Inspection Reports for
Medicalodges Frontenac

The complaint investigation found that on 03/16/25, a resident exited the facility unattended in his motorized wheelchair. Video surveillance showed a family member of another resident turned off the door alarm without notifying staff. The resident was returned to the facility 20 minutes later without injury. Staff interviews and video review were conducted, and staff education on elopement was completed.

The facility failed to prevent one resident from exiting the facility unattended, despite having an elopement risk assessment and care plan updates. Additionally, the facility failed to post accurate daily nurse staffing information as required.

The facility failed to maintain a safe, sanitary, and homelike environment, failed to provide timely notifications and signed bed holds, lacked comprehensive care plans for residents, failed to provide adequate personal care including shaving, failed to ensure safe transfers, failed to keep chemicals locked, failed to provide adequate toileting and incontinence care, failed to complete annual staff performance reviews, failed to accurately report staffing data to CMS, failed to implement infection prevention and control protocols, and failed to ensure appropriate antibiotic stewardship.

The immediate jeopardy was first identified on 2024-02-20 following an anonymous complaint about one-person mechanical lift transfers. The facility provided a plan of removal and education by 2024-04-18, and the immediate jeopardy was removed on the same day.

The facility failed to ensure adequate staff to safely transfer 12 residents requiring mechanical lifts, with staff regularly using only one person for transfers contrary to OSHA, FDA, and manufacturer guidelines. This deficient practice placed residents in immediate jeopardy, though the immediate jeopardy was removed after corrective actions on 2024-04-18.

The complaint investigation found that Resident R1 missed nine of 21 bathing opportunities from 12/04/23 through 02/12/24, including two periods of 10 days without bathing. Resident R3 missed nine of 21 bathing opportunities from 12/02/23 through 02/10/24, including a 17-day period without bathing. Both residents were dependent on staff and did not reject care.

The facility failed to provide adequate bathing for two of three sampled residents dependent on staff, resulting in multiple missed bathing opportunities over several months. Observations and interviews confirmed residents had poor hygiene and the facility lacked a formal bathing policy.

The investigation was triggered by a fall incident involving Resident 2 on 05/20/23. The complaint was substantiated as the facility failed to ensure proper wheelchair use and staff education, leading to the fall and injury.

The facility failed to ensure staff used wheelchair foot pedals and placed residents in the correct wheelchair, resulting in Resident 2 falling forward out of her wheelchair and sustaining a traumatic hematoma to her forehead.

The complaint investigation found substantiated issues with medication administration delays, medication errors, and infection control lapses involving urinary catheter and IV tubing management.

The facility failed to ensure timely administration of physician-ordered medications for multiple residents, maintain a medication error rate below five percent, and uphold proper infection control practices related to urinary catheter and IV tubing management.

The visit was complaint-related due to failure to follow a physician-ordered therapeutic diet. The resident choked on an unauthorized peanut butter and jelly sandwich and died. The complaint was substantiated with findings of immediate jeopardy.

The facility failed to provide Resident 1 with the prescribed mechanically altered diet, giving the resident a peanut butter and jelly sandwich that led to choking and death. The facility identified corrective actions including staff education, diet order reviews, and changes to snack cart procedures.

The facility was found deficient in multiple areas including inadequate bathing and activity programs for dependent residents, unsanitary wound and catheter care, improper wheelchair positioning, unsafe resident transfers, failure to complete annual staff performance reviews, medication administration errors, and inadequate bowel movement monitoring and treatment.

The facility was found deficient in multiple areas including failure to revise care plans for restorative nursing and oxygen use, failure to assist a resident with bathing, failure to provide restorative ambulation programs, failure to properly change and store oxygen nasal cannula tubing, failure to monitor bowel function and administer medications for constipation, and failure to store acidophilus medication according to manufacturer instructions.

The plan addresses multiple deficiencies including medication coding accuracy, care plan revisions, nail care, CPR certification, restorative services, resident transfers, catheter care, and staff competency evaluations. The facility outlines corrective actions, staff education, and monitoring plans to ensure compliance.

The facility was found deficient in multiple areas including accuracy of resident assessments, care plan timing and revision, ADL care, CPR certification, restorative services, accident prevention, infection control, and nurse aide performance reviews.

The survey found a most serious deficiency at level "F", 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, leading to a finding of substantial compliance effective 2019-01-19.

The facility failed to ensure dialysis care was provided consistent with professional standards, failed to timely implement a physician's medication order change, and did not maintain a fully functional resident call light system.

The facility failed to ensure proper dialysis care for resident #202, timely administration of antidepressant medications for resident #17, and provision of a fully functional call light system for all residents.

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).

Complaint investigation #KS00135348 focused on allegations of failure to investigate and report elopement incidents involving Resident #1. The complaint was substantiated with findings of inadequate investigation, reporting, and supervision.

The facility failed to investigate and report an elopement incident on 8/19/18 and failed to provide adequate supervision to Resident #1 who eloped on 11/10/18 without staff knowledge, exposing the resident to immediate jeopardy due to cold weather and lack of protective clothing. The facility also failed to implement an effective care plan and supervision after the initial incident.

The plan addresses past noncompliance issues identified under tags F609-D and F689-J, for which no plan of correction was required. The document confirms completion of corrective actions by 11/20/2018.

The complaint investigation found that the facility did not follow the care plan requiring foot pedals on wheelchairs when staff pushed residents. A resident fell on 7/20/18 after staff propelled the wheelchair without foot pedals, resulting in a neck fracture and lacerations. The resident was transferred to a hospital for evaluation.

The facility failed to ensure that wheelchairs were properly equipped with foot pedals when staff propelled residents, resulting in a resident falling from a wheelchair and sustaining a cervical spine fracture. This deficient practice affected five residents whose wheelchairs lacked foot pedals during staff propulsion.

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, audits, and care plan updates.

The facility failed to comply with multiple regulatory requirements including investigation of abuse allegations, employee background checks, dignity and respect in care, housekeeping and maintenance, comprehensive assessments, care planning, behavioral management, ADL assistance, pressure sore treatment, toileting, supervision and device use, dietary sanitation, timely physician visits, infection control, and equipment maintenance.

The survey found a 'F' level deficiency that was widespread and constituted no actual harm but had 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.

The inspection included complaint investigations related to abuse allegations and other concerns.

The facility had multiple deficiencies including failure to thoroughly investigate abuse allegations, incomplete background checks for employees, dignity and respect issues, housekeeping and maintenance concerns, incomplete resident assessments and care plans, inaccurate MDS coding, inadequate behavioral management, insufficient assistance with ADLs, pressure ulcer care deficiencies, inadequate toileting programs, failure to ensure timely physician visits, infection control lapses, and unsafe mechanical lift equipment.

The report confirms that the previously cited deficiency under regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of 06/30/2017. No other deficiencies or findings are noted.

The survey found the most serious deficiency to be a 'D' level deficiency, constituting 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 credible allegation of compliance and evidence of correction.

Complaint #116962 was investigated and substantiated. The facility failed to prevent elopement of one resident despite identified risks and care plans.

The facility failed to provide adequate supervision to prevent one resident from eloping when a visitor let the resident out the front door without staff knowledge. The resident was found walking toward the parking lot but returned without injury.

This plan of correction addresses deficiencies cited in response to a complaint investigation regarding resident elopement.

Resident #1 eloped but was returned immediately without injury. The facility implemented multiple corrective actions including staff and family education, enhanced door alarms and signage, increased resident monitoring, and ongoing monthly drills and audits to prevent future elopements.

The plan addresses past non-compliance issues identified under tags F0000 and F425-G, for which no plan of correction was required at the time of the original findings.

The deficiency citation represents findings from complaint investigations #114607 and #114655. The resident did not receive four medications as ordered after discharge from a behavior unit, resulting in increased aggression and readmission to the behavioral unit.

The facility failed to provide four prescribed medications to one resident for 17 days after readmission, resulting in increased verbal and physical behaviors and the resident's return to the behavioral unit for further treatment.

The survey found the most serious deficiencies at the facility to be at 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

All deficiencies previously cited were corrected as of 04/09/2016. The revisit confirms completion of corrective actions for multiple regulatory requirements.

The report shows that the previously cited deficiency under regulation 26-40-302 (b)(c) was corrected as of 04/09/2016. No other deficiencies or findings are listed.

The plan details multiple corrective actions including maintenance and housekeeping improvements, education and re-education of staff on care plans, MDS assessments, skin condition monitoring, behavior documentation, and other compliance areas. The facility commits to audits and ongoing monitoring to ensure substantial compliance by April 9, 2016.

The visit was triggered by multiple complaint investigations numbered 95545, 95759, 96703, 96861, 97436, 97443, 97228, and 97665.

The facility failed to ensure the electrical monitoring system on the main and service entrance doors remained activated to prevent 15 confused and self-mobile residents from leaving without staff knowledge. Observations and interviews confirmed the door alarms were turned off during times when no staff monitored the doors, and the facility lacked a policy for alarm monitoring.

The visit was triggered by complaint investigations 92326, 94501, and 95798. The medication error was substantiated by observation, interview, and record review.

The facility failed to ensure one resident's physician order to hold Coumadin prior to a heart procedure was followed, resulting in a significant medication error that caused the scheduled procedure to be aborted and rescheduled.

The facility had medication administration issues including discontinuation of Coumadin for resident #03 and rescheduling of cardiac therapy. The facility implemented education for nurses on medication order processes and will conduct random audits to ensure compliance.

The facility identified issues related to medication administration, including failure to notify physicians when medications were not administered, and improper procedures for handling unavailable medications. The plan outlines education and monitoring steps to ensure compliance.

The complaint investigation (#93621) found substantiated failures in medication administration and notification procedures leading to a resident stroke.

The facility failed to notify the physician of missed doses of Lovenox injections for one resident, failed to provide a physician-ordered supplement (Gatorade) for sodium deficiency, and failed to administer three consecutive doses of Lovenox resulting in a resident stroke and hospital admission.

The plan addresses updates to resident care plans focusing on personal sitters, toileting, repositioning, and procedures for residents refusing care. The facility commits to staff re-education, random audits, and ongoing monitoring to achieve substantial compliance by November 12, 2015.

The report documents that previously identified deficiencies under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(d) were corrected as of the revisit date.

The complaint investigation involved allegations that the facility failed to update care plans appropriately and neglected toileting needs, leading to resident discomfort and potential health risks. The complaints were substantiated based on interviews, observations, and record reviews.

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 a resident with a history of UTIs. The resident was found soaked in urine after being left in the recliner for an extended period without toileting or brief changes.

The survey found the most serious deficiencies to be 'D' level, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The plan addresses care plan updates for resident #4 related to elopement risk and the implementation of 15-minute visual checks. The facility also changed door coding and posted notices to prevent resident elopement, with staff re-education planned to ensure compliance.

The revisit confirmed that the previously reported deficiencies under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) were corrected as of the revisit date.

The complaint investigations #91954 and #91673 were related to failure to timely revise care plans and failure to prevent a resident from exiting the facility without staff knowledge. The resident was cognitively impaired with a high elopement risk and exited the facility alone on 9/22/15. The facility failed to update the care plan timely and did not adequately monitor or prevent the elopement.

The facility failed to timely review and revise the care plan for a high elopement risk resident following an elopement incident. The facility also failed to follow planned interventions to prevent the resident from exiting the facility unattended, despite alarms and monitoring procedures.

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 plan.

The plan addresses multiple deficiencies including bathing preferences, housekeeping and maintenance issues, nephrostomy care, medication handling, accident hazards, documentation, food service sanitation, and pharmacy services. The facility outlines corrective actions, staff education, and timelines for compliance.

The facility failed to follow resident bathing preferences, maintain sanitary housekeeping and maintenance, develop comprehensive care plans for special needs, provide adequate assistance with ADLs, properly treat pressure ulcers, maintain a safe environment free of hazards, provide appropriate nephrostomy care, monitor unnecessary drug use, maintain proper nurse staffing records, ensure sanitary food preparation, follow pharmacist recommendations, label and store medications properly, maintain infection control practices, and provide a safe and functional environment.

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, resulting in a finding of substantial compliance effective June 14, 2015.

The complaint investigation found that one adult 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 later discovered during a weekly audit. The resident was assessed as high risk for elopement and had a diagnosis of senile dementia Alzheimer's type.

The facility failed to provide adequate supervision to prevent one adult day care resident from leaving the facility without staff knowledge. Additionally, the facility did not complete a nursing assessment upon admission to the adult day care program as required by their policy.

The facility was required to implement security measures including locking all entrance doors with key code access and updating elopement assessments for all residents. Staff education and procedural updates were also mandated to ensure compliance with admission and assessment protocols.

The revisit confirmed that the deficiency identified under regulation 483.15(h)(2) was corrected by the revisit date of 2014-03-11.

The plan outlines corrective actions to address maintenance issues including replacement and repair of bathroom fixtures, sinks, flooring, and other facility equipment. It also includes staff training and ongoing monitoring to ensure compliance.

The facility failed to maintain a sanitary environment in all five resident hallways, with multiple issues including broken fixtures, rust, discoloration, grime, torn materials, and unclean equipment observed throughout the building.

The report confirms that the previously identified deficiencies under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) were corrected as of the revisit date.

The findings represent the results of complaint investigations #67096 and 67283. The facility failed to report the fall of resident #4 with injuries to the State agency as required.

The facility failed to report to the State agency the unwitnessed fall with injuries of one sampled resident (#4). The resident sustained a hematoma and skin tears from the fall, and the facility did not comply with reporting requirements.

Complaint investigation related to a resident fall and incident reporting. The investigation found deficiencies in timely reporting to the State Agency.

The facility was found to have deficiencies in reporting alleged violations involving mistreatment, abuse, neglect, and injuries of unknown source to the State Agency. The facility has implemented corrective actions to improve Quality Assurance and ensure timely reporting of incidents.

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 June 28, 2013.

The report is based on complaint investigations #65740 and #66186.

The facility failed to adequately assess the medical justification for physical restraints on one resident, failed to revise a care plan to prevent repeated falls for another resident, and failed to provide appropriate treatment and assessment for pressure ulcers in a resident admitted with wounds.

Multiple deficiencies were identified affecting resident safety, care planning, wound care, medication storage, equipment maintenance, and facility cleanliness. The facility acknowledged potential or actual resident impact and described corrective measures to achieve substantial compliance.

The inspection included a complaint investigation related to allegations of improper restraint use, failure to investigate falls, and inadequate supervision leading to resident injury.

The facility was found deficient in multiple areas including improper use of restraints, failure to investigate and report resident falls, inadequate dignity during meal service, unsanitary conditions, incomplete care plans, failure to prevent and treat pressure ulcers, inadequate supervision to prevent accidents, unsafe environment hazards, improper food handling and sanitation, expired laboratory supplies, unsafe narcotic storage, infection control lapses, inadequate ventilation in utility rooms, lack of emergency procedure training, and ineffective quality assurance committee oversight.

The inspection included complaint investigations #48486 and #50211. The complaints involved failure to notify physicians timely after resident falls, mismanagement of resident funds, failure to respond to grievances, infection control breaches, and other care and safety concerns.

The facility was found deficient in multiple areas including failure to notify physicians timely after resident falls, improper management of resident funds, failure to respond to grievances, inadequate maintenance and housekeeping, noise control issues, incomplete care plans, failure to monitor residents' health conditions and medications, infection control breaches, malfunctioning call light systems, pest control issues, and improper storage of clinical records and medications.