Inspection Reports for
Medicalodges Neosho

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.

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.

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.

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.

The facility was found noncompliant with several federal regulations including resident self-determination, notification of changes, safe environment, coordination of PASARR assessments, comprehensive care planning, and quality of care. Deficiencies involved failure to promote resident self-determination, inadequate notification of changes in condition, unsafe and unclean environment, incomplete PASARR screening, and insufficient care planning and fall management.

The facility failed to maintain the sprinkler system properly, with escutcheons around sprinkler heads not secure and attic sprinkler coverage obstructed by insulation and plastic sheeting. The facility also lacked a policy on sprinkler maintenance and did not have an annual consultation and review of fire and evacuation plans with the local fire department.

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.

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.

The complaint investigation found substantiated deficiencies related to wound care and infection control practices, including failure to wash hands and sanitize properly during treatment of residents' wounds.

The facility failed to perform wound care following professional standards and infection control practices, including proper handwashing and sanitizing by staff during wound treatment for two residents. Observations and interviews confirmed multiple lapses in hand hygiene and wound care procedures.

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.

The facility failed to properly assess and document the use of bed rails for six residents, including obtaining informed consent and ongoing assessments. Additionally, the facility had a medication error rate exceeding 5%, with errors related to PEG-tube medication administration.

The facility failed to maintain sprinkler coverage in the attic due to obstructions, did not maintain smoke resistive properties of corridor doors, and failed to keep records of electrical system maintenance and testing. These deficiencies had the potential to affect all residents, staff, and visitors in case of fire or electrical malfunction.

The complaint investigation found an immediate jeopardy situation where a resident eloped from the locked memory care unit through an unlocked door and was found offsite. The facility had not implemented adequate protective oversight or updated care plans accordingly. The immediate jeopardy was removed during the onsite visit, and corrective actions were initiated.

The facility failed to provide protective oversight to residents on the locked memory care unit, resulting in a resident eloping through an unlocked door and being found offsite. Staff also failed to update the care plan timely after incidents of wandering, exit seeking, and elopement. The immediate jeopardy was removed during the onsite visit, and the deficiency severity was lowered to a Class I violation.

The complaint investigation found substantiated deficiencies related to incomplete and inaccurate documentation of residents' medical records, which led to inadequate monitoring and delayed hospital transfers for residents #1 and #10.

The facility failed to maintain accurate and complete medical records documentation for residents, including vital signs, assessments, and notifications related to changes in condition. This failure contributed to inadequate monitoring and delayed interventions for residents experiencing acute symptoms.

The facility failed to fully implement infection control policies and CDC recommended practices for COVID-19, including social distancing measures in the Special Care Unit (SCU) dining area. Staff did not consistently enforce seating arrangements to maintain appropriate distancing among residents.

The facility failed to meet applicable provisions of the Life Safety Code related to egress doors and locking mechanisms. Staff did not properly inspect, test, and maintain fire egress gates, and staff lacked adequate training on the operation of locking devices on gates used for emergency egress.

The complaint investigation found substantiated deficiencies related to failure to provide ordered respiratory care and failure to ensure proper nursing care consistent with resident needs.

The facility failed to provide a CPAP machine and adequate respiratory care to a resident requiring such treatment, including failure to document and follow physician orders and failure to ensure staff properly administered respiratory care devices.

The facility failed to notify residents and their representatives in writing about transfers or discharges as required. Medication error rates exceeded the allowed 5 percent threshold. The resident call system was inadequate, and environmental cleanliness issues were noted in the kitchen. The facility census was 78 with a licensed capacity of 120 beds.

The facility failed to conduct required semi-annual fire alarm inspections and did not maintain electrical systems safely, creating potential fire hazards. Deficiencies were identified related to fire alarm testing and maintenance, and electrical outlets being obstructed by furnishings.