Inspection Reports for Medicalodges Independence
1000 MULBERRY P.O. BOX 627, INDEPENDENCE, KS, 67301
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 16, 2014, found that all previously cited deficiencies had been corrected. Earlier inspections noted multiple deficiencies related to housekeeping and maintenance, pain management, restorative therapy, medication monitoring including expired insulin, infection control, dietary services, and quality assurance processes. Complaint investigations in 2012 substantiated verbal abuse by staff and cited the facility for failure to report these incidents promptly. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with corrective actions implemented and follow-up visits confirming resolution of prior issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
28 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
367% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
44 residents
Based on a February 2014 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 14
Date: Apr 16, 2014
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers and prefix codes were corrected by 03/29/2014.
Deficiencies (14)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(a)(2)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(e)(1)
Deficiency related to regulation 483.25(e)(2)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(c)
Deficiency related to regulation 483.35(i)
Deficiency related to regulations 483.60(a) and (b)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 14
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 16, 2014
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 the previously cited deficiency with regulation number 28-39-158(a) and ID prefix S0600 was corrected on 2014-03-29.
Deficiencies (1)
Deficiency previously reported under regulation 28-39-158(a) with ID prefix S0600
Report Facts
Correction completion date: Mar 29, 2014
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Mar 29, 2014
Visit Reason
This document is a Plan of Correction submitted in response to an annual survey inspection, outlining corrective actions to address cited deficiencies.
Findings
The plan details corrective actions for multiple deficiencies including maintenance and housekeeping repairs, restorative therapy program revisions, pain monitoring, medication management, dietary staff education, infection control, and overall wellness program implementation.
Deficiencies (13)
Facility maintenance and housekeeping to clean and repair grouted tile areas, bedside commode, walls, recliner, emesis basin, privacy curtains, and over the bed tables.
Revision of Restorative Therapy program for resident #22 and others, including RN coordination and oversight.
Nursing staff to monitor pain each shift and coordinate pain control interventions.
Revision of Restorative Therapy program for resident #38 and others with RN coordination.
Nursing staff to follow policy for developing toileting programs and monitoring compliance.
Revision of Restorative Therapy program for resident #17 and others with RN coordination.
Revision of Restorative Therapy program for residents #22, #27 and others with RN coordination.
Establishment of blood sugar parameters for resident #6 and others, with education and monitoring of nursing staff.
Additional education to dietary staff on portion sizes for pureed food items.
Additional education to dietary staff on proper glove use and food handling procedures; monitoring of nourishment area cleanliness.
Expired insulin discarded; nursing staff to be in-serviced on insulin storage and medication expiration policies.
Education and monitoring of nursing staff on cleaning and storage of aerosol breathing treatment and PEG tube supplies; infection control policies and procedures.
Facility QAPI committee to monitor overall compliance and implement wellness program with quarterly reviews.
Report Facts
Date for completion of corrective actions: Mar 29, 2014
Expired insulin discard date: Feb 20, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Travis McBride | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Census: 44
Deficiencies: 13
Date: Feb 28, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements including housekeeping, care planning, pain management, rehabilitation services, infection control, medication management, and quality assurance.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance services, failure to review and revise care plans, inadequate pain management, failure to provide appropriate rehabilitation and restorative services, failure to prevent urinary tract infections, improper medication monitoring including expired insulin administration, inadequate infection control practices, failure to follow dietary menus, and ineffective quality assurance processes.
Deficiencies (13)
Failed to provide housekeeping and maintenance services on 2 of 2 hallways, including stained privacy curtains, rusted commode parts, and gouged walls.
Failed to review and revise the plan of care for a resident with range of motion and pain issues, including failure to implement alternatives for refusal of arm splint and pain management.
Failed to implement measures to decrease pain for a resident, including lack of care plan and inadequate pain interventions.
Failed to provide appropriate treatment and services to maintain or improve rehabilitation abilities for a resident, including inadequate restorative care and failure to encourage ambulation and transfers.
Failed to provide appropriate treatment and services to prevent urinary tract infection and restore bladder function for a resident with urinary incontinence, including lack of toileting schedule and voiding diaries.
Failed to ensure restorative services to prevent unavoidable decline in range of motion of the hands for a resident, including failure to identify resistance to exercises and lack of RN oversight.
Failed to provide services to maintain or prevent further decline in range of motion for two residents, including inadequate restorative therapy and failure to provide hand roll as ordered.
Failed to ensure staff did not administer expired insulin to a diabetic resident, with insulin used beyond 28 days of opening.
Failed to adequately monitor medications of a resident, including failure to identify need for blood sugar parameters to guide staff in notifying physician of abnormal blood sugars.
Failed to follow planned menu for pureed diets, providing incorrect portion sizes for pureed meatloaf and scalloped potatoes.
Failed to maintain sanitary conditions in food preparation and serving areas, including unclean cooking range, improper glove use, and inadequate cleaning of nebulizer equipment and resident isolation rooms.
Failed to maintain an effective infection control program, including inadequate infection tracking, lack of causative organism documentation, and insufficient cleaning protocols for isolation rooms.
Failed to maintain a quality assurance committee that develops and implements appropriate plans of action to correct identified quality deficiencies, including pain management, rehabilitation, infection control, medication monitoring, and restorative services.
Report Facts
resident_census: 44
deficiency_days_expired_insulin: 19
restorative_care_sessions: 5
restorative_care_sessions: 7
pureed_diet_residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Restorative Staff | Named in range of motion and pain management findings for resident #22 |
| Staff C | Licensed Administrative Staff | Named in care plan and restorative program oversight findings |
| Staff K | Consulting Therapy Staff | Named in restorative therapy and range of motion findings |
| Staff M | Licensed Nursing Staff | Named in pain management and medication monitoring findings |
| Staff R | Licensed Nursing Staff | Named in pain management and medication monitoring findings |
| Staff J | Direct Care Staff | Named in rehabilitation and restorative care findings |
| Staff L | Direct Care Staff | Named in rehabilitation and restorative care findings |
| Staff S | Licensed Nursing Staff | Named in infection control and medication monitoring findings |
| Staff U | Licensed Nursing Staff | Named in infection control findings |
| Staff D | Dietary Staff | Named in dietary and food service findings |
| Staff W | Dietary Staff | Named in dietary and food service findings |
| Staff A | Administrative Staff | Named in quality assurance committee findings |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 18, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection.
Findings
The facility acknowledged deficiencies related to dietary management and outlined corrective actions including hiring a certified dietary manager and monitoring the dietary department to ensure cleanliness and resident dietary needs are met.
Deficiencies (1)
Deficiency related to dietary management and sanitation in the dietary department.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Hamilton | Certified Dietary Manager | Submitted the Plan of Correction. |
Inspection Report
Follow-Up
Deficiencies: 16
Date: Jan 10, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that all previously cited deficiencies, identified by regulation numbers and prefix codes, were corrected by 12/07/2012 as verified during the revisit on 1/10/2013.
Deficiencies (16)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(f)(1)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(b)(1)
Deficiency related to regulation 483.20(b)(2)(ii)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(k)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(a),(b)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 16
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 1
Date: Jan 10, 2013
Visit Reason
The visit was a non-compliant revisit to assess the facility's compliance with dietary services regulations following previous deficiencies.
Findings
The facility failed to retain the services of a certified dietary manager to oversee and manage the dietary department on a full-time basis, resulting in non-compliance with state guidelines.
Deficiencies (1)
Failure to retain the services of a certified dietary manager to oversee and manage the dietary department on a full-time basis.
Report Facts
Census: 49
Inspection Report
Plan of Correction
Deficiencies: 18
Date: Dec 7, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior inspection survey.
Findings
The Plan of Correction details multiple deficiencies related to resident care, assessment, activity programming, housekeeping, medication administration, dietary services, infection control, and safety. The facility outlines corrective actions, staff education, audits, and quality assurance programs implemented to address each deficiency.
Deficiencies (18)
Use of terms of endearment instead of residents' preferred names
Activity needs of residents not being met
Furniture in need of cleaning and repair
Absence of comprehensive assessments (CAA's) for certain residents
Absence of significant change comprehensive assessment for a resident
Lack of individualized care plans addressing specific resident needs
Lack of coordination of care between facility and hospice services
Use of side rails and chemical hazards related to supervision and safety
Residents experiencing weight loss without adequate nutritional interventions
Residents experiencing weight loss without adequate nutritional interventions
Improper treatment and care for oxygen therapy
Drug regimen not free from unnecessary drugs and inadequate monitoring
Dietary department not maintained clean and sanitary
Deficient practice in medication administration
Monthly drug regimen review by licensed pharmacist not followed
Improper storage of drugs and biologicals (unopened insulin pens found)
Potential for cross contamination in linen distribution
Lack of certified dietary manager
Report Facts
Date of Plan of Correction completion: Dec 7, 2012
Date of staff education: Nov 15, 2012
Date of quality assurance program implementation: Nov 16, 2012
Scheduled dietitian consult date: Nov 29, 2012
Date of gradual dose reduction order clarification: Nov 19, 2012
Date of medication administration in-service: Nov 16, 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Skyedean | RN/DON | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Census: 51
Deficiencies: 15
Date: Nov 9, 2012
Visit Reason
The inspection was conducted to assess compliance with dietary services regulations, specifically focusing on the facility's retention of a certified dietary manager and the sanitary conditions of the dietary department.
Findings
The facility failed to retain a certified dietary manager to oversee dietary staff and maintain a clean and sanitary dietary department. Multiple sanitation issues were observed, including unsanitary conditions of cabinets, drawers, food preparation tables, and accumulation of black slime near the ice machine.
Deficiencies (15)
Failed to retain the services of a certified dietary manager to perform managerial duties overseeing dietary staff and maintaining a clean and sanitary dietary department.
Cabinet base under the 3 compartment sink with bare wood around edges creating a surface not easily sanitized.
Window ledge with build-up of dust and debris.
Splash guard ledge behind 3 compartment sink with build-up of dust, debris, and sticky to touch.
Radio on cabinet top covered with dust and sticky to touch.
Two drawers under toaster with crumbs in bottom.
Two pans under toaster with dark brown baked-on material.
Seven of eight cabinets with torn, stained shelf paper lining shelves.
Food preparation table with sticky top shelf and torn/stained paper lining bottom shelf.
Six drawers under juice machine with marred edges creating surfaces not easily sanitized.
Three drawers under juice machine with crumbs inside bottoms of drawers.
One 10 inch skillet with discolored brown build-up on inside edges.
Food preparation table first door off hinges and unable to close.
Food preparation table top shelf sticky with all four cabinet doors having marred edges creating surfaces not easily sanitized.
Accumulation of black matter (black slime) around the end of the white plastic drainage pipe near the ice machine.
Report Facts
Census: 51
Duration of dietary manager absence: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Dietary Staff | Provided information about dietary manager absence and verified sanitation findings |
| DD | Administrative Staff | Stated being the dietary manager on record and described management situation |
| BB | Dietary Staff | Verified sanitation findings regarding torn shelf paper and marred cabinets |
| H | Maintenance Staff | Verified presence of black slime near ice machine drainage pipe |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 24, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report indicates that the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of the revisit date.
Deficiencies (1)
Deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Report Facts
Deficiency correction date: Jul 24, 2012
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Jul 11, 2012
Visit Reason
The inspection was conducted as an investigation of complaints #55496 and 58233 regarding alleged abuse by direct care staff.
Complaint Details
The investigation was triggered by complaints #55496 and 58233 involving verbal abuse by two direct care staff (E and F) towards residents. The allegations were substantiated, and both staff were terminated. The facility failed to report the abuse to the state agency in a timely manner.
Findings
The facility failed to immediately report and thoroughly investigate two reports of verbal abuse by two direct care staff members affecting at least 7 residents. Both staff members were terminated after internal investigations, but the facility did not report the incidents to the state agency as required.
Deficiencies (1)
Failure to immediately report and thoroughly investigate allegations of verbal abuse by direct care staff affecting multiple residents.
Report Facts
Census: 43
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Direct Care Staff | Named in verbal abuse allegations and terminated |
| Staff F | Direct Care Staff | Named in verbal abuse allegations and terminated |
| Administrative Nursing Staff B | Administrative Nursing Staff | Conducted investigations and terminated staff but failed to report abuse to state agency |
| Administrative Staff A | Administrative Staff | Reported confusion about reporting responsibility for abuse allegations |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 5, 2012
Visit Reason
This document is a Plan of Correction submitted in response to complaint investigations #55496 and #58233 completed and turned into the State agency on 7/5/12.
Complaint Details
Investigation of complaints #55496 and #58233 were completed and turned into the State agency on 7/5/12. The plan addresses allegations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property.
Findings
The plan outlines procedures for investigating and reporting allegations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. It details corrective actions such as staff in-service training, monitoring by the Director of Nursing or designee, and ongoing quality assurance reviews to ensure compliance.
Deficiencies (1)
Investigation of complaint #55496 and #58233 related to mistreatment, neglect, or abuse.
Report Facts
Complete Date: Jul 24, 2012
Monitoring Duration: 8
Staff In-service Date: Jul 25, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Skye Dean | RN/DON | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 9
Date: Sep 27, 2011
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously cited in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that all previously reported deficiencies were corrected as of the revisit date, with multiple regulatory items marked as corrected on 09/27/2011.
Deficiencies (9)
Deficiency related to regulation 483.15(a)
Deficiency related to regulations 483.20(d), 483.20(k)(1)
Deficiency related to regulations 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(e)(2)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.70(c)(2)
Deficiency related to regulation 483.70(h)(4)
Report Facts
Deficiencies corrected: 9
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 8
Date: Aug 29, 2011
Visit Reason
Annual health facility resurvey to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during assisted dining, incomplete comprehensive care plans especially for residents with urinary catheters, failure to review and revise care plans after significant changes, inadequate prevention of urinary tract infections related to catheter care, failure to monitor medications with Black Box Warnings, inadequate infection control practices including improper disinfection of glucometers and laundry sanitation, and ineffective pest control with presence of flies in resident areas.
Deficiencies (8)
Staff failed to treat 9 dependent residents with dignity during assisted dining by using clothing protectors instead of napkins and standing over residents rather than sitting.
Facility failed to develop comprehensive care plans for 2 of 3 residents reviewed for urinary catheters, lacking interventions and parameters for physician notification.
Facility failed to review and revise care plans for 3 residents after significant changes including pelvic fracture, contractures, and altered posture.
Facility failed to provide appropriate treatment and services to prevent urinary tract infections for 3 residents with indwelling urinary catheters.
Facility failed to ensure medication regimens were free from unnecessary drugs and failed to monitor medications with Black Box Warnings for 8 of 10 residents reviewed.
Facility failed to maintain an infection control program by not disinfecting glucometers between resident use and failing to adequately sanitize laundry.
Facility failed to maintain laundry equipment in safe operating condition, resulting in inadequate processing of linens and potential infection risk.
Facility failed to maintain an effective pest control program, with flies observed in resident rooms and activity room.
Report Facts
Residents sampled: 19
Residents with dignity deficiency: 9
Residents with catheter care deficiency: 3
Residents with medication monitoring deficiency: 8
Water temperature: 130
Water temperature: 163
Residents with flies observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Licensed Nursing Staff | Named in findings related to dignity during dining, catheter care, and medication monitoring. |
| Staff L | Direct Care Staff | Named in findings related to dignity during dining and catheter care. |
| Staff F | Licensed Nursing Staff | Named in findings related to care plan updates and medication monitoring. |
| Staff D | Administrative Staff | Named in findings related to laundry equipment and sanitation. |
| Staff E | Administrative Staff | Named in findings related to laundry equipment and pest control. |
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