Inspection Reports for
Medicalodges Neosho
400 LYON DR, NEOSHO, MO, 64850-9194
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
50 residents
Based on a April 2024 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Apr 18, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely notify the physician, responsible party, and registered nurse on-call of a resident's fall and subsequent injury.
Complaint Details
The investigation was complaint-related, focusing on the failure to timely notify the physician and responsible party after a resident fall. The complaint was substantiated with findings of delayed notification and communication issues among nursing staff.
Findings
The facility failed to promptly notify the physician and responsible party after Resident #41 fell and complained of left hip pain, potentially delaying treatment of a fractured femur. The resident initially refused hospital evaluation but was later sent to the emergency room where surgery was performed. Interviews revealed communication lapses between nursing staff and delayed physician notification.
Deficiencies (1)
Failure to timely notify the physician, responsible party, and registered nurse on-call of a resident fall with injury.
Report Facts
Residents sampled: 16
Facility census: 50
Pain rating: 7
Pain rating after medication: 3
Tylenol dosage: 1000
Falls sustained: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN N | Licensed Practical Nurse | Documented fall and administered pain medication; did not notify physician directly |
| LPN M | Licensed Practical Nurse | Day shift nurse who assessed resident and convinced resident to go to hospital |
| CMT J | Certified Medication Technician | Assessed resident on morning after fall and facilitated hospital transfer |
| LPN C | Licensed Practical Nurse | Described fall assessment procedures in interview |
| DON | Director of Nursing | Provided multiple interviews regarding fall notification procedures and findings |
| NP G | Nurse Practitioner | Provided expectations for physician notification after fall |
| ADON | Assistant Director of Nursing | RN on-call during fall; educated night nurse on notification requirements |
| Administrator | Facility Administrator | Provided interview on notification expectations and procedures |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 6
Date: Apr 18, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to promote resident self-determination related to roommate conflicts, failure to immediately notify physician and responsible party of a fall with injury, failure to maintain a clean and homelike environment, failure to coordinate PASARR screening for a resident with serious mental illness, failure to develop comprehensive care plans addressing side rail usage, and failure to timely notify physician and responsible party of a resident fall with injury.
Complaint Details
The complaint investigation focused on issues including resident rights violations related to roommate conflicts, failure to notify physician and responsible party of a fall with injury, environmental cleanliness, PASARR screening compliance, care planning deficiencies, and fall management. The investigation substantiated failures in all these areas, with minimal harm to residents.
Findings
The facility failed to promote resident self-determination by not adequately addressing roommate conflicts for Resident #27 and Resident #39. The facility also failed to immediately notify the physician and responsible party of a fall with injury for Resident #41, resulting in delayed treatment of a fractured hip. Additionally, the facility did not maintain a clean environment in Resident #29's bathroom due to uncleaned toilet riser. The facility failed to coordinate PASARR Level II screening for Resident #51 despite a diagnosis requiring further review. Care plans for Residents #5, #12, #26, and #47 did not address side rail usage. Overall, the facility did not timely notify the physician and responsible party following Resident #41's fall, contrary to policy and best practice.
Deficiencies (6)
Failure to promote resident self-determination by not resolving roommate conflicts for Resident #27 and Resident #39.
Failure to immediately notify physician and responsible party of a fall with injury for Resident #41, delaying treatment of fractured hip.
Failure to maintain a clean and homelike environment due to uncleaned toilet riser with fecal-like substance in Resident #29's bathroom.
Failure to coordinate PASARR Level II screening for Resident #51 despite diagnosis of schizophrenia and increased care needs.
Failure to develop and implement comprehensive care plans addressing side rail usage for Residents #5, #12, #26, and #47.
Failure to timely notify physician and responsible party following Resident #41's fall with injury.
Report Facts
Census: 50
Residents sampled: 16
Fall date: 2024
Pain rating: 7
Pain rating after medication: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Documented behavior notes regarding Resident #27 and roommate conflicts |
| LPN C | Licensed Practical Nurse | Interviewed about Resident #27 and #39 roommate issues and side rail usage |
| CNA H | Certified Nurse Assistant | Interviewed about Resident #27 and #39 roommate disagreements |
| CNA I | Certified Nurse Assistant | Interviewed about Resident #27 and #39 disagreements |
| SSD | Social Service Designee | Interviewed about Resident #27 and #39 roommate conflicts and resolution attempts |
| DON | Director of Nursing | Interviewed about Resident #27 and #39 roommate conflicts and fall notification procedures |
| NP G | Nurse Practitioner | Interviewed about expectations for fall notification and Resident #41 care |
| LPN N | Licensed Practical Nurse | Documented Resident #41 fall and pain assessment; interviewed about fall notification |
| LPN M | Licensed Practical Nurse | Day shift nurse who assessed Resident #41 after fall and sent resident to hospital |
| Housekeeper A | Housekeeper | Interviewed about cleaning procedures for Resident #29's bathroom |
| Housekeeper B | Housekeeper | Interviewed about cleaning restrictions in Resident #29's bathroom |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about cleaning restrictions in Resident #29's bathroom |
| BOM | Business Office Manager | Interviewed about PASARR screening process |
| Infection Control Nurse | Infection Control Nurse | Interviewed about PASARR screening process |
| MDS Coordinator E | Minimum Data Set Coordinator | Interviewed about care planning for side rails |
| ADON | Assistant Director of Nursing | Interviewed about fall notification and on-call RN responsibilities |
| Administrator | Facility Administrator | Interviewed about facility policies on roommate conflicts, fall notification, and care planning |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Oct 18, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to perform wound care following professional standards and infection control practices, including appropriate handwashing, during wound care treatment for two residents.
Complaint Details
The visit was complaint-related due to concerns about improper wound care and infection control practices. The deficiency was substantiated with observations and interviews confirming lapses in hand hygiene during wound treatments.
Findings
The facility failed to ensure proper hand hygiene and infection control during wound care treatments for two residents, with observations showing staff did not wash or sanitize hands appropriately, potentially contaminating wounds and supplies. The Director of Nursing confirmed expectations for hand hygiene were not met.
Deficiencies (1)
Failure to perform wound care following professional standards and infection control practices, including appropriate handwashing, during wound care treatment for two residents.
Report Facts
Residents affected: 2
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Observed failing to perform proper hand hygiene and wound care procedures during treatments of Residents #1 and #2. |
| Director of Nursing | Interviewed and confirmed expectations for hand hygiene and wound care procedures. |
Inspection Report
Routine
Census: 49
Deficiencies: 3
Date: May 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the use of bed rails and medication administration practices in the nursing home.
Findings
The facility failed to properly document assessments, informed consents, and care plans related to the use of side rails for multiple residents. Additionally, the facility failed to ensure medication error rates were below 5%, with errors identified in medication administration via PEG-tube for one resident.
Deficiencies (3)
Failed to document identification and use of possible alternatives prior to use of side rails; failed to document side rail assessments of risk versus benefits; failed to obtain written informed consents for the use of side rails prior to installation; and failed to complete ongoing assessments of appropriateness of side rails use for six residents.
Failed to ensure a medication error rate of less than 5% when staff made three errors out of 33 opportunities, resulting in an error rate of 9.09%, due to failure to correctly flush between medications administered via PEG-tube for one resident.
Failed to ensure residents were free from significant medication errors when staff failed to correctly flush between medications administered via PEG-tube for one resident.
Report Facts
Residents affected: 6
Medication errors: 3
Medication error rate: 9.09
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication error finding for combining medications during PEG-tube administration |
| LPN B | Licensed Practical Nurse | Named in medication error finding for proper medication administration procedures via PEG-tube |
| Maintenance Director | Interviewed regarding side rail installation and safety checks | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding side rail policies and medication administration practices |
| Administrator | Interviewed regarding medication administration practices and side rail measurements |
Inspection Report
Deficiencies: 0
Date: Aug 20, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction for Medicalodges Neosho, summarizing the results of a regulatory survey completed on 2019-08-20.
Findings
No health deficiencies were found during the survey.
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