Inspection Reports for
Medicalodges Fort Scott
915 SOUTH HORTON, P. O. BOX 510, FORT SCOTT, KS, 66701
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
17.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
192% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
76% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 3
Date: Jul 2, 2025
Visit Reason
The inspection was conducted following an allegation of abuse involving Resident 1 (R1). The investigation focused on the facility's response to the abuse allegation and compliance with care plan updates and medication monitoring.
Complaint Details
The complaint involved an allegation of sexual abuse by staff against Resident 1 on 06/29/25. The facility did not remove or restrict the alleged perpetrator's access during the investigation. The allegation was reported to the hotline on 06/30/25. The investigation found failures in protective measures and care plan updates.
Findings
The facility failed to provide protective measures for R1 following an abuse allegation and did not update R1's care plan to reflect care needs, putting the resident at risk. Additionally, the facility failed to ensure accurate monitoring and reconciliation of narcotic medications in emergency kits, risking medication misappropriation.
Deficiencies (3)
F 0610: The facility failed to provide protective measures for Resident 1 following an allegation of abuse, including not removing the alleged perpetrator from resident access during investigation.
F 0657: The facility failed to update Resident 1's care plan to include instructions for staff to provide care in pairs, risking inadequate care due to uncommunicated care needs.
F 0755: The facility failed to ensure an accurate and adequate system for monitoring and reconciliation of narcotic medications in emergency kits, risking misappropriation of medications.
Report Facts
Resident census: 34
Hydrocodone-acetaminophen tablets: 10
Hydrocodone-acetaminophen tablets: 5
Morphine sulfate volume: 15
Alprazolam tablets: 5
APAP-Codeine #3 tablets: 5
Clonazepam tablets: 5
Lorazepam tablets: 5
Zolpidem tablets: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Administrative Staff | Notified of abuse allegation and involved in investigation |
| Licensed Nurse G | Licensed Nurse | Provided information on medication reconciliation and resident care |
| Certified Nurse Aide O | Certified Nurse Aide | Provided stand-by assistance to Resident 1 during toileting |
| Certified Nurse Aide M | Certified Nurse Aide | Reported resident behavior and care needs |
| Administrative Nurse D | Administrative Nurse | Provided statements on medication reconciliation expectations and care plan review |
| Licensed Nurse LN G | Licensed Nurse | Reported on resident psychotic episodes and staff care practices |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
The inspection was conducted due to a complaint regarding neglect of a dependent and cognitively impaired resident during medication administration.
Complaint Details
The complaint involved neglect of Resident 1 during medication administration. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure Resident 1, who had swallowing difficulties and cognitive impairment, remained free from neglect when a Certified Medication Aide continued administering medications despite the resident's request to slow down. Additionally, staff failed to timely report the incident as required by facility policy.
Deficiencies (2)
F 0600: The facility failed to protect Resident 1 from neglect when a Certified Medication Aide administered medications despite the resident's request to slow down due to difficulty swallowing and made inappropriate remarks after administration.
F 0609: The facility failed to timely report suspected neglect when staff delayed reporting the medication administration incident involving Resident 1, contrary to facility policy.
Report Facts
Resident census: 26
Medication doses administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA S | Certified Medication Aide | Named in neglect finding for improper medication administration to Resident 1 |
| Housekeeping/CNA U | Housekeeping/CNA | Witnessed medication administration and delayed reporting incident |
| Outside Resource Staff EE | Outside Resource Staff | Witnessed medication administration and delayed reporting incident |
| Administrative Nurse D | Administrative Nurse | Reported delayed awareness of incident |
| Administrative Staff A | Administrative Staff | Received delayed reports of the incident |
Inspection Report
Routine
Census: 37
Deficiencies: 30
Date: Apr 3, 2024
Visit Reason
Routine inspection of Medicalodges Fort Scott nursing home to assess compliance with regulatory requirements including resident care, medication management, infection control, staffing, and safety.
Findings
The facility had multiple deficiencies including failure to post State Survey Agency contact information accessibly, inconsistent mail services on Saturdays, failure to post previous survey results accessibly, failure to provide Medicare non-coverage notices, lack of anonymous grievance system, failure to provide transfer/discharge notices and bed hold notices, incomplete care plans, inadequate assistance with hearing aids, lack of weekend activities, failure to follow physician orders for daily weights and medication administration, improper pressure ulcer care, unsafe siderails, inadequate infection control, incomplete immunization documentation, medication errors, and inadequate staff training and evaluations.
Deficiencies (30)
F575: The facility failed to post the State Survey Agency contact information in a manner accessible to residents and their representatives, placing residents at risk for ongoing abuse and unresolved grievances.
F576: The facility failed to ensure residents received mail services on Saturdays, impacting communication and privacy.
F577: The facility failed to post previous state inspection survey results in a location accessible to residents and visitors.
F582: The facility failed to issue Medicare Non-Coverage Notification Forms for residents discharged from Medicare Part A services, risking decreased autonomy and impaired decision-making.
F585: The facility failed to implement a system allowing residents to file grievances anonymously, risking unresolved grievances and decreased psychosocial well-being.
F623: The facility failed to provide written notice of transfer or discharge for Resident 10's hospitalizations, risking uninformed choices and miscommunication.
F625: The facility failed to provide bed hold notice for Resident 10 during hospitalizations, risking uninformed choices.
F657: The facility failed to review and revise care plans with resident-specific interventions for Residents 7, 10, 14, and 25, risking impaired care due to uncommunicated needs.
F676: The facility failed to provide necessary assistance with Resident 25's hearing aids, risking communication difficulties, confusion, and decreased dignity.
F679: The facility failed to provide consistent weekend activities, placing residents at risk for decreased psychosocial well-being.
F684: The facility failed to follow physician's order for daily weights for Resident 14 to monitor for fluid overload, risking delayed treatment and untreated illness.
F686: The facility failed to ensure Resident 7's low air-loss mattress pump was set appropriately to his weight, risking skin breakdown and pressure ulcers.
F688: The facility failed to ensure Resident 10 received services and treatment to prevent worsening contractures, risking discomfort and decreased range of motion.
F689: The facility failed to ensure Resident 25's siderails were properly secured and safe, risking injury and entrapment.
F690: The facility failed to ensure a safe environment free from hazardous materials and pests, including cockroach infestation and unsecured oxygen storage, risking resident safety and infection.
F690: The facility failed to provide sanitary catheter care education and assessment for Resident 2, risking catheter-related complications.
F692: The facility failed to obtain accurate weights as ordered for Resident 4 receiving enteral nutrition, risking complications related to weight loss.
F695: The facility failed to ensure appropriate respiratory care and sanitary storage of oxygen equipment for Residents 2 and 33, risking respiratory complications.
F700: The facility failed to ensure documented consent, alternatives tried, and risk/benefit discussion for use of siderails for Resident 25, risking uninformed decisions.
F725: The facility failed to ensure adequate weekend staffing levels, risking impaired mental and physical well-being of residents.
F730: The facility failed to ensure five Certified Nurse Aides had required yearly performance evaluations, risking inadequate care.
F732: The facility failed to retain daily posted nurse staffing data for 18 months as required.
F756: The facility failed to ensure the consultant pharmacist identified and reported inappropriate use of antipsychotic medication for Resident 3 and failed to follow recommendations related to Resident 30's Midodrine administration, risking adverse medication effects.
F758: The facility failed to ensure staff possessed appropriate skills and knowledge to administer Resident 30's Midodrine, risking impaired quality of care.
F849: The facility failed to ensure a communication process and documentation between the facility and hospice provider for Resident 25, risking missed or delayed hospice services and impaired care.
F880: The facility failed to ensure adequate infection control standards including enhanced barrier precautions, laundry services, and sanitary care practices, placing residents at risk for infectious diseases.
F883: The facility failed to provide consent, declination, or documentation of ineligibility for pneumococcal vaccinations for Residents 2, 19, and 33, risking complications related to pneumococcal diseases.
F887: The facility failed to provide consent, declination, or documentation of ineligibility for COVID-19 vaccinations for Resident 3, risking complications related to infectious diseases.
F925: The facility failed to provide effective pest control, resulting in a cockroach infestation in the facility, placing residents at risk for impaired comfort and disease.
F947: The facility failed to ensure five Certified Nurse Aides had required 12 hours of in-service education, risking inadequate care.
Report Facts
Residents present: 37
Sample residents reviewed: 12
Medication errors: 37
Medication errors by LN G: 20
Cockroach sightings: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Administered Midodrine outside parameters; reported on oxygen tubing storage and medication administration |
| Administrative Nurse D | Administrative Nurse | Provided multiple statements on policies, care plans, medication errors, staffing, and infection control |
| Certified Nurse Aide O | Certified Nurse Aide | Reported on mail services, catheter care, hospice communication, and infection control practices |
| Certified Nurse Aide N | Certified Nurse Aide | Reported on loose siderails and infection control glove use |
| Administrative Staff A | Administrative Staff | Reported on weekend staffing and missing immunization documentation |
Inspection Report
Deficiencies: 0
Date: Jun 19, 2023
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility Medicalodges Fort Scott.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: May 31, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to safely secure a resident in a wheelchair during transport, which resulted in the resident falling and sustaining injury.
Complaint Details
The complaint investigation found that Certified Nurse Aide M failed to apply the seatbelt and full four-point belt system securing Resident 1 in the wheelchair during transport on 05/23/23, causing the resident to fall and sustain injury. The facility provided immediate education to CNA M and retraining to all authorized van drivers. The deficiency was deemed past-noncompliance at a J scope and severity.
Findings
The facility failed to ensure staff safely secured Resident 1 in her wheelchair during transport, causing the resident to slide out of the wheelchair and sustain a laceration requiring emergency treatment. The facility implemented corrective actions including staff education and training prior to the surveyor's visit.
Deficiencies (1)
F0689: The facility failed to ensure staff safely secured Resident 1 in her wheelchair during transport, resulting in the resident falling and sustaining a 13 cm by 2 cm laceration to her left knee requiring 11 sutures and emergency treatment.
Report Facts
Resident census: 40
Laceration size: 13
Laceration width: 2
Sutures: 11
Antibiotic dosage: 300
Pain medication dosage: 5
Pain medication acetaminophen dosage: 325
Staff trained for van driving: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Failed to secure resident in wheelchair during transport leading to injury |
| LN H | Licensed Nurse | Assisted with resident transfer and reported incident |
| Administrative Staff A | Reported failure to secure resident and provided education to CNA M | |
| LN G | Licensed Nurse | Reported staff should not drive with resident on floor of van |
Inspection Report
Routine
Census: 50
Deficiencies: 13
Date: Sep 6, 2022
Visit Reason
Routine inspection of Medicalodges Fort Scott nursing home to assess compliance with regulatory requirements including resident care, facility maintenance, infection control, medication management, and safety.
Findings
The facility failed to maintain a sanitary, orderly, and comfortable environment, provide appropriate resident care including safe transfers, pressure ulcer care, personal hygiene, catheter care, respiratory care, medication management, infection control, and COVID-19 vaccination monitoring. Multiple deficiencies were noted in care plans, staff practices, and facility maintenance.
Deficiencies (13)
F 0584: The facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior environment for residents.
F 0657: The facility failed to review and revise care plans for residents related to transfers and pressure ulcer treatment, lacking staff instructions and individualized interventions.
F 0677: The facility failed to provide appropriate personal hygiene, including facial shaving, for dependent residents.
F 0686: The facility failed to ensure appropriate monitoring, treatment, and prevention of pressure ulcers for a resident, including lack of wound staging and dressing changes.
F 0689: The facility failed to provide safe transfers for a resident who required extensive assistance and was unable to bear weight during transfers.
F 0690: The facility failed to ensure sanitary catheter care for a resident, including tubing dragging on the floor and lack of cleaning supplies during catheter drainage.
F 0693: The facility failed to ensure appropriate treatment and services to prevent complications and metabolic interactions related to tube feeding and medication administration through a PEG tube.
F 0695: The facility failed to provide appropriate respiratory care by not maintaining and storing oxygen equipment and tubing properly to prevent infection.
F 0757: The facility failed to monitor bowel movements and administer laxatives for residents at risk for constipation and failed to obtain laboratory results to monitor medication effectiveness for one resident.
F 0880: The facility failed to ensure effective infection control and prevention practices, including improper storage of isolation gowns, lack of N95 masks, and placing meal trays on the floor.
F 0881: The facility failed to implement an antibiotic stewardship program to monitor antibiotic use, lacking tracking of causative organisms and adherence to surveillance criteria.
F 0887: The facility failed to offer COVID-19 second booster vaccines timely and failed to monitor residents' vaccination status for booster eligibility.
F 0921: The facility failed to maintain a sanitary, orderly environment in storage closets, with supplies stored directly on the floor.
Report Facts
Residents affected: 50
Residents reviewed: 16
Days without bowel movement: 7
Days without bowel movement: 4
Urinary tract infections: 7
Urinary tract infections: 8
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 8
Date: Feb 23, 2021
Visit Reason
Annual inspection of Medicalodges Fort Scott nursing home to assess compliance with regulatory requirements including resident care, safety, nutrition, medication management, and facility conditions.
Findings
The facility had multiple deficiencies including failure to timely notify physicians of significant weight loss, failure to ensure resident privacy, inadequate care plan revisions after falls, failure to provide appropriate pressure ulcer care, failure to implement fall interventions, unsafe wheelchair mobility due to missing foot pedals, inadequate nutritional assessment and intervention for weight loss, failure to act on pharmacist recommendations, and unsanitary kitchen conditions.
Deficiencies (8)
F 0580: The facility failed to notify the physician timely of Resident 43's significant unplanned weight loss, delaying assessment and intervention.
F 0583: The facility failed to provide personal privacy for Residents 25, 37, and 44 while in their rooms, exposing them to others in the hallway.
F 0657: The facility failed to review and revise care plans for Residents 25 and 33 following falls, delaying appropriate fall interventions.
F 0686: The facility failed to provide appropriate pressure ulcer care for Residents 1 and 30, including failure to reposition timely, monitor wounds, and treat pressure ulcers, resulting in facility-acquired stage III pressure ulcers.
F 0689: The facility failed to implement appropriate fall interventions for Residents 25 and 33 and failed to provide safe wheelchair mobility for Resident 15 due to missing foot pedals.
F 0692: The facility failed to ensure adequate nutritional assessment and timely interventions for Resident 43's unplanned weight loss of 41 pounds (23.83%) in 67 days.
F 0756: The facility failed to act upon pharmacist recommendations for gradual dosage reduction of Resident 21's antidepressant medication.
F 0812: The facility failed to store and prepare food under sanitary conditions in the kitchen, including dirty spice containers, staff personal items in food areas, and lack of maintenance.
Report Facts
Resident census: 44
Weight loss: 41
Weight loss percentage: 23.83
Weight loss percentage: 9.65
Weight loss: 23
Weight loss percentage: 13.37
Residents sampled: 15
Residents reviewed for privacy: 3
Residents reviewed for pressure ulcers: 4
Residents reviewed for accidents: 6
Residents reviewed for nutrition: 3
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified physician notification delays, privacy issues, fall interventions, nutritional assessment, and pharmacy recommendation follow-up |
| Licensed Nurse J | Licensed Nurse | Provided statements on privacy, fall interventions, and care plan revisions |
| Certified Nurse Aide MM | Certified Nursing Assistant | Assisted Resident 15 in wheelchair without foot pedals |
| Dietary BB | Dietary Staff | Commented on lack of dietary interventions for Resident 43 |
| Pharmacy Consultant GG | Pharmacy Consultant | Reported lack of physician response to pharmacist recommendations |
| Consultant staff HH | Wound Care Consultant | Classified pressure ulcers and provided wound care assessments |
| Activity Staff Z | Activity Staff | Observed wheelchair use of Resident 15 without foot pedals |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 22, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies related to various regulatory provisions were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 7
Date: Jan 23, 2017
Visit Reason
Health Resurvey and Complaint Investigation visits were conducted to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity by not providing a catheter drainage bag cover, inadequate housekeeping and maintenance resulting in unsanitary conditions, failure to monitor a dialysis resident's access site, unsanitary food storage and preparation conditions, incomplete infection control program with poor infection trending and antibiotic stewardship, nonfunctional resident call lights, and unsafe, unsanitary environmental conditions in public and staff areas.
Deficiencies (7)
483.10(a)(1) The facility failed to promote dignity by not providing a catheter drainage bag cover for a resident with a urostomy.
483.10(i)(2) The facility failed to maintain sanitary, orderly, and comfortable interior conditions in resident rooms, dining rooms, and the beauty shop with multiple areas of grime, stains, corrosion, and damage.
483.24, 483.25(k)(l) The facility failed to adequately monitor a dialysis resident's central line site for bleeding or infection after dialysis treatments.
483.60(i)(1)-(3) The facility failed to store and prepare food under sanitary conditions including unsanitary refrigerator shelving, dirty pans, and an unclean stove.
483.80(a)(1)-(3), (e), (f) The facility failed to maintain an infection control program with incomplete infection trending, lack of organism identification, and inadequate antibiotic stewardship.
483.90(f)(2) The facility failed to ensure 7 resident call lights on 3 halls were in working order to allow residents to communicate needs.
483.90(h)(5) The facility failed to provide a safe, functional, sanitary, and comfortable environment in the public bathroom, nurses' station floors, and kitchen floor with issues including corrosion, grime, worn flooring, and broken concrete.
Report Facts
Resident census: 49
Residents reviewed: 17
Urinary tract infections reported: 6
Gastrointestinal infections with clostridium difficile: 3
Skin infections reported: 2
Residents treated with antibiotics: 7
Call lights not working: 7
Pans with brown substance: 7
Areas of broken concrete floor: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Administrative Nursing Staff | Confirmed infection control log incompleteness and dialysis site monitoring failure |
| Staff C | Maintenance Staff | Reported call lights repair and confirmed environmental concerns |
| Staff F | Licensed Nursing Staff | Discussed dialysis resident monitoring and catheter care |
| Staff G | Licensed Nursing Staff | Discussed catheter drainage bag cover requirement |
| Staff K | Dietary Staff | Verified unsanitary conditions in dietary department |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 23, 2017
Visit Reason
The visit was a Health survey conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, 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 credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had 'F' level deficiencies that were 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 letter accepting the plan of correction and confirming substantial compliance. |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: 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.
Findings
The facility submitted corrective actions addressing 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 improvements. The facility commits to monitoring and reporting compliance to the Quality Assurance committee.
Deficiencies (8)
F0000 This plan of correction constitutes a written allegation of substantial compliance with Federal Medicaid/Medicare requirements and is submitted pursuant to applicable regulations without admission of violation.
F241-D The facility will ensure dignity bags are placed over urostomy or catheter bags for applicable residents and added as a care plan task with staff inservice and monitoring.
F253-E The facility will maintain a sanitary, orderly, and comfortable interior by cleaning carpets, replacing sinks, repairing door jambs, and assigning housekeeping and maintenance responsibilities with monitoring.
F309-D The facility will ensure residents requiring dialysis receive appropriate services with staff education and monitoring of dialysis site care.
F371-F The facility will store, prepare, distribute, and serve food in accordance with professional safety standards, including replacing equipment and staff inservice.
F441-F The facility will maintain an infection control program with updated logs, resident infection reviews, and staff education.
F463-E The facility will maintain a functional call light system with repairs, staff notification procedures, and ongoing maintenance checks.
F465-E The facility will provide a safe, functional, sanitary, and comfortable environment by repairing sinks, cleaning public bathrooms, and maintaining medication and kitchen areas.
Report Facts
Complete Date: Feb 7, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lynette Emmerson | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 7, 2016
Visit Reason
The document is a Plan of Correction submitted in response to a revised complaint inspection related to allegations of abuse, neglect, or exploitation at the facility.
Findings
The facility will ensure all allegations of abuse, neglect, or exploitation are reported and investigated per established procedures. Follow-up monitoring, care plan reviews, resident and staff interviews, and staff re-education will be conducted to maintain compliance and protect residents.
Deficiencies (1)
F225-K: The facility failed to ensure all allegations of abuse, neglect, or exploitation were properly reported and investigated. Corrective actions include monitoring, interviews, re-education, and reporting to ensure resident protection.
Report Facts
Follow-up monitoring frequency: 1
Interview frequency: 3
Correction completion date: Oct 7, 2016
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Oct 4, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#106212) and a partial extended survey related to allegations of staff to resident sexual abuse.
Complaint Details
The complaint investigation (#106212) involved allegations of staff to resident sexual abuse by direct care staff H. The allegation was substantiated by interviews and documentation. The facility failed to suspend the alleged perpetrator immediately, allowing him to work for approximately 3.5 hours after the report. The facility abated the immediate jeopardy by suspending the staff and conducting staff education.
Findings
The facility failed to immediately protect 34 other gender residents after a report of sexual abuse by direct care staff H. The facility conducted an in-service on abuse and suspended the alleged perpetrator after a delay of approximately 3.5 hours, placing residents in immediate jeopardy.
Deficiencies (1)
483.13(c)(1)(ii)-(iii), (c)(2)-(4) - The facility failed to immediately protect 34 other gender residents after a report of sexual abuse by direct care staff H, placing residents in immediate jeopardy.
Report Facts
Resident census: 62
Residents at risk: 34
BIMS score: 8
BIMS score: 12
BIMS score: 7
Hours worked post-allegation: 3.5
In-service education dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff H | Alleged perpetrator of sexual abuse who was not immediately suspended. | |
| Licensed nursing staff I | Notified administrative staff of the abuse allegation and reassigned direct care staff H. | |
| Direct care staff G | Worked with direct care staff H after the allegation. | |
| Administrative staff A | Confirmed delay in suspending direct care staff H after the allegation. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 15, 2016
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. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with deficiencies at the 'F' severity level, indicating no harm but potential for more than minimal harm without immediate jeopardy.
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 is responsible for licensure certification and enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: 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 have been corrected.
Findings
The report confirms that all cited deficiencies have been corrected as of the revisit date. No uncorrected deficiencies remain.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 05/25/2016.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as 'ml ft scott complaint 04262016'.
Findings
The facility was found deficient in ensuring adequate supervision of residents at risk for elopement. Corrective actions include enhanced supervision, staff education on 15-minute checks, door alarm adjustments, and ongoing monitoring through QAPI meetings.
Deficiencies (1)
F323 The facility failed to ensure adequate supervision of residents assessed as at risk for elopement. Door alarms were changed to sound in 7 seconds and staff received education on monitoring and documentation.
Report Facts
Plan of Correction completion date: May 25, 2016
Resident transfer date: Apr 14, 2016
Staff education date: Mar 25, 2016
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Apr 26, 2016
Visit Reason
The inspection was conducted as a complaint investigation related to an incident where a resident eloped from the facility without staff knowledge.
Complaint Details
The complaint investigation #98660 found that the resident eloped on 3/23/16 via a coded exit door when a non-facility worker exited using the keypad. The door alarm did not sound. The resident was found two blocks away and returned safely. The resident was placed on 15-minute checks upon return and the family was assisted with finding other placement.
Findings
The facility failed to provide adequate supervision to prevent a resident with severe cognitive impairment and known elopement risk from leaving the building unnoticed. The resident was found two blocks away and returned safely without injury.
Deficiencies (1)
483.25(h) The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent a known elopement risk resident from leaving the facility without staff knowledge.
Report Facts
Resident census: 47
Elopement risk residents: 7
Sampled residents: 3
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 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.
Deficiencies (1)
The facility was cited with a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 9, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report documents that previously identified deficiencies under regulations 483.10(b)(4) and 483.75(l)(1) were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 4, 2015
Visit Reason
This document is a plan of correction submitted by the facility in response to deficiencies identified during an annual survey and complaint investigation.
Findings
The facility identified issues related to maintaining and verifying code status documentation for residents. The plan outlines corrective actions including staff training, chart audits, and ongoing monitoring to ensure compliance.
Deficiencies (2)
F155: The facility will maintain a system of identification of code status for all residents. Staff were trained and charts audited to verify code status documentation.
F514-D: The facility will maintain complete and accurate clinical records including code status information. Staff training and audits were conducted to ensure records are accessible and organized.
Report Facts
Plan of correction completion date: Dec 9, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 23, 2015
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 deficiencies to be '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 and the plan.
Deficiencies (1)
The facility had 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Date: 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.
Complaint Details
The complaint investigation #93883 found the facility failed to maintain identification of full code status for a resident, leading to a failure to initiate CPR when the resident was found without pulse or respirations.
Findings
The facility failed to maintain an accurate system to identify residents' code status, resulting in a nurse not initiating CPR on a resident with full code status. The medical record was incomplete and inaccurate regarding the resident's death and code status documentation.
Deficiencies (2)
F 155: The facility failed to maintain a system to identify full code status for 1 of 3 residents reviewed, resulting in failure to initiate CPR on a resident with full code status.
F 514: The facility failed to maintain complete, accurate, and accessible clinical records for 1 of 3 residents reviewed, lacking accurate documentation of death and code status.
Report Facts
Resident census: 52
Residents with full code status: 6
Residents reviewed: 3
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jul 27, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to an annual survey to address identified deficiencies and ensure compliance with federal and state regulations.
Findings
The plan outlines corrective actions for multiple deficiencies including housekeeping responsibilities, dietary care plans, skin assessments, nutritional interventions, bowel movement monitoring, sanitary food preparation, and staff education on policies and procedures.
Deficiencies (8)
F0000: This plan of correction constitutes a written allegation of substantial compliance with federal and state regulations and will be submitted to the Quality Assurance Committee by July 27, 2015.
F253: Housekeeping duties have been expanded to include daily cleaning of specific areas and weekly cleaning of vents and blinds, with staff education and facility monitoring planned by July 27, 2015.
F280: Resident #71's diet orders were clarified and care plans updated; staff education and monitoring for compliance are scheduled by July 27, 2015.
F309: Licensed staff will complete skin assessments for new skin tears or bruises and be educated on monitoring and documentation policies, with ongoing compliance monitoring.
F325: Nutritional interventions will be provided to prevent weight loss, with weekly evaluations and communication among dietary and nursing staff, monitored by the Dietary Manager.
F329: Bowel movements for resident #29 and all residents will be closely monitored with appropriate treatments and alerts to nursing staff and physicians as needed.
F371: The facility will ensure sanitary food storage, preparation, and service, with revamped cleaning responsibilities and replacement of damaged utensils by July 27, 2015.
F441: Licensed nurses will review and demonstrate understanding of glucometer policy; CNAs will be re-educated on glove usage and cleaning of equipment, with monitoring by the Director of Nursing.
Inspection Report
Follow-Up
Deficiencies: 7
Date: Jul 27, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date of 07/27/2015.
Deficiencies (7)
Regulation 483.15(h)(2) deficiency was corrected by 07/27/2015.
Regulations 483.20(d)(3) and 483.10(k)(2) deficiencies were corrected by 07/27/2015.
Regulation 483.25 deficiency was corrected by 07/27/2015.
Regulation 483.25(i) deficiency was corrected by 07/27/2015.
Regulation 483.25(l) deficiency was corrected by 07/27/2015.
Regulation 483.35(i) deficiency was corrected by 07/27/2015.
Regulation 483.65 deficiency was corrected by 07/27/2015.
Inspection Report
Follow-Up
Deficiencies: 7
Date: Jul 27, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies identified by regulation numbers F0253, F0280, F0309, F0325, F0329, F0371, and F0441 were corrected as of the revisit date.
Deficiencies (7)
Regulation 483.15(h)(2) deficiency F0253 was corrected on 07/27/2015.
Regulations 483.20(d)(3) and 483.10(k)(2) deficiency F0280 was corrected on 07/27/2015.
Regulation 483.25 deficiency F0309 was corrected on 07/27/2015.
Regulation 483.25(i) deficiency F0325 was corrected on 07/27/2015.
Regulation 483.25(l) deficiency F0329 was corrected on 07/27/2015.
Regulation 483.35(i) deficiency F0371 was corrected on 07/27/2015.
Regulation 483.65 deficiency F0441 was corrected on 07/27/2015.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 30, 2015
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 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 based on the credible allegation of compliance and the submitted plan.
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 that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter and referenced as contact for questions concerning the information in the letter. |
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 7
Date: Jun 22, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with previously cited deficiencies and overall facility conditions.
Findings
The facility failed to maintain sanitary housekeeping and maintenance services in multiple resident areas, failed to review and revise care plans for residents with nutrition and toileting needs, failed to monitor skin bruises, failed to prevent unplanned weight loss, failed to adequately monitor medications for diabetes, failed to store and prepare food under sanitary conditions, and failed to maintain an effective infection control program including proper cleaning of lift equipment and glucometers.
Deficiencies (7)
F253: The facility failed to provide adequate housekeeping and maintenance services on 3 of 4 hallways, including cluttered rehabilitation room, dirty bathrooms, unlocked storage rooms with debris, and soiled carpets and floors.
F280: The facility failed to review and revise care plans for 2 residents, including failure to address refusal of pureed diet and thickened liquids and toileting hygiene needs after amputation.
F309: The facility failed to monitor skin bruises for one resident, lacking documentation and assessment of bruising after a fall and skin tear.
F325: The facility failed to provide nutritional interventions to prevent unplanned weight loss for one resident, including failure to offer planned health shakes and fortified foods consistently.
F329: The facility failed to adequately monitor medications for two residents, including failure to monitor bowel elimination and blood sugar levels with appropriate physician notification and interventions.
F371: The facility failed to store, prepare, distribute, and serve food under sanitary conditions, including dirty floors, soiled equipment, damaged utensils, and unclean storage areas.
F441: The facility failed to maintain an effective infection control program, including failure to properly clean and sanitize glucometers and mechanical lifts between resident use, and improper glove use increasing infection risk.
Report Facts
Resident census: 53
Weight loss: 9
Weight: 90
BIMS score: 7
BIMS score: 15
Blood sugar reading: 50
Blood sugar reading: 161
Blood sugar reading: 51
Blood sugar reading: 78
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 12, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies noted in a prior survey. It outlines corrective actions to achieve substantial compliance with Medicare and Medicaid Services requirements.
Findings
The facility was found deficient in ensuring adequate supervision of residents at risk for elopement. The plan addresses supervision, staff re-education, elopement drills, and protocols during door alarm repairs.
Deficiencies (1)
F323-D The facility will ensure adequate supervision of all residents especially those assessed as being at risk for elopement. The director of nursing will be responsible for facility compliance with the elopement policy including timely assessment and care planning.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 12, 2015
Visit Reason
This post-certification revisit was 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 revisit confirmed that the previously cited deficiency under regulation 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date of 06/12/2015.
Report Facts
Deficiency correction date: Jun 12, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 20, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility was cited with a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: 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.
Complaint Details
Investigation of complaint #86383 found the facility failed to supervise a high elopement risk resident who left the facility unnoticed on 4/23/15. The incident occurred during front door keypad replacement when staff were distracted or not assigned to monitor the exit.
Findings
The facility failed to provide 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 not assigned to monitor the exit, resulting in the resident exiting alone.
Deficiencies (1)
483.25(h) The facility failed to ensure adequate supervision for one elopement risk resident who exited the facility without staff knowledge during front door keypad replacement.
Report Facts
Resident census: 56
Elopement risk residents: 4
Sampled elopement risk residents: 3
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 20, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a 'D' level deficiency 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 facility was cited with a 'D' level deficiency indicating no actual harm but potential for more than minimal harm without immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 30, 2014
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 plans to address restorative care staffing and food service temperature issues to achieve substantial compliance by November 30, 2014.
Deficiencies (2)
F318-E: The facility will provide a planned restorative program by fully staffing restorative aides and training additional CNAs to meet residents' restorative needs. The director of nursing and MDS coordinator will oversee assignments, schedules, and care plan updates.
F364-E: The facility will ensure food is palatable, attractive, and served at the right temperature by routine temperature checks and monitoring by dietary staff and managers. The tray delivery system has been revised to improve timeliness and temperature control.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Nov 30, 2014
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 the deficiencies previously reported on the CMS-2567 have been corrected as of the revisit date.
Deficiencies (2)
Regulation 483.25(e)(2) deficiency was corrected by 11/30/2014.
Regulation 483.35(d)(1)-(2) deficiency was corrected by 11/30/2014.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Date: Nov 13, 2014
Visit Reason
Investigation of complaints #77686, 79380, and 80774 regarding failure to provide appropriate restorative services and food temperature issues.
Complaint Details
The investigation was triggered by complaints #77686, 79380, and 80774 regarding failure to provide restorative services and food temperature issues.
Findings
The facility failed to provide planned restorative services to residents at risk for decline in range of motion, as restorative staff were often pulled to floor duties. Additionally, the facility failed to serve food at proper temperatures, resulting in resident dissatisfaction.
Deficiencies (2)
483.25(e)(2) The facility failed to provide appropriate restorative services to 4 sampled residents to prevent further decline in range of motion as planned.
483.35(d)(1)-(2) The facility failed to serve food at the proper temperature to ensure palatability and resident satisfaction.
Report Facts
Facility census: 57
Food temperature: 100
Food temperature: 120
Days without food temperature documentation: 3.5
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 29, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-04-10.
Findings
The report confirms that the previously cited deficiency with regulation 483.25(h) was corrected as of 2014-05-10. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected by 2014-05-10 as verified during this revisit.
Report Facts
Deficiency correction date: May 10, 2014
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 17, 2014
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation related to resident safety and medication management issues at the facility.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Med Fort Scott facility, addressing issues related to resident falls, medication management, and alarm use.
Findings
The facility identified deficiencies related to resident accident hazards, supervision, medication adjustments, and use of alarms and restraints. The Plan of Correction outlines interventions including care plan reviews, therapy evaluations, staff education, and ongoing monitoring to ensure substantial compliance.
Deficiencies (2)
F0000: The facility alleges substantial compliance with Medicare and Medicaid requirements and submits this Plan of Correction without admitting any violations. Compliance is expected by 05/10/2014.
F323-G: The facility will ensure the resident environment is free of accident hazards and residents receive adequate supervision and assistive devices. Care plans and interventions will be reviewed and updated by the Interdisciplinary Team by 05/10/2014.
Report Facts
Completion date for Plan of Correction: May 10, 2014
Date of resident care plan reviews: Apr 25, 2014
Date of therapy and medication reviews: Apr 16, 2014
Date of staff inservicing completion: May 2, 2014
Date of initiation of daily interdisciplinary meetings: Apr 21, 2014
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Apr 10, 2014
Visit Reason
Investigation of complaint #73491 regarding inadequate supervision and assistive devices to prevent resident falls.
Complaint Details
The investigation was triggered by complaint #73491. The complaint was substantiated as the facility failed to prevent falls and injuries for two residents.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent repeated falls for two residents, resulting in hip fractures. Staff and family members sometimes removed personal alarms, contributing to the risk.
Deficiencies (1)
483.25(h) The facility failed to ensure adequate supervision and assistive devices to prevent repeated falls for two residents, resulting in hip fractures.
Report Facts
Resident census: 55
Fall assessment score: 20
Cognition score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff C | Found resident on floor after fall and assisted resident. | |
| Licensed nursing staff D | Assessed resident after fall and notified physician. | |
| Administrative staff A | Reported investigation findings and staff/family interviews. | |
| Certified nursing staff F and G | Reported family requests to remove alarms during visits. | |
| Licensed nursing staff E | Reported family requests to remove alarms and education after fall. | |
| Nursing staff B, C, E, and H | Reported resident known for removing personal alarm. |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: 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, environmental repairs, care plan updates, infection control improvements, and monitoring processes to resolve deficiencies related to resident care, housekeeping, maintenance, medication monitoring, and infection control.
Deficiencies (12)
F0000 This plan of correction constitutes a written allegation of substantial compliance with federal and state regulations following the annual survey.
F166-D The facility will resolve grievances timely and re-educate staff to report missing or lost resident personal items, with monitoring by social worker and administrator.
F242-D Resident #33's care plan was updated to reflect sleep preferences, and staff were educated to respect resident preferences for arising times.
F253-E The facility will maintain sanitary dining and resident areas through housekeeping and maintenance actions including cleaning, repairs, and repainting.
F253EX1 The resident bathroom damage was repaired and repainted; personal care items were properly labeled and environmental cleaning was scheduled.
F312-D Resident #3's nail care was assessed and trimmed; staff will be educated and monitored for compliance.
F314-D The Director of Nursing will educate staff on positioning and pressure ulcer prevention, with ongoing monitoring.
F329-D The facility will monitor blood pressure and pulse weekly for hypertensive residents, with documentation and staff education.
F428-D A pharmacist will review resident drug regimens monthly; the Director of Nursing will monitor medication records for blood pressure documentation.
F441-E The facility will maintain an ongoing Infection Control Program with staff education and monitoring to prevent disease transmission.
F464-D The facility will ensure sufficient space in dining and activity rooms, with rearrangements to accommodate resident needs without staff moving residents.
F465-E The facility will maintain a clean and sanitary kitchen environment through cleaning, repairs, and monitoring of dietary areas.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Brown | Administrator | Administrator submitting the Plan of Correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 9, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected.
Findings
All deficiencies previously reported were corrected as of the revisit date. The report lists multiple regulation citations with correction completion dates of 04/09/2014.
Inspection Report
Follow-Up
Deficiencies: 10
Date: Apr 9, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All deficiencies previously reported were corrected by the revisit date of 04/09/2014, as documented by the correction completion dates for each cited regulation.
Deficiencies (10)
Regulation 483.10(f)(2): Previously cited deficiency corrected as of 04/09/2014.
Regulation 483.15(b): Previously cited deficiency corrected as of 04/09/2014.
Regulation 483.15(h)(2): Previously cited deficiency corrected as of 04/09/2014.
Regulation 483.25(a)(3): Previously cited deficiency corrected as of 04/09/2014.
Regulation 483.25(c): Previously cited deficiency corrected as of 04/09/2014.
Regulation 483.25(l): Previously cited deficiency corrected as of 04/09/2014.
Regulation 483.60(c): Previously cited deficiency corrected as of 04/09/2014.
Regulation 483.65: Previously cited deficiency corrected as of 04/09/2014.
Regulation 483.70(g): Previously cited deficiency corrected as of 04/09/2014.
Regulation 483.70(h): Previously cited deficiency corrected as of 04/09/2014.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 10
Date: Mar 11, 2014
Visit Reason
Health resurvey inspection conducted to evaluate compliance with previously identified deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, failure to honor resident personal choices, inadequate housekeeping and maintenance services, insufficient assistance with activities of daily living such as fingernail hygiene, failure to provide timely repositioning to prevent pressure sores, inadequate monitoring of medications, failure to maintain infection control preventing spread of C-Diff, insufficient dining room space for residents, and unsanitary kitchen conditions.
Deficiencies (10)
F 166: Facility failed to promptly resolve grievances reported by residents related to missing personal items and money, delaying resolution for months.
F 242: Facility failed to provide personal choice of awakening times for a resident, causing discomfort and fatigue.
F 253: Facility failed to maintain sanitary conditions in 15 resident rooms and 2 dining rooms, including unclean tables, floors, and equipment.
F 312: Facility failed to ensure dependent resident received adequate fingernail hygiene, with unclear staff responsibility and missed care.
F 314: Facility failed to provide timely repositioning for 3 residents at risk for pressure sores, placing them at risk for skin breakdown.
F 329: Facility failed to ensure adequate monitoring of blood pressure and pulse for a resident on antihypertensive medication, risking unnecessary drug use.
F 428: Facility pharmacist failed to identify irregularities in medication monitoring, resulting in failure to ensure resident remained free of unnecessary medications.
F 441: Facility failed to maintain infection control program to prevent spread of C-Diff, including improper cleaning and handling of linens and surfaces.
F 464: Facility failed to provide sufficient space in one dining area to accommodate three residents, impairing their ability to eat without staff repositioning.
F 465: Facility failed to maintain a clean and sanitary kitchen environment, with heavily soiled floors, missing paint, and buildup of grime and substances.
Report Facts
Resident census: 54
Residents reviewed: 21
Residents reviewed for choices: 3
Residents reviewed for ADL: 3
Residents reviewed for unnecessary medications: 5
Residents with pressure sore risk sampled: 3
Tables with missing finish: 8
Tables with gritty surface: 2
Blood pressure readings documented: 2
Pulse readings documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Nurse | Named in grievance resolution failure for missing necklace |
| Staff A | Administrative Staff | Responsible for investigation of missing quarters grievance |
| Staff N | Housekeeping Staff | Observed cleaning resident room with C-Diff and dining tables |
| Staff E | Licensed Nursing Staff | Reported on fingernail care responsibilities and medication monitoring |
| Staff CC | Pharmacy Consultant | Interviewed regarding medication regimen review and monitoring |
| Staff B | Administrative Nursing Staff | Reported on blood pressure monitoring expectations and infection control |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 3, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited 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
Follow-Up
Deficiencies: 0
Date: Feb 3, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 8
Date: Jan 4, 2013
Visit Reason
The inspection was a health resurvey to assess compliance with previously identified deficiencies and overall regulatory requirements at Medicalodges Fort Scott.
Findings
The facility failed to maintain resident dignity during bathing, provide adequate housekeeping and maintenance services, properly review and revise care plans for urinary incontinence, prevent unnecessary medication duplication, maintain sanitary food preparation and storage conditions, and ensure a safe and functional environment in laundry and kitchen areas.
Deficiencies (8)
F241: The facility failed to provide bathing in a manner that maintained or enhanced the dignity of three residents, evidenced by residents waiting in wheelchairs with undergarments exposed.
F253: The facility failed to provide adequate housekeeping and maintenance services to maintain a sanitary and comfortable interior environment in bathing areas, corridors, and dining rooms.
F280: The facility failed to review and revise resident #17's care plan to ensure appropriate care for urinary incontinence, lacking an individualized toileting plan.
F315: The facility failed to provide care and services to prevent a decline in urinary incontinence for resident #17, including failure to offer toileting and check for incontinence.
F329: The facility failed to ensure resident #17's drug regimen was free from unnecessary drugs, administering duplicate antihistamine medications (Claritin and Zyrtec) for 41 days.
F371: The facility failed to store, prepare, and serve food under sanitary conditions, including dirty utensils, food stains on plexiglass, cracked air conditioner panel, and cups stored on the floor.
F428: The facility's consultant pharmacist failed to identify and report duplicative antihistamine therapy for resident #17, resulting in continued unnecessary medication use.
F465: The facility failed to provide a safe, functional, sanitary, and comfortable environment, including a malfunctioning dishwasher, poor housekeeping and maintenance in laundry and kitchen areas, and damaged exterior siding.
Report Facts
Resident census: 54
Duration of duplicate medication use: 41
Residents reviewed: 20
Residents reviewed for unnecessary medications: 10
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jan 2, 2013
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Fort Scott in response to deficiencies cited during an annual survey inspection.
Findings
The plan addresses multiple deficiencies including resident dignity during transport, housekeeping and maintenance issues, care plan updates for urinary incontinence, medication administration errors, dietary sanitation, and laundry area repairs. Corrective actions and monitoring plans are detailed with compliance targeted by 02/03/2013.
Deficiencies (8)
F241-D: Affected residents will be provided tote bags for personal belongings during transport to the shower room to maintain dignity and respect.
F253-E: Housekeeping and maintenance services will maintain a sanitary, orderly, and comfortable interior including repairs and cleaning of bathing areas and dining tables.
F280-D: Resident #17's care plan was updated after a bladder assessment; nursing staff will be inserviced on urinary incontinence policy and procedures.
F315-D: A bladder assessment was conducted and an individualized toileting plan placed on the care plan for resident #17; staff will be inserviced on related policies.
F329-D: Resident #17's Claritin was discontinued; nurses will be inserviced on reviewing medication records for duplicate therapy and medication orders will be monitored regularly.
F371-F: Dietary areas will be cleaned and maintained including replacement of stained plexi-glass, cleaning of utensil drawers, and repair or removal of a damaged air conditioner panel.
F428-D: Pharmacist contacted regarding medication administration record inaccuracies; monthly reviews and monitoring by Director of Nursing will continue.
F465-E: Laundry areas needing repair will be fixed by contract labor; cleaning checklists and monitoring will ensure a safe and sanitary environment.
Report Facts
Deficiencies cited: 8
Inspection Report
Follow-Up
Deficiencies: 7
Date: Oct 28, 2011
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All deficiencies previously reported were corrected by the revisit date of 10/28/2011, as documented by the correction completion dates for each cited regulation.
Deficiencies (7)
Regulation 483.15(h)(2): Deficiency previously cited was corrected by 10/28/2011.
Regulation 483.20(i)-(j): Deficiency previously cited was corrected by 10/28/2011.
Regulation 483.25(h): Deficiency previously cited was corrected by 10/28/2011.
Regulation 483.25(l): Deficiency previously cited was corrected by 10/28/2011.
Regulation 483.35(i): Deficiency previously cited was corrected by 10/28/2011.
Regulation 483.65: Deficiency previously cited was corrected by 10/28/2011.
Regulation 483.75(m)(2): Deficiency previously cited was corrected by 10/28/2011.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 7
Date: Sep 28, 2011
Visit Reason
Annual health facility resurvey to assess compliance with regulatory requirements including housekeeping, assessment accuracy, accident hazards, drug regimen, food safety, infection control, and emergency procedures.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance services, inaccurate resident assessments, unsafe environmental hazards, failure to monitor and manage medications with black box warnings, inadequate food storage and sanitation, infection control lapses, and lack of staff training on emergency procedures such as bomb threats.
Deficiencies (7)
F253 Housekeeping and maintenance services were inadequate, with multiple areas including therapy room, dining room, and resident bathrooms showing dirt, rust, discoloration, odors, and physical damage.
F278 The facility failed to complete accurate comprehensive assessments for a sampled resident, missing key information on activities of daily living, fall history, and weight loss.
F323 The facility failed to maintain a safe environment free of accident hazards, including unsecured chemicals and protruding toilet bolts in resident bathrooms.
F329 The facility 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.
F371 The facility failed to store, prepare, and serve food under sanitary conditions, including improper storage of buttered bread and unclean kitchen equipment and floors.
F441 The facility failed to properly cleanse the plastic container holding glucose monitoring equipment, risking infection spread.
F518 The facility failed to train employees in emergency procedures related to bomb threats or scares.
Report Facts
Deficiencies cited: 7
Resident census: 49
Residents sampled: 10
Cracked tiles: 6
Rooms with maintenance issues: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff J | Observed placing unclean plastic container on resident floor and counters during glucose monitoring. | |
| licensed staff B | Verified improper handling of glucose monitoring container and acknowledged lack of black box warnings on care plans. | |
| consultant pharmacist M | Provided black box warning information to facility and confirmed staff responsibilities. | |
| licensed nursing staff N | Reported lack of documentation of medications with black box warnings on care plans. | |
| direct care staff T | Reported pain medication administration and documentation practices. | |
| licensed nursing staff Q | Reported need for baseline dyskinesia assessments for residents on psychotropic medications. | |
| licensed staff A | Verified need for black box warnings on care plans and blood sugar parameters. | |
| CNA D | Described actions to take in case of bomb threat. | |
| housekeeping staff D | Uncertain about bomb threat procedures. | |
| dietary staff F | Unaware of bomb threat procedures. | |
| licensed staff G | Described bomb threat response but unsure about training. | |
| CNA H | Unaware of bomb threat training. | |
| maintenance staff I | Reported disaster inservices but no specific bomb threat training. | |
| administrative staff A | Verified lack of bomb threat inservice training. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N006002 POC JTDY11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder indicating no records found for the Plan of Correction.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N006002 POC YVQ211
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility with State ID N006002 and Event ID YVQ211.
Findings
No deficiency details or findings are included in this Plan of Correction document. It only references the related deficiency report and provides contact information for assistance.
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