Inspection Reports for
Medicalodges Great Bend

The plan details corrective actions for multiple deficiencies including required postings, advanced directives, discharge notices, care plan timing and revisions, pressure ulcer treatment, accident hazard supervision, catheter care, drug regimen review, medication monitoring, psychotropic drug use, medication storage, food service temperature, and infection prevention and control. The facility commits to ongoing audits, staff education, and monitoring until compliance is attained by 03/05/2021.

The facility was found deficient in multiple areas including failure to post required complaint hotline information, incomplete advance directive documentation, failure to notify ombudsman of resident hospital transfers, incomplete care plan updates, inadequate pressure ulcer prevention and treatment, fall prevention interventions, urinary catheter care, medication regimen review and monitoring, labeling and storage of insulin, meal assistance timing, and infection control practices related to COVID-19 precautions.

The facility acknowledged deficiencies in care plan updates and wound care interventions, and outlined corrective actions including staff in-service training, care plan audits, and monitoring by the Director of Nursing and MDS Coordinator to ensure compliance and substantial compliance by 09/24/2020.

The visit was complaint-related involving investigations #150972, #154140, and #154505. The facility failed to revise care plans and provide timely treatment for pressure ulcers identified on Resident 3.

The facility failed to revise Resident 3's care plan for pressure ulcers after the resident developed three pressure ulcers on her heels and failed to provide appropriate treatment and interventions to prevent pressure ulcers, placing the resident at risk for delayed wound healing.

The plan details multiple corrective actions including staff education, audits, monitoring, and care plan updates related to physician notification, risk management, wound care, medication management, infection control, and staffing levels. The facility aims to achieve and maintain compliance by 06/28/2019.

The visit included complaint investigations related to failure to notify physicians of critical changes, failure to report and investigate a resident's critically low blood sugar, and other care concerns.

The facility failed to notify physicians of critical changes, failed to report and investigate a resident's critically low blood sugar, failed to develop and revise comprehensive care plans, failed to provide adequate nutritional support and pressure ulcer prevention, failed to ensure appropriate use of medications including antipsychotics, failed to maintain a safe environment, and failed to provide sufficient nursing staff.

The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety. Deficiencies were cited that resulted in enforcement remedies including denial of payment for new admissions.

Complaint investigation #136269 regarding abuse of Resident #1 by Medication Aide M who grabbed the resident's wrist causing bruising. Nurse G witnessed the incident but delayed reporting until the next day. Medication Aide M continued working the shift. The facility failed to immediately send the staff member home and notify administration. The resident had multiple bruises and abrasions documented. The facility terminated the alleged perpetrator and conducted staff in-service after the incident.

The facility failed to provide a safe environment free from abuse when a Medication Aide grabbed a resident's wrist causing bruising. The incident was not reported immediately, and the staff member continued working. The facility also failed to implement policies to protect residents and prevent abuse, and failed to ensure timely reporting of the incident. Additionally, the facility did not ensure certified nurse aides received required annual in-service training hours.

All previously cited deficiencies identified by regulation numbers 26-41-202 (c), 26-41-204 (d), 26-41-205 (d)(1-2), and 26-41-205 (g)(3) were corrected as of the revisit date 10/10/2018.

The visit was triggered by complaint #132729. The findings included failures related to negotiated service agreements, medication administration, and labeling of over-the-counter medications.

The facility failed to develop initial negotiated service agreements at admission for 2 of 4 residents, failed to include the name of the licensed nurse responsible for health care services in the agreements for all 4 residents, failed to administer medications according to medical provider orders for 1 resident, and failed to ensure over-the-counter medications were labeled with the resident's full name.

The plan addresses deficiencies related to the improper use of mechanical lifts by Certified Nursing Aides, outlining corrective actions including staff education, skills demonstration, and ongoing monitoring by administrative nurses.

The survey found the most serious deficiencies to be a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective March 14, 2018.

The findings represent the results of complaint investigations #124022, #124747, #125030, and #126391. The facility failed to prevent a fall of Resident #6 during a sit to stand lift transfer due to inadequate staff assistance and supervision.

The facility failed to ensure adequate supervision and staff assistance as care planned, and did not follow the manufacturer's recommendations for the use of a sit to stand assistive device, which caused a resident to fall during a transfer.

This Plan of Correction relates to a complaint revisit inspection conducted on 2017-11-06.

All deficiencies identified in the complaint revisit inspection have been corrected, and no new noncompliance was found as of the correction date.

This plan of correction is related to a revisit complaint inspection conducted on 09/19/2017 at Cherry Village.

The plan addresses deficiencies related to notification and documentation of nonsuspicious bruising on residents, including corrective actions such as physician and family notification, implementation of a communication tool for skin issues, and daily follow-up by the Director of Nursing.

The visit was a complaint investigation triggered by allegations of failure to notify physicians of changes in residents' conditions and inadequate skin impairment care. The complaint was substantiated based on findings.

The facility failed to notify physicians of new bruises and skin impairments for two residents, Resident #1 and Resident #2, placing them at risk for further skin injury. Documentation and communication regarding bruises were inadequate, and interventions to prevent skin impairment were not consistently implemented.

The denial of payment action was based on deficiencies found on the complaint survey conducted on August 29, 2017.

The revisit found the most serious deficiency to be a 'D' level deficiency, indicating actual harm or above. As a result, a denial of payment for new Medicare and Medicaid admissions was imposed effective August 29, 2017, and termination of the provider agreement was recommended if substantial compliance is not achieved by February 9, 2017.

This Plan of Correction is related to the Cherry Village complaint investigation dated 08/09/2017.

The plan addresses skin integrity issues for one affected resident who has since been discharged, outlines preventive measures for other residents at risk, and describes staff in-service training and quality assurance follow-up procedures to ensure physician notification and treatment orders are implemented.

Complaint investigation #119015 focused on the facility's failure to provide adequate care to prevent skin breakdown in Resident #1, who developed large blisters and wounds shortly after admission.

The facility failed to assess and provide timely interventions for Resident #1 who developed large blisters and open wounds on the thighs within days of admission. Treatment was delayed by several days, and the wounds progressed to large ulcerations, placing the resident at risk for infection.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to deficiencies cited in this survey and a prior noncompliance history from an April 27, 2017 survey, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.

All previously cited deficiencies listed on the CMS-2567 were corrected as of 05/26/2017, with no uncorrected deficiencies remaining at the time of this revisit.

This Plan of Correction is in response to a complaint investigation at Cherry Village.

The plan outlines corrective actions for multiple deficiencies related to skin care, pain management, wound care, physician visits, wound dressing techniques, and nurse aide training. It includes weekly and monthly monitoring, staff in-service training, and involvement of wound care specialists to ensure sustained compliance.

The facility was found not in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety related to pressure ulcers (F314). Enforcement remedies including denial of payment for new admissions were imposed.

Complaint Investigation #114603 was conducted, focusing on allegations related to pressure ulcer care, pain management, infection control, and staff education deficiencies.

The facility failed to accurately assess residents' risk for pressure ulcers, revise care plans timely, provide adequate pain management, prevent and treat pressure ulcers, ensure timely physician visits, maintain infection control during wound care, and provide required nurse aide education hours. Resident #1 developed multiple pressure ulcers and was not seen by a physician within 30 days of admission. Resident #2 had facility-acquired pressure ulcers and wounds with inadequate care and infection control.

The revisit report indicates that the previously cited deficiency with regulation number 26-43-206(d) was corrected and completed as of 02/17/2017. No other deficiencies or findings are noted.

The Plan of Correction outlines specific corrective actions for multiple deficiencies including hospice resident rights, grievance resolution, bathing preferences, toileting plans, transfer rail safety, food sanitation, environmental cleanliness, and quality assurance program implementation.

The facility was found deficient in multiple areas including failure to provide required Medicare non-coverage notices, unresolved resident grievance regarding missing personal property, failure to provide scheduled bathing, inadequate assessment and intervention for urinary incontinence, unsafe transfer rail posing entrapment risk, unsecured hazardous chemicals accessible to residents, unsanitary kitchen conditions, improper infection control practices, and failure to maintain an effective Quality Assessment and Assurance (QAA) committee.

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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction effective February 17, 2016.

The facility failed to store, prepare, and serve food under sanitary conditions in the kitchen, as evidenced by lint blowing from vents, soiled microwave plate, broken spatulas, and deteriorating food prep counter caulking.

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

The complaint investigation #95401 and 92986 focused on Resident #1 who eloped from the facility, sustained injuries, and whose physician was not promptly notified. The investigation found failures in notification, care planning, and supervision.

The facility failed to notify Resident #1's physician after the resident left the facility unattended and sustained injuries. The care plan for the resident was not individualized to address elopement risk. The facility also failed to provide adequate supervision, allowing the resident to leave the secured unit and the facility unattended, resulting in injury. The courtyard door was unlocked without continuous alarm, and the activity room door was left unlocked, facilitating the resident's elopement.

The revisit confirmed that all previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.

The report indicates that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 11/05/2015.

The plan addresses multiple deficiencies including dietary protocol for weight loss, dignity in care during dining, preventive maintenance, fall prevention, ADL care routines, catheter care, infection control, and staff training. Quality assurance measures and monitoring plans are described for each deficiency.

The plan addresses deficiencies related to dietary manager certification, environmental maintenance including carpet replacement and ceiling repairs, and timely completion of negotiated service agreements for new admissions.

The visit was triggered by multiple complaints resulting in a Health Resurvey and Complaint Investigation.

The facility was found deficient in multiple areas including failure to notify responsible parties of significant weight loss for residents, failure to maintain dignity and respect during care, inadequate housekeeping and maintenance, incomplete care plans for fall prevention, failure to provide necessary ADL assistance, improper catheter care, inadequate fall supervision, failure to maintain nutritional status, unsanitary food preparation practices, and inadequate infection control.

The facility failed to employ a full-time qualified dietary manager, failed to maintain a sanitary and comfortable physical environment, and failed to ensure the development of initial negotiated service agreements at admission for some residents.

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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The report documents that the previously cited deficiency with ID prefix F0323 related to regulation 483.25(h) was corrected as of 2015-08-06.

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

The complaint investigation #89728 found substantiated deficiencies related to inadequate supervision resulting in potential accident hazards for residents, including one resident sent alone on public transportation despite severe cognitive impairment and behavioral issues.

The facility failed to provide adequate supervision to Resident #1, who had severe cognitive impairment and increased behaviors, by sending him/her alone on public transportation to a doctor's appointment. Additionally, the facility failed to provide adequate supervision to four unsampled residents in the special care unit dining room, leaving them unattended.

The survey found the most serious deficiencies to be 'F' level, widespread, with 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.

The report confirms that the deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of 03/12/2015. No other deficiencies are listed.

This Plan of Correction is related to a complaint investigation at Cherry Village, as indicated by the reference to 'Complaint Revised' and the event ID.

The facility was found to have employed individuals who had been found guilty of abuse, neglect, or mistreatment of residents. The plan includes staff in-service on abuse, neglect, and mistreatment policies and monthly review of resident falls by the Quality Assurance committee.

The visit was complaint-related, triggered by complaints #83512, #81943, and #82488. The facility failed to investigate and report incidents involving Resident #1 and Resident #3 as required.

The facility failed to investigate and report to the state agency an unwitnessed incident where Resident #1 was found unresponsive on the floor and a fall with injury for Resident #3. Both incidents were not reported as required by facility policy and state law.

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

The facility identified deficiencies related to providing ongoing activity programs to meet residents' interests and well-being, developing comprehensive care plans including activity programs, and maintaining a Quality Assessment and Assurance committee.

The report confirms that the deficiencies previously cited under regulations 483.15(f)(1), 483.20(d), 483.20(k)(1), and 483.75(o)(1) have been corrected as of the revisit date.

The visit was a complaint investigation #77206 and a non-compliance revisit.

The facility failed to provide an ongoing activity program designed to meet the interests and physical, mental, and psychosocial well-being of residents in the Special Care Unit. Additionally, the facility failed to develop comprehensive care plans including individualized activity programs for sampled residents. The Quality Assessment and Assurance Committee failed to identify and implement corrective plans for these deficiencies.

The report confirms that the previously cited deficiency with ID prefix S0490 related to regulation 28-39-153(f) was corrected by 07/31/2014.

The revisit found the most serious deficiency in the facility to be an "F" level deficiency, indicating the facility was not in substantial compliance. Enforcement remedies including denial of payment for new Medicare/Medicaid admissions and recommendation for termination of the provider agreement were imposed.

The report shows that all previously identified deficiencies were corrected by the facility as of 07/31/2014, with no uncorrected deficiencies noted at the time of this revisit.

The Plan of Correction outlines multiple corrective actions including staff in-service training, reassignment of responsible personnel, environmental repairs, and enhanced monitoring by the Quality Assurance Committee to address various deficiencies.

The plan outlines corrective actions to expand the environmental and maintenance program to include both inside and outside residence areas, identify affected residents, seek bids for building repairs, and submit monthly environmental observation checklists to the Quality Assurance Committee.

The report confirms that the previously identified deficiency with regulation number 28-39-162 was corrected as of 07/31/2014. No other deficiencies or uncorrected issues are noted.

The survey found the most serious deficiencies in the facility to be at an 'F' level, indicating substandard quality of care. Enforcement remedies including denial of payment for new Medicare admissions were imposed effective October 2, 2014, with potential termination recommended if substantial compliance is not achieved within six months.

Complaint Investigation #74690 and #76167 triggered the visit.

The facility failed to notify physicians of significant changes in residents' conditions, failed to provide dignity and respect, failed to provide adequate activity programs, failed to provide medically related social services, failed to maintain a sanitary environment, failed to complete comprehensive assessments and care plans, failed to provide necessary care and services to maintain residents' well-being, failed to provide oral care assistance, failed to prevent pressure ulcers, failed to ensure safety from accidents, failed to monitor medications properly, failed to prepare and serve food under sanitary conditions, failed to dispose of garbage properly, failed to provide routine dental care, failed to maintain an infection control program, and failed to provide required nurse aide in-service training.

The inspection included a complaint investigation #75742 and was substantiated by observations and verification from Administrative Staff O and Administrative Staff S.

The facility failed to provide and maintain a sanitary, orderly, and comfortable interior environment for the 16 residents. Multiple physical environment deficiencies were observed including structural damage, unsanitary conditions, and maintenance issues both outside and inside the facility.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with 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.

The report confirms that the deficiency identified under regulation 483.25(c) with ID prefix F0314 was corrected on 2014-03-21. No other deficiencies are noted.

Complaint investigation #72867 found the facility failed to prevent pressure ulcers in Resident #1, who was admitted with an immobilizer and high risk for ulcers. The facility lacked appropriate care plans and interventions to prevent skin breakdown.

The facility failed to prevent the development of pressure ulcers on both heels of Resident #1, who was admitted with an immobilizer on the left lower leg and assessed as high risk for pressure ulcers. The care plan lacked interventions such as repositioning schedules or heel protectors, and the ulcers developed despite the resident's high risk status.

The revisit report shows that the previously cited deficiencies identified by regulation numbers 483.13(b), 483.13(c)(1)(i), and 483.13(c)(1)(ii)-(iii), (c)(2)-(4) were corrected as of 08/30/2013.

This Plan of Correction is related to a complaint investigation identified as Cherry Village 082213 Complaint.

The plan addresses deficiencies related to verbal abuse and failure to report and investigate injuries of unknown origin, with corrective actions including staff inservice training and monitoring by facility leadership.

The complaint investigation (#68185) was triggered by reports of verbal abuse by Nurse Aide Staff E towards Resident #1 and failure of the facility to investigate and protect residents from abuse. The facility also failed to report and investigate a skin tear and bruise of unknown origin on Resident #5.

The facility failed to ensure one resident was free from verbal abuse by a staff member and failed to investigate and report allegations of abuse and injuries of unknown origin for two residents. The facility allowed the alleged perpetrator to continue working during the investigation.

The report shows that all previously cited deficiencies identified by regulation numbers and prefix codes were corrected by 07/15/2013 as verified during the revisit.

The plan addresses multiple deficiencies including employment of individuals without background checks, updating resident care plans, ensuring safety in resident living areas, maintaining proper dishwashing temperatures, infection control practices related to oxygen cannulas, administrative staffing, and dietary management certification.

The complaint investigation focused on allegations that Resident #18, a cognitively impaired resident, left the locked special care unit unattended without staff knowledge or supervision. The investigation found failures in supervision, investigation, and care planning related to this incident.

The facility failed to thoroughly investigate allegations of potential abuse and neglect for a cognitively impaired resident who left a locked special care unit unattended. The facility also failed to conduct criminal background checks for new hires, develop and revise comprehensive care plans for residents with nutritional and behavioral concerns, provide adequate supervision and a safe environment free of hazards, maintain proper infection control practices, and effectively manage resources to ensure resident well-being.

The revisit report documents that all previously cited deficiencies were corrected by the facility as of 06/07/2013, with no uncorrected deficiencies remaining.

The Plan of Correction outlines corrective actions for multiple deficiencies affecting residents, including notification of Medicare letters, condition change interventions, confidentiality breaches, safety precautions, care plan updates, infection control, staffing, and emergency procedures. The facility commits to completing corrective actions by specified dates and monitoring compliance through QA oversight.

Complaint Investigation #65058 was included in the survey and several deficiencies relate to complaint allegations including failure to investigate and report abuse, failure to notify physicians of changes, and failure to maintain resident dignity and privacy.

The facility had multiple deficiencies including failure to provide proper notification of Medicare rights, failure to notify physicians of significant changes, failure to maintain resident privacy, failure to post survey results accessibly, failure to investigate and report abuse and neglect, failure to conduct criminal background checks timely, failure to provide dignity and respect, inadequate housekeeping and maintenance, failure to develop and revise care plans, failure to monitor nutritional status and medication side effects, failure to provide infection control, failure to maintain functional call light systems, insufficient nursing staff, inadequate nurse aide training, and failure to train staff in emergency procedures.

The plan outlines corrective actions for multiple deficiencies affecting residents, including weight loss policy compliance, dignity and respect, dental care, medication monitoring, food service, communication systems, and care planning. The facility commits to monitoring compliance through Quality Assurance committee activities and resident/family interviews.

All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by the revisit date of 05/11/2012.

The visit was complaint-related, investigating complaint #52209.

The facility was found deficient in multiple areas including failure to notify physicians of significant weight loss for residents, failure to promote dignity and respect, inadequate provision of medically-related social services, failure to maintain comfortable sound levels, inaccurate resident assessments, incomplete care plans, inadequate monitoring of nutritional status and medications, unsanitary food preparation, failure to provide dental services, malfunctioning resident call system, and ineffective quality assurance program.

The plan addresses deficiencies related to sanitary storage of prepared and served food, with corrective actions including staff education, monitoring, and monthly reporting to the Quality Assurance committee.

The plan addresses deficiencies related to resident assessment with injury noted, abuse prevention and reporting, staff education on abuse policies, and staff performance reviews including required in-service education hours.

This Plan of Correction is related to a complaint investigation at Cherry Village.

The plan addresses deficient practices related to skin care and prevention of pressure ulcers, including reviewing assessment and care plan practices, assigning weekly skin checks to an RN, and mandatory staff in-service training.

This Plan of Correction is related to a complaint investigation at Cherry Village, referenced as Complaint 01052016.

The plan addresses deficiencies related to notification of physicians in elopement situations, expanded care plans for residents with wandering behavior, and security measures including locking doors and alarm systems to prevent elopement.

This Plan of Correction is related to a complaint investigation at Cherry Village.

The plan addresses deficiencies related to resident assessments for ability to transport without immediate staff presence, particularly for residents with low BIMS scores, and outlines weekly reviews by the Quality Assurance committee to ensure resident safety during appointments.