Additionally, the medical record was incomplete and inaccurate regarding the resident's death and code status.
Complaint Details
The complaint investigation #93883 found that the facility failed to identify the full code status of a resident, leading to a nurse not initiating CPR when the resident was found unresponsive. The resident had a full code status documented but the code status sticker was missing from the face sheet after the resident was readmitted following leaving AMA. The nurse assumed a DNR status based on the absence of the sticker and prior discussions, and did not start CPR.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain a system of identification of full code status for 1 of 3 full code residents reviewed. | SS=D |
| Failure to ensure the medical record contained a complete, accurate accounting of information related to the death and code status of 1 of 3 residents reviewed. | SS=D |
Report Facts
Census: 52
Residents with full code status: 6
Residents reviewed: 3
Staff CPR certifications reviewed: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff D | Spoke with the resident 80 minutes prior to being noted without pulse and respirations. | |
| direct care staff E | Noted the resident asleep and snoring 25 minutes prior to noted lack of pulse and respirations. | |
| administrative staff A | Explained the situation surrounding the resident's death. | |
| direct care staff C | Found the resident unresponsive and summoned licensed nursing staff B. | |
| licensed nursing staff B | Checked the resident for pulse and respirations, did not start CPR due to assumption of DNR status. | |
| licensed nurse A | Acknowledged facility policy on placement of code status stickers and documentation. | |
| social service staff F | Responsible for tagging medical records with residents' code status; failed to place code status sticker after resident readmission. |
Inspection Report
Plan of Correction
Deficiencies: 7
Jul 27, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to an annual survey inspection, outlining corrective actions to address cited deficiencies.
Findings
The plan details corrective actions for multiple deficiencies including housekeeping responsibilities, dietary and nursing care plans, skin assessments, nutritional interventions, bowel movement monitoring, food safety, and infection control practices. The facility commits to staff education, monitoring, and reporting compliance to the Quality Assurance Performance Improvement committee by July 27, 2015.
Severity Breakdown
E: 2
D: 4
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Housekeeping responsibilities revamped to include daily cleaning of various areas and repairs to floors and walls. | E |
| Physician orders clarified and care plans updated for resident diet and toileting hygiene. | D |
| Licensed staff to complete skin assessments for new skin tears or bruises and monitor documentation. | D |
| Nutritional interventions planned to prevent weight loss with weekly evaluations and communication. | D |
| Monitoring of bowel movements and appropriate treatments if no bowel movement after 3 days. | D |
| Facility to store, prepare, and serve foods under sanitary conditions with ongoing prevention measures. | F |
| Licensed nurses to review glucometer policy and CNAs to follow glove usage and cleaning procedures. | E |
Report Facts
Plan of Correction completion date: Jul 27, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lynette Emmerson | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Jul 27, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-06-30.
Findings
All previously cited deficiencies identified by regulation numbers F0253, F0280, F0309, F0325, F0329, F0371, and F0441 were corrected as of the revisit date 2015-07-27.
Report Facts
Deficiencies corrected: 7
Inspection Report
Enforcement
Deficiencies: 1
Jun 30, 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 '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, resulting in a finding of substantial compliance effective July 27, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator in relation to the enforcement action and report. |
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 7
Jun 22, 2015
Visit Reason
The inspection was a health resurvey to evaluate compliance with regulatory requirements including housekeeping, care planning, nutrition, medication management, infection control, and food service sanitation.
Findings
The facility failed to maintain sanitary housekeeping and maintenance services in multiple areas, failed to revise care plans for residents with weight loss and toileting needs, failed to monitor skin bruises and medication regimens adequately, failed to prevent unplanned weight loss, failed to maintain sanitary food storage and preparation areas, and failed to maintain effective infection control practices including proper cleaning of lift equipment and glucometers.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services on 3 of 4 hallways, including clutter, dirty floors, soiled bathrooms, unlocked utility rooms, stained carpets, and damaged fixtures. | SS=D |
| Failed to review and revise care plans for residents with nutrition and toileting needs, including failure to address refusal of pureed diet and thickened liquids and toileting hygiene needs. | SS=D |
| Failed to monitor skin bruises for a resident with a skin tear and bruising, lacking documentation and assessment of bruising progression. | SS=D |
| Failed to provide nutritional interventions to prevent unplanned weight loss, including failure to offer planned health shakes and fortified foods consistently. | SS=D |
| Failed to adequately monitor medications for diabetes, including lack of blood sugar parameters and failure to respond to low blood sugar readings. | SS=F |
| Failed to store, prepare, distribute, and serve food under sanitary conditions, including dirty floors, soiled equipment, dusty shelves, damaged utensils, and unclean refrigerators and ice machines. | SS=E |
| Failed to maintain an effective infection control program, including failure to properly clean resident lift equipment between uses, improper glove use, and inadequate sanitization of shared glucometers. | SS=E |
Report Facts
Resident census: 53
Weight loss: 9
Weight measurements: 100
Weight measurements: 90
Bowel movement intervals: 4
Bowel movement intervals: 6
Bowel movement intervals: 7
Insulin units: 36
Insulin units: 5
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 12, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to achieve substantial compliance with Medicare and Medicaid requirements.
Findings
The facility was found deficient in ensuring adequate supervision of residents at risk for elopement. The plan includes re-education of staff on elopement policy, monitoring of elopement drills, and protocols for door alarm repairs to ensure resident safety.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Inadequate supervision of residents assessed as being at risk for elopement. | D |
Report Facts
Plan of Correction completion date: Jun 12, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lynette Emmerson | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Jun 12, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as of the revisit date.
Findings
The report indicates that the deficiency identified as F0323 under regulation 483.25(h) was corrected by the revisit date of 06/12/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency identified as F0323 under regulation 483.25(h) |
Report Facts
Deficiencies corrected: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 20, 2015
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 rated as 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 based on the credible allegation of compliance and the plan of correction.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency rated as a "D" level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person regarding the survey and plan of correction. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
May 20, 2015
Visit Reason
The inspection was conducted as an investigation of complaint #86383 regarding the facility's supervision of residents at risk for elopement.
Findings
The facility failed to ensure adequate supervision for one high elopement risk resident who left the facility without staff knowledge during a keypad replacement at the front door. Staff were distracted or unaware, allowing the resident to exit alone.
Complaint Details
Investigation of complaint #86383 found the facility did not provide adequate supervision for one of three sampled elopement risk residents, who left the facility unnoticed during a keypad replacement at the front door.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure adequate supervision for a high elopement risk resident who exited the facility without staff knowledge. | SS=D |
Report Facts
Census: 56
Elopement risk residents: 4
Sampled elopement risk residents: 3
Incident date: Apr 23, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| nursing staff C | Explained the elopement incident on 4/23/15 | |
| certified staff D | Caught up with the resident and convinced them to return | |
| licensed nurse B | Acknowledged technician interaction and resident exit | |
| licensed nurse D | Acknowledged being distracted during resident elopement | |
| nursing staff B | Acknowledged no staff assigned to monitor front door during keypad replacement |
Inspection Report
Follow-Up
Deficiencies: 2
Nov 30, 2014
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 revisit confirmed that the deficiencies related to regulations 483.25(e)(2) and 483.35(d)(1)-(2) were corrected as of 11/30/2014.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.25(e)(2) |
| Deficiency related to regulation 483.35(d)(1)-(2) |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 13, 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 deficiencies to be 'E' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'E' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person for questions concerning the information in the letter |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Nov 13, 2014
Visit Reason
The investigation was conducted based on complaints #77686, 79380, and 80774 regarding the facility's provision of rehabilitative/restorative services and food service quality.
Findings
The facility failed to provide appropriate restorative services as planned for 4 sampled residents, resulting in risk of further decline in range of motion. Additionally, the facility failed to serve food at the proper temperature, leading to resident dissatisfaction with cold meals.
Complaint Details
The investigation was triggered by complaints #77686, 79380, and 80774. The complaints were substantiated as the facility failed to provide planned restorative services and proper food temperature management.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide appropriate restorative services to prevent further decline in range of motion for 4 sampled residents. | SS=E |
| Failed to serve food at the proper temperature to ensure palatability for residents. | SS=E |
Report Facts
Facility census: 57
Restorative services sample size: 4
Food trays noted: 15
Food temperature: 100
Food temperature: 120
Days without food temperature documentation: 3.5
Inspection Report
Follow-Up
Deficiencies: 1
May 29, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies from the prior survey completed on 2014-04-10.
Findings
The revisit report shows that the previously cited deficiency under regulation 483.25(h) was corrected as of 2014-05-10. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(h) corrected |
Report Facts
Deficiency correction date: May 10, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 20, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a complaint investigation to address deficiencies related to resident safety, supervision, and medication management.
Findings
The facility identified issues with resident accident hazards, supervision, medication management, and use of alarms/restraints. The plan outlines corrective actions including care plan reviews, therapy evaluations, medication adjustments, staff training, and ongoing monitoring to ensure substantial compliance by 05/10/2014.
Complaint Details
This Plan of Correction is related to a complaint investigation as indicated by the reference to 'Med Fort Scott 041114 Complaint Revised'.
Deficiencies (1)
| Description |
|---|
| Resident environment not free of accident hazards and inadequate supervision and assistive devices to prevent accidents. |
Report Facts
Completion date for substantial compliance: May 10, 2014
Date for care plan review for Resident #2: Apr 25, 2014
Date for therapy evaluation for Resident #2: Mar 5, 2014
Date for medication review and adjustment: Apr 16, 2014
Date for consultant pharmacist medication review: Apr 15, 2014
Date for staff inservicing on Falls and Restraint reduction: May 2, 2014
Date for root cause analysis re-education: May 10, 2014
Date for identification of residents at high risk for falls: Apr 17, 2014
Date for initiation of daily interdisciplinary team meetings: Apr 21, 2014
Date for initiation of Advancing Excellence Mobility module: Apr 18, 2014
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Apr 10, 2014
Visit Reason
The inspection was conducted as an investigation of complaint #73491 regarding the facility's failure to ensure adequate supervision and assistive devices to prevent repeated falls for residents.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent falls for two residents who sustained hip fractures. The investigation revealed that personal alarms were often removed by residents or family members, and staff failed to ensure alarms were in place, contributing to falls and injuries.
Complaint Details
Investigation of complaint #73491 found the facility failed to prevent falls for residents #1 and #2, both of whom sustained hip fractures. The complaint was substantiated by observations, record reviews, and staff interviews.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and/or assistive devices to prevent repeated falls for 2 of 3 sampled residents, resulting in hip fractures. | SS=G |
Report Facts
Census: 55
Fall assessment score: 20
Fall history: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff C | Found resident on floor after fall and assisted resident | |
| Licensed nursing staff D | Assessed resident post-fall and notified physician | |
| Administrative staff A | Reported investigation findings and staff interviews | |
| Certified nursing staff F and G | Reported family requests to remove alarms during visits | |
| Licensed nursing staff E | Reported family often asked for alarms to be removed | |
| Nursing staff B, C, E, and H | Reported resident known for removing personal alarm |
Inspection Report
Plan of Correction
Deficiencies: 10
Apr 9, 2014
Visit Reason
This document is a Plan of Correction submitted in response to an annual survey inspection, outlining corrective actions to address identified deficiencies and achieve substantial compliance by April 9, 2014.
Findings
The plan details multiple corrective actions including staff re-education, maintenance and housekeeping improvements, resident care plan updates, infection control program enhancements, and monitoring procedures to ensure compliance with health and safety regulations.
Deficiencies (10)
| Description |
|---|
| Failure to resolve grievances in a timely manner and report missing/lost resident personal items. |
| Resident care plans not reflecting sleep preferences. |
| Housekeeping and maintenance deficiencies including unsanitary dining room surfaces, damaged walls, slow draining sinks, and soiled carpeted walls. |
| Inadequate nail care for residents requiring assistance. |
| Insufficient staff education on positioning and pressure ulcer prevention. |
| Lack of blood pressure monitoring and documentation for hypertensive residents. |
| Pharmacist not reviewing resident drug regimens monthly as required. |
| Infection Control Program not fully implemented or staff not fully educated on protocols. |
| Insufficient space and inadequate arrangement in dining and activity rooms. |
| Unsanitary and damaged kitchen areas including floors and walls. |
Report Facts
Compliance deadline: Apr 9, 2014
Staff inservice date: Mar 25, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Brown | Administrator | Administrator who submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 9, 2014
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 had been corrected.
Findings
All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date, April 9, 2014.
Report Facts
Deficiencies corrected: 10
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 9
Mar 11, 2014
Visit Reason
Health resurvey conducted to assess compliance with regulatory requirements including grievance resolution, resident rights, housekeeping, ADL care, pressure sore prevention, medication management, infection control, dining and activity room adequacy, and environmental sanitation.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, failure to honor resident choices for awakening times, inadequate housekeeping and maintenance services, insufficient assistance with fingernail hygiene, failure to provide timely repositioning to prevent pressure sores, inadequate monitoring of antihypertensive medication, failure to maintain infection control preventing spread of C-Diff, insufficient dining room space for residents, and unsanitary kitchen environment.
Severity Breakdown
SS=D: 6
SS=E: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to seek prompt resolution of resident grievances related to missing personal items for two residents. | SS=D |
| Failure to provide personal choices of awakening times for one resident. | SS=D |
| Failure to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in multiple resident rooms and dining areas. | SS=E |
| Failure to provide adequate fingernail hygiene for a dependent resident. | SS=D |
| Failure to provide timely position changes for three residents to prevent pressure sores. | SS=D |
| Failure to ensure adequate monitoring of antihypertensive medication for one resident. | SS=D |
| Failure to maintain an infection control program preventing spread of C-Diff from an infected resident. | SS=E |
| Failure to ensure sufficient space in one dining area to accommodate three residents' needs. | SS=D |
| Failure to maintain a clean and sanitary environment in the kitchen areas. | SS=E |
Report Facts
Census: 54
Residents reviewed: 21
Residents reviewed for choices: 3
Residents reviewed for ADLs: 3
Residents reviewed for unnecessary medications: 5
Blood pressure monitoring occasions: 2
Blood pressure monitoring occasions: 1
Blood pressure monitoring occasions: 3
Positioning interval: 2
Positioning delay: 3.25
Positioning delay: 3.25
Positioning delay: 2.83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Named in grievance finding for failure to promptly report missing necklace | |
| Administrative staff A | Named in grievance finding for failure to resolve missing money complaint | |
| Social service staff D | Named in grievance finding for lack of knowledge of missing necklace and quarters | |
| Direct care staff AA | Interviewed regarding resident awakening times | |
| Direct care staff I | Observed providing care without fingernail hygiene | |
| Direct care staff V | Observed providing care without fingernail hygiene | |
| Direct care staff U | Reported fingernail care schedule and resident care needs | |
| Activity staff W | Reported fingernail care schedule | |
| Direct care staff X | Reported fingernail care responsibilities | |
| Licensed nursing staff E | Reported fingernail care responsibilities and medication monitoring | |
| Certified staff L | Acknowledged failure to reposition resident #56 | |
| Certified staff M | Acknowledged failure to reposition resident #56 | |
| Direct care staff K | Reported repositioning needs for residents | |
| Direct care staff BB | Reported repositioning needs for resident #5 | |
| Direct care staff O | Observed failure to reposition resident #5 | |
| Direct care staff Z | Assisted resident #5 to bed | |
| Nursing staff Y | Reported repositioning policy | |
| Licensed nursing staff S | Reported repositioning expectations | |
| Administrative nursing staff B | Reported medication monitoring expectations and infection control | |
| Pharmacy consultant staff CC | Reported consultant pharmacist responsibilities and limitations | |
| Housekeeping staff N | Observed cleaning resident room with C-Diff and infection control practices | |
| Dietary staff R | Reported kitchen floor cleaning and maintenance issues | |
| Administrative nursing staff H | Reported dining room space concerns |
Inspection Report
Plan of Correction
Deficiencies: 8
Feb 3, 2013
Visit Reason
This document is a Plan of Correction submitted in response to an annual survey inspection, outlining corrective actions to address cited deficiencies and achieve substantial compliance by February 3, 2013.
Findings
The plan addresses multiple deficiencies including resident dignity during transport, sanitary and maintenance issues in bathing and dining areas, care plan updates for urinary incontinence, medication administration errors, dietary sanitation, laundry area cleanliness, and environmental repairs. The facility commits to staff inservices, monitoring, and contractor repairs to ensure compliance.
Severity Breakdown
D: 5
E: 2
F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Affected residents provided tote bags for personal belongings during transport to shower room to maintain dignity. | D |
| Housekeeping and maintenance services to maintain sanitary, orderly, and comfortable interior including repairs and cleaning of water fountains, bathing areas, dining tables, and walls. | E |
| Care plan updated after bladder assessment; staff inserviced on urinary incontinence policy and procedure. | D |
| Bladder assessment conducted with individualized toileting plan placed on care plan for resident. | D |
| Medication administration record reviewed; Claritin discontinued for resident; staff inserviced on duplicate therapy review. | D |
| Dietary area sanitation issues including food stains on plexi-glass divider, dead bug in utensil drawer, cracked air conditioner panel, and improper storage of Styrofoam cups addressed and monitored. | F |
| Pharmacist contacted regarding medication administration inaccuracies; monthly reviews and monitoring established. | D |
| Laundry areas needing repair to be addressed by contract labor; cleaning and monitoring of washers, dryers, and folding room implemented. | E |
Report Facts
Deficiencies cited: 8
Completion date: Feb 3, 2013
Dates of staff inservices: Jan 15, 2013
Dates of maintenance cleaning: Jan 7, 2013
Inspection Report
Follow-Up
Deficiencies: 8
Feb 3, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers and prefix codes were corrected as of the revisit date.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.70(h) |
Report Facts
Deficiencies corrected: 8
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 8
Jan 4, 2013
Visit Reason
The inspection was a health resurvey to assess compliance with previously identified deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during bathing, inadequate housekeeping and maintenance services leading to unsanitary conditions in bathing areas, corridors, dining rooms, laundry, kitchen, and exterior. The facility also failed to properly assess and revise care plans for residents with urinary incontinence, administer unnecessary duplicate medications, and maintain a safe and sanitary environment in food preparation and laundry areas.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide bathing in a manner that maintains or enhances resident dignity for 3 residents. | SS=D |
| Failure to provide adequate housekeeping and maintenance services to maintain a sanitary and comfortable interior environment in bathing areas, corridors, and dining rooms. | SS=E |
| Failure to review and revise resident #17's plan of care to maintain bladder control and provide appropriate toileting assistance. | SS=D |
| Failure to ensure resident #17 received care to prevent decline in urinary incontinence. | SS=D |
| Failure to ensure resident #17's drug regimen was free from unnecessary duplicate medications (Claritin and Zyrtec). | SS=D |
| Failure to store, prepare, and serve food under sanitary conditions in the kitchen. | SS=F |
| Failure to review and report irregularities in drug regimen by consultant pharmacist related to duplicate antihistamine therapy for resident #17. | SS=D |
| Failure to provide a safe, functional, sanitary, and comfortable environment in laundry, kitchen, and exterior areas including damaged siding, rust, dust, lint accumulation, and malfunctioning dishwasher. | SS=E |
Report Facts
Census: 54
Duplicate medication duration days: 41
Number of residents reviewed for urinary incontinence: 2
Number of residents reviewed for unnecessary medications: 10
Number of residents in sample: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff B | Reported on bathing dignity issues and resident toileting needs | |
| maintenance staff J | Reported on water fountain and siding conditions | |
| maintenance staff M | Reported on debris and cleaning schedules | |
| licensed nursing staff H | Reported resident toileting recommendations | |
| direct care staff D, F, G, I | Assisted resident #17 with transfers and toileting | |
| administrative nursing staff B | Interviewed regarding resident care and medication issues | |
| consultant pharmacist O | Interviewed regarding failure to identify duplicate medications | |
| acting dietary manager N | Acknowledged kitchen sanitation issues | |
| administrative staff A | Participated in environmental tours and reported dishwasher issues |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 28, 2011
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 revisit report shows that all previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 7
Sep 28, 2011
Visit Reason
The inspection was a health facility resurvey to assess compliance with regulatory requirements including housekeeping, assessment accuracy, accident hazards, drug regimen, food sanitation, infection control, and emergency procedures.
Findings
The facility failed to maintain sanitary conditions in multiple areas, failed to complete accurate resident assessments, failed to ensure a safe environment free of accident hazards, failed to monitor and document medications with Black Box Warnings and pain management adequately, failed to store and prepare food under sanitary conditions, failed to properly clean equipment to prevent infection spread, and failed to train staff on emergency procedures including bomb threats.
Severity Breakdown
SS=E: 4
SS=D: 2
SS=F: 1
SS=C: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior in multiple areas including therapy room, dining room, shower rooms, and resident rooms. | SS=E |
| Failed to ensure staff completed an accurate comprehensive assessment for a sampled resident including activities of daily living, prior history of falls, and identification of significant weight loss. | SS=D |
| Failed to ensure the resident environment remained free of accident hazards including unlocked closets with hazardous materials and protruding toilet bolts in resident bathrooms. | SS=E |
| Failed to ensure residents' drug regimens were free from unnecessary drugs including failure to monitor Black Box Warnings, blood sugar parameters, and pain responses for multiple residents. | SS=E |
| Failed to store, prepare, and serve food under sanitary conditions including storing buttered bread at improper temperature and failure to clean kitchen cart wheels and floors. | SS=F |
| Failed to thoroughly cleanse the plastic container holding glucose monitoring equipment after placing it on the floor, creating potential for infection spread. | SS=D |
| Failed to train employees in emergency procedures including bomb threat and/or scare. | SS=C |
Report Facts
census: 49
deficiencies cited: 8
weight loss: 11
tiles cracked: 6
toilet bolts protruding: 2
pain medication administrations: 14
pain medication administrations: 7
blood sugar readings: 262
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff J | Placed glucose monitoring container on floor and failed to clean it | |
| licensed staff B | Verified staff should not place glucose container on floor and acknowledged failure to identify Black Box Warnings on care plans | |
| consultant pharmacist M | Provided facility staff with website listing Black Box Warnings | |
| licensed nursing staff N | Reported facility had not identified medications with Black Box Warnings on care plans | |
| direct care staff P | Reported pain medication documentation and monitoring procedures | |
| direct care staff R | Reported pain medication documentation procedures | |
| licensed nursing staff G | Confirmed resident received pain medications | |
| licensed nursing staff Q | Reported staff should do baseline DISCUS assessment for residents receiving psychotropic medications | |
| CNA D | Responded to bomb threat scenario | |
| housekeeping staff D | Responded to bomb threat scenario | |
| dietary staff F | Responded to bomb threat scenario | |
| licensed staff G | Responded to bomb threat scenario | |
| CNA H | Responded to bomb threat scenario | |
| maintenance staff I | Reported disaster inservices every 6 months but no bomb threat training | |
| administrative staff A | Verified failure to conduct bomb threat inservice |
Inspection Report
Plan of Correction
Deficiencies: 2
N006002 POC S2Q611
Visit Reason
This document is a Plan of Correction submitted in response to a complaint survey for Medicalodges Fort Scott.
Findings
The plan outlines corrective actions to address deficiencies related to restorative care staffing and food service temperature and delivery, aiming for substantial compliance by November 30, 2014.
Complaint Details
This Plan of Correction is related to a complaint survey identified as Medicalodges Fort Scott 111314 Complaint.
Severity Breakdown
E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide a planned restorative program with adequate staffing and monitoring. | E |
| Failure to provide food that is palatable, attractive, and served at the right temperature with proper monitoring. | E |
Report Facts
Completion date for compliance: Nov 30, 2014
In-service training date: Nov 21, 2014
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