Inspection Reports for Medicalodges Frontenac
206 S. DITTMANN STREET, KS, 66763-2299
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 18, 2020, found the facility in compliance with all regulations and no deficiencies were cited. Prior inspections showed a pattern of deficiencies primarily related to resident care planning, medication management, infection control, and supervision, including issues with CPR certification, restorative services, and safe transfers. Several complaint investigations substantiated concerns such as inadequate supervision leading to resident elopement and medication errors resulting in adverse outcomes. Enforcement actions included denial of payment for new Medicare and Medicaid admissions at times, but no fines or license suspensions were listed in the available reports. The facility appears to have addressed prior deficiencies effectively, with multiple revisits confirming corrections and recent inspections showing improvement.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
27.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
355% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
54 residents
Based on a December 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 18, 2020
Visit Reason
An offsite revisit was conducted on 02/18/2020 for all previous deficiencies cited on 12/18/2019.
Findings
All deficiencies have been corrected as of the compliance date of 02/01/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 9
Dec 18, 2019
Visit Reason
Annual health resurvey of Medicalodges Frontenac nursing facility to assess compliance with federal regulations including resident care, safety, and infection control.
Findings
The facility had multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments for anticoagulant use, failure to review and revise care plans for residents with infections and restorative needs, inadequate assistance with activities of daily living, lack of CPR certified staff on all shifts and during transportation, failure to provide restorative services and proper splinting, unsafe resident transfers without mechanical lift, improper handling of urinary catheter collection bags, and failure to maintain an effective infection control program related to PICC line care.
Severity Breakdown
Level D: 5
Level E: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to accurately assess the Minimum Data Set (MDS) for anticoagulant use for three residents due to incorrect coding of antiplatelet medication as anticoagulant. | Level D |
| Failed to review and revise care plans for residents with infections, restorative needs, and PICC line care. | Level D |
| Failed to provide necessary assistance with activities of daily living including nutrition and fingernail care. | Level D |
| Failed to provide CPR certified staff on all shifts and during transportation for residents with full code status. | Level E |
| Failed to provide restorative services and proper splinting/positioning devices to residents with contractures and limited range of motion. | Level E |
| Failed to safely transfer a resident using a mechanical lift as required by care plan. | Level D |
| Failed to handle urinary catheter collection bag in a clean and sanitary manner to prevent urinary tract infections. | Level D |
| Failed to provide annual performance reviews for four direct care staff to ensure competency. | Level E |
| Failed to maintain an effective infection control program including proper care of PICC line dressing and lack of policy. | Level E |
Report Facts
Residents selected for review: 16
Residents with full code status: 16
Resident transports: 72
Residents transported with full code status: 11
Restorative services provided: 7
Restorative services provided: 10
Restorative services provided: 12
Restorative services provided: 7
Restorative services provided: 9
Restorative services provided: 12
Restorative services provided: 7
Restorative services provided: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse F | Administrative Nurse | Confirmed MDS coding errors for anticoagulant use. |
| Administrative Nurse D | Administrative Nurse | Reported expectations for MDS coding and care plan revisions. |
| Administrative Nurse E | Administrative Nurse | Observed PICC line dressing issues and confirmed restorative service reviews. |
| Consultant GG | Consultant | Reported expectation for CPR certified staff and lack of PICC line care policy. |
| Administrative Nurse RR | Administrative Nurse | Confirmed lack of PICC line care instructions on eMAR. |
| Certified Nurse Aide NN | Certified Nurse Aide | Reported inability to provide restorative care due to transportation duties. |
| Licensed Nurse I | Licensed Nurse | Confirmed catheter bag handling and PICC line dressing care. |
Inspection Report
Plan of Correction
Deficiencies: 9
Dec 18, 2019
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Frontenac in response to deficiencies cited during a prior inspection conducted on December 18, 2019.
Findings
The plan outlines corrective actions for multiple deficiencies including medication coding accuracy, care plan revisions, nail care, CPR certification, restorative services, resident transfers, catheter care, and staff competency evaluations. Each corrective action is assigned a completion date of February 1, 2020, with ongoing monitoring by the Director of Nursing and facility committees.
Severity Breakdown
D: 6
E: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Inaccurate coding of anticoagulant and anti-platelet medications for residents 19, 43, and 2 | D |
| Care plans lacking details for PICC line care and restorative nursing needs for residents 38, 24, and 43 | D |
| Improper nail care and insufficient assistance during meals for residents 19 and 47 | D |
| Lack of certified CPR staff on all shifts and during transportation | E |
| Failure to provide prescribed restorative services and proper splinting/hand positioning for residents 24, 38, 42, 50, and 51 | E |
| Improper transfer care planning and assistance for resident 4 | D |
| Improper care and handling of catheter and catheter collection bag for resident 4 | D |
| Missing competency and performance reviews for 4 nursing staff | E |
| Improper PICC line treatment for resident 43 and lack of proper treatment for other residents with PICC lines | D |
Report Facts
Residents referenced: 9
Completion date: Feb 1, 2020
Staff missing competency reviews: 4
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 14, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 12/20/2018.
Findings
All deficiencies have been corrected as of the compliance date of 01/19/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 3
Dec 20, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #124380 and #129435 to assess compliance with regulatory requirements.
Findings
The facility failed to ensure dialysis care was provided consistent with professional standards, including proper assessment of the dialysis fistula post-treatment. Additionally, the facility failed to timely implement a physician's medication order change for an antidepressant, and the resident call light system was not fully functional, resulting in delayed staff response times.
Complaint Details
The visit included complaint investigations #124380 and #129435.
Severity Breakdown
SS=D: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure dialysis resident received care consistent with professional standards, including assessment of fistula and dressing post dialysis. | SS=D |
| Failed to administer antidepressant medication following physician orders in a timely manner (9 days delay). | SS=D |
| Failed to provide a fully functional resident call light system, resulting in delayed response times. | SS=F |
Report Facts
Census: 52
Residents sampled: 19
Residents reviewed for dialysis cares: 1
Residents reviewed for unnecessary medications: 5
Days delay in medication order implementation: 9
Minutes delay in call light response: 41
Minutes delay in call light response: 21
Minutes delay in call light response: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Nursing Staff | Lifted pressure dressing from fistula and assessed bleeding |
| Staff L | Licensed Nursing Staff | Assessed resident upon return from dialysis |
| Staff G | Direct Care Staff | Reported usual dressing on fistula and nursing assessments |
| Staff H | Dialysis Licensed Nursing Staff | Provided expert guidance on dressing maintenance post dialysis |
| Staff A | Administrative Nursing Staff | Confirmed assessment procedures and facility policy gaps |
| Staff E | Direct Care Staff | Noted timing of medication order change implementation |
| Staff C | Licensed Nursing Staff | Explained delay in receiving physician orders |
| Staff F | Maintenance Staff | Reported call light monitor system was not functioning |
| Staff B | Administrative Staff | Reported expectations for call light response times |
Inspection Report
Plan of Correction
Deficiencies: 3
Dec 20, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during an annual survey inspection conducted on 12/20/2018.
Findings
The facility failed to ensure proper dialysis care for resident #202, timely administration of antidepressant medication for resident #17, and provision of a fully functional call light system for residents. Corrective actions including care plan updates, staff education, and system repairs were implemented.
Severity Breakdown
D: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure resident #202 received dialysis care consistent with standards and care plan. | D |
| Failed to administer antidepressant medications to resident #17 following physician orders in a timely manner. | D |
| Failed to provide a fully functional call light system for residents. | F |
Report Facts
Resident sampled for dialysis: 1
Residents sampled for medication administration: 5
Education completion deadline: Jan 19, 2019
Call system correction date: Dec 20, 2018
Inspection Report
Re-Inspection
Deficiencies: 1
Dec 20, 2018
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency classified as a '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 reviewed and accepted, and the facility was found to be in substantial compliance effective 2019-01-19.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency classified as a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure & Certification Enforcement Manager | Named as contact and signatory related to enforcement and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 20, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report dated 11/20/2018.
Findings
The plan addresses past noncompliance issues identified under tags F609-D and F689-J, for which no plan of correction was required. The corrective actions are cross-referenced to the deficiencies.
Deficiencies (2)
| Description |
|---|
| Past noncompliance under tag F609-D |
| Past noncompliance under tag F689-J |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Nov 20, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#KS00135348) regarding allegations of elopement and failure to report and investigate incidents involving resident safety.
Findings
The facility failed to thoroughly investigate and report an incident of elopement involving Resident #1, who exited the facility without staff knowledge and without adequate clothing in cold weather, placing the resident in immediate jeopardy. The facility also failed to provide adequate supervision and implement effective care plans to prevent elopement despite known risks and prior incidents.
Complaint Details
The complaint investigation (#KS00135348) was substantiated. The facility failed to investigate and report an elopement incident on 8/19/18 and failed to adequately supervise Resident #1 who eloped on 11/10/18 in cold weather without proper clothing, placing the resident in immediate jeopardy.
Severity Breakdown
SS=D: 1
SS=J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment in a timely manner as required by regulation. | SS=D |
| Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision to prevent accidents, resulting in resident elopement and immediate jeopardy. | SS=J |
Report Facts
Resident census: 53
Elopement risk scores: 10
Elopement risk scores: 18
Elopement risk scores: 16
Temperature: 19
Time of elopement: 305
Time of police call: 313
Time of staff assessment: 345
Duration of nurse assessments: 72
Staff education timeframe: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Administrative Nursing Staff | Interviewed regarding vague recollections of the 8/19/18 incident and failure to investigate. |
| Licensed nursing staff C | Licensed Nursing Staff | Reported residents at risk for elopement are posted with pictures and pertinent information at nursing desks. |
| Direct care staff H | Direct Care Staff | Reported residents at risk are posted at the desk and monitored every 15 minutes for exit seeking. |
| Direct care staff J | Direct Care Staff | Reported rumors about resident getting into an unlocked vehicle but no direct knowledge. |
| Social services/activity staff L | Social Services/Activity Staff | Visited resident at time of locking self into employee's vehicle and discussed impulsive behaviors. |
| Direct care staff F | Direct Care Staff | Reported knowledge of residents at risk and updated elopement book at nursing desks. |
| Direct care staff G | Direct Care Staff | Reported awareness of 3 residents able to go outside without assistance. |
| Direct care staff I | Direct Care Staff | Verified resident was an elopement risk and documented frequent checks. |
| Licensed nursing staff K | Licensed Nursing Staff | Reported resident's family plans and checked elopement book. |
| Direct care staff M | Certified Nurse Aide | Witnessed resident elopement on 11/10/18 and failed to complete every 15-minute checks. |
| Administrative staff A | Administrator | Participated in QAPI meeting and staff education on elopement policy. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 20, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted Immediate Jeopardy and Past Non-compliance to resident health or safety under F689, "J" CFR 483.25 (d)(1)(2).
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility conditions constituted Immediate Jeopardy and Past Non-compliance to resident health or safety under F689, "J" CFR 483.25 (d)(1)(2). | Immediate Jeopardy |
Report Facts
Timeframe for compliance: 3
Timeframe for compliance: 6
Provider Number: 175363
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Ricks | Administrator | Named as facility administrator |
| Caryl Gill | Complaint Coordinator | Author of the letter and contact for questions |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 22, 2018
Visit Reason
A revisit survey was conducted on 08/22/18 to verify correction of all previous deficiencies cited on 07/25/18.
Findings
All deficiencies cited in the previous inspection have been corrected as of 07/26/18 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Jul 25, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#131625) related to accidents involving wheelchair transportation and resident safety.
Findings
The facility failed to ensure that wheelchairs were properly equipped with foot pedals when staff propelled residents, resulting in a resident (#3) falling from a wheelchair and sustaining a cervical spine fracture. Similar deficiencies were noted for four other residents whose wheelchairs lacked foot pedals during staff propulsion.
Complaint Details
The complaint investigation (#131625) substantiated that the facility failed to prevent accidents related to wheelchair transportation, resulting in a resident fall with injury.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure wheelchairs were properly and safely used with appropriate foot pedals in place during staff propulsion, leading to a resident fall and injury. | SS=G |
Report Facts
Resident census: 52
Residents reviewed: 5
BIMS score: 7
BIMS score: 4
Distance pushed: 75
Distance pushed: 100
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 1
Jul 25, 2018
Visit Reason
The visit was conducted in response to a complaint regarding inappropriate wheelchair transportation and related accidents.
Findings
The facility failed to ensure proper and safe use of wheelchairs for 5 residents, resulting in a fall and neck fracture for one resident. The facility implemented corrective actions including staff training, resident evaluations, and monitoring to prevent future incidents.
Complaint Details
Complaint investigation related to inappropriate wheelchair transportation; substantiation status not explicitly stated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure wheelchairs were properly and safely used when staff propelled residents without appropriate foot pedals in place, resulting in a resident fall and neck fracture. |
Report Facts
Census: 52
Residents reviewed for accidents: 5
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jul 25, 2018
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services 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 deficiency to be at a level of actual harm that is not immediate jeopardy, requiring corrections. Based on this deficiency, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions effective August 10, 2018.
Severity Breakdown
level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency at a level of actual harm that is not immediate jeopardy requiring corrections | level of actual harm |
Report Facts
Denial of payment effective date: Aug 10, 2018
Timeframe for substantial compliance: 6
Civil Money Penalty threshold: 10483
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Ricks | Administrator | Named as facility administrator |
| Caryl Gill | Complaint Coordinator | Contact person for questions regarding the matter |
| Benton Williams | CMS Contact | Contact person at CMS for questions |
| Brad Fischer | Commissioner | Recipient of informal dispute resolution requests |
| Morsophia R. Powers | Branch Manager | Authorized the letter |
Inspection Report
Follow-Up
Deficiencies: 0
Dec 18, 2017
Visit Reason
An offsite visit was completed on 12/18/17 to verify correction of previous deficiencies cited on 10/24/17.
Findings
The deficiencies previously cited have been corrected and no new non-compliance was found. The facility is in compliance with all regulations surveyed effective 11/23/17.
Inspection Report
Plan of Correction
Deficiencies: 17
Nov 23, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a regulatory inspection, addressing multiple areas of non-compliance including investigation of incidents, employee background checks, dignity and respect of residents, housekeeping, assessments, care plans, behavioral management, ADL care, pressure sore treatment, toileting, supervision, dietary sanitation, physician visits, infection control, and equipment maintenance.
Findings
The facility failed to comply with multiple regulatory requirements affecting resident care and safety, including inadequate investigation of abuse incidents, incomplete employee background checks, failure to provide dignified care, insufficient housekeeping and maintenance, incomplete assessments and care plans, inadequate behavioral management, poor ADL assistance, improper pressure sore treatment, lack of toileting support, inadequate supervision and call light access, unsanitary dietary conditions, untimely physician visits, improper infection control practices, and failure to maintain mechanical lifts.
Deficiencies (17)
| Description |
|---|
| Failed to thoroughly investigate one of 3 incidents involving resident to resident abuse. |
| Failed to ensure 5 employees received criminal background and reference checks prior to hire. |
| Failed to provide care in a dignified manner for two residents related to appropriate dress and toileting. |
| Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. |
| Failed to thoroughly assess 4 residents, identifying causal factors and determining all potential needs in care plans. |
| Failed to ensure accuracy of Minimum Data Set assessments for 4 residents. |
| Failed to develop comprehensive care plans for 3 residents. |
| Failed to review and revise care plans for 3 residents to ensure staff awareness of individualized needs. |
| Failed to provide adequate behavioral management for 2 residents. |
| Failed to provide adequate assistance with personal hygiene for 4 residents. |
| Failed to provide adequate care and treatment for one resident with a pressure ulcer. |
| Failed to ensure 4 residents received toileting opportunities to maintain urinary continence. |
| Failed to ensure 3 residents received adequate supervision and assistive devices for safe transfers and ambulation; failed to ensure 5 residents had access to call lights. |
| Failed to maintain a clean and sanitary dietary department for storage, preparation, and service of food. |
| Failed to ensure 3 residents were seen by physician in a timely manner. |
| Failed to ensure appropriate application and disposal of PPE, food waste disposal, handwashing, and sanitation of equipment to prevent infection spread. |
| Failed to ensure essential maintenance and repair of mechanical lifts to keep them in safe operating condition. |
Report Facts
Residents reviewed: 19
Residents affected: 5
Residents affected: 4
Residents affected: 3
Residents affected: 4
Residents affected: 5
Audit frequency: 3
Audit duration: 4
Inspection Report
Re-Inspection
Deficiencies: 1
Oct 24, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a 'F' level deficiency that was widespread, constituting no actual harm but with potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 11/23/17.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiency, widespread, no actual harm with potential for more than minimal harm, not immediate jeopardy | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Named as contact and signatory related to findings and plan of correction acceptance |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 15
Oct 24, 2017
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation involving multiple complaint investigation numbers.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate abuse allegations, incomplete employee background checks, failure to maintain resident dignity, inadequate housekeeping and maintenance, incomplete resident assessments and care plans, failure to provide adequate assistance with ADLs, untimely physician visits, infection control breaches, and unsafe mechanical lift equipment.
Complaint Details
The visit was complaint-related as indicated by the multiple complaint investigation numbers referenced in the initial comments.
Severity Breakdown
SS=D: 5
SS=E: 4
SS=F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate one of three incidents involving resident to resident abuse, including lack of witness statements. | SS=D |
| Failure to ensure five employees received criminal background and reference checks prior to hire. | SS=E |
| Failure to provide care in a dignified manner for residents, including inappropriate dress and lack of toileting assistance. | SS=D |
| Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. | SS=E |
| Failure to thoroughly assess residents' needs and develop individualized care plans for multiple residents, including falls, behaviors, toileting, and transfers. | SS=E |
| Failure to develop and implement comprehensive person-centered care plans including measurable objectives and timeframes for residents with behavioral and toileting needs. | — |
| Failure to support resident participation in care planning and failure to revise care plans to reflect changes in resident needs and behaviors. | — |
| Failure to provide adequate assistance with personal hygiene, including failure to shave residents and failure to assist with hand hygiene after toileting. | SS=D |
| Failure to provide adequate care and treatment for a resident with a pressure ulcer, including lack of specific interventions to promote healing and prevent infection. | SS=D |
| Failure to provide appropriate treatment and services to maintain or restore urinary continence for multiple residents, including lack of individualized toileting programs and missed toileting opportunities. | — |
| Failure to ensure resident environment is free from accident hazards and failure to provide adequate supervision and assistive devices, including failure to use gait belts during transfers and lack of accessible call lights. | SS=E |
| Failure to maintain sanitary conditions in dietary department including unlabeled and undated food containers, unclean snack containers, and improper food handling practices. | — |
| Failure to ensure proper infection control practices including appropriate use and disposal of PPE, hand hygiene, cleaning of respiratory and glucose monitoring equipment, and proper handling of meal trays in isolation rooms. | SS=F |
| Failure to maintain mechanical equipment in safe operating condition, including a sit to stand lift with a cracked base and uncleanable surfaces. | SS=D |
| Failure to ensure timely physician visits every 60 days for multiple residents, resulting in residents not being seen by a physician or designee as required. | — |
Report Facts
Residents with missing background checks: 5
Residents reviewed for ADL care: 5
Residents reviewed for behavior management: 4
Residents reviewed for physician visit timeliness: 7
Residents reviewed for infection control: 13
Residents reviewed for accident prevention: 4
Fall risk assessment scores: 30
Days medication administered: 5
Pressure ulcer size: 0.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Verified incomplete investigations and background check issues. |
| Staff K | Direct Care Staff | Reported on resident behaviors and care needs. |
| Staff J | Administrative Nursing Staff | Verified care plan incompleteness and resident behavior issues. |
| Staff L | Licensed Nursing Staff | Reported on resident toileting and behavior management. |
| Staff MM | Direct Care Staff | Observed improper PPE use and notified maintenance of lift issues. |
| Staff OO | Maintenance Staff | Verified sit to stand lift was unsafe to use. |
| Staff UU | Dietary Staff | Verified unlabeled food containers and unclean snack bins. |
| Staff C | Licensed Nursing Staff | Observed improper food handling and verified infection control practices. |
Inspection Report
Follow-Up
Deficiencies: 1
Jun 30, 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
The report confirms that the deficiency identified under regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of 06/30/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(d)(1)(2)(n)(1)-(3) |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Jun 21, 2017
Visit Reason
The inspection was conducted as an investigation of complaint #116962 regarding the facility's failure to provide adequate supervision to prevent resident elopement.
Findings
The facility failed to provide adequate supervision and assistive devices, resulting in one resident eloping when a visitor let the resident out the front door without staff knowledge. The resident was found walking toward the parking lot and was returned safely without injury.
Complaint Details
The complaint investigation found that a visitor let resident #01 out the front door without staff knowledge, leading to the resident leaving the building and walking toward the parking lot. The resident was returned safely and placed on 1:1 observation. The resident had a history of muscle weakness, repeated falls, and cognitive impairment. The facility's elopement policy requires identification of elopement risk and individualized care plans, but supervision was inadequate in this case.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent resident elopement. | SS=D |
Report Facts
Census: 60
Elopement risk residents: 11
Residents selected for review: 3
BIMS score pre-elopement: 7
BIMS score post-elopement: 9
Date of resident admission: Apr 24, 2017
Date of elopement incident: Jun 10, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 21, 2017
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 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 credible allegation of compliance and evidence of correction.
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
Plan of Correction
Deficiencies: 1
Jun 10, 2017
Visit Reason
The plan of correction addresses deficiencies related to an elopement incident involving Resident #1 and outlines corrective actions taken to ensure compliance with federal Medicare/Medicaid requirements.
Findings
Resident #1 eloped but was returned immediately without injury. The facility implemented multiple corrective actions including staff education, enhanced door signage, door alarm checks, increased resident monitoring, and ongoing monthly elopement drills and audits to prevent future incidents.
Complaint Details
This plan of correction is linked to the ML Frontenac complaint dated 06/21/2017.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident #1 was returned to the facility immediately without injury and placed on one-on-one monitoring after elopement. | D |
Report Facts
Complete Date: Jun 30, 2017
Elopement drill date: Jun 10, 2017
Resident monitoring interval: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for plan of correction assistance | |
| Randall Alsup | Administrator | Submitted the plan of correction |
| Caryl Gill | Modified the plan of correction |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
May 3, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration and pharmaceutical services at the facility.
Findings
The facility failed to provide one resident with four prescribed medications as ordered upon readmission, resulting in increased verbal and physical behaviors toward staff and the resident's return to a behavioral unit for re-evaluation and treatment. The failure was due to nursing staff not reviewing and inputting new medication orders into the electronic system.
Complaint Details
The complaint investigations #114607 and #114655 found that the facility failed to provide medications as ordered to a resident readmitted from a behavioral unit, leading to increased aggressive behaviors and readmission to the behavioral unit.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide 1 of 3 sampled resident's medications as ordered, resulting in missed administration of 4 medications over 17 days. | SS=G |
Report Facts
Resident census: 61
Missed medications: 4
Days medications missed: 17
Medication dosages: 1000
Medication dosages: 2.5
Medication dosages: 15
Medication dosages: 50
Tylenol dosage: 325
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Failed to identify, review, and input new medication orders into the electronic system on 3/28/17 | |
| Licensed nurse A | Reported that the medical records nurse did not complete an admission audit and the admission failed to be reviewed at the daily clinical meeting | |
| Behavioral unit psychiatrist | Psychiatrist | Commented on the importance of medication administration as prescribed on discharge |
Inspection Report
Plan of Correction
Deficiencies: 2
May 3, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in the ML Frontenac complaint dated 05/03/2017.
Findings
The Plan of Correction addresses past non-compliance issues identified under tags F0000 and F425-G, for which no Plan of Correction was required.
Complaint Details
Related to the ML Frontenac complaint dated 05/03/2017.
Deficiencies (2)
| Description |
|---|
| Past non-compliance under tag F0000 |
| Past non-compliance under tag F425-G |
Inspection Report
Life Safety
Deficiencies: 1
May 26, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. 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. | F |
Report Facts
Effective date for denial of payments: Aug 26, 2016
Provider agreement termination date: Nov 26, 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 plan of correction. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 17
May 11, 2016
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 and to confirm the date such corrective action was accomplished.
Findings
All previously cited deficiencies were corrected as of 04/09/2016, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (17)
| Description |
|---|
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(b)(2)(ii) |
| Deficiency related to regulation 483.20(g) - (j) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.20(k)(3)(i) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.30(a) |
| Deficiency related to regulation 483.45(a) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.70(f) |
| Deficiency related to regulation 483.70(h) |
Report Facts
Deficiencies corrected: 17
Inspection Report
Re-Inspection
Deficiencies: 1
May 11, 2016
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report documents that previously identified deficiencies have been corrected as of 04/09/2016, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (1)
| Description |
|---|
| Deficiency identified by regulation 26-40-302 (b)(c) was corrected |
Report Facts
Date of correction: Apr 9, 2016
Inspection Report
Plan of Correction
Deficiencies: 16
Apr 9, 2016
Visit Reason
This document is a Plan of Correction submitted in response to an annual survey to address deficiencies identified during the inspection and to demonstrate substantial compliance with federal and state regulations.
Findings
The plan outlines multiple corrective actions including housekeeping and maintenance repairs, education and training for staff on MDS assessments, care plan updates, skin condition monitoring, behavior documentation, and other compliance measures. The facility commits to completing all corrections and reporting to the Quality Assurance Committee by April 9, 2016.
Severity Breakdown
E: 2
D: 9
F: 4
Deficiencies (16)
| Description | Severity |
|---|---|
| Housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior including bathroom floor repairs, toilet repairs, shower room floor repairs, repainting, and faucet replacement. | E |
| Completion and education on significant change MDS assessments for residents with changes in condition. | D |
| Education on PASRR coding and monitoring for residents with PASRR level 2 assessments. | D |
| Care plan updates and education on procedures for updating care plans after incidents or new orders. | D |
| Educational in-service on monitoring skin conditions and ensuring effectiveness of treatment regimens. | D |
| Restorative program updates and staff education on implementation and documentation. | D |
| Bathing preference documentation and staff education on ensuring resident preferences are met. | D |
| Education on incontinence management policy and toileting schedules with audits. | D |
| Education on updating care plans immediately after falls and implementing interventions to prevent repeated falls. | E |
| Education on documentation of behaviors related to antipsychotic and psychoactive medications and quarterly assessments. | D |
| Skills check off in-service for all staff and onboarding program for new hires. | F |
| Education on obtaining and processing physician orders for therapy services with monitoring. | D |
| Random audits by pharmacist and nurse consultant on behavior documentation and medication monitoring. | D |
| Education on call light system, shift meetings, and maintenance of pagers and call lights. | F |
| Replacement of laundry hampers and carts to maintain a safe, functional, sanitary, and comfortable environment. | F |
| Installation of electrical door monitoring system to ensure residents do not leave facility without staff knowledge. | F |
Report Facts
Completion date: Apr 9, 2016
Educational in-service dates: Mar 22, 2016
Audit frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzie Sexton | Administrator | Administrator who submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Mar 11, 2016
Visit Reason
The inspection was conducted as a Licensure Resurvey and complaint investigation involving multiple complaint numbers.
Findings
The facility failed to ensure the electrical monitoring system on the main entrance and service entrance doors remained activated to alert staff, risking that 15 confused and self-mobile residents could leave the facility without staff knowledge. The facility also lacked a policy and procedure for monitoring the door alarms.
Complaint Details
The visit was triggered by multiple complaint investigations (#'s 95545, 95759, 96703, 96861, 97436, 97443, 97228, and 97665).
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to have an electrical monitoring system turned on in the main entrance and service entrance to ensure 15 confused and self-mobile residents did not leave the facility without staff knowledge. | SS=F |
Report Facts
Resident census: 68
Residents identified as confused and self mobile: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff D | Stated unawareness that the door alarms were off. | |
| direct care staff P | Stated the door alarms are off every night. | |
| administrative staff A | Stated door alarms should be on from 7 PM to 7 AM and was unaware they had been turned off. |
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 11, 2016
Visit Reason
A health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at 'F' level, indicating significant noncompliance. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level | F |
Report Facts
Denial of Payment effective date: Jun 11, 2016
Termination recommendation date: Sep 11, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Sexton | Administrator | Facility administrator named in the report |
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Jan 12, 2016
Visit Reason
The inspection was conducted as a first non-compliant revisit and complaint investigations related to medication errors and compliance issues at the facility.
Findings
The facility failed to ensure that one resident's physician order to hold Coumadin prior to a heart procedure was followed, resulting in the medication being administered contrary to the order and the scheduled procedure being aborted and rescheduled.
Complaint Details
The deficiency citation represents findings from complaint investigations 92326, 94501, and 95798. The medication error was substantiated by observations, interviews, and record reviews.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to hold Coumadin as ordered by the physician prior to a heart procedure for one resident, leading to a significant medication error. | SS=D |
Report Facts
Census: 74
Residents reviewed for medication errors: 3
Residents with medication error: 1
Medication dosage: 9
Date range medication was incorrectly administered: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Received phone order to hold Coumadin but failed to update the order correctly in the computer | |
| Licensed nursing staff D | Acknowledged all Coumadin medications are administered by licensed nurses and reported resident non-compliance |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 12, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a complaint revisit inspection conducted on 01/12/2016 at the ML Frontenac facility.
Findings
The plan addresses medication administration deficiencies including discontinuation of Coumadin for resident #03 and rescheduling of cardiac therapy. The facility has educated nursing staff on medication order processes and will conduct random audits to ensure compliance.
Complaint Details
This plan of correction is related to a complaint revisit inspection at ML Frontenac conducted on 01/12/2016.
Deficiencies (1)
| Description |
|---|
| Medication administration not in compliance with physician orders for resident #03 |
Report Facts
Date medication discontinued: Jan 5, 2016
Date therapy rescheduled: Jan 12, 2016
Plan completion date: Jan 13, 2016
Inspection Report
Plan of Correction
Deficiencies: 3
Dec 8, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during an annual survey and complaint investigation at the facility.
Findings
The plan addresses medication administration issues including failure to notify physicians when medications are not administered, proper handling of over-the-counter medications and supplements, and procedures for medication unavailability including emergency kit use and pharmacy notification. The facility aims to achieve substantial compliance by 12/8/2015 through staff education and monitoring.
Complaint Details
This plan of correction is related to a complaint investigation as referenced by the linked complaint report (2567) and the mention of complaint in the document header.
Deficiencies (3)
| Description |
|---|
| Failure to notify physician when medication is not administered as ordered. |
| Non-compliance with providing physician orders and medication coverage according to payer source requirements. |
| Improper procedure for handling medication unavailability including emergency kit access and pharmacy notification. |
Report Facts
Completion date: Dec 8, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzie Sexton | Administrator | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 3
Nov 23, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#93621) focusing on medication administration and notification of changes related to resident care.
Findings
The facility failed to notify the physician of missed doses of Lovenox injections for one resident, failed to provide a physician-ordered sodium supplement (Gatorade), and failed to administer three consecutive doses of Lovenox, resulting in the resident suffering a stroke and hospital admission.
Complaint Details
The complaint investigation revealed failures in medication administration and communication with the physician regarding missed doses of Lovenox, leading to a resident stroke and hospital ICU admission.
Severity Breakdown
Level D: 1
Level G: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify the physician of missed doses of Lovenox injections for one resident. | Level D |
| Failed to provide a physician-ordered supplement (Gatorade) for sodium deficiency for one resident. | Level G |
| Failed to administer three consecutive doses of Lovenox injections as ordered, resulting in a significant medication error and resident stroke. | Level G |
Report Facts
Census: 82
Missed Lovenox doses: 3
Medication sample size: 3
Mental status score: 11
Sodium level: 129
Stroke scale score: 4
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 12, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during an annual survey and complaint investigation at Medicalodges Frontenac.
Findings
The plan addresses deficiencies related to updating and following care plans, specifically regarding toileting, repositioning, and handling residents who refuse care. The facility commits to re-educating nursing staff, conducting audits, and achieving substantial compliance by 11/12/2015.
Complaint Details
This Plan of Correction is related to a complaint investigation at Medicalodges Frontenac.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Care plan of resident #1 updated to reflect personal sitters, toileting, repositioning, and steps to take in the event of refusal of care; all residents' care plans to be reviewed and updated accordingly. | D |
| Care plan of resident #1 continues with toileting and repositioning every 2 hours and updated to reflect proper actions for refusal of care; all residents' care plans to be reviewed and updated. | D |
Report Facts
Completion date: Nov 12, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Suzie Sexton | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 2
Nov 12, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(d) have been corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(d) |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Oct 30, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers #88384, #91789, and #92620.
Findings
The facility failed to revise the care plan to include instructions for resident refusal of care and failed to provide adequate toileting assistance to prevent potential urinary tract infections for one resident. The resident was found soaked in urine and left in the recliner for extended periods without toileting or brief changes, despite a history of UTIs and documented care needs.
Complaint Details
The complaint investigation revealed that the resident frequently refused care, was combative, and was left in wet briefs for extended periods, including approximately 16 hours in a recliner without toileting or brief changes. Staff reported refusal of care, but some staff denied the resident was combative or refused care. Family members and visitors reported concerns about inadequate care and toileting. The facility lacked a toileting policy and failed to update the care plan with refusal of care instructions.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to review and revise the care plan to include instructions for resident refusal of care. | SS=D |
| Failed to ensure adequate toileting assistance to prevent potential urinary tract infections for a resident with a history of UTIs. | SS=D |
Report Facts
Residents sampled: 3
Census: 86
Brief Interview for Mental Status score: 15
Brief Interview for Mental Status score: 12
Hours resident left in recliner without toileting: 16
Inspection Report
Abbreviated Survey
Deficiencies: 1
Oct 30, 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 of correction.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'D' level that constitute 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 the contact person regarding the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 2
Oct 22, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that deficiencies previously cited under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) have been corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(h) |
Inspection Report
Plan of Correction
Deficiencies: 2
Oct 22, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during an annual survey and complaint investigation at the facility.
Findings
The plan addresses updating the care plan for resident #4 following a previous elopement incident, re-educating nursing staff on care plan updates and elopement policies, and implementing security measures such as changing door coding and posting notices to prevent residents from leaving without supervision.
Complaint Details
This plan of correction is related to a complaint investigation involving resident #4's elopement from the facility with no injuries.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Care plan of resident #4 updated to reflect previous elopement and continued 15 minute visual checks; staff re-education on care plan updates after incidents. | D |
| Resident #4 remains on 15 minute visual checks; facility changed door coding and posted notices to prevent elopement; staff re-education on elopement policy. | D |
Report Facts
Complete Date: Oct 22, 2015
Visual check interval: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzie Sexton | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Oct 7, 2015
Visit Reason
The inspection was conducted as a result of complaint investigations #91954 and #91673 concerning the facility's failure to review and timely revise the care plan and failure to follow planned interventions to prevent a resident from exiting the facility without staff knowledge.
Findings
The facility failed to timely revise the care plan for a high elopement risk resident following an elopement incident and failed to implement adequate supervision and safety measures to prevent the resident from exiting the facility unattended. Multiple staff interviews and documentation confirmed the resident left the facility alone without staff knowledge, despite being identified as a high elopement risk.
Complaint Details
The visit was complaint-related, triggered by complaints #91954 and #91673. The complaints involved failure to revise care plans and prevent resident elopement. The findings substantiated that the facility failed to timely update the care plan and failed to prevent the resident from leaving the facility unattended.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to review and timely revise the care plan for a high elopement risk resident following an elopement incident. | SS=D |
| Failure to follow planned interventions to prevent a high elopement risk resident from exiting the facility without staff knowledge. | SS=D |
Report Facts
Resident census: 80
Sampled residents: 4
Elopement risk score: 20
Days care plan revision delayed: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Administrative Nursing Staff | Explained the care plan revision process and acknowledged the 14-day delay in updating the care plan after the resident's elopement |
| Staff B | Direct Care Staff | Described the security alarm system and procedures for redirecting elopement risk residents |
| Staff A | Social Service Staff | Monitored the resident for exit seeking behaviors and documented observations |
| Staff C | Direct Care Staff | Witnessed the resident elopement and assisted the resident back inside |
| Staff G | Direct Care Staff | Observed the resident outside and reported the elopement |
| Staff H | Administrative Nursing Staff | Reported uncertainty about immediate post-elopement safety measures |
| Staff J | Licensed Nursing Staff | Assisted resident after elopement and initiated 15-minute checks |
| Staff K | Licensed Nursing Staff | Reported on alarm system and visitor traffic during elopement |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Oct 7, 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 and 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 regarding the survey and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 14
Jun 14, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies were corrected as of the revisit date, with corrections completed on 06/14/2015 for multiple regulatory items.
Deficiencies (14)
| Description |
|---|
| Deficiency related to regulation 483.15(b) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(k) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.30(e) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(h) |
Report Facts
Deficiencies corrected: 14
Inspection Report
Plan of Correction
Deficiencies: 11
Jun 14, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to an annual survey conducted on or before 2015-06-14, addressing deficiencies identified during the inspection.
Findings
The plan outlines corrective actions for multiple deficiencies including resident bathing preferences, housekeeping and maintenance issues, staff education on clinical procedures, medication handling, infection control, environmental safety, and documentation practices. The facility commits to compliance and ongoing monitoring by the Quality Assurance Committee.
Severity Breakdown
D: 6
E: 1
C: 1
F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to consistently provide resident bathing preferences and update care plans accordingly. | D |
| Housekeeping and maintenance issues including broken window frames, damaged bathroom floors, and cluttered linen closets. | E |
| Inadequate care planning and staff education related to nephrostomy and catheter care. | D |
| Improper procedures for incontinent residents and documentation of resident refusals for bathing. | D |
| Failure to timely and properly follow physician orders and update medication parameters. | D |
| Inadequate documentation on daily staffing sheets. | C |
| Unsanitary food preparation and storage conditions requiring re-education and equipment repair. | F |
| Lack of timely pharmacy review and follow-up on potentially unnecessary medications. | D |
| Improper medication storage leading to unnecessary destruction of medications. | D |
| Failure to properly clean blood glucose monitors and document infection control culture results. | F |
| Unsafe and unsanitary environmental conditions including damaged floors and uneven concrete surfaces. | F |
Report Facts
Residents affected: 44
Residents potentially affected: 73
Date compliance due: Jun 2, 2015
Date compliance due: Jun 14, 2015
Inspection Report
Plan of Correction
Deficiencies: 1
May 15, 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 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 the credible allegation of compliance and the plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Sexton | Administrator | Named as facility administrator in relation to the survey. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter related to the survey findings. |
| Janice VanGotten | Regional Manager | Copied on the enforcement letter. |
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 13
May 15, 2015
Visit Reason
Annual health resurvey of Medicalodges Frontenac nursing facility to assess compliance with federal regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to follow resident bathing preferences, inadequate housekeeping and maintenance, incomplete care plans for special needs such as nephrostomy care, insufficient assistance with activities of daily living, improper pressure sore treatment, environmental hazards, improper medication management, infection control deficiencies, incomplete nurse staffing data, and unsanitary food service conditions.
Severity Breakdown
SS=D: 6
SS=E: 3
SS=C: 1
SS=F: 4
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to follow resident bathing preferences for 2 of 3 residents reviewed. | SS=D |
| Failed to provide housekeeping and maintenance services to maintain a sanitary environment in resident areas on all 5 hallways. | SS=E |
| Failed to develop a comprehensive care plan for a resident with nephrostomy tube to prevent trauma and infection. | SS=D |
| Failed to provide assistance with personal hygiene for 2 of 3 sampled residents. | SS=D |
| Failed to provide treatment as ordered for a resident's unstageable pressure ulcer with eschar. | SS=E |
| Failed to ensure environment free of accident hazards including jagged handrail, narrow walkways, lack of GFCI outlet for hydrocollator, and trip hazards on front sidewalk. | SS=D |
| Failed to provide appropriate nephrostomy care including timely drainage bag emptying and securing drainage tubing. | SS=D |
| Failed to ensure drug regimen free from unnecessary drugs by lacking blood pressure parameters for monitoring and failing to act on pharmacist recommendations to discontinue or reduce medications. | SS=C |
| Failed to post complete nurse staffing information daily and maintain staffing data for 18 months. | SS=F |
| Failed to maintain a clean and sanitary kitchen environment including wet utensils, rusted shelves, and dishwasher issues. | SS=D |
| Failed to ensure drug records and medication storage met regulatory requirements; medications were pre-set in cups without resident or medication identification. | SS=F |
| Failed to maintain an infection control program including inadequate cleaning of multi-use glucometers and incomplete infection tracking and trending. | SS=F |
| Failed to maintain a safe, functional, sanitary, and comfortable environment including damaged kitchen flooring and unsafe exterior sidewalk areas. | SS=F |
Report Facts
Residents reviewed for choices: 3
Residents reviewed for ADLs: 3
Residents reviewed for pressure ulcers: 2
Residents reviewed for unnecessary medications: 5
Residents receiving blood sugar monitoring: 18
Gouges in kitchen floor in front of dishwasher: 17
Gouges in kitchen floor in front of 3 compartment sink: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Nursing Staff | Named in nephrostomy care and pressure ulcer treatment findings |
| Staff B | Administrative Nursing Staff | Named in nephrostomy care, medication management, infection control, and pressure ulcer treatment findings |
| Staff S | Direct Care Staff | Named in nephrostomy care and bathing assistance findings |
| Staff O | Direct Care Staff | Named in nephrostomy care and bathing assistance findings |
| Staff K | Licensed Nursing Staff | Named in bathing assistance and glucometer cleaning findings |
| Staff R | Direct Care Staff | Named in medication labeling deficiency |
| Staff F | Dietary Staff | Named in kitchen sanitation findings |
| Staff G | Maintenance/Housekeeping Staff | Named in environmental hazards and kitchen sanitation findings |
| Staff I | Licensed Nursing Staff | Named in bathing assistance and glucometer cleaning findings |
| Staff X | Direct Care Staff | Named in bathing assistance findings |
| Staff BB | Direct Care Staff | Named in medication monitoring findings |
| Staff D | Consultant Pharmacist | Named in medication monitoring findings |
Inspection Report
Re-Inspection
Deficiencies: 1
Oct 14, 2014
Visit Reason
This report is a revisit to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
The report confirms that the deficiency identified by regulation 28-39-160 with ID prefix S0770 was corrected as of 10/14/2014. No other deficiencies are listed.
Deficiencies (1)
| Description |
|---|
| Deficiency identified under regulation 28-39-160 with ID prefix S0770 |
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Oct 2, 2014
Visit Reason
The inspection was conducted as a Health Licensure Complaint Investigation #79260 regarding the facility's provision of adult day care services.
Findings
The facility failed to provide adequate supervision to prevent one of the two day care residents from leaving the facility without staff knowledge and failed to complete an admission nursing assessment for that resident, violating their adult day care policy.
Complaint Details
The complaint investigation found that a day care resident exited the facility unaccompanied by staff and was found approximately four blocks away. The incident was not fully reported by nursing staff initially and was discovered during a weekly audit. The resident was assessed after the incident and found to have severe cognitive deficits and high risk for elopement.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent a day care resident from leaving the facility without staff knowledge. | SS=D |
| Failure to complete a nursing assessment upon admission to adult day care as required by facility policy. | SS=D |
Report Facts
Census: 82
Day care residents: 2
Date of admission: Sep 6, 2014
Date of elopement incident: Sep 8, 2014
Date of incident investigation: Sep 16, 2014
Resident cognition score: 3
Temperature: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) | Brought the resident back into the facility after elopement. | |
| Licensed Nurse C | Realized the resident was missing and notified administrator and director of nursing. | |
| Administrative Licensed Staff B | Reported the incident during a weekly audit and completed investigation. | |
| Social Service Staff E | Signed admission agreement with family member for day care services. | |
| Direct Care Staff D | Located the resident approximately four blocks from the facility. | |
| Director of Nursing (DON) | Notified about the incident and involved in planning for wander guard. |
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 1
Sep 12, 2014
Visit Reason
This document is a plan of correction submitted in response to a complaint survey for Medicalodges Frontenac ALF, addressing compliance with federal and state regulations.
Findings
The facility was found to have deficiencies related to security of entrances, elopement assessments, and admission procedures for daycare residents. Corrective actions include locking doors with key codes, updating elopement assessments for all 80 residents, and ensuring proper admission assessments and screenings.
Complaint Details
This plan of correction is in response to a complaint survey.
Deficiencies (1)
| Description |
|---|
| Facility entrances will be locked at all times and require a key code to exit; elopement assessments updated for all residents; admission assessments and screenings for daycare residents improved. |
Report Facts
Residents assessed for elopement: 80
Plan of correction completion date: Facility compliance expected by 10/14/14.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzie Sexton | Administrator | Submitted the plan of correction. |
| Shirley Boltz | Contact person for plan of correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 1
Mar 11, 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 had been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.15(h)(2) with ID prefix F0253 was corrected as of 03/11/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.15(h)(2) identified by ID prefix F0253 |
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 20, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in an annual survey inspection.
Findings
The plan outlines multiple corrective actions to address facility maintenance issues including replacement and repair of bathroom fixtures, sinks, flooring, and other equipment, as well as staff training and monitoring to ensure compliance.
Report Facts
Completion dates: 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzie Sexton | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 22
Feb 10, 2014
Visit Reason
The inspection was a health resurvey to assess housekeeping and maintenance services in the facility.
Findings
The facility failed to maintain a sanitary environment in all five resident hallways, with multiple issues including broken fixtures, rusted equipment, discolored and stained surfaces, torn furniture, and areas needing cleaning or repair as verified by maintenance staff.
Deficiencies (22)
| Description |
|---|
| Common men's shower room toilet tank lid broken corner measuring 2 inches by 1.5 inches. |
| Resident room bedside table with missing chipped laminate exposing unfinished wood surface. |
| Resident room air filter on floor under heating/cooling unit. |
| Two resident rooms with discolored sink drains. |
| Resident bathroom with loose baseboard 12 inches behind toilet. |
| Resident bathroom toilet riser with rusted legs. |
| Resident bathroom floor with dark discoloration. |
| Clean utility room sink and faucet with grime and cracked caulking. |
| Three resident bathrooms with rust colored sink drains. |
| Shared resident bathroom with rusted commode and unlabeled bedpan and urine measuring device on floor. |
| Resident chair with torn positioning footboard material approximately 3 inches each. |
| Two resident bathrooms with commode risers with rusted legs and peeled paint. |
| Resident bathroom sink with discolored caulking. |
| Shared resident bathroom door with gouges across entire lower portion. |
| Shared resident bathroom with brown orange stain around toilet and stain extending 1 foot in front. |
| Shared resident bathroom sink faucet with build-up of crusted substance needing replacement. |
| Linen closet shelves with missing laminate covering measuring 8 inches by 8 inches. |
| Beauty shop shampoo sink with broken jagged edges and green corrosive surface, hair and debris in bowl, and hair dryers with dust on vents. |
| Resident bathroom floor with dark discolorations. |
| Three resident bathrooms with rust discoloration around sink drains and corrosion on faucets and plumbing. |
| Resident bathroom with bedpan on floor under sink and unlabeled toothbrush on back of toilet. |
| Resident room air filter on floor under heating/cooling unit and multiple areas of chipped paint on unit. |
Report Facts
Census: 95
Resident hallways: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff A verified deficiencies and confirmed issues needing repair or replacement |
Inspection Report
Follow-Up
Deficiencies: 1
Aug 1, 2013
Visit Reason
This is a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-07-17.
Findings
The report documents that the previously identified deficiency with regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of 2013-08-01.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Jul 17, 2013
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of failure to report a resident fall with injuries.
Findings
The facility failed to report to the State agency the unwitnessed fall of one resident (#4) who sustained significant injuries including a hematoma and skin tears. The resident was at high risk for falls and had multiple interventions in place, but the fall was not reported as required by policy and regulations.
Complaint Details
The complaint investigations #67096 and 67283 were the basis for the visit. The facility failed to report the fall of resident #4 with injuries to the State agency within the required timeframe.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report to the State agency the unwitnessed fall of resident #4 with injuries. | SS=D |
Report Facts
Resident census: 97
Fall risk assessment score: 21
Hematoma size: 9
Hematoma size: 7
Skin tear size: 1
Skin tear size: 2
Skin tear size: 0.5
BIMS score: 3
Date of resident re-admission: Mar 1, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed administrative staff A | Verified the facility failed to report the resident's fall to the State agency. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 5, 2013
Visit Reason
The visit was conducted in response to a complaint regarding a resident fall on 7/4/13 and subsequent reporting and investigation of incidents.
Findings
The facility identified issues with reporting alleged violations involving mistreatment, abuse, neglect, and injuries of unknown source. Corrective actions include education of key staff and enhanced Quality Assurance committee oversight to ensure compliance with reporting requirements.
Complaint Details
The complaint involved a resident fall on 7/4/13 that was investigated and reported to the State Agency on 7/17/13. An audit of incident reports in the prior 30 days found no additional reportable incidents. The facility committed to reporting all alleged violations and injuries of unknown source within 24 hours.
Deficiencies (1)
| Description |
|---|
| Failure to report alleged violations involving mistreatment, abuse, neglect, and injuries of unknown source in a timely manner. |
Report Facts
Incident investigation date: Jul 5, 2013
Incident report date: Jul 17, 2013
Audit completion date: Jul 21, 2013
Plan of correction completion date: Aug 1, 2013
Inspection Report
Follow-Up
Deficiencies: 3
Jun 28, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.13(a), 483.20(d)(3), 483.10(k)(2), and 483.25(c) were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.13(a) |
| Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2) |
| Deficiency related to regulation 483.25(c) |
Inspection Report
Plan of Correction
Deficiencies: 3
Jun 28, 2013
Visit Reason
This Plan of Correction addresses deficiencies identified in a complaint investigation (Event ID 79ST11) at Medicalodges Frontenac.
Findings
The facility identified issues related to restraint assessments, fall prevention care plans, and skin assessments. Corrective actions include audits, education for nursing staff, and ongoing Quality Assurance committee reviews to ensure substantial compliance by 6/28/2013.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to complete appropriate restraint assessments for residents using restraints. | D |
| Care plan not updated with fall prevention interventions for residents at risk of falls. | D |
| Incomplete skin assessments and documentation for residents with skin issues. | D |
Report Facts
Deficiencies cited: 3
Completion date: Jun 28, 2013
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 3
Jun 5, 2013
Visit Reason
The inspection was conducted as a result of complaint investigations #65740 and #66186 to assess compliance with regulations related to physical restraints, care planning, and pressure ulcer treatment.
Findings
The facility failed to adequately assess a resident prior to applying a physical restraint, failed to review and revise a resident's care plan to prevent repeated falls, and failed to provide appropriate care and treatment to promote healing of pressure ulcers for a resident admitted with existing wounds.
Complaint Details
The inspection was triggered by complaint investigations #65740 and #66186.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to adequately assess resident #1 prior to application of a physical restraint to ensure it was not used for staff convenience or discipline. | SS=D |
| Failure to review and revise the care plan for resident #4 to include interventions to prevent repeated falls. | SS=D |
| Failure to provide care and services to promote healing for resident #5 who was admitted with pressure ulcers. | SS=D |
Report Facts
Census: 98
Residents sampled: 7
Fall Risk Assessment Score: 6
Fall Risk Assessment Score: 22
Fall Risk Assessment Score: 12
Pressure Ulcers: 2
Inspection Report
Follow-Up
Deficiencies: 15
Jan 3, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of 12/04/2012, indicating compliance with the required standards.
Deficiencies (15)
| Description |
|---|
| Deficiency related to regulation 483.13(a) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(h) |
| Deficiency related to regulation 483.70(h)(2) |
| Deficiency related to regulation 483.75(m)(2) |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 15
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 14
Nov 7, 2012
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation to assess compliance with regulatory requirements and investigate specific complaints.
Findings
The facility was found deficient in multiple areas including improper use of restraints, failure to investigate and report an unwitnessed fall resulting in a fractured hip, failure to promote dignity during meal service, unsanitary conditions, incomplete care plans, inadequate pressure ulcer prevention and treatment, unsafe environment with accident hazards, improper food handling and sanitation, expired laboratory supplies and unsafe narcotic storage, inadequate infection control practices, lack of adequate ventilation in utility rooms, insufficient emergency procedure training, and ineffective quality assurance committee oversight.
Complaint Details
The complaint investigation focused on allegations related to improper use of restraints, failure to investigate falls, inadequate supervision, unsafe environment hazards, and infection control issues. The facility was found to have substantiated deficiencies in these areas.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=G: 1
SS=C: 2
SS=F: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to ensure resident remained free from physical restraints imposed for staff convenience, specifically use of side rails without proper assessment. | SS=D |
| Failure to thoroughly investigate and report an unwitnessed fall resulting in fractured hip requiring surgery. | SS=D |
| Failure to serve meals in a manner that promotes dignity and respect, including indiscriminate use of divided built-up plates. | SS=E |
| Failure to maintain a clean, sanitary, and orderly environment including cracked wheelchair arms, torn fall mats, dirty cushions, torn window screens, and dusty plants. | SS=E |
| Failure to develop individualized care plans reflecting actual resident needs, including failure to document resident sleeping in recliner and use of Hoyer lift for transfers. | SS=D |
| Failure to review and revise care plans to include appropriate interventions for pressure ulcers and failure to follow physician orders for pressure ulcer treatment. | SS=D |
| Failure to provide adequate supervision and assistive devices to prevent accidents, including failure to toilet cognitively impaired resident, unsafe recliner use without fall pad, and presence of accident hazards such as uncovered rusty toilet bolts in multiple bathrooms and showers. | SS=G |
| Failure to store, prepare, and distribute food under sanitary conditions including dirty refrigerators, dusty fans blowing on clean dishes, bare hand contact with plates, dropped meal cards placed on prep tables without cleaning, and unclean ice machines and ovens. | — |
| Failure to monitor expiration dates of laboratory test tubes and failure to ensure narcotic medications are stored securely in locked compartments. | — |
| Failure to prevent cross contamination and transmission of infections during dressing changes and failure to properly clean suction machine equipment. | SS=D |
| Failure to maintain a safe, functional, sanitary, and comfortable kitchen environment including debris behind stove, rusted equipment, and damaged surfaces. | SS=C |
| Failure to ensure adequate working ventilation in soiled utility rooms. | SS=D |
| Failure to train all staff in emergency procedures including bomb threats and tornadoes. | SS=C |
| Failure to maintain an effective quality assurance committee that meets at least quarterly and implements plans of action to correct identified quality deficiencies. | SS=F |
Report Facts
Residents present: 102
Residents sampled: 26
Fall risk score: 9
Pressure ulcer measurements: 2.25
Pressure ulcer measurements: 1.7
Pressure ulcer measurements: 2
Expired laboratory vials: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Direct care staff | Reported resident tipped recliner and fall on 10-25-12. |
| Staff W | Direct care staff | Reported resident climbs over side rails and tipped recliner. |
| Staff M | Direct care staff | Reported fall prevention strategies for resident #117. |
| Licensed nursing staff I | Licensed nurse | Performed dressing changes and measured wounds. |
| Licensed nursing staff D | Licensed nurse | Responsible for care planning and acknowledged lack of knowledge of pressure ulcer. |
| Licensed nursing staff N | Licensed nurse | Performed wound cleansing but did not measure wound. |
| Licensed nursing staff O | Licensed nurse | Reported physician debrided right heel and dressing orders. |
| Licensed nursing staff R | Licensed nurse | Confirmed expired laboratory vials. |
| Dietary manager F | Dietary manager | Reported sanitation concerns and cleaning responsibilities. |
| Housekeeping/Maintenance/Laundry staff U | Environmental staff | Reported on uncovered toilet bolts and suction machine cleaning. |
| Administrative nursing staff A | Administrator | Reported on fall investigation and quality assurance committee. |
Inspection Report
Plan of Correction
Census: 102
Deficiencies: 14
Nov 1, 2012
Visit Reason
This document is a Plan of Correction submitted by Sunset Manor in response to deficiencies cited in a prior inspection report, addressing multiple areas of non-compliance including side rail assessments, incident reporting, wound care, safety hazards, medication storage, and staff education.
Findings
The facility identified several deficiencies affecting residents, including improper use of side rails, incomplete incident reporting, pressure ulcer care issues, unsafe recliners, maintenance hazards, medication storage problems, and lapses in infection control and staff training. Corrective actions and policy updates were planned with compliance targeted by late November to early December 2012.
Severity Breakdown
D: 6
E: 2
F: 2
G: 1
C: 2
Deficiencies (14)
| Description | Severity |
|---|---|
| Resident side rails were a potential restraint and were removed; 15 of 102 residents at potential risk due to deficient side rail assessments. | D |
| Incident reporting deficiencies affecting one resident; improvements planned for incident documentation and reporting timelines. | D |
| New wing dining residents to be evaluated for need of divided/built-up plates to meet individual abilities. | E |
| Maintenance issues including torn mats, caulking, and cleaning schedules to be addressed. | E |
| Care plan updates and communication improvements for residents with specific needs. | D |
| Pressure ulcer care deficiencies affecting two residents; wound care protocols and tracking to be implemented. | D |
| Unsafe recliners and missing bolt covers on toilets identified; maintenance and staff education planned. | G |
| Dietary staff re-educated on cleaning and sanitation procedures; maintenance of kitchen equipment scheduled. | F |
| Medication room audit found expired laboratory tubes destroyed; narcotics properly stored; staff re-educated. | D |
| Licensed nursing staff observed failing to sanitize equipment properly; re-education and treatment nurse role established. | D |
| Dietary cleaning and maintenance issues including rust removal and painting scheduled. | C |
| Ventilation fan motors replaced and functioning; maintenance monitoring ongoing. | D |
| Nursing staff education on tornado and bomb threat evacuation procedures planned. | C |
| Policy and procedure developed for Quality Assurance meeting scheduling and leadership coverage. | F |
Report Facts
Residents at potential risk for side rail deficiency: 15
Total residents: 102
Residents identified with potential toileting deficiency: 33
Residents affected by pressure ulcer deficiency: 2
Residents affected by unsafe recliners: 2
Laboratory tubes destroyed: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff H | Licensed Nursing Staff | Observed placing soiled dressing on bedside table and failing to sanitize; re-educated on proper dressing change technique |
| Licensed nursing staff I | Licensed Nursing Staff | Observed removing scissors from pocket and failing to sanitize; re-educated on equipment cleaning |
| Certified Medication Aid | Certified Medication Aid | Signed in narcotics improperly; re-educated and disciplined with written warning |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 29, 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
All previously cited deficiencies listed by regulation numbers and prefix codes were corrected as of 09/07/2011, indicating compliance with the required corrective actions.
Report Facts
Correction completion date: Sep 7, 2011
Date of revisit: Sep 29, 2011
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 20
Aug 8, 2011
Visit Reason
The inspection was conducted as a Health Facility resurvey and complaint investigation related to multiple complaint investigations (#48486 and #50211).
Findings
The facility was found deficient in multiple areas including failure to notify physicians timely after resident falls, improper management of resident funds, failure to maintain dignity of residents, inadequate housekeeping and maintenance, uncomfortable sound levels, incomplete care plans, failure to monitor residents' health conditions and medications properly, infection control breaches, malfunctioning call light systems, pest control issues, and improper safeguarding of clinical records.
Complaint Details
The inspection included complaint investigations #48486 and #50211.
Severity Breakdown
SS=D: 8
SS=E: 8
SS=B: 1
Deficiencies (20)
| Description | Severity |
|---|---|
| Failed to notify physician timely of resident #14's fall and progressing facial ecchymosis. | SS=D |
| Failed to establish and maintain a full and complete accounting system for resident funds, including lack of written authorization and failure to provide quarterly statements. | SS=E |
| Failed to purchase a surety bond sufficient to cover all resident funds. | SS=E |
| Failed to respond promptly to grievances related to lost personal property. | SS=D |
| Failed to maintain survey results in a manner accessible to all residents including those confined to wheelchairs. | SS=B |
| Failed to maintain dignity of residents by allowing bare abdominal skin exposure during meal service. | SS=D |
| Failed to maintain a clean, homelike, and orderly environment including dust, soiled floors, corroded fixtures, and odors in shower rooms. | SS=E |
| Failed to maintain comfortable sound levels; excessive noise from overhead pagers, carts, and staff conversations. | SS=E |
| Failed to develop comprehensive care plans for residents including side rails, discharge planning, hydration, and hypnotic usage. | SS=E |
| Failed to develop an initial care plan for resident #37 requiring oxygen, insulin, isolation, and assistance with activities of daily living. | SS=D |
| Failed to provide services to meet professional standards for resident #20 by not monitoring physician ordered daily weights and for resident #14 by failing to notify physician timely after fall with increased ecchymosis. | SS=D |
| Failed to have appropriate medical justification for indwelling catheters for residents #10 and #141 and failed to provide proper care to prevent infection including improper handling of urine collection bags. | SS=E |
| Failed to provide sufficient fluid intake to resident #129 to maintain proper hydration and health. | SS=E |
| Failed to ensure drug regimen free from unnecessary drugs; lack of diagnosis and monitoring for Ambien use for resident #135 and lack of blood pressure monitoring for resident #129 on antihypertensive medication. | SS=D |
| Failed to maintain infection control including failure to follow contact isolation policy for residents #78 and #109 with MRSA infections; staff failed to wear gowns and properly dispose of contaminated equipment. | SS=D |
| Failed to maintain functioning call light system for 14 residents on East hall to ensure timely staff response. | SS=E |
| Failed to maintain effective pest control program; presence of flies in dining rooms and resident rooms. | SS=E |
| Failed to safeguard clinical records from water damage; records stored in cardboard boxes in areas vulnerable to sprinkler activation. | SS=E |
| Failed to provide food at proper temperature to maintain palatability; cold food items served too warm. | SS=E |
| Failed to provide pharmaceutical services including safe storage of medications and supplies; expired medications and fluids found; medication carts unlocked and unattended. | SS=E |
Report Facts
Resident census: 98
Residents selected for review: 24
Residents with managed funds: 41
Residents with missing written authorization for funds: 5
Residents with malfunctioning call lights: 14
Expired intravenous fluid bags: 4
Expired blood sampling vials: 70
Expired insulin storage days: 32
Fluids recommended daily intake: 1624
Resident #129 average daily fluid intake: 1000
Deficit in fluid intake: 764
Resident #78 fall risk score: 16
Resident #14 fall risk score: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Administrative Staff | Discussed physician notification policy and fax procedures |
| Staff C | Licensed Nursing Staff | Interviewed regarding notification of physician and noise complaints |
| Staff G | Licensed Staff | Confirmed lack of care plan for Ambien use |
| Staff H | Licensed Nursing Staff | Reported on insulin storage and medication cart observations |
| Staff L | Consulting Pharmacy Staff | Interviewed regarding monitoring of Ambien and blood pressure |
| Staff M | Certified Nurse Aide | Observed providing care without gown in isolation |
| Staff V | Licensed Nursing Staff | Interviewed about fall incident and physician notification |
| Staff X | Certified Nursing Assistant | Observed assisting resident with fluids |
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