Inspection Reports for
Medicalodges Great Bend

The complaint investigation substantiated that CNA M verbally and mentally abused six residents and that the facility failed to timely report the suspected abuse. The abuse included derogatory comments, forced handling, and neglect of care.

The facility failed to protect six residents from verbal and mental abuse by CNA M, who exhibited aggressive and unprofessional behavior. The facility also failed to timely report suspected abuse. Immediate corrective actions were implemented prior to the survey.

The complaint investigation substantiated that the facility failed to prevent elopement of Resident R1, who exited through an unsecured door and fell outside. The resident was transported to the hospital with injuries and a urinary tract infection. The facility implemented corrective actions including installation of mag-locks, re-education of staff, and enhanced monitoring.

The facility failed to provide adequate supervision to prevent an elopement of Resident R1, who exited through an unlocked door without an alarm. This resulted in R1 falling outside the facility and requiring hospital evaluation. The facility also failed to ensure functioning door alarms and locks, placing R1 in immediate jeopardy.

The facility failed to ensure a safe environment by not securing oxygen cylinders, did not implement effective fall prevention interventions for a resident with multiple falls, failed to ensure proper medication administration and pharmacist oversight, and did not provide required in-service education for certain nursing aides. These deficiencies placed residents at risk for accidents, medication errors, and decreased quality of care.

The complaint investigation substantiated that the facility failed to provide thickened liquids as ordered and failed to accurately transcribe and administer antibiotic orders for Resident 1, resulting in aspiration pneumonia and hospitalization.

The facility failed to provide Resident 1 with thickened liquids as ordered, resulting in aspiration and hospitalization for aspiration pneumonia. Additionally, the facility failed to accurately transcribe and administer antibiotic orders upon Resident 1's return from the ER, placing her at risk for ineffective treatment and complications.

The complaint investigation was substantiated. Resident 1, who had severe cognitive impairment and a high risk for elopement, was found outside the facility after staff failed to secure his bedroom window. The facility acknowledged the failure and implemented corrective actions.

The facility failed to identify and secure likely avenues of exit, including windows, resulting in Resident 1 eloping through an open bedroom window. This failure placed the resident in immediate jeopardy and indicated inadequate supervision and environmental safety measures.

The facility failed to ensure proper storage of oxygen tubing, adequate hand hygiene, prevention of cross-contamination with sit-to-stand lift and glucometer usage, and proper use of personal protective equipment (PPE). These deficiencies posed a risk of spreading illness and infection to residents.

The facility failed to ensure proper storage of oxygen tubing, adequate hand hygiene, prevention of cross-contamination with sit-to-stand lifts and glucometers, and proper use of PPE. These deficiencies posed a risk of spreading illness and infection to residents.

The complaint investigation substantiated neglect of Resident 1, who suffered from medication omissions, multiple falls with injuries, and a fatal choking incident. The facility was found to have failed in providing necessary care and services, placing R1 in immediate jeopardy.

The facility failed to ensure R1 remained free from neglect by not administering prescribed blood pressure medication for 12 days, failing to communicate a swallowing evaluation order to speech therapy, and inadequately preventing multiple falls. These failures led to R1's respiratory arrest and death.

The facility had multiple deficiencies including failure to report and investigate missing fentanyl patches, incomplete care plans for residents, inadequate nutritional monitoring and supplementation, unsafe environment issues, failure to coordinate hospice care, incomplete immunization documentation, improper medication administration, and inadequate behavioral health and social services.

The plan outlines corrective actions for multiple deficiencies including required postings, advanced directives, discharge notices, care plan revisions, pressure ulcer treatment, accident prevention, catheter care, drug regimen review, medication monitoring, psychotropic drug use, medication storage, food service, and infection control. The facility commits to substantial compliance by 03/05/2021.

The facility had multiple deficiencies including failure to post complaint hotline, lack of physician-signed advance directives, failure to notify ombudsman of hospital transfers, incomplete care plans, inadequate pressure ulcer prevention and care, fall prevention deficiencies, inadequate catheter care, medication regimen review failures, improper insulin pen labeling, delayed meal assistance, and improper infection control procedures for COVID-19 isolation.

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 tract infection prevention, medication regimen review and monitoring, labeling and disposal of insulin pens, meal assistance timing, and infection control procedures for a resident in isolation.

The facility acknowledged deficiencies related to care plan updates and pressure ulcer treatment interventions. The plan outlines corrective actions including staff training, care plan audits, and monitoring to achieve substantial compliance by September 24, 2020.

The inspection was triggered by complaint investigations #150972, #154140, and #154505.

The facility failed to revise the care plan and provide appropriate treatment and interventions to prevent and heal pressure ulcers for Resident 3, who developed multiple pressure ulcers on both heels. The resident was at risk due to cognitive impairment and dependency, and the facility did not provide timely or adequate wound care.

The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The plan details multiple corrective actions including physician notifications, staff in-services, audits, care plan updates, risk management improvements, and infection control education to ensure compliance with federal and state regulations.

The facility had multiple deficiencies including failure to notify physicians of critical changes, failure to report and investigate incidents, inadequate care planning, failure to prevent pressure ulcers, insufficient nursing staff, inappropriate medication use, and infection control issues.

The survey found the facility was not in substantial compliance and conditions constituted immediate jeopardy to resident health or safety. Enforcement remedies including denial of payment for new admissions were imposed.

Complaint investigation #136269 involved allegations of abuse where Medication Aide M grabbed a resident's wrist causing bruising. The incident was not reported until the next day, and the aide continued working the shift. The facility failed to protect residents from abuse and failed to investigate and report the incident timely.

The facility failed to provide a safe environment free from abuse when a Medication Aide grabbed a resident's wrist causing bruising. The facility also failed to promptly report the incident and prevent further potential abuse. Additionally, the facility failed to ensure certified nurse aides received required annual in-service training.

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

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.

The visit was triggered by complaint #132729. The complaint was substantiated as deficiencies were found 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 the health service plan in agreements for all 4 residents, failed to administer medications according to physician orders for 1 resident, and failed to label over-the-counter medications with the resident's full name.

The facility identified deficiencies in the proper use of mechanical lifts by Certified Nursing Aides, posing potential harm to residents dependent on lifts. The plan outlines education, skills demonstration, and ongoing monitoring to ensure safe lift use.

The survey found a 'D' level deficiency indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction 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 ensure adequate supervision and staff assistance as care planned for one resident during the use of a sit to stand assistive device, resulting in a fall. The resident was transferred with fewer staff than recommended by the manufacturer, causing the lift to tip over.

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

The plan addresses corrective actions for residents affected by nonsuspicious bruising, including notification of physicians and families, implementation of a communication tool for identifying new skin issues, and daily follow-up by the Director of Nursing to ensure documentation and reporting.

This action is based on deficiencies found on the complaint survey conducted on August 29, 2017, which constituted a level of actual harm or above.

The revisit found the most serious deficiency to be a 'D' level deficiency. Due to deficiencies constituting a level of actual harm or above found on the complaint survey conducted on August 29, 2017, a denial of payment for new Medicare and Medicaid admissions was imposed effective August 29, 2017.

The visit was complaint-related, triggered by allegations of failure to notify physicians of changes in residents' conditions and failure to provide adequate skin care interventions. The findings confirmed these issues.

The facility failed to notify physicians of new skin impairments for 2 of 3 sampled residents, resulting in untreated large bruises. The facility also failed to assess and provide timely interventions to prevent skin impairment for one resident, placing them at risk for further injury.

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

The plan addresses skin integrity issues related to one discharged resident and outlines preventive measures for other residents at risk, including weekly nursing assessments and physician notification protocols.

Complaint investigation #119015 found the facility failed to timely assess and treat skin breakdown in Resident #1, resulting in large blisters and wounds with risk of infection.

The facility failed to assess and provide timely interventions to prevent skin breakdown for Resident #1, who developed large blisters 5 days after admission that progressed to large open wounds. The resident was at risk for infection due to delayed treatment and inadequate physician notification.

This Plan of Correction addresses deficiencies cited during a complaint investigation at Cherry Village facility. The document references the complaint ID and corrective actions taken in response to the complaint findings.

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 quality assurance committee oversight to ensure sustained compliance.

The facility was found not to be in substantial compliance, 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 training.

The facility failed to accurately assess residents' risk for pressure ulcers, failed to revise care plans appropriately, did not provide adequate pain management, failed to prevent and treat pressure ulcers properly, did not ensure timely physician visits, and failed to maintain proper infection control and nurse aide education.

The report confirms that the previously cited deficiency related to regulation 26-43-206(d) was corrected as of 02/17/2017. No other deficiencies or issues were noted.

The plan addresses multiple deficiencies including hospice resident status, grievance rights, bathing alternatives, toileting plans, transfer rail safety, food sanitation, environmental cleanliness, and quality assurance program implementation.

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

The facility identified issues with storing prepared and served food under sanitary conditions and outlined corrective actions including staff education and ongoing monitoring to ensure compliance.

The facility was found deficient in multiple areas including failure to provide required Medicare Part A notices, unresolved resident grievances, inadequate scheduled bathing, insufficient urinary incontinence assessment and intervention, unsafe transfer rail assessment, improper storage of hazardous chemicals, unsanitary kitchen conditions, inadequate infection control practices, and failure to maintain an effective Quality Assessment and Assurance (QAA) committee.

The facility failed to store, prepare, and serve food under sanitary conditions in the kitchen. Observations included lint blowing from vents, soiled microwave plate, broken spatulas, and damaged food prep counters.

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

The plan addresses deficiencies related to notification of physicians in elopement situations, care planning for residents with wandering behavior, and securing doors in the special care unit to prevent elopement.

The complaint investigation #95401 and 92986 focused on Resident #1 who left the facility unattended, sustained injuries, and whose care plan and supervision were inadequate. The resident was found outside after wandering off the secured unit and crossing streets in cold weather.

The facility failed to notify a resident's physician after the resident left the facility unattended and sustained injuries. The care plan was not individualized for an elopement risk resident, and the facility failed to provide adequate supervision to prevent the resident from leaving the secured unit, resulting in injury.

The report documents that previously identified deficiencies were corrected as of the revisit date.

The report documents that the deficiency identified by regulation 28-39-158(a) with ID prefix S0600 was corrected as of the revisit date.

The plan outlines corrective actions for multiple deficiencies including dietary protocol adherence, dignity in care, 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 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 November 5, 2015.

The inspection was conducted as a Health Resurvey and Complaint Investigation for complaint numbers #90282, #90815, #91684, #91196, and #92026.

The facility failed to notify responsible parties of significant weight loss for multiple residents, failed to maintain dignity during care and dining, did not provide adequate housekeeping and maintenance, failed to complete fall prevention care plans, did not provide necessary ADL assistance, failed to prevent urinary tract infections, did not maintain a safe environment to prevent falls, failed to maintain nutritional status for a resident with weight loss, failed to prepare and serve food under sanitary conditions, and failed to maintain infection control standards.

The facility failed to employ a full-time qualified dietary manager, did not provide adequate housekeeping and maintenance services to maintain a sanitary and comfortable environment, and failed to ensure the development of initial negotiated service agreements at admission for some residents.

The revisit confirmed that the previously reported deficiency under regulation 483.25(h) was corrected as of 08/06/2015. No other deficiencies are noted.

The survey found a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective August 8, 2015.

The complaint investigation #89728 substantiated that the facility did not provide adequate supervision to Resident #1 and other residents in the special care unit, resulting in safety risks due to unsupervised transport and unattended residents in the dining area.

The facility failed to provide adequate supervision to Resident #1, who had severe cognitive impairment and increased behaviors, by allowing the resident to travel alone on public transportation to a doctor's appointment. Additionally, the facility left four unsampled cognitively impaired residents unattended in the special care unit dining room, posing safety concerns.

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

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

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

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

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

The investigation was triggered by complaints #83512, #81943, and #82488. The facility did not complete investigations or report the incidents involving Resident #1 and Resident #3 to the state agency as required.

The facility failed to investigate and report to the state agency two unwitnessed incidents involving residents found on the floor with injuries. Resident #1 was found unresponsive on the floor and Resident #3 suffered a fall with injuries that was not reported or investigated as required by facility policy and state law.

The facility plans to develop and implement a system to assure correction and continued compliance with regulations, including ongoing activity programs and maintaining a Quality Assessment and Assurance committee.

The report documents that deficiency S0490 related to regulation 28-39-153(f) was corrected by 2014-07-31. No other deficiencies are listed as corrected or uncorrected.

The visit was complaint-related as a Non-compliance Revisit and Complaint investigation #77206. The complaint focused on the lack of individualized activity programs and comprehensive care plans for residents in the Special Care Unit. The complaint was substantiated based on observations, record reviews, and interviews.

The facility failed to provide an ongoing activity program designed to meet the interests and physical, mental, and psychosocial well-being of residents #4, #26, and #47 in the Special Care Unit. Additionally, the facility failed to develop comprehensive care plans including individualized activity programs for these residents. The Quality Assessment and Assurance Committee did not effectively identify or correct these deficiencies.

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

The report documents that the previously cited deficiency with ID prefix S0845 and regulation number 28-39-162 was corrected as of the revisit date.

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 survey found the most serious deficiencies at the facility to be at an 'F' level, indicating substandard quality of care. As a result, enforcement remedies including denial of payment for new Medicare admissions were imposed.

The facility had multiple deficiencies including failure to notify physicians of significant changes in residents' conditions, failure to promote dignity and respect, inadequate activity programs, poor housekeeping and maintenance, incomplete assessments and care plans, failure to provide necessary care and services, improper medication management, unsanitary food preparation and disposal, inadequate infection control, insufficient nurse aide training, and ineffective quality assurance oversight.

Complaint investigation #75742 was part of the visit. The findings confirmed the complaint regarding the unsanitary and unsafe physical environment.

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

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but 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 report confirms that the deficiency identified under regulation 483.25(c) was corrected on 2014-03-21. No other deficiencies are listed as outstanding.

The complaint investigation #72867 found substantiated failure to prevent pressure ulcers in Resident #1, with detailed documentation of the resident's condition, care plan deficiencies, and staff interviews confirming lack of preventative care.

The facility failed to prevent 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 heel protectors or scheduled repositioning, and staff did not implement preventative measures until after ulcers developed.

The report confirms that deficiencies previously cited under regulations 483.13(b) and 483.13(c)(1)(i), as well as 483.13(c)(1)(ii)-(iii) and (c)(2)-(4), were corrected by 08/30/2013.

This Plan of Correction addresses deficiencies identified during a complaint investigation.

The facility was found deficient in ensuring residents are free from verbal abuse and in reporting and investigating all injuries of unknown origin. Corrective actions include staff inservice training and ongoing monitoring by the Administrator and Director of Nursing.

The complaint investigation (#68185) was triggered by reports of verbal abuse by Nurse Aide Staff E toward Resident #1 and failure of the facility to investigate and protect residents. The investigation also included a skin tear and bruise of unknown origin on Resident #5 that was not reported to the state agency.

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

The plan outlines corrective actions for 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, and expanding administrative oversight.

The complaint investigation focused on allegations of abuse and neglect involving Resident #18, who left a locked special care unit without staff knowledge or supervision. The investigation found the facility failed to thoroughly investigate the incident and implement adequate supervision and safety measures.

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 to prevent accidents, maintain a safe environment free of chemical hazards, and implement an effective infection control program. Additionally, the facility's Quality Assessment and Assurance Committee failed to adequately identify and address these deficiencies.

Complaint Investigation #65058 was included in the survey findings. The facility failed to thoroughly investigate and report incidents of possible abuse, neglect, or mistreatment, including injuries of unknown origin, and failed to provide required notifications and protections for residents.

The facility was found deficient in multiple areas including failure to provide required resident rights notifications, failure to notify physicians of significant changes, failure to maintain resident privacy, failure to post survey results, failure to investigate and report incidents of abuse and neglect, failure to conduct criminal background checks timely, failure to maintain dignity and respect for residents, failure to maintain sanitary environment, failure to develop and revise comprehensive care plans, failure to monitor nutritional status and medication side effects, failure to provide adequate staffing and training, failure to maintain infection control, failure to maintain functional call light systems, and failure to maintain an effective quality assurance program.

The Plan of Correction addresses multiple deficiencies related to resident care, dignity, dental services, medication monitoring, nutrition, communication systems, and quality assurance processes. Corrective actions include staff inservices, policy reviews, equipment repairs, and monitoring by the Quality Assurance committee.

The visit was complaint-related, investigating complaint #52209 regarding multiple care and compliance issues at the facility.

The facility failed to notify physicians of significant weight loss for two residents, maintain dignity and respect for residents, provide medically-related social services, maintain comfortable sound levels, accurately assess residents' vision, develop and revise comprehensive care plans, monitor nutritional status, ensure drug regimens were free from unnecessary drugs, provide palatable and properly tempered food, maintain sanitary food preparation, provide routine and emergency dental services, ensure pharmacist reports of drug irregularities, maintain a working resident call system, and maintain an effective quality assessment and assurance program.

The plan addresses environmental and maintenance program deficiencies, including expanding maintenance protocols and oversight for both inside and outside residence areas.

The Plan of Correction outlines corrective actions for multiple deficiencies affecting residents, including notification procedures, care plan updates, confidentiality breaches, safety precautions, staff training, and infection control policies. The facility commits to monitoring compliance and completing corrective actions by specified dates.

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

This Plan of Correction is related to a complaint investigation identified as Cherry Village 073015 Complaint.

The plan addresses concerns related to residents' ability to transport without immediate staff presence, specifically assessing residents with low BIMS scores and ensuring staff accompaniment when family is unavailable. The facility's Quality Assurance committee will review appointments weekly to ensure resident safety.