Inspection Reports for
Medicalodges Paola

The facility failed to maintain comfortable temperature levels in resident rooms and common areas, failed to complete accurate resident assessments, failed to monitor and document black box warnings for medications, failed to maintain sanitary food preparation conditions, failed to maintain essential equipment in safe operating condition, and failed to ensure pharmacist review identified care plan omissions.

The survey found the most serious deficiency to be an 'F' level deficiency, 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 Plan of Correction outlines specific corrective actions for multiple deficiencies including room temperature adjustments, accurate MDS coding, monitoring of medications with black box warnings, sanitation improvements in dietary areas, and maintenance repairs.

The revisit report indicates that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected and completed as of 04/14/2016. No other deficiencies or uncorrected issues are noted.

The survey found the most serious deficiencies 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 investigation was triggered by complaints #97875 and #98169. The resident eloped from the facility without staff knowledge, was missing for approximately 11 hours, and was found with a minor injury. The resident had a history of schizophrenia, moderate cognitive impairment, and was assessed as high risk for elopement.

The facility failed to ensure that one of five residents sampled for elopement did not leave the facility without staff knowledge. The resident, who had moderate cognitive impairment and a high risk for elopement, left the facility after 7:30 P.M. and was missing until staff and police found him approximately 11 hours later about 0.1 mile from the facility with minor injury.

This plan of correction is linked to a complaint investigation identified as ML Paola complaint dated 03/16/2016.

The facility implemented corrective actions including moving resident #1 closer to the nurse's station, initiating 15-minute observation checks, updating care plans for residents at risk of elopement, educating staff on missing resident policies, and installing cameras at exits.

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 of correction.

This Plan of Correction is linked to a complaint investigation (ML Paola complaint 02122016) involving Resident #1's observation and elopement risk management.

Resident #1 was under 1 to 1 observation until hospitalization screening, then sent to a psychiatric facility. Upon return, the resident was placed on 15-minute visual checks with an elopement assessment completed. The care plan was updated, staff educated, and alerts sent to staff regarding elopement risk.

The complaint investigations #96687 and #93170 found that the resident eloped from the facility on 1-30-16 at 12:15 p.m. The resident had increased hallucinations, delusions, manic behavior, and medication refusal prior to elopement. The resident was placed on safety checks upon return and qualified for hospitalization but no bed was available immediately. The facility failed to prevent the elopement despite risk assessments indicating no elopement risk.

The facility failed to ensure that one resident with schizophrenia and psychosis eloped from the facility without staff knowledge, despite documented risks and behavioral changes. The resident was found off premises and returned with police assistance. The facility did not prevent the elopement, violating safety and supervision requirements.

The report documents that corrections were completed for deficiencies identified under regulations 483.15(h)(2), 483.35(i), and 483.70(h) as of the revisit date.

The survey found the most serious deficiencies to be 'F' level deficiencies, 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 the credible allegation of compliance and the submitted plan.

The visit was triggered by a complaint investigation #75812. The findings represent deficiencies identified during this complaint-related resurvey.

The facility failed to maintain sanitary housekeeping and maintenance services in resident hallways, failed to store, prepare, and serve food under sanitary conditions in the dietary department, and failed to maintain a safe, functional, sanitary, and comfortable environment in the kitchen and front exterior of the building.

The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.

The report confirms that the deficiency identified under regulation 483.60(b), (d), (e) with ID prefix F0431 was corrected as of 12/26/2013.

The visit included complaint investigations #69598, 70548, and 70640. The deficiencies were substantiated as evidenced by observations and interviews.

The facility failed to monitor medication expiration dates, administer medications according to standards of practice, and maintain accurate reconciliation of discontinued medications to be returned to the pharmacy.

The facility was found deficient in medication storage and destruction practices, including improper handling of discontinued medications and expired medications. The plan outlines corrective actions including staff education, routine inspections, and ongoing monitoring to ensure compliance.

The revisit confirmed that all previously cited deficiencies identified by regulation numbers 483.15(h)(2), 483.25(h), 483.25(l), and 483.60(c) were corrected as of 09/02/2012.

The facility failed to maintain a sanitary and comfortable environment, with multiple housekeeping and maintenance deficiencies noted. The facility also failed to provide an environment free of accident hazards. Additionally, the facility failed to identify, monitor, and act on adverse consequences related to medications with black box warnings for multiple residents, and lacked policies and procedures to address these issues.

The facility identified multiple deficiencies related to housekeeping and maintenance services, resident environment safety, and medication management, particularly regarding monitoring and administration of antipsychotic drugs and black box warning medications. The plan details specific corrective actions, including cleaning schedules, repairs, staff education, and ongoing audits.

The plan addresses multiple environmental and cleanliness deficiencies including cleaning and repairing rooms, bathrooms, kitchen equipment, and facility grounds. Specific corrective actions and timelines for achieving substantial compliance by 04/11/2015 are detailed.