Inspection Reports for
Medicalodges Paola
501 ASSEMBLY LANE, PAOLA, KS, 66071-1854
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
90% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 6
Date: Jul 29, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in maintaining a clean and homelike environment, accurate nurse staffing postings, proper medication administration, sanitary food preparation, infection control practices, and mandatory nurse aide education.
Deficiencies (6)
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment in four resident rooms on the south hall, including build-up of black substances and unrepaired wall damage.
F 0732: The facility failed to ensure posted daily nurse staffing sheets included accurate and complete information for licensed and unlicensed staff hours and daily census.
F 0757: The facility failed to administer a prescribed hypertensive medication (clonidine) for Resident 50 when blood pressure exceeded ordered parameters, risking ineffective medication regimen.
F 0812: The facility failed to prepare and serve food under sanitary conditions, with multiple areas in the kitchen showing dirt, food debris, and unsanitizable surfaces.
F 0880: The facility failed to implement Enhanced Barrier Precautions for residents with wounds, lacking required PPE and signage, increasing infection risk.
F 0947: The facility failed to ensure one Certified Nurse Aide completed the mandatory 12 hours of education required annually, risking decreased quality of care.
Report Facts
Resident census: 63
Sample size for medication and infection control review: 17
Residents reviewed for unnecessary medications: 5
Dates with missing nurse staffing information: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nurse Aide | Named in deficiency for not completing mandatory 12 hours of education |
| CMA S | Certified Medication Aide | Provided information on blood pressure monitoring and staffing sheet completion |
| LN I | Licensed Nurse | Provided information on blood pressure monitoring and PRN medication administration |
| Administrative Nurse E | Administrative Nurse | Provided information on staffing sheet procedures and medication order monitoring |
| Administrative Staff A | Administrative Staff | Provided information on staffing sheet procedures and infection control expectations |
| Administrative Staff B | Administrative Staff | Provided information on staffing sheet completion process |
| Licensed Nurse G | Licensed Nurse | Provided information on infection control practices and wound care |
| Licensed Nurse H | Licensed Nurse | Provided information on infection control practices and wound care |
Inspection Report
Routine
Census: 63
Deficiencies: 6
Date: Jul 29, 2025
Visit Reason
Routine inspection to assess compliance with regulatory standards including environment, staffing, medication management, food safety, infection control, and staff training.
Findings
The facility had multiple deficiencies including unclean and unrepaired resident rooms, incomplete nurse staffing postings, failure to administer prescribed hypertensive medication, unsanitary kitchen conditions, inadequate infection control practices, and incomplete mandatory nurse aide education.
Deficiencies (6)
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment in four resident rooms on the south hall, including black substance buildup and unrepaired walls.
F 0732: The facility failed to ensure posted daily nurse staffing sheets included accurate and complete information for all shifts and daily census.
F 0757: The facility failed to administer prescribed hypertensive medication to Resident 50 as ordered, placing the resident at risk for complications.
F 0812: The facility failed to prepare and serve food under sanitary conditions, with multiple areas of dirt, grime, and food debris noted in the kitchen.
F 0880: The facility failed to implement Enhanced Barrier Precautions for residents with wounds, increasing risk of infection transmission.
F 0947: The facility failed to ensure one Certified Nurse Aide completed the mandatory 12 hours of education, risking decreased quality of care.
Report Facts
Residents reviewed for unnecessary medications: 17
Dates blood pressure exceeded 160 mmHg without medication given: 5
Number of resident rooms with environmental issues: 4
Number of kitchen sanitation issues noted: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide S | Certified Medication Aide | Reported on blood pressure monitoring and staffing sheet procedures. |
| Licensed Nurse I | Licensed Nurse | Described CMA responsibilities and communication regarding blood pressure. |
| Administrative Nurse E | Administrative Nurse | Verified medication administration issues and infection control policies. |
| Administrative Staff B | Administrative Staff | Reported on staffing sheet completion process. |
| Administrative Staff A | Administrative Staff | Confirmed expectations for education and staffing sheet postings. |
| Licensed Nurse G | Licensed Nurse | Observed wound care and PPE use. |
| Licensed Nurse H | Licensed Nurse | Reported on wound care and PPE practices. |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 3
Date: Sep 4, 2024
Visit Reason
The inspection was conducted due to complaints regarding neglect of Resident 1 during transfer and failure to report the elopement of Resident 2 to the State Agency.
Complaint Details
The complaint investigation involved neglect of Resident 1 during transfer without proper equipment causing injury, and failure to report the elopement of Resident 2 who left the facility unsupervised, threatened a store clerk, and was returned by staff in an unauthorized personal vehicle.
Findings
The facility failed to prevent neglect of Resident 1 by not using appropriate transfer equipment, resulting in a fracture. The facility also failed to report the elopement of Resident 2, who left unsupervised and threatened a store clerk. Both issues placed residents in immediate jeopardy.
Deficiencies (3)
F 0600: The facility failed to prevent neglect of Resident 1 by not using appropriate transfer equipment, causing a femoral fracture during transfer.
F 0609: The facility failed to timely report the elopement of Resident 2 to the State Agency as required.
F 0689: The facility failed to protect Resident 2 from harm when he exited unsupervised and threatened a store clerk, placing him in immediate jeopardy.
Report Facts
Resident census: 65
Elopement Risk Assessment score: 5
Fall Risk Assessment score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Involved in transfer of Resident 1 and reported details of neglect incident |
| CNA M | Certified Nurse Aide | Assisted in Resident 1 transfer and reported gait belt issue |
| CNA N | Certified Nurse Aide | Assisted in Resident 1 transfer and provided interview on incident |
| CMA R | Certified Medication Aide | Assisted in Resident 1 transfer and reported gait belt issue |
| Administrative Nurse D | Administrator Nurse | Assessed Resident 1 after fall and provided witness statement |
| LN H | Licensed Nurse | Responded to Resident 2 elopement, transported resident in personal vehicle |
| Administrative Staff A | Administrative Staff | Reported on Resident 2 elopement and follow-up actions |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 8
Date: Nov 6, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, unsafe and unsanitary environment, inadequate care plan revisions, failure to draw physician-ordered labs, inadequate supervision leading to resident elopement, unsanitary food preparation conditions, improper infection control, and unsafe facility environment.
Deficiencies (8)
F 0550: The facility failed to honor the resident's right to dignity by not providing a dignity bag for an indwelling urinary catheter bag, which was visible to staff, residents, and visitors.
F 0584: The facility failed to ensure a safe, sanitary, and homelike environment, with multiple areas showing accumulation of dirt, grime, and staining.
F 0657: The facility failed to review and revise the care plan to include staff instructions on the use of a dignity bag for a resident's urinary catheter bag.
F 0684: The facility failed to draw physician-ordered labs for a dependent resident due to an unpaid lab balance and lack of follow-up, impacting monitoring of the resident's health.
F 0689: The facility failed to provide adequate supervision to prevent elopement of a cognitively impaired resident, who was missing for over four hours and found off-site, placing the resident in immediate jeopardy.
F 0812: The facility failed to prepare and serve food under sanitary conditions, with multiple areas in the kitchen showing dirt, grime, rust, and food debris.
F 0880: The facility failed to contain biohazardous waste properly and failed to obtain identification of the causative organism for a resident's chronic wound.
F 0921: The facility failed to provide a safe, functional, sanitary, and comfortable environment in the kitchen, with floors and equipment showing heavy buildup of dirt and grime.
Report Facts
Residents Affected: 62
Residents Sampled: 18
Resident Elopement Duration: 263
Resident Elopement Distance: 0.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide R | Certified Medication Aide | Named in dignity bag finding and elopement supervision failure |
| Administrative Nurse D | Administrative Nurse | Named in dignity bag expectation and lab draw failure |
| Administrative Nurse E | Administrative Nurse | Named in lab draw failure and dignity bag care plan revision |
| Certified Medication Aide S | Certified Medication Aide | Named in elopement supervision failure |
| Licensed Nurse H | Licensed Nurse | Named in elopement supervision failure |
| Licensed Nurse I | Licensed Nurse | Named in elopement supervision failure |
| Dietary Staff CC | Dietary Staff | Named in kitchen sanitation deficiencies |
| Licensed Nurse G | Licensed Nurse | Named in infection control deficiency related to wound care |
| Certified Medication Aide T | Certified Medication Aide | Named in infection control deficiency related to biohazard waste |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and a safe environment for a cognitively impaired resident who eloped from the facility.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent elopement of Resident 44, who left the facility unsupervised and was missing for four hours and 23 minutes. The resident was found by police at a grocery store. The facility lacked door alarms prior to the incident and staff failed to perform required safety checks.
Findings
The facility failed to ensure adequate supervision for Resident 44, who eloped and was missing for over four hours, placing the resident in immediate jeopardy. Staff falsely documented 15-minute checks, and the facility lacked door alarms prior to the incident.
Deficiencies (1)
F0689: The facility failed to ensure a safe and secure environment by not providing adequate supervision for Resident 44, who eloped and was missing for over four hours. Staff falsely documented 15-minute checks and did not physically verify the resident's presence.
Report Facts
Resident census: 62
Resident elopement duration (hours and minutes): 263
Distance walked by resident (miles): 0.6
Elopement risk score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA S | Certified Medication Aide | Falsely documented 15-minute safety checks for Resident 44 |
| CMA R | Certified Medication Aide | Did not verify Resident 44's presence upon arrival and failed to physically see the resident |
| LN H | Licensed Nurse | Did not complete scheduled 15-minute checks and did not physically verify Resident 44's presence |
| Administrative Nurse D | Administrative Nurse | Expected staff to physically visualize resident during safety checks and confirmed false documentation by CMA S |
| Administrative Staff A | Administrative Staff | Reported lack of door alarms prior to elopement and was informed of immediate jeopardy |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident 1 eloped from the facility unsupervised and remained missing for approximately four and a half hours.
Complaint Details
The complaint investigation confirmed that Resident 1 eloped on 07/30/23, was missing for about four and a half hours, and the facility failed to activate the elopement protocol. The deficient practice was cited as past non-compliance with a J scope and severity.
Findings
The facility failed to prevent Resident 1 from eloping and did not activate the elopement protocol in a timely manner. Resident 1 left the facility grounds, walked 0.5 miles to a convenience store, developed chest pain, and was transported to the emergency room. Staff did not realize the resident was missing until notified by the emergency room.
Deficiencies (1)
F 0689: The facility failed to ensure Resident 1 remained free from accident hazards by not preventing elopement and not activating the elopement protocol when the resident was missing for approximately four and a half hours.
Report Facts
Resident census: 62
Elopement Risk Scores: 15
Elopement Risk Scores: 14
Elopement Risk Scores: 21
Elapsed time missing: 4.5
Distance walked: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Assessed resident upon return, notified physician, and placed resident on monitoring |
| CMA R | Certified Medication Aide | Did not locate resident at dinner and notified Licensed Nurse H |
| LN H | Licensed Nurse | Instructed CMA R to look for resident but did not activate elopement protocol |
| Administrative Staff A | Provided information on sign-out privileges and facility camera footage | |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding resident's elopement behavior |
| Administrative Nurse E | Administrative Nurse | Interviewed regarding elopement protocol expectations and resident's mental health |
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 9
Date: Mar 7, 2022
Visit Reason
Annual inspection of Medicalodges Paola nursing home to assess compliance with regulatory requirements including resident care, environment, medication management, and safety.
Findings
The facility had multiple deficiencies including failure to maintain a sanitary environment, inadequate care planning for weight loss, failure to ensure residents received scheduled bathing and hygiene care, improper medication administration, failure to maintain oxygen equipment properly, and unsanitary food preparation and storage areas.
Deficiencies (9)
F 0584: Facility failed to provide housekeeping and maintenance services to maintain a safe, clean, and comfortable environment in multiple resident rooms and dining areas, including stained floors, peeling furniture, and unclean walls.
F 0657: Facility failed to review and revise the care plan for a resident with continued weight loss and fluctuating nutritional status, despite documented weight loss and related health issues.
F 0677: Facility failed to ensure three residents received scheduled bathing and hygiene care, including failure to educate staff on effective approaches to resident refusals, resulting in missed showers and poor hygiene.
F 0692: Facility failed to initiate alternative interventions for weight loss for a resident with significant weight loss and inaccurate meal intake documentation, despite ongoing nutritional concerns.
F 0695: Facility failed to maintain oxygen tubing and humidifier bottles properly by not dating or changing tubing weekly and not ensuring humidifier bottles contained water, increasing risk of respiratory infections.
F 0761: Facility failed to follow physician orders to reduce a resident's psychotropic medication dose, administering an incorrect higher dose for 47 days after the order.
F 0761: Facility failed to label six insulin pens with opened dates for three residents to ensure medication quality and safety.
F 0812: Facility failed to maintain sanitary food preparation, storage, and distribution areas, including grime on kitchen equipment and dust on shelves.
F 0921: Facility failed to maintain clean and sanitary floors in the kitchen and dry food storage areas, with grime and dirt build-up near walls.
Report Facts
Resident census: 63
Weight loss percentage: 6.9
Medication dose reduction delay: 47
Number of insulin pens unlabeled: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Discussed medication dose error, oxygen tubing policies, and bathing follow-up |
| Licensed Nurse H | Licensed Nurse | Provided information on resident bathing refusals and care challenges |
| Certified Medication Aide R | Certified Medication Aide | Administered medication and discussed medication dose error |
| Dietary Staff BB | Dietary Staff | Confirmed kitchen sanitation deficiencies |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 19, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies identified on the CMS-2567 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jun 20, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection of the facility.
Findings
The plan addresses multiple deficiencies including room temperature adjustments, accurate resident MDS documentation, medication black box warnings, sanitation and cleaning in dietary areas, and maintenance of facility equipment.
Deficiencies (6)
F257-E: Room temperatures have been adjusted to comfortable levels and will be periodically checked. Resident interviews will ensure comfort.
F278-D: Quarterly MDS for Resident #58 and correction for Resident #8 will accurately reflect ambulation and assistance needs. Staff will receive additional ADL coding training.
F329-D: Black box warnings for Lamictal on Resident #31 are documented on EMAR and physician’s orders. Skin observations will continue each shift for monitoring.
F371-F: Dietary area sanitation improved by cleaning fan, disposing of syrup, cleaning cabinet knobs, replacing trash cans with lids, and monitoring sanitation levels each shift.
F428-D: Black box warnings for Resident #31 are audited with each new order and reviewed monthly by pharmacist consultant.
F456-E: Facility will fix floor drain, replace exhaust fan in beauty shop, and perform periodic equipment checks.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 20, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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 which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the letter regarding the plan of correction acceptance. |
Inspection Report
Re-Inspection
Census: 81
Deficiencies: 6
Date: Jun 20, 2016
Visit Reason
Health resurvey inspection to evaluate compliance with regulatory requirements including temperature levels, assessment accuracy, drug regimen, food sanitation, equipment maintenance, and other care standards.
Findings
The facility failed to maintain comfortable temperature levels in multiple 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 and storage conditions, and failed to maintain essential equipment in safe operating condition.
Deficiencies (6)
F 257: The facility failed to maintain comfortable temperature levels in 5 resident rooms, a common TV room, and a men's bathing room, with temperatures measured as low as 61.1°F.
F 278: The facility failed to complete accurate comprehensive assessments for 2 of 9 sampled residents related to activities of daily living, including inaccurate documentation of supervision needs.
F 329: The facility failed to ensure that resident #31's care plan included appropriate black box warnings for Lamictal, missing the life-threatening skin rash warning.
F 371: The facility failed to store, prepare, and serve food under sanitary conditions, including dusty fans blowing on clean dishes, expired food items, unclean cabinet surfaces, improper sanitizer bucket maintenance, and grime buildup on kitchen equipment.
F 428: The facility's consulting pharmacist failed to identify and report the omission of black box warnings for Lamictal in resident #31's care plan during monthly drug regimen reviews.
F 456: The facility failed to maintain essential equipment in safe operating condition, including two resident bathtubs out of order, a nonfunctional beauty shop exhaust vent, and a kitchen oven with grime buildup that was not repaired despite work orders.
Report Facts
Resident census: 81
Resident sample size: 9
Residents reviewed for unnecessary medications: 5
Lamictal dosage: 200
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 14, 2016
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously identified deficiency under regulation 483.25(h) was corrected as of the revisit date. No uncorrected deficiencies were noted.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 04/14/2016.
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 22, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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.
Report Facts
Effective date for denial of payments: Jun 22, 2016
Provider agreement termination date: Sep 22, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 16, 2016
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified during a complaint investigation at the facility.
Complaint Details
This plan of correction is related to a complaint investigation identified as ML Paola complaint 03162016.
Findings
The plan addresses concerns related to resident #1's risk of elopement, including increased observation and care plan updates. The facility also implemented staff education and installed cameras at exits to enhance resident safety.
Deficiencies (2)
F0000 statement of deficiencies will be brought to the QA committee on 4/14/2016.
F323-D For resident #1, increased observation and care plan updates were implemented to address elopement risk. Staff were educated and cameras are being installed at exits to improve safety.
Report Facts
Complete Date for F0000: Apr 14, 2016
Complete Date for F323-D: Apr 14, 2016
Camera installation completion date: Mar 28, 2016
Observation interval: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for plan of correction assistance | |
| Nanci Rowlett | Business Office Manager | Submitted the plan of correction |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Date: Mar 16, 2016
Visit Reason
The inspection was conducted as an investigation of complaints #97875 and #98169 regarding resident safety and supervision.
Complaint Details
The investigation was triggered by complaints #97875 and #98169 concerning resident elopement and supervision. The complaint was substantiated as the resident eloped and was missing for an extended period.
Findings
The facility failed to prevent a high-risk resident from eloping without staff knowledge, resulting in the resident being missing for approximately 11 hours and 45 minutes before being found and returned safely. The resident was placed on increased supervision following the incident.
Deficiencies (1)
483.25(h) The facility failed to ensure one resident at high risk for elopement did not leave the facility without staff knowledge. The resident was missing for nearly 12 hours before being found and returned safely.
Report Facts
Resident census: 83
Elopement duration (hours and minutes): 11.75
Elopement risk assessment scores: 15
Elopement risk assessment scores: 18
BIMS score: 12
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 16, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
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, resulting in a finding of substantial compliance.
Deficiencies (1)
The most serious deficiency was a D level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 17, 2016
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified related to Resident #1's care and elopement risk management.
Findings
Resident #1 was under 1 to 1 observation before hospitalization and was placed on 15-minute visual checks upon return. The facility updated the care plan, conducted an elopement assessment, and educated staff on elopement risk and policy.
Deficiencies (1)
F323-D: Resident #1 was initially under 1 to 1 observation until hospitalization and was placed on 15-minute visual checks after return. The care plan was updated for elopement risk and staff were educated on the policy.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Date: Feb 12, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on complaints #96687 and #93170 regarding resident safety and supervision.
Complaint Details
The visit was triggered by complaints #96687 and #93170. The resident elopement was substantiated as the facility failed to prevent the resident from leaving without staff knowledge.
Findings
The facility failed to ensure that one resident with schizophrenia and psychosis did not leave the facility without staff knowledge, despite documented risks and behaviors indicating potential for elopement. The resident eloped on 2016-01-30, requiring police intervention to return him/her to the facility.
Deficiencies (1)
483.25(h) Free of accident hazards/supervision/devices: The facility failed to prevent a cognitively impaired resident with psychosis from eloping without staff knowledge.
Report Facts
Resident census: 82
Sample size: 4
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 11, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report documents that previously identified deficiencies under regulations 483.15(h)(2), 483.35(i), and 483.70(h) were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.15(h)(2): Previously cited deficiency was corrected by the revisit date.
Regulation 483.35(i): Previously cited deficiency was corrected by the revisit date.
Regulation 483.70(h): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Mar 19, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection of the facility.
Findings
The plan addresses multiple environmental and sanitation deficiencies including cleaning and repairing resident rooms, bathrooms, kitchen equipment, and facility grounds. The facility aims to achieve substantial compliance by April 11, 2015.
Deficiencies (3)
F253-E: Rooms identified require cleaning of floors, corners, window sills, CPAP machines, shelves, dressers, and bathroom grout. Repairs include replacing mirrors, light switches, hair brushes, and repairing bathroom walls and doors.
F371-F: The dry food storage area requires cleaning and rust removal on racks, cleaning of condiment containers, refrigerator handles and shelves, and replacement of cutting boards and plastic scoop handles. Kitchen equipment such as ovens, dishwashers, and toasters also require cleaning or replacement.
F465-F: The kitchen floor and facility grounds require cleaning and debris removal. Maintenance will inspect grounds weekly and conduct periodic audits to ensure cleanliness.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 12, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
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 the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 3
Date: Mar 11, 2015
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation to assess housekeeping, maintenance, food sanitation, and environmental conditions at the facility.
Complaint Details
The inspection was triggered by a complaint investigation #75812. The findings confirmed multiple sanitation and maintenance deficiencies.
Findings
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, and sanitary environment in the kitchen and front exterior of the building.
Deficiencies (3)
F 253 Housekeeping and maintenance services were inadequate, with dirty carpets, dusty and grimy resident rooms, damaged doors, and unclear cleaning responsibilities for resident equipment.
F 371 The dietary department had unsanitary conditions including dusty and rusty storage racks, dirty condiment tubs, uncovered salad dressing nozzles, sticky refrigerator handles, dirty baking sheets and pans, damaged cutting boards, dirty utensils, and inadequate cleaning documentation.
F 465 The facility failed to provide a sanitary environment in the kitchen with grime and food debris on floors and equipment, and the front exterior had cigarette butts, dirt, and debris compromising sanitation.
Report Facts
Resident census: 87
Date of inspection: Mar 11, 2015
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 17, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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 and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
The facility was cited with an "F" level deficiency indicating widespread noncompliance with Life Safety Code requirements posing potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Sep 17, 2014
Effective date for provider agreement termination: Dec 17, 2014
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 26, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies had been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.60(b), (d), (e) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.60(b), (d), (e): Previously cited deficiency was corrected by the revisit date of 12/26/2013.
Report Facts
Deficiency correction date: Dec 26, 2013
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 26, 2013
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited during a survey conducted on November 26, 2013, related to medication storage and handling.
Findings
The facility was found to have issues with medication storage, including expired medications and improper documentation of discontinued medications. The plan outlines corrective actions including staff education, routine inspections, and ongoing monitoring to ensure compliance.
Deficiencies (1)
F431-E relates to the storing and destruction of medications. Expired medications were identified and removed, and staff education on medication procedures was planned. Random inspections and observations of medication passes will be conducted to ensure compliance.
Report Facts
Deficiency cited survey date: Nov 26, 2013
Plan of Correction completion date: Dec 26, 2013
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 3
Date: Nov 26, 2013
Visit Reason
The inspection was a health resurvey and complaint investigations related to medication management and drug storage.
Complaint Details
The visit included complaint investigations #69598, 70548, and 70640.
Findings
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.
Deficiencies (3)
The facility failed to monitor expiration dates on medications, including expired Simethicone and Vitamin E found in medication carts. Medications were not consistently checked every shift as required.
Medications were set up in advance prior to administration, contrary to facility policy requiring administration at the time of preparation.
The facility lacked a policy and procedure to address discontinued medications and failed to accurately reconcile and document discontinued medications returned to the pharmacy.
Report Facts
Resident census: 86
Expired medication tablets: 6
Expired medication quantity: 3
Discontinued medication counts: 30
Discontinued medication counts: 3
Discontinued medication counts: 3
Discontinued medication counts: 3
Discontinued medication counts: 3
Discontinued medication counts: 27
Discontinued medication counts: 13
Discontinued medication counts: 81
Discontinued medication counts: 27
Discontinued medication counts: 30
Discontinued medication counts: 28
Discontinued medication counts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Reported on medication aide checks and medication administration policies | |
| Direct care staff B | Reported on medication setup practices and filling out medication return forms | |
| Direct care staff C | Reported on medication expiration date monitoring |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 2, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date of 09/02/2012.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Aug 3, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a survey completed on August 3, 2012, aimed at correcting and ensuring continued compliance with regulations.
Findings
The facility was cited for deficiencies related to housekeeping and maintenance services, resident environment safety, and medication management, specifically regarding antipsychotic drug use and monitoring of black box warnings. The plan outlines corrective actions including cleaning schedules, repairs, staff education, and ongoing audits.
Deficiencies (5)
F253-E: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specific cleaning and repair actions were planned for various areas including flooring replacement and wall maintenance.
F323-E: The facility must ensure the resident environment remains free of accident hazards and residents receive adequate supervision and assistance devices to prevent accidents. Maintenance will modify toilet bolts and ensure proper materials are used for repairs.
F329-E: The facility must ensure residents not using antipsychotic drugs are not given them unless necessary, and those using them receive gradual dose reductions and behavioral interventions unless contraindicated. Care plans and medication records will be reviewed and revised for sample residents with ongoing audits.
F428-CON: The licensed pharmacy consultant must meet monthly with the Director of Nursing to review the drug regimen and ensure recommendations are communicated and followed. Audits of physician orders and lab results will be performed regularly.
F428-E: The drug regimen of each resident must be reviewed at least monthly by a licensed pharmacist who reports irregularities to the attending physician and director of nursing, with required actions taken. Care plans and medication records will be reviewed and revised with ongoing audits and staff education.
Report Facts
Deficiencies cited: 5
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 4
Date: Aug 3, 2012
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies and pharmacy recommendations.
Findings
The facility failed to maintain a sanitary and safe environment, with multiple housekeeping and maintenance deficiencies observed. The facility also failed to identify and monitor residents for adverse consequences associated with medications with black box warnings, and did not act on pharmacy recommendations for monitoring therapeutic effects of medications.
Deficiencies (4)
F253: Facility failed to provide housekeeping and maintenance services to maintain a sanitary and comfortable interior, including dirt buildup, damaged flooring, and loose wallpaper.
F323: Facility failed to maintain an environment free of accident hazards, including exposed toilet bolts without covers in resident bathrooms.
F329: Facility failed to identify and monitor 7 residents for adverse consequences of medications with black box warnings and lacked a policy for managing these medications.
F428: Facility failed to ensure pharmacist recommendations were acted upon, including monitoring of adverse side effects and timely laboratory testing for residents on medications with black box warnings.
Report Facts
Resident census: 83
Residents reviewed for medication monitoring: 8
Residents with medication monitoring deficiencies: 7
Medication administration record review date: Jul 1, 2012
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N061002 POC BCVW11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiencies or findings are detailed in this document. It serves solely as a Plan of Correction submission with no records found linked.
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